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Lower Blepharoplasty: Exploring 2 Innovative Techniques

Changes in the eyelids and periorbital region have a significant impact on the signs of aging and are a major concern for those seeking facial rejuvenation. Aging eyelids show various changes, including skin laxity, orbital septum and canthal tendon laxity, and changes in the orbicularis muscles. Lower eyelid blepharoplasty is a common procedure used to address these changes and achieve cosmetic results.


The two common techniques used in lower blepharoplasty: the transconjunctival approach and the transcutaneous approach. The transconjunctival approach is suitable for younger patients with prominent lower fat pad herniation and no excess skin, while the transcutaneous approach is used for patients who require skin excision.


Anatomical Considerations


The surgical anatomy of the lower eyelid is crucial to understand in order to avoid complications during lower lid blepharoplasty. Special attention must be paid to the orbital septum (OS), inferior oblique muscle, and lower lid retractors or capsulopalpebral fascia (CPF) to prevent iatrogenic complications. The "critical zone," which contains the facial nerve branches supplying the orbicularis oculi muscle, should be handled carefully to avoid postoperative complications like iatrogenic ectropion or weakness of the lower eyelid.


The lower eyelid is divided into three lamellas: the anterior lamella (skin and orbicularis oculi muscle), middle lamella (OS), and posterior lamella (tarsal plate, eyelid retractors, and palpebral conjunctiva). The OS is a fibrous structure that separates the orbit from the superficial face and inserts on the inferior margin of the lower tarsus. The CPF inserts on the inferior border of the tarsus and may merge with the OS in some cases.


The lateral attachment between the orbicularis muscle and bone is formed by the orbital retaining ligament, which blends with the lateral orbital thickening. Skin attachment to the bone results in localized hollowing in specific regions, including the orbital rim hollow, zygomatic hollow, and septal confluence hollow. The tear trough deformity, characterized by volume loss and tissue descent, is a significant concern in lower lid rejuvenation.


Retroseptal fat pads, including the inferior oblique, medial, central, and lateral fat pads, play a role in the lower eyelid contour and should be considered during lower blepharoplasty. Preservation of ligamentous expansions and support structures, such as Clifford's ligament and the arcuate expansion, is important to maintain proper support and prevent displacement.


Contemporary aesthetic trends in lower eyelid blepharoplasty aim to reduce eye-bag prominence, create a smooth transition at the lower lid-cheek junction, and address orbital fat prolapse or herniation known as steatoblepharon, which causes the appearance of "bags under the eyes."



Operative Techniques of Blepharoplasty

The two main surgical approaches for lower eyelid blepharoplasty are the transcutaneous approach and the transconjunctival approach. In the past, the transcutaneous approach was more common, except in young patients where a scarless procedure was preferred. However, a recent study in the US showed a shift towards the transconjunctival approach among oculoplastic surgeons.


Both approaches aim to address herniated orbital fat and volume loss in the midface. However, completely removing all three prolapsed orbital fat pads can result in a hollow appearance of the lower eyelid. It is now more favorable to preserve and reposition the orbital fat, creating a gradual transition to the malar eminence and a smoother contour of the upper face. Combining these approaches with procedures to strengthen the septum, tighten the orbicularis muscle, lateral canthal tendon, and skin leads to better outcomes.


The most common reason for surgeons to avoid the transcutaneous approach is the resulting scars, which can cause inferior scleral show (the white of the eye being visible below the iris). A comparative study showed that the transconjunctival approach had a 3% rate of scleral show, while the transcutaneous approach had a higher rat2e of 28%.


Lower eyelid blepharoplasty can be performed under local or general anesthesia, depending on the patient's and surgeon's preferences, the need for additional procedures, and surgical planning.


1) Transconjunctival lower lid blepharoplasty

During the procedure, a local anesthetic solution containing lidocaine and epinephrine is injected into the inferior fornix and eyelid skin. Additional anesthesia is injected into the three fat pads. An incision is made below the tarsus through the conjunctiva. Radiofrequency monopolar cautery is used for better hemostasis. Gentle pressure on the eyeball allows the fat pads to prolapse, and they are then carefully dissected using cautery. The inferior oblique muscle is preserved. Surgeons may choose to either excise or reposition the orbital fat.


The medial, central, and lateral fat pads are fashioned into pedicles and repositioned beyond the infraorbital rim into the suborbicularis oculi fat (SOOF) area. The orbito-malar ligament is released to allow for transposition of the prolapsed fat beneath the orbicularis muscle beyond the infraorbital rim, with the help of temporary sutures. This technique yields a smoother and revitalized contour of the midface.


If the fat pedicles are transposed along the subperiosteal plane, an incision is made below the inferior orbital rim, and the periosteum is lifted to create a pocket for fat transposition. Care must be taken to avoid damage to the infraorbital neurovascular bundle. In supraperiosteal fat transposition, the dissection is done along the suborbicularis plane. Both subperiosteal and supraperiosteal fat transposition can yield similar outcomes, but there may be more bruising, swelling, and contour abnormalities with supraperiosteal transposition.


The conjunctival incision is typically not sutured, but the edges of the conjunctival epithelium are juxtaposed to prevent overlapping. However, some surgeons may choose to suture the conjunctival incision. The incision usually heals within a week, resulting in the desired outcome.


See below the figure which illustrates the steps involved in transconjunctival lower lid blepharoplasty. The figure also demonstrates the transconjunctival incision located 8 mm from the lid margin, the formation of LLF pedicles, the positioning of the IOM, the release of the orbitomalar ligament, and schematic representations of the redraping and tying of LLF pedicles over bolsters. (From Bhattacharjee, et al, 2020)

Transconjunctival Lower Lid Blepharoplasty

2)Transcutaneous lower eyelid blepharoplasty

Transcutaneous lower eyelid blepharoplasty with fat excision is an established method for addressing aging effects on the eye. Skin markings are done before injecting local anesthesia, and the "skin pinch" technique helps assess skin laxity. A subciliary incision is made, and redundant skin is conservatively excised while preserving the orbicularis muscle. The orbital septum is then incised to access and resect or fashion the orbital fat pads into pedicles for transfer to the suborbicularis oculi fat (SOOF) region after releasing the orbito-malar ligament.


The transcutaneous approach offers the advantage of combining it with a midface lift and lateral canthopexy or canthoplasty, depending on the severity of canthal laxity. For minimal lateral canthus laxity of 1-2 mm, lateral canthal suture canthopexy is preferred, while for moderate canthal laxity of 3-6 mm, lateral retinacular canthopexy is more suitable. However, canthoplasty with cantholysis or the lateral tarsal strip procedure is advocated for severe laxity (>6 mm).


See below the figure which demonstrates the steps of transcutaneous lower lid blepharoplasty, including a preoperative photograph, sub-ciliary incision, exposure of three fat pedicles, release of the orbicularis retaining ligament, and a postoperative photograph. (From Bhattacharjee, et al, 2020)

Transcutaneous Lower Lid Blepharoplasty

Complications


Lower lid blepharoplasty carries the risk of complications such as retro-orbital hemorrhage, edema, hemorrhage of the orbicularis muscle, and various postoperative issues. Transconjunctival approach is favored to avoid certain complications associated with the transcutaneous approach, such as scleral show, lagophthalmos, insufficient skin removal, lower eyelid cicatrization, retraction, skin scar, and ectropion.


Common complications associated with both approaches to lower eyelid blepharoplasty include bruising, superficial hematoma or ecchymosis, dry eyes, corneal trauma, infections, inadequate fat removal, damage to the inferior oblique muscle resulting in diplopia, postoperative pigmentation around the eyes, and eyelid asymmetry.



Conclusion


Overall, conservative excision of intraorbital fat in both transcutaneous and transconjunctival lower blepharoplasty procedures has been proven to be effective and aesthetically pleasing for rejuvenating the lower eyelid. Optimal preservation of orbital fat is preferable to complete excision. While the transconjunctival approach is often preferred, the transcutaneous technique is necessary in cases with excessive skin redundancy. The ultimate goal is high patient satisfaction with minimal postoperative complications. Each surgeon must consider patient requirements and surgical trends, as there is no universally best approach to lower eyelid blepharoplasty. Continued research and advancements will shape future practices in this field.


Reference

Lower eyelid blepharoplasty: An overview (2020)

An Update on Lower Lid Blepharoplasty (2017) Lower Eyelid Blepharoplasty (2016)

Lower Eyelid Blepharoplasty: A Procedure in Evolution (2010)

 

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