Patient Selection
Transconjunctival laser blepharoplasty is ideal for addressing isolated lower eyelid fat pad herniation ( Fig. 11.1 ). Compared to other approaches, the transconjunctival technique avoids any cutaneous stitches or incisions, disrupts neither the orbicularis layer nor its motor innervation, and affords a remarkably brief convalescence.
However, the transconjunctival technique does not address common concurrent eyelid conditions such as eyelid laxity, wrinkles, festoons, malar edema and folds, tear trough deformity, and suborbicularis oculi fat (SOOF) descent ( Fig. 11.2 ). The transconjunctival approach is often combined with other procedures to address any of the previously listed concurrent conditions, and may be modified to allow repositioning of the lower eyelid fat pads to address tear trough deformities ( Fig. 11.3 ).
It is important to determine preoperatively the relative extent of fat prolapse when the patient is upright. For example, some patients may have only nasal fat pad prolapse and not require any other fat pad removal. In others, one fat pad may herniate more than another, so these findings should be noted ahead of time and may be referred to during surgery.
When tear trough deformity is a concern, this may be addressed through fat repositioning which is discussed in the supplemental steps at the end of this chapter.
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Primary problem is lower eyelid fat pad herniation
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No significant eyelid margin malposition
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Satisfactory lower eyelid skin without significant wrinkling
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Satisfactory midface continuum
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No significant tear-trough deformity
Laser Selection and Parameters
Incisional CO 2 lasers suitable for blepharoplasty are available from several manufacturers including Lumenis (formerly the medical laser division of Coherent Inc. and Sharplan/ESC) and Nidek. Each company uses a slightly different CO 2 delivery system and actual incisional parameters vary accordingly. A small spot size of 0.3mm or less is important to reduce the zone of thermal injury. CO 2 lasers that use a hollow waveguide (rather than an articulated) arm to transmit the beam from the laser tube to the handpiece are not recommended because the exit beam is divergent rather than coherent, collimated, and focused ( Figs 11.4 & Figs 11.5 ) Appropriate formal didactic training in laser blepharoplasty and laser safety is essential and is beyond the scope of this chapter. Further references are provided.
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Focused spot size of 0.3mm or less
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Wattage setting varies by manufacturer
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Continuous-wave or pulsed setting
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Articulated-arm beam delivery
Laser Safety
Laser safety is crucial because of the numerous hazards associated with unsafe laser blepharoplasty ( Fig. 11.6 ). The surgeon must acquire appropriate knowledge, motor skills, and laser-safe instrumentation before embarking upon laser blepharoplasty ( Fig. 11.7 ; Table 11.1 ). Complete discussion of this issue is beyond the scope of this chapter. For further information, see Reference .
| Globe protection | Metal interpositional shield or scleral shield |
| Tissue protection | Metal backstop or hemostat |
| Tissue protection | Appropriate laser, laser settings and laser focus |
| Laser reflection hazard | Antireflection treatment of metal instruments |
| Combustion hazard | Use wet drapes |
| Operator smoke hazard | Use smoke evacuator and laser masks |
| Operator ocular hazard | Wear wavelength-appropriate laser-safe goggles |
| Governmental standards | Follow OSHA and State standards |
Anatomic Landmarks and Surgical Tips
The location of the inferior oblique muscle should be clearly envisioned prior to embarking upon transconjunctival blepharoplasty. The inferior oblique is reliably located in the cleft or separation between the nasal and central fat pads ( Fig. 11.8 ). The inferior oblique muscle originates from the periosteum adjacent to the proximal bony nasolacrimal duct and passes inferior to the nasal fat pad and superior to the central fat pad. Arising from the inferior oblique is an expansion of connective tissue that sometimes restrains the contiguous fat of the central and lateral fat pads. This tissue, termed the arcuate expansion , may be divided if necessary ( Fig. 11.9 ).
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Recommended instruments (Storz Instrument Co., St Louis, MO, USA) include a Khan–Jaeger Laser Eyelid Plate, Castroviejo O.5mm toothed platform tying forceps, Desmarres retractor (dull finish), bipolar cautery, hemostat (fine curved), protective metal scleral contact lens.
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The inferior oblique can always be located between the nasal and central fat pads.
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If the fat is restrained between the central and lateral fat pads, look for and divide the anteriorly located fibrous band of tissue (arcuate expansion).
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The lateral fat pad is easier to remove once separated from the underlying lower eyelid retractor.
Clinical pearls Surgical Steps
1.
Prolapse the inferior fat pads and fornix
Adequate prolapse and exposure of the conjunctival fornix is an essential prelude to successful transconjunctival incision ( Fig. 11.10 ). The key to this step is to ballot the globe so as to prolapse the fat and conjunctiva anteriorly whilst simultaneously having the assistant retract the lower eyelid margin with two fingers. Retraction of the lower eyelid margin requires that the pads of the assistant’s fingers be placed directly upon the eyelid margin itself in order to exert sufficient inferior traction. When performed successfully, a liberal horizontal roll of prolapsing fat and overlying conjunctiva will present itself quite reliably and visibly. The use of the titanium Khan–Jaeger plate allows one to ballot the globe posteriorly in order to prolapse the fat anteriorly whilst also protecting the globe.
