Transconjunctival Blepharoplasty Research Articles

Orbital fat graft retroseptal transconjunctival blepharoplasty for treatment of groove in the infraorbital region.

To investigate the efficacy of the retroseptal transconjunctival blepharoplasty together with tear trough ligament (TTL) and Orbicularis retaining ligament (ORL) release with orbital fat graft in the management of groove in the infraorbital region (GIR). A prospective study of 80 eyes of 40 patients that underwent retroseptal transconjunctival lower blepharoplasty together with TTL and ORL release and resected orbital fat grafting. An ophthalmic examination includes lower eyelid evaluation and Barton's Tear trough deformity grading was done at baseline, 2weeks, 3months, and 6months after the surgery. Patient satisfaction was evaluated using Global aesthetic improvement scale (GAIS) and Blepharoplasty outcomes evaluation (BOE). Baseline tear trough defects were graded into grade 1, 2, and 3 in 12(15%), 39(48.75%) and 29(36.25%) eyes, respectively. While at 6months follow-up, grade 0 was recorded in 63(78.75%) eyes, and grade 1 was recorded in 17(21.25%) eyes. The amount of fat removed was 0.52 ± 0.04mL per eye, whereas the amount of injected fat graft was 0.24 ± 0.04. The mean operative time was 33.2 ± 4.1min per eye. GAIS showed degree 1, 2, and 3 in 8(20%), 29(72.5%), and 3(7.5%) patients at 6months follow-up, respectively. The mean baseline BOE increased significantly from 36.5 ± 5.9 to 86.9 ± 5.5 at 6months follow-up. Our cohort highlights the beneficial effects of TTD/ORL release with resected orbital fat grafting in the management of GIR and infraorbital hollow.

Persistent Conjunctival Chemosis after Lower Lid Blepharoplasty: A Comparison of Different Surgical Techniques.

Background: Conjunctival chemosis, a complication of lower blepharoplasty, can cause persistent discomfort and functional disturbances with worsening in the postoperative period following surgery. Methods: A review of the records of the lower blepharoplasty procedures carried out at the Humanitas Research Hospital, Rozzano, Milan, Italy was performed. Patients were categorized into two groups depending on the procedure performed: (1) transconjunctival blepharoplasty with the removal of the fatty lodges with canthopexy and (2) transcutaneous blepharoplasty with the removal of the fatty lodges with lateral canthoplasty. Each group was further divided into two more groups based on the surgical method used, that is either (a) cold blade and disposable cautery or (b) radiofrequency cut and coagulation and colorado tip (respectively 1a, 1b, 2a and 2b). All patients underwent a postoperative follow-up up to 24 months, which included an evaluation of cosmetic appearance, eyelid scarring and the severity of chemosis. The aim of the study was to investigate which of the surgical procedures causes a lower incidence of persistent type 3 conjunctival chemosis. Results: A total of 1047 patients who underwent lower lid blepharoplasty were included in the study. A total of 512 patients underwent transcutaneous blepharoplasty and 535 underwent the transconjunctival procedure. Among the first group of patients, 266 belong to group 1a and 246 to group 1b. In the second group, 264 were categorized as group 2a and 271 as group 2b. The incidence of type 3 chemosis in the transcutaneous blepharoplasty procedure with lateral canthoplasty was statistically significantly higher than in the transconjunctival approach, considering both the cold blade and the radiofrequency (p = 0.012, 0.010, 0.006, 0.004, respectively). Conclusions: A higher incidence of persistent type 3 conjunctival chemosis is associated with lateral canthus surgery and with the use of radiofrequency.

Role of fractional carbon dioxide laser resurfacing in post-operative transconjunctival lower eyelid blepharoplasty

Background: Transconjunctival blepharoplasty is the management of lower eyelid structures via the conjunctival approach and is usually applied to the cosmetic improvement of the lower eyelid using this approach. Aim and objectives: The study aimed to evaluate and compare the aesthetic result for residual fine wrinkles after transconjunctival lower eyelid blepharoplasty alone or combined with post-operative fractional CO2 laser. Subjects and methods: The present study was carried out on 20 patients with lower eyelid puffiness without skin redundancy just fine wrinkles who were selected from patients that were admitted to department of plastic and reconstructive surgery, AL-Azhar University hospitals. Results: Skin tightening and residual wrinkles improvement in group (A) show that 9(90.0%) were improved and 1(10.0%) were not improved while in group (B) 6(60.0%) were not improved and 4(40.0%) were worsen. There was highly statistically significant differences between groups where P<0.001 with better result in group (A) in comparing with group (B). Conclusion: Our results demonstrated that both lower eyelid transconjunctival blepharoplasty alone or with combination with postoperative fractional CO2 laser were safe and effective in the treatment of lower eyelid puffiness. Both of the investigated methods had comparable outcomes in terms of complications and satisfaction.

A new combined method for the treatment of involutional changes in the periorbital region

Background. The solution to the problem of correction of involutional changes in the periorbital region requires a multidisciplinary approach, as this location can comprise a broad range of problems that need to be addressed. For so many years, laser therapy methods have been the standard for correcting age-related changes. However, many issues concerning combined methods remain open, and the search and development of the most effective protocols for their use is therefore an urgent task of modern medicine.
 Objective. The goal of the study was to develop a combined method to correct involutional skin changes in the periorbital region in young and middle-aged patients using a fractional Nd:YAG and CO2 laser in conjunction with lower transconjunctival blepharoplasty, based on the study of clinical efficacy results and taking into account the indicators of the qualitative characteristics of the skin, as well as microcirculation.
 Material and methods. The study enrolled 108 patients with involutional changes in the skin of the lower eyelid. These patients were classified into groups based on the method of treatment. In the study, relevant methods were used, namely, the study of the qualitative characteristics of the skin (cutometry, TEVA-metry, and corneometry) and microcirculatory processes using laser flowmetry.
 Results. The effectiveness of the developed combined method is based on a substantial positive impact on active and passive hemodynamic mechanisms at all levels of the microvasculature, as demonstrated by an increase of 45.92% in the integral indicator of microcirculation compared to 26.35% and 5.77% in the comparison groups, while the coefficient of variation in the microcirculation indicator increased by 33.02% compared to 24.19% and 6.46% following the use of the method components. The use of the combined treatment method restores the qualitative characteristics of the skin, namely, the moisture index increased by 27% (p 0.05) compared to 14.1% and 7.8% in groups 1 and 2, respectively; the rate of transepidermal water loss decreased by 47% (p 0.05) compared to 35% and 12.7% in groups 1 and 2, respectively; and the elasticity index Ua/Uf increased by 23.2% (p 0.05) compared to 18.4% and 16.4% in groups 1 and 2, respectively.
 Conclusion. Based on the study, it can be concluded that the combined treatment method developed is highly effective.

Transconjunctival lower eyelid blepharoplasty with fat transposition above the orbicularis muscle for improvement of the tear trough deformity.

The tear trough is the hollow concavity of the medial lower eyelid. Surgery can address tear trough deformities and reverse visible signs of periorbital aging. The previous methods of transconjunctival blepharoplasty with fat transposition were first described with subperiosteal placement of fat (Plast Reconstr Surg, 125, 2010,699, Aesthetic Surg J, 32, 2012, 426). This was followed by techniques with submuscular transposition of fat, which overcame certain difficulties associated with the subperiosteal methods (Clin Plast Surg, 20, 1993, 393, Arch Facial Plast Surg, 2, 2000, 16). We present a detailed description, evaluate the efficacy, safety, and advantages of transconjunctival blepharoplasty with fat pedicle transposition above the orbicularis muscle for lower eyelid rejuvenation and improvement of the tear trough deformity. Forty-one patients underwent lower eyelid blepharoplasty with fat transposition above the orbicularis muscle. Clinical and photographic documentation along with patient satisfaction ratings were evaluated for a minimum of 44months postoperatively. Significant improvements of lower eyelid aesthetics and correction of tear trough abnormalities were observed in most patients. At 44months postoperatively, surgical correction was maintained in all patients with a high satisfaction and long-term survival. No contour irregularities or significant long-term complications were detected in any of the patients. Transconjunctival blepharoplasty with the fat pedicle transposition placed above the orbicularis muscle is a safe and effective technique for lower eyelid rejuvenation. Compared to previously described techniques of repositioning fat into the subperiosteal or submuscular plane, this technique of transposing fat above the orbicularis muscle is an alternative technique resulting in long-term improvement of tear trough abnormalities with no major complications.

Lower Blepharoplasty

This review provides an overview of lower eyelid blepharoplasty, with discussion focused on relevant anatomy, the effects of aging on the lower eyelid and lid/cheek junction, patient evaluation, the most common surgical techniques, complications from surgery, and outcomes assessment. Emphasis is placed on tailoring surgical approaches to the specific aesthetic and functional concerns for each patient. Keywords: blepharoplasty, lower lid surgery, transconjunctival blepharoplasty, transcutaneous blepharoplasty, pseudoherniation, cosmetic surgery, surgery techniques, aesthetic surgery, tear trough deformity, orbital fat, eyelid laxity, canthoplasty This review contains 6 figures, 2 tables, and 50 references.

A Six-Year Review of the Latest Oculoplastic Surgical Development.

The aim of this study was to summarize the literature from 2012 to 2018 on 4 common cosmetic periocular operative procedures including epicanthoplasty, lateral canthoplasty, and upper and lower blepharoplasty. Systematic review of epicanthoplasty, lateral canthoplasty, upper and lower blepharoplasty in the period of 6 years. A systematic MEDLINE search by 2 independent reviewers was performed on PubMed using the search terms (blepharoplasty) OR double eyelid) OR lateral canthopexy) OR fat repositioning) OR epicanthoplasty) OR love band) AND (From January 2012 to January 2018). After screening 1456 abstracts from search results, 1377 were eliminated due to irrelevant content. Full text of the remaining 79 articles and relevant cross-references were reviewed and summarized. Studies on cosmetic epicanthoplasty reported Z-plasty or modifications (n=8), advancement flap (n=4) or skin redraping procedures (n=1), removal or release of the orbicularis muscle (n = 14), with (n = 6) or without (n = 11) tightening medial canthal tendon. In lateral canthoplasty, approaches to preserve continuity of eyelid margin prevent lateral canthal deformity with inconspicuous incision via gray line (n = 2) or upper eyelid (n = 2) were described. Techniques of upper blepharoplasties described included open incision method (n = 9) with (n = 5) or without (n = 3) orbicularis resection, subbrow approach (n = 1), nonincisional suture blepharoplasty (n = 2), or partial incision blepharoplasty (n = 1). For lower blepharoplasties, techniques described included blepharoplasty with fat transposition (n = 7), transconjunctival blepharoplasty (n = 3), transcutaneous blepharoplasty and canthopexy (n = 1) or orbicularis flap (n = 2), minimally invasive or laser-assisted blepharoplasty (n = 2). The recent trend of periocular surgical rejuvenation focuses on preserving soft tissue volume, avoiding skin or use hidden incision, taking the eyebrow and midface position into account, and measures to minimize iatrogenic eyelid malposition.

Lower eyelid transconjunctival blepharoplasty with fat repositioning: outcomes and complications

The lower eyelid changes with aging include atrophy of the orbital septum with subsequent forward herniation of orbital fat, descent of the sub-orbicularis oculi muscle fat, ptosis of the orbicularis oculi muscle, weakening of the orbito-malar ligament and the development of laxity of the eyelid skin, the tarsus and the canthal tendons. In this article we aim at describing our experience of using a modified lower lid blepharoplasty with fat repositioning in patients with lower lid fat prolapse and tear trough deformity. A retrospective, non-randomised non-comparative interventional consecutive case series of patients seeking surgical treatment. Patients underwent surgery between April 2010 and October 2019 by a single surgeon (BL). Patient demographics, clinical examination, preoperative and postoperative clinical photography, outcomes and complications were recorded. Follow-up was initially at 2 weeks and finally at 16–20 weeks. Outcomes were recorded as subjective improvement and degree of patient satisfaction. A total of 150 patients were recruited in the study period. The mean age at the time of surgery was 49. One hundred forty-one (94%) patients were very satisfied with the final outcome of their surgery, 5 were satisfied and 4 were dissatisfied. One patient developed a bilateral lower lid infection requiring abscess drainage. Seventeen other patients experienced minor complications in the postoperative period, including 2 with a unilateral lower lid infection requiring oral antibiotics, 3 with a temporary inferior oblique palsy, 1 with temporary unilateral infraorbital nerve dysfunction, 3 with residual prolapses of the lateral fat pads, 1 with a medial lower lid lump, 2 with a conjunctival granuloma, 2 with a temporary medial ectropion, 1 with persistent unilateral lower lid oedema, 1 with persistent bilateral lower lid oedema and 1 with unilateral lower lid retraction. We report a high patient satisfaction with a low rate of significant complications following our modified lower lid transconjunctival blepharoplasty with fat repositioning. Level of evidence: Level III, therapeutic study

Percutaneous Lower Blepharoplasty: A Novel Technique in Lower Eyelid Aesthetics.

More preservative approaches are being adopted in periorbital surgery each day. To avoid the possible complications of transcutaneous and transconjunctival blepharoplasty, the author has developed the safe and simple "Percutaneous Lower Blepharoplasty" technique, which he has been performing since 2008. The technique consists of the removal and transfer of lower orbital fat pads through 4-mm skin incisions with minimal dissection. The study is designed as a retrospective analysis of the operations done by the author from 2008 to 2018. The author performed 297 percutaneous lower blepharoplasty operations alone or in combination with tear-trough deformity correction, pinch skin excision, and/or carbon dioxide laser application. The video of the technique is demonstrated in the supplemental digital content. The patients were followed for an average of 58.8 months. All the patients were satisfied with the result. There were no retractions or scleral show seen. The only complication was chemosis in 1 patient that subsided with steroid ointment. Percutaneous lower blepharoplasty is a novel technique that has the following advantages: Simple and fast, low complication rates, good cosmetic outcomes, tear trough deformity correction, better estimation of fat amount to be removed, and minimal dissection and avoidance of violation of lamellar structures. It can be performed safely alone or in combination with pinch excision and/or fractional laser resurfacing.

A Rare Complication Following Trans-Conjunctival Lower Blepharoplasty

A Rare Complication Following Trans-Conjunctival Lower Blepharoplasty

A new combined method for treating involutive changes in the periorbital region

Objective. To solve the problem of correction of involutive changes in the periorbital region, it is necessary to approach from the position of a multidisciplinary approach, since a wide range of problems that need to be solved is possible in this localization. Laser therapy methods have been the standard for correcting age-related changes for many years. However, many questions of combined methods remain open, so the search and development of the most effective protocols for their use is an urgent task of modern medicine.
 Purpose of the study. Based on the study of the results of clinical efficacy and taking into account the indicators of quality characteristics of the skin, as well as microcirculation, to develop a combined method for correcting involutive skin changes in the periorbital region in young and middle-aged patients using fractional Nd:YAG and CO2 laser in combination with lower transconjunctival blepharoplasty.
 Material and methods. The study involved 108 patients with involutive changes in the skin of the lower eyelid. Depending on the method of treatment, patients were divided into groups. Special methods were used in the study: the study of qualitative characteristics of the skin (cutometry, TEVA-metry, corneometry), microcirculatory processes using laser flowmetry.
 Results. The effectiveness of the developed combined method is based on a pronounced positive effect on the active and passive mechanisms of hemodynamics at all levels of the microcirculatory bed, which is confirmed by an increase in the integral indicator of MC by 45.92% against 26.35% and 5.77% in the comparison groups, while the coefficient of variation of the indicator of MC increased by 33.02% against 24.19% and 6.46% after applying the components of the method. The use of the combined treatment method leads to the restoration of skin quality characteristics: the moisture index increased by 27% (p 0.05) compared to 14.1%, 7.8% in groups 1 and 2, respectively, the transepidermal water loss index decreased by 47% (p 0.05) (compared to 35%, 12.7% in groups 1 and 2, respectively), the ua/Uf elasticity index increased by 23.2% (p 0.05) (compared to 18.4%, 16.4% in groups 1 and 2, respectively).
 Conclusion. On the basis of the conducted research it can be concluded that the developed combined method of treatment is highly effective.

Pyogenic granuloma after a non-sutured transconjunctival blepharoplasty in the lower eyelid

Pyogenic granuloma (PG) is a vasoproliferative inflammatory response composed of granulation tissue. The pathogenesis is not entirely clear. Pyogenic granuloma was found involving the skin or mucosal surfaces, and it is associated with tissue irritation or inflammation. Pyogenic granuloma as a complication after blepharoplasty is uncommon. The treatment is simple and saves the patients from the discomfort caused by the lesion. Surgical excision is effective in patients who do not improve with a local application of steroids. We describe two cases of uncommon pyogenic granuloma occurring after lower transconjunctival blepharoplasty, with no suture and alert ophthalmologists and oculoplastic surgeons to the possibility of encountering and treating these lesions. Level of Evidence: Level V, therapeutic/diagnostic study.

Treating Tear Trough Deformity: Transconjunctival Blepharoplasty with Fat Pad Repositioning and Fixation in the Intranasal Mucosa-18Years' Experience.

With aging, progressive changes occur in the eyelid region. The novel technique for repositioning of the fat pads described herein addresses Hester classification type II, lower eyelid aging with minimal decrease in the eyelid/cheek juncture. In this retrospective study of patients undergoing surgery at our clinic between 2000 and 2018, 92 were classified as Hester II and a transconjunctival surgical procedure was performed with repositioning of the fat pads and intranasal fixation assisted by the Casagrande needle. Erasure of the nasojugal fold was observed in all patients, offering a greater uniformity in the convexity of the middle third and resulting in better rejuvenation of the target area while eliminating visible scarring from a suture through the skin. The repositioning of fat pads using intranasal fixation offers the necessary anchoring qualities without worrying about unsightly scars or the need to remove stitches early, which can decrease the proper scarring and adhesion of the pads in their new pockets. The quality and longevity of the results of this retrospective study allow us to offer this novel fat pad fixation method in transconjunctival blepharoplasty. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of tear trough deformity with and without tear trough-orbicularis retaining ligament complex release in transconjunctival blepharoplasty: a comparative study

To evaluate the effect of releasing the orbicularis retaining ligament (ORL) complex of the tear trough combined with the transconjunctival blepharoplasty in the surgical management of tear trough deformity compared with the effect of blepharoplasty alone. A prospective, randomized (by closed envelope technique), controlled surgical trial which included 50 patients (100 eyes) with bilateral visible tear trough deformity and lower eyelid fat bulging, was divided into two groups where 25 patients (50 eyes) had tear trough-ORL release with blepharoplasty and 25 patients (50 eyes) didn't. Qualitative and quantitative assessments of tear trough deformity were done at 6mo postoperatively, achieving grade 0 or 1 of Barton's classification was considered a success. Standardized photographic documentation of each patient was done pre and postoperatively, also assessment of the patients' satisfaction postoperatively was done and ranked as excellent, very good, good or fair. There was statistically significant difference between the two groups in the overall aesthetic results postoperatively regarding the qualitative and quantitative analysis of the tear trough deformity, where patients who had tear trough-ORL complex release had more successful outcomes than those of the second group. ORL release should be done in patients with tear trough deformity in order to release the tethering effect of this ligament which causes the prominence of the naso jugal groove.

Managing Periocular Filler-Related Syndrome Prior to Lower Blepharoplasty.

Hyaluronic acid (HA) fillers are extensively used in periocular volume augmentation. Although they have an excellent safety profile, filler-related issues such as visibility/palpability, contour abnormalities, malar edema, and blue-gray dyschromia can occur. Recognition and management of filler-related issues are critical prior to subsequent procedures. The clinical course of patients who had periocular HA filler-related issues and subsequently underwent lower eyelid blepharoplasty is described. HA filler was dissolved with hyaluronidase (15-30 U/cm2) treatment. Visible lower eyelid fat prolapse after filler removal was corrected with transconjunctival blepharoplasty with fat repositioning and skin resurfacing. Complications and outcome were assessed and recorded. Twenty-three patients (46 eyelids) were treated. All presented with contour abnormalities, 19 with contour abnormalities and malar edema, and seven with blue-gray dyschromia. In 15 patients, one session of hyaluronidase completely dissolved the filler, and in eight patients, two sessions were required. Of these eight patients, edema resolved after the second hyaluronidase injection in four; in the remaining four, mild edema persisted despite absence of visible/palpable filler. Postblepharoplasty, 19 patients had an acceptable outcome with no complications (82.6%). Four patients had prolonged edema postoperatively; three had a resolution by 6 months. In 23 patients who had skin resurfacing procedures, there was no incidence of postinflammatory hyperpigmentation. HA filler-related issues need to be identified and managed prior to further intervention. Hyaluronidase treatment effectively dissolves the filler, but mild malar edema can persist. Outcomes are acceptable after subsequent blepharoplasty, but adequate patient counseling is necessary about expectations and limitations. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution

Sir: In the August of 2017 issue of Plastic and Reconstructive Surgery, Wong and Mendelson published an interesting article in which the authors described in detail their methods of subtotally releasing the tear trough ligament and the orbicularis retaining ligament and redistributing the free orbital fat for the correction of the tear trough (lacrimal groove, nasojugal crease) and palpebromalar groove (lid-cheek junction) through the transconjunctival approach.1 Because the authors and we have similar treatment subjects (mainly Asians), and the periorbital rejuvenation is a subject on which we have worked intensively, we would like to share our thoughts about this technique. Wong and Mendelson have been consistently committed to studies of the anatomy of the periorbital region and midcheek and the antiaging treatments of the middle face.1–4 Their research achievements and surgical techniques of course contribute to better understanding the structures of these regions and choosing the optimum surgical procedure. The tear trough deformity is considered to be directly associated with the tear trough ligament, and the formation of the palpebromalar groove is mainly attributable to the orbicularis retaining ligament.2 It is also well known that the degree of infraorbital groove depends on the status of the tissue above (i.e., eye protrusion, prominence of the orbital fat pads, and looseness of the orbicularis oculi muscle and skin) and below (i.e., atrophy and descent of the malar fat pad and retrusion of maxillary) this furrow. Once the groove is seen, does it have to deal with the region? Everyone has the structure of the tear trough ligament (although it may be fragile and thus invisible), and almost all of the patients with eye bags have different degrees of prominence of the nasojugal crease. With these factors in mind, it is important for us to classify the tear trough deformity according to the morphologic features of the lacrimal groove and the situations of the surrounding tissue (because of the limit of article length, this section is not described here in detail). In other words, a judgment of which factor (i.e., the tear trough ligament, the surrounding tissues, or a combination of them) plays the major role in increasing the prominence of the tear trough must be correctly made preoperatively. In the article by Wong and Mendelson,1 the extended transconjunctival lower eyelid blepharoplasty with ligament release was performed on the patient (shown in Fig. 11) who had a mild eye bag and a slight tear trough even when smiling on the frontal view. According to our experience, we usually attribute the formation of this type of crease to the protruded orbital fat compartment. We do believe that transconjunctival blepharoplasty only with orbital fat removal can achieve a similar effect. The tear trough deformity that is visible in the static condition should be treated by ligament release, as shown in Figures 6 through 10. However, the surgical approach should be appropriately selected based on the laxity of the orbicularis oculi muscle and skin. Thus, we think that a transcutaneous approach may be preferential for the patient shown in Figure 10. Skin removal and tightening/suspending the orbicularis oculi can be performed simultaneously for better cosmetic outcome. It has been widely accepted that lifting is an essential step after releasing the tear trough ligament and orbicularis retaining ligament for treatment of the aging middle face, and that tissue suspension or repositioning seems unnecessary following the release of the two ligaments when aiming at correcting the periorbital groove. Although releasing the ligament does not lead to tissue ptosis in young patients or in short-term follow-up (as most of the cases presented in previously published articles), it is uncertain whether such a release procedure without suspension or repositioning will contribute to tissue ptosis over a long observation period such as 10 or 20 years. After all, a ligament, although it may create a depression or a crease/groove, may play a role in balancing the related tissue and preventing ptosis of tissue. DISCLOSURE The authors declare no potential conflicts of interest with the respect to the research, authorship, or publication. Qianwen Wang, M.D., Ph.D.Jiaqi Wang, M.D.Head & Neck Cosmetic Surgery CenterPlastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing, People’s Republic of China

Take, Give, and Peel

Surgeons performing lower eyelid blepharoplasties continue to seek an efficient method and predictable outcome to restore the aesthetic ideal of the lower eyelid and cheek junction. Current popular methods frequently fall short. Three patients were chosen as examples from the senior author’s past 30 years of practice where they desired improvement in the aesthetic appearance of their lower eyelids. They were treated with a combination of transconjunctival blepharoplasty, fat grafting, and 88% phenol peel. The preoperative and postoperative photos of the patients were analyzed by the patient and senior author. Having undergone the methods described for treatment, all selected patients reported significant improvement with their postoperative appearance. Minimal complications were reported and are mentioned below. No surgical revisions were requested, and the results were stable over an acceptable period of time with an average follow-up time of 2 years. Two of the 3 patients chosen had a follow-up time of at least 8 years. Transconjunctival lower eyelid blepharoplasty when combined with fat grafting and phenol peeling offers a treatment modality to restore the aesthetic ideal of the lower eyelid and cheek junction and, in our hands, is superior to other methods previously described.

Quantified Incision Placement for Postseptal Approach Transconjunctival Blepharoplasty.

This study quantifies the incision location in transconjunctival lower eyelid blepharoplasty to optimize postspetal (direct) access to the eyelid/orbital fat. A retrospective chart review of patients undergoing transconjunctival blepharoplasty by one surgeon (GGM) from January 2013 to January 2014 was performed. Simultaneous globe retropulsion and lower eyelid inferior displacement was used to balloon the conjunctiva forward to maximally visualize the transconjunctival surface anatomical landmarks of importance. A caliper was used to measure the distance in millimeters from the inferior tarsus to the most superior projection of visible fat. The conjunctival incision was made 0.5 mm posterior to this measured distance. For each procedure it was noted whether the preseptal or postseptal plane was entered. Sixty-six patients were assessed. Fifty patients were women, and the mean patient age was 54 years (range 36-71 years). The mean distance from the inferior tarsus to the visualized superior tip of fat was 6.03 mm (range 5-7 mm) and the mean incision placement was 6.53 mm (range 5.5-7.5 mm). The postseptal space (direct access to fat) was entered in 54 cases (82%). The inferior vascular arcade was identified in 23 cases (35%) cases. In this instance, the incision was placed below this landmark in 16 cases (70%). There were 5 cases (7.6%) of postoperative chemosis which all resolved within 2 months with conservative measures. There were no other complications related to the conjunctival incision. Placing the conjunctival incision for postseptal approach transconjunctival blepharoplasty 0.5 mm posterior to the most superior projection of clinically visible fat (with adjunctive globe retropulsion and lower eyelid infraplacement) accesses the postspetal space directly in 82% of cases. Previously suggested incision placements: between 2 and 5 mm below the tarsus, at the fornix, or at the inferior vascular arcade are subjective/anecdotal at best and without similar quantitative validation.

Stop Blaming the Septum.

To identify if isolated surgical violation of the orbital septum predisposes to "middle lamellar" scarring and subsequent postblepharoplasty lower eyelid retraction. A retrospective review of patients who underwent transconjunctival blepharoplasty in either a postseptal (orbital septum undisturbed) or preseptal (septal incision required) plane was performed. Patients undergoing skin excision, orbicularis muscle plication, and canthal suspension were excluded. The presence of clinically apparent postoperative lower eyelid retraction and limitation of forced superior eyelid excursion (forced traction testing) were assessed. Two hundred eighty-eight patients (576 eyelids) were evaluated. One hundred fifty-eight patients (316 eyelids, 55%) had transconjunctival blepharoplasty performed in a postseptal plane and 130 patients (260 eyelids, 45%) in a preseptal plane. Two hundred two patients (404 eyelids, 70%) had forced traction testing performed postoperatively. After surgery, there were no patient complaints of change in lower eyelid position, subjective physician assessment of clinically apparent lower eyelid retraction, and only 1 case (0.5%) of a positive forced traction test in a patient with conjunctival scarring after significant postoperative infection. Lower eyelid scars leading to eyelid retraction after blepharoplasty are not likely related to "isolated" orbital septal scars (middle lamellar scars). Their designation as a "multilamellar scar" is more appropriate.

A minimally invasive approach to lower lid blepharoplasty

SURGICAL CHALLENGE Over the last decade, there has been a steady increase in the demand for lower eyelid rejuvenation. Still, the danger of side effects when performing lower blepharoplasty has kept many patients and physicians away from the surgery, often choosing fillers to correct the teartrough deformity, sometimes even to the aesthetic detriment of the patient. The side effects prompting this concern range from rare cases of blindness caused by retrobulbar hematoma, ectropion from excessive lower eyelid skin excision, chronic conjunctivitis from the transconjunctival blepharoplasty scar rubbing against the eyelid conjunctiva, and to chronic lower eyelid edema sometimes lasting for more than 3 months.