Ez-Tcon for internal fixation in lower blepharoplasty
Chang, C. H., Bae, J., Cha, M. K., Bang, S. I., & Lee, K.-T. (2020). Internal fixation method using EZ-Tcon for transconjunctival fat repositioning: Clinical outcomes and efficacy. Aesthetic Plastic Surgery, 44(5), 1584–1595. https://doi.org/10.1007/s00266-020-01873-1
Introduction
For doctors performing transconjunctival fat repositioning, correction of the tear trough requires more than moving orbital fat below the infraorbital rim. The pedicle must reach the intended position, distribute volume appropriately and remain there during healing. Fixation therefore affects both the immediate contour and the conditions under which that contour is maintained.
In their 2020 study, Cheol Ho Chang and colleagues compared internal fixation using EZ-Tcon with conventional externalized percutaneous sutures (EPS). The clinical interest lies in how the technique addresses the limitations of existing fixation methods—and how much of the proposed explanation the study actually establishes.
What was compared
This was a retrospective, single-surgeon review of primary tear trough correction at Wannabe Plastic Surgical Clinic. EPS cases were treated from January 2010 to July 2016; EZ-Tcon cases from August 2016 to May 2019. Of 1,119 initially identified patients, 545 met the study criteria, including at least one month of postoperative follow-up. Median follow-up was 70 days.
Importantly, this was a comparison with EPS, not a direct clinical comparison with conventional internal fixation. The paper discusses conventional internal fixation to explain the device’s rationale, but did not include it as a third treatment cohort.
Why change the fixation method
EPS facilitates placement at the distal, lowermost end of the dissected pocket through a relatively short conjunctival incision. Its sutures remain externalized temporarily and, in this series, were removed after five to six days. The authors identify two potential disadvantages: skin irritation around external sutures or taping, and dependence on early tissue adhesion after the sutures are removed.
Conventional internal fixation leaves the anchoring suture buried. However, direct placement and knot tying at the distal pocket can be difficult in the narrow transconjunctival field. The authors describe the risk of anchoring more cephalically than intended or extending the incision for access.
EZ-Tcon is intended to combine the positioning access of EPS with buried internal anchoring. Both EPS and EZ-Tcon can reach the lowermost pocket.
Fig. 1. Fixation position of transposed fat pedicles. Orbital fat can be secured at the lowermost end of the dissected space with the externalized percutaneous suture technique (a) and internal fixation technique by EZ-Tcon (b), whereas fixation may be conducted at a more cephalic position with the conventional internal fixation technique owing to limited working space (c)
Step 1 Prepare the pocket and mobilize the fat pedicle
The reported operation uses a transconjunctival approach. In the EPS description, an approximately 12-mm incision is made 3–4 mm above the fornix, followed by dissection along the orbital septum toward the arcus marginalis. A supraperiosteal pocket is developed approximately 10–12 mm inferiorly, releasing the tear trough and palpebromalar ligaments. Surrounding fibrous tissue is dissected to prepare the orbital fat pedicle.
The EZ-Tcon group used the same pocket preparation and pedicle mobilization. These are shared foundations, rather than device-specific advantages. Mechanically, an adequately prepared pocket creates space for redistribution; mobilization allows the pedicle to reach it without excessive tension. A fixation device cannot compensate for inadequate release or an unsuitable distribution of fat.
The paper discusses possible use in both supraperiosteal and subperiosteal planes, but the reported comparative protocol used supraperiosteal preparation. It did not test which plane is superior. Step 2 Use the needle design to access the intended anchoring position
EZ-Tcon combines Chang’s needle with absorbable thread. The commercial needle described in the article is 28 mm long, curved through three-eighths of a circle and bidirectional. Its skin-facing end is sharp; its conjunctival-facing end is blunt. A laser mark helps the operator judge the thread position during the external passage.
The rationale is practical: the needle enables access to the distal fixation site through a short incision, rather than relying entirely on conventional needle-holder manoeuvres within the pocket. The blunt end and laser marking are design features intended to help control tissue passage and thread placement. They should not be presented as proof that vascular, ocular or skin complications cannot occur.
Fig. 2. Picture of EZ-Tcon. EZ-Tcon is composed of Chang’s needle and absorbable thread connected with it. Chang’s needle is 28 mm in length, 3/8 circle, and bidirectional type. The skin side end is sharp round or cutting style for easy skin penetration, whereas the conjunctival side end is blunt round style to reduce the chance of blood vessels and eyeball injury. There is a laser mark from the thread attachment point for easy prediction of thread’s position from skin side to facilitate prevention of skin dimpling caused by unintentional
exposure of thread.
Step 3 Pass outward at the distal pocket then return to create a tissue anchor
In the described technique, the skin-facing end of 5-0 EZ-Tcon passes through the prepared fat pedicle and outward from the lowermost dissected space to the skin. The operator monitors the laser marking and avoids excessive advancement. The needle then returns into the pocket at a point approximately 2–3 mm from the original puncture.
This return passage captures a segment of premaxillary soft tissue with the absorbable thread. The knot is tied internally, securing the transposed fat to the distal pocket. Figure 3 documents this sequence with operative photographs.
The proposed benefit is a buried anchor at the intended inferior position without leaving a pull-out suture across the skin for several days. “Internal fixation” therefore describes the final suture arrangement; it does not mean that the skin is never punctured.
The authors also relate the laser mark to avoiding unintended thread exposure and skin dimpling. Correct needle advancement remains part of the technique, rather than an automatic property of the device.
Fig. 3. The internal fixation technique using EZ-Tcon. The devised needle is placed at the fat pedicle (above, left). EZ-Tcon is passed from the distal end of the dissected space to the skin with paying attention to not pulling it beyond the laser mark (above, right). After checking the laser mark, the needle is passed back into the supraperiosteal dissected space, which is 2-3 mm from the original puncture point (below, left). As a result, part of the absorbable thread is trapped in the premaxillary soft tissue, and the transposed orbital fat can be fixed to the lowermost dissected space by placing several knots Aesth Plast Surg (2020) 44:1584–1595 1587 1
Step 4 Tailor fixation points to the distribution of fat
The series generally used three fixation points, adjusted to two or four according to fat distribution. Figure 4 is particularly useful because it shows why anchoring location and volume coverage are connected.
The authors illustrate how two separate fixation points for the medial and central pedicles can leave an uneven contour. Three-point fixation is intended to spread these pedicles more evenly. When the central compartment has more volume, the second fixation point can be shifted medially to broaden coverage from central fat; the reverse arrangement is illustrated when medial fat predominates.
For a longer tear trough, an additional point can support coverage along its length. For an isolated lateral depression, two fixation points using central fat may be sufficient in the illustrated pattern.
These examples explain a technique principle: fixation should support the required contour, rather than follow an identical pattern in every patient. They do not demonstrate that three points are universally superior. The study did not randomize patients by fixation-point number or isolate the contribution of this adjustment to outcomes.
Fig. 4. Individualizing the distribution of fixation points. The authors’ six-panel diagram of two-, three- and additional-point arrangements, including adjustments for unequal medial and central fat volumes and the distribution of the depression. These patterns illustrate planning choices; they were not separately compared in a trial.
Step 5 Leave the fixation buried and reduce prolonged skin suture exposure
The EZ-Tcon protocol included a single central 6-0 absorbable conjunctival wound suture and a light hydrocolloid dressing, usually removed by the patient the next day. EPS pull-out threads were removed after five to six days.
This distinction offers a plausible explanation for fewer persistent stitch marks: EZ-Tcon avoids several days of externalized fixation sutures and associated taping. In the study, conspicuous lower-eyelid scars lasting beyond four weeks occurred in 17 EPS patients and none in the EZ-Tcon group.
This result concerns the study’s specific scar definition and follow-up. It should not be translated into a claim of “scar-free surgery”. Likewise, eliminating fixation-suture removal does not eliminate the need for postoperative review. Earlier return to social activity is an advantage discussed by the authors, not a quantified recovery-time endpoint.
Step 6 Consider whether internal anchoring maintains the intended contour
Both EPS and EZ-Tcon permit lowermost placement. The authors therefore propose that better retention of the repositioned fat may help explain the aesthetic difference. After EPS removal, maintenance depends on sufficient adhesion; residual pedicle tension or an external mechanical force could disturb positioning. Buried absorbable fixation is intended to support the pedicle during healing.
This is a biomechanical explanation, not a separately proven mechanism. The study assessed postoperative appearance; it did not directly measure anchoring strength, track fat migration or establish long-term recurrence rates. The median follow-up of 70 days is too short to confirm durable superiority over years.
Fig. 5. Case 1. A 35-year-old man presented a tear trough deformity of Modified-Barton grade IL (lateral mild groove without medial depression) (Above). He was treated with transconjunctival fat repositioning with internal fixation technique using EZ-Tcon (Cohort 2). Appearance atpost-operative 3 months (Below)
Fig. 6. Case 2. A 44-year-old woman had tear trough deformity of modified Barton Grade II and mild skin laxity (Above). She underwent transconjunctival fat repositioning using EZ-Tcon and lateral partial incision blepharoplasty (Cohort 2). Tear trough deformity was improved to grade 0 with preservation of the pretarsal roll which can make her look younger and healthier (Below)
What were the measured outcomes
Two plastic surgeons who were not involved in the operations assessed photographs and were blinded to treatment group. They used a modified Barton grading system. An “excellent” result meant improvement by at least two grades; it was not a patient-satisfaction rating.
Outcome | EPS | EZ-Tcon | Reported p-value |
Overall complications | 24/211 (11.4%) | 5/334 (1.5%) | <0.001 |
Conspicuous scars beyond four weeks | 17/211 (8.1%) | 0/334 (0%) | <0.001 |
Complication-related reoperation | 6/211 (2.8%) | 2/334 (0.6%) | 0.034 |
Excellent photographic outcome | 70/211 (33.2%) | 196/334 (58.7%) | <0.001 |
No photographic improvement | 20/211 (9.5%) | 11/334 (3.3%) | 0.002 |
Source: Tables 3–4 of the supplied article.[1] Cohort sizes here follow the tables and main results. The abstract prints 344 for the EZ-Tcon cohort, whereas the body and tables give 334; 211 + 334 equals the reported total of 545.
In the EZ-Tcon group, 88.9% had grade 0 or I postoperative deformity. Infection, haematoma, granuloma and diplopia rates were not individually significantly different between groups. Consequently, the lower composite complication rate should not be described as a proven reduction in every complication.
The study’s reoperations were returns to theatre for complications, principally haematoma or infection. They should not be interpreted as the rate of elective aesthetic revision or recurrent tear trough correction.
What the findings mean for clinical practice
The technique presents a coherent rationale: prepare an appropriate pocket, place the pedicle distally, distribute volume with individualized fixation points, and maintain buried anchoring while avoiding prolonged external skin sutures. The strongest measured support concerns the comparative photographic outcomes and the reduction in persistent conspicuous stitch-related scars.
However, this Level IV study used sequential historical cohorts. Operator experience, changes in practice and unmeasured patient factors may contribute to the differences. Adjunctive lateral partial incision blepharoplasty was more frequent in the EZ-Tcon group (30.5% versus 22.7%), and follow-up duration differed. Multivariable analyses support an association with fixation method but cannot remove all retrospective confounding.
EZ-Tcon complications still occurred, including haematoma, infection and granuloma. The first author disclosed that he invented the device and had a financial interest in its manufacturer and supplier. These considerations favour careful appraisal of the evidence and further independent, longer-term evaluation.
For doctors, the article is valuable as an explanation of fixation mechanics and a clinical outcomes comparison. It provides a basis for discussing why the technique may improve contour control and postoperative convenience, while preserving realistic expectations about what has—and has not—been demonstrated.
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