10 Transconjunctival Lower Eyelid Blepharoplasty
Lower eyelid transconjunctival blepharoplasty is a commonly performed aesthetic procedure with numerous technique nuances and adjuncts which when properly performed results in high patient satisfaction. This chapter will discuss the various surgical options along with an explanation of their goals, including fat repositioning and adjunctive skin pinch. There are many possible pitfalls and complications that can occur if the surgeon is not well versed in the regional anatomy, makes unwise decisions regarding the approach or fails to address all of the related anatomic factors. Special attention is also directed to management of complications including retrobulbar hemorrhage, diplopia and eyelid retraction.
Goals of lower eyelid blepharoplasty:
Rejuvenate the lower eyelids and mid-face.
Improve the appearance of the lower eyelids and mid-face.
Restore a more youthful appearance by addressing signs of aging.
Signs of aging in the lower eyelid:
Herniation of orbital fat (“under eye bags”).
Accumulation of excess skin.
Aging changes of the lower eyelid and mid-face may be approached surgically, as will be elucidated in this chapter, or by nonsurgical mechanisms including botulinum toxin, filler, chemical peeling, or laser treatments. There are two primary advantages of a surgical approach. First, it directly addresses the underlying etiology, by removing or repositioning herniated orbital fat, or by excising excess skin. The nonsurgical alternatives can enhance the appearance of the aberrant tissue, but do not correct the inciting issue. Second, surgical approaches tend to confer longer lasting results of 10 to 15 years or more in comparison to filler injections (9–18 months). Botulinum toxin injections, laser resurfacing, or chemical peels all are adjuncts to surgery, not alternatives.
Safe and effective operation.
Long-term cosmetic enhancement of the lower eyelid.
Bias toward undercorrection:
Generally may be successfully addressed with in-office enhancement.
Avoidance of overcorrection:
Complications can be devastating:
Lower eyelid retraction and ectropion (Fig. 10‑1).
Severe dry eye.
10.4 Key Principles
10.4.1 Relevant Anatomy
The lower eyelid consists of seven layers (Fig. 10‑2), the composition of which depends on the level within the eyelid. From anterior to posterior, these are skin, orbicularis oculi muscle, orbital septum, orbital fat, lower eyelid retractors, tarsus, and conjunctiva. Near the orbital rim, all layers are present except for tarsus. More superiorly, the septum and retractors condense and insert into the tarsus. There is no orbital fat present above this condensation. Moving more superiorly, near the eyelid margin, only skin, orbicularis, tarsus, and conjunctiva are present.
The lower eyelid skin, like the upper eyelid skin, is the thinnest skin of the body. With age, it loses elasticity. The orbicularis oculi is the primary eyelid protractor. It is a circumferentially oriented muscle that is responsible for voluntary and involuntary eyelid closure. The orbital septum is a thin, but firm, connective tissue, which originates from the arcus marginalis at the inferior orbital rim and combines with the capsulopalpebral fascia just inferior to the tarsus such that they insert together onto the inferior tarsal border. It is an important landmark, in that it separates the anterior eyelid structures from the posterior orbital structures. Orbital fat lies just posterior to the septum, and is divided into three distinct fat pads (Fig. 10‑3, Fig. 10‑4). The medial and central pads are divided by the inferior oblique muscle, whereas the central and lateral pads are divided by the same muscle’s arcuate expansion. Posterior to the orbital fat are the eyelid retractors: the capsulopalpebral fascia, which is analogous to the levator palpebrae superioris in the upper eyelid, and the sympathetically innervated inferior tarsal muscle, which is analogous to Müller muscle in the upper eyelid. The tarsus is a dense connective tissue that confers structural support to the eyelid, and the most posterior layer is the conjunctiva, which is contiguous with the conjunctiva of the globe itself.
Oftentimes with aging, herniation of orbital fat arises in concert with infraorbital hollowing, which occurs when the sub-orbicularis oculi fat (SOOF) descends below its native position at the inferior orbital rim. When this occurs, the surgeon may consider using the fat that would otherwise be removed to add volume to the nearby atrophic area.
Herniation of orbital fat (“bags” under the eyes).
Excess or sagging lower eyelid skin.
Descent of the mid-face tissues (Fig. 10‑5).
Patient should desire aesthetic enhancement or rejuvenation of the lower eyelids.
Patient and surgeon should agree on intended aesthetic outcome.
Surgeon must reasonably believe that the intended outcome may be achieved surgically.
Patients with unrealistic expectations:
The only true measure of success in a cosmetic procedure is the patient’s satisfaction.
Failure to align patient and surgeon views of an optimal result preoperatively virtually guarantees an unhappy postoperative patient.
Overly picky, demanding, critical, or particular patient:
Extreme care should be taken preoperatively to review goals, risks, and plan for addressing postoperative dissatisfaction.
High bleeding risk (intrinsic coagulopathy, patient in whom it is unsafe to discontinue anticoagulation):
Given the potentially devastating consequences of intraorbital hemorrhage, caution should be exercised in these patients.
10.5 Preoperative Preparation
Preoperative preparation for lower eyelid blepharoplasty is similar to that for any oculoplastic procedure.
10.5.1 Operative Setting
The procedure may be performed in an ambulatory surgery center or in the office setting. It is important to note, however, that manipulation of fat is painful, and as such, discretion in patient selection is advised if choosing the office setting, with careful attention to both the personality of the patient and the intended surgical plan. If fat repositioning is to be employed, an ambulatory surgery center is recommended. If the office setting is chosen, the surgeon should consider preoperative treatment with oral pain medication and anti-anxiolytic agents.