Transconjunctival Blepharoplasty Research Articles

Lower Lid Blephroplasty and Midface Lifting via Subtarsal Incision

Over the past decade the transconjunctival blepharoplasty technique has been written about extensively as a means to rejuvenate the lower eyelids with no visible scar and minimal risk of ectropion. Most older adults, however, also suffer some degree of midface ptosis, malar festooning, lower eyelid dermatochalasis, and/or orbicularis oculi hypertrophy, none of which can be addressed through the transconjunctival approach. The Oral and Maxillofacial Surgeon will learn that a direct transcutaneous subtarsal approach allows for correction of all of these sequella of facial aging leaving a virtually non noticeable scar hidden in the subtarsal fold and little chance of post-op ectropion.

Deepening of the Superior Sulcus After Isolated Lower Transconjunctival Blepharoplasty

To retrospectively determine the incidence of deepening of the superior sulcus after isolated CO2 laser lower transconjunctival blepharoplasty. Retrospective case review and prospective measurement of the amount of fat resected in isolated laser lower blepharoplasty in 39 patients. Significant deepening of the superior sulcus occurred in 10% of CO2 laser lower transconjunctival blepharoplasties. The amount of fat resected ranged from 0.4 to 0.9 ml per eyelid, with an average of 0.55 ml. Upper eyelid changes may be an overlooked result of CO2 laser lower transconjunctival blepharoplasty.

Transconjunctival lower lid blepharoplasty with simultaneous chemical peel: predictable results with minimal complications

The most common complication associated with lower lid blepharoplasty is lid malposition/retraction. Clinical postoperative presentation may range from increased scleral show to lateral canthal rounding or ectropion. Any of these complications can exacerbate other ocular problems, such as dry eye syndrome, requiring more extensive oculoplastic correction.Transconjunctival lower lid blepharoplasty has been proven to produce a lower incidence of postoperative lid malposition versus open excision techniques. Coupled with surgical lid tightening and skin resurfacing, transconjunctival blepharoplasty is a safe and effective method for improving lower lid contour and reducing rhytids while producing minimal complications.Keys to predictable clinical success are understanding lower lid anatomy and its relation to structure/support of the lid complex, recognizing changes associated with the aging eyelid complex, assessment and planning for surgery to restore structure, and avoiding operative techniques with a high probability of complications in patients with pre-existing eyelid or ocular problemsReferencesPopp JC: Complications of blepharoplasty and their management. Dermatol Surg Oncol 992:1122, 1992Shorr N, Enzer YR: Considerations in aesthetic eyelid surgery. Dermatol Surg Oncol 992:1081,1992Zarem HA, Resnick JI: Operative techniques for transconjunctival lower lid blepharoplasty. Clin Plast Surg 19:351, 1992 The most common complication associated with lower lid blepharoplasty is lid malposition/retraction. Clinical postoperative presentation may range from increased scleral show to lateral canthal rounding or ectropion. Any of these complications can exacerbate other ocular problems, such as dry eye syndrome, requiring more extensive oculoplastic correction. Transconjunctival lower lid blepharoplasty has been proven to produce a lower incidence of postoperative lid malposition versus open excision techniques. Coupled with surgical lid tightening and skin resurfacing, transconjunctival blepharoplasty is a safe and effective method for improving lower lid contour and reducing rhytids while producing minimal complications. Keys to predictable clinical success are understanding lower lid anatomy and its relation to structure/support of the lid complex, recognizing changes associated with the aging eyelid complex, assessment and planning for surgery to restore structure, and avoiding operative techniques with a high probability of complications in patients with pre-existing eyelid or ocular problems References Popp JC: Complications of blepharoplasty and their management. Dermatol Surg Oncol 992:1122, 1992 Shorr N, Enzer YR: Considerations in aesthetic eyelid surgery. Dermatol Surg Oncol 992:1081,1992 Zarem HA, Resnick JI: Operative techniques for transconjunctival lower lid blepharoplasty. Clin Plast Surg 19:351, 1992

Noninvasive lower eyelid blepharoplasty: a new technique using nonablative radiofrequency on periorbital skin.

Laxity and rhytids of the lower eyelids are common cosmetic concerns. Historically, correction has either been surgical through either transcutaneous or transconjunctival blepharoplasty or ablative through laser resurfacing or chemical peeling. Therapeutic options usually require significant postoperative healing and have the potential risk of scarring ectropion or pigmentary loss. To report the use of a new technique that uses nonablative radiofrequency (NARF) to tighten noninvasively and nonsurgically the flaccid skin of the lower eyelids by treating the periorbital area to produce cosmetic improvement. Nine patients with skin flaccidity of the lower eyelids had a single treatment session with NARF in a small area of skin in the periorbital region, specifically the zygomatic and/or temporal areas. All patients were treated with topical anesthesia only. The treatment lasted approximately 10 minutes. No postoperative care was required. All of the nine patients in the study achieved cosmetic improvement of the eyelids ostensibly through skin contraction. All patients were able to return to their normal routines immediately. Although the results were gradual, patient satisfaction was remarkable. No complications were seen in this study. This new procedure using NARF was successful in providing a safe, noninvasive, cosmetic improvement in these patients with excessive skin laxity of the lower eyelids. Postoperative morbidity, including down time and complications, was not seen.

Atypical mycobacterial infection of the periocular region after periocular and facial surgery.

To delineate the clinicopathologic features of patients who have atypical mycobacterial infections of the periorbital region after periocular and facial surgery and to define the sequelae after treatment and their management. A case series of patients from 7 practices of ophthalmic plastic and reconstructive surgeons was analyzed retrospectively. Thirteen patients had infection in the following clinical settings: 8 patients had infections after blepharoplasty, 2 patients had infections that involved the anophthalmic socket, 1 patient had orbital cellulitis after orbital fracture repair with an alloplastic implant, and 2 patients had infections involving the lacrimal system, one after silicone tube insertion and the other after dacryocystorhinostomy with silicone tube intubation. Sequelae of infection included eyelid retraction and ectropion requiring surgical repair (two patients) and enophthalmos (one patient). Twelve of 13 patients required extensive antibiotic therapy. One infection resolved after local excision of eyelid lesions. Another patient had recurrent infection after 4 weeks of antibiotic treatment. Delayed infection with erythematous nodules, particularly when a foreign body is implanted weeks after periocular surgery, should arouse suspicion of an atypical mycobacterial infection. Delayed infection after blepharoplasty may mimic a chalazion, develop in a sutured incision, or occur without any inflammatory signs. Orbital abscess formation may occur in the setting of transconjunctival blepharoplasty. Cultures for acid-fast bacilli and excisional biopsy of nodules with performance of acid-fast stains may be necessary for diagnosis. The selection of systemic antibiotic therapy, usually clarithromycin, and the length of treatment should be guided by results of culture and sensitivity laboratory studies, biopsy results, and clinical response to treatment. Surgical removal of any implanted foreign bodies should be performed expeditiously. Consultation with an infectious disease specialist may be useful in selected cases. Sequelae of infection may include eyelid scarring and retraction and enophthalmos.

Lower Eyelid Blepharoplasty: Analysis of Indications and the Treatment of 100 Patients

Traditionally, lower lid blepharoplasty has been confined to a choice of skin or skin-muscle flap transcutaneous blepharoplasty. In the past decade, in particular, various new techniques and technologies have emerged, altering our ability to treat the lower eyelids. These techniques include transconjunctival blepharoplasty, a variety of canthopexy procedures, fat-conserving or fat-replacing methods, wedge excision, and laser resurfacing techniques, and they allow a more individualized approach based on variations in anatomical features and patient goals. A retrospective review of data for 100 consecutive patients (ranging in age from 30 to 80 years) who underwent lower eyelid procedures during a 12-month period is presented. Procedures were categorized as follows: lower lid blepharoplasty, 35 cases; lower lid transconjunctival blepharoplasty, 27 cases; lower lid transconjunctival blepharoplasty with laser resurfacing, 17 cases; lower lid laser resurfacing, 16 cases; tarsorrhaphy with lower lid operation, three cases; tarsorrhaphy with laser resurfacing, two cases. Two complications of retained fat pads (one medial and one lateral) were encountered and were addressed with a secondary operation using a transconjunctival blepharoplasty approach. The results indicate that laser treatment has become the predominant form of lower eyelid resurfacing and that transconjunctival blepharoplasty is now the most common surgical procedure for the lower eyelid. All of our tarsorrhaphy procedures were performed for patients who had previously undergone surgical treatment of the lower eyelids. An algorithm based on physical findings and these techniques has been developed, for appropriate tailoring of the procedure to each patient's specific concerns. With the availability of a variety of techniques, an individualized approach based on variations in anatomical features is feasible.

Transconjunctival upper blepharoplasty: a safe and effective addition to facial rejuvenation techniques.

Transconjunctival techniques for eyelid rejuvenation are now well accepted in the lower eyelid. Transconjunctival upper blepharoplasty is a relatively new technique for which overall experience has been limited. Since October 1998, the authors performed 42 bilateral transconjunctival upper blepharoplasties on patients undergoing facial and eyelid rejuvenation. They describe the essential anatomy and technique of the procedure. The CO2 laser is used concomitantly for treating fine rhytids and tightening loose upper eyelid skin. This procedure is an effective method of removing medial upper eyelid fat with minimal complications.

Laser blepharoplasty in Asians.

Traditional blepharoplasty removes periorbital wrinkles by cutting and stretching the skin. However, this method has a substantial risk of producing ectropion or scleral show. In addition, fine periocular wrinkles may persist because this method does not change skin texture. The pulsed CO2 laser has recently become a primary surgical tool in treating aging eyelids. Periorbital wrinkles vary in depth not only from person to person, but also among different races. Compared with whites, most Asians have a thicker dermis, so more laser passes and a higher power may be required to remove periorbital wrinkles, but concerns about hyperpigmentation and prolonged erythema have limited its use on Asian skin. In this study, 346 patients underwent laser blepharoplasty at the Korea University Medical Center and at Dr Choi's Aesthetic Clinic. They were followed for 12 months on average from September 1995 to September 1999. The CO2 laser was used in resurfacing periorbital wrinkles, transcutaneous skin excision, and transconjunctival blepharoplasty, including fat removal. The authors assessed the benefit of using the UltraPulse CO2 laser in Asian blepharoplasty. They found that 291 patients (84%) had good to excellent results. The incidence of side effects was very low. Prolonged erythema occurred in 19 patients (5%) and hyperpigmentation occurred in 35 patients (10%), but the erythema disappeared spontaneously within 2 months and the hyperpigmentation could be managed readily by the topical use of retinoids and hydroquinone cream. Therefore, the authors conclude that postoperative hyperpigmentation is no longer a problem limiting laser resurfacing in Asian blepharoplasty. The UltraPulse CO2 laser is a safe and effective rejuvenation method for treating aging eyelids in Asians.

Transconjunctival Blepharoplasty: The Preferred Approach for Rejuvenation of the Lower Eyelid

Transconjunctival Blepharoplasty: The Preferred Approach for Rejuvenation of the Lower Eyelid

Coblation: a new technology and technique for skin resurfacing and other aesthetic surgical procedures.

After years performing CO2 laser skin resurfacing, I started testing a new technology based on the modification of a bipolar electrosurgical unit in 1998. This technology called Coblation works by a radiofrequency mechanism and from the beginning it showed many advantages over lasers. My histologic and clinical preliminary results have already been published, but now, with a larger group and a 2-year follow-up, I can state that this new device is very effective and safe for skin resurfacing. The device works at low temperatures, avoiding the great thermal injury of a CO2 laser, but is able to cause some damage in the superficial dermis. The working temperature is high enough to cause shrinkage of collagen and the dermal damage promotes the deposition of new collagen during the postoperative months. During surgery, Coblation can act as an electrosurgical unit and can coagulate the small vessels, achieving a bloodless surgical field. The clinical results show good, long-term results with a short and comfortable recovery period and minimal complications. I combined this resurfacing with face lifts without any special problems. The new cutting-coagulating terminals allow this new technology to be used in other surgical procedures, like transconjunctival blepharoplasties. The Coblation transconjunctival blepharoplasty, combined with Coblation resurfacing, seems to be very effective, with fast healing, due to the low temperatures used during the procedure, and a good aesthetic result. The device is small, light, and it is safer than a laser since it doesn't need any safety measures, such as goggles. After two years and more than 80 patients, I can state that Coblation is a very good alternative to laser skin resurfacing and that it will be used for many other aesthetic surgery procedures in the future.

Transconjunctival sub-orbicularis oculi fat (SOOF) pad lift blepharoplasty: a new technique for the effacement of nasojugal deformity.

Transconjunctival sub-orbicularis oculi fat (SOOF) pad lift blepharoplasty: a new technique for the effacement of nasojugal deformity.

Management of infraorbital dark circles. A significant cosmetic concern.

Despite the frequency with which it occurs, little has been written in the scientific literature on the treatment of infraorbital dark circles. I have developed a technique that simultaneously treats the 2 contributing causes of these circles: hyperpigmentation of skin and pseudoherniation of orbital fat. The technique involves simultaneous transconjunctival blepharoplasty and deep-depth phenol chemical peel. Successful outcomes have been obtained in patients with Fitzpatrick classification skin types 1 to 5, with a low incidence of complications. Adequate preoperative counseling regarding prolonged erythema and careful postoperative monitoring with, if necessary, medical intervention are essential if both surgeon and patient are to be satisfied with the outcomes.

Primary and secondary orbit surgery: the transconjunctival approach.

The transconjunctival approach to the orbit is underutilized because of concern regarding inadequate exposure and higher postoperative rates of lower eyelid shortening and ectropion. All patients who had a transconjunctival incision performed for orbital surgery over the last 6 years (1990 to 1996) were studied. Patients who had a transconjunctival blepharoplasty were excluded. A total of 35 patients, average age 32 years, had 45 transconjunctival incisions performed. Lateral canthotomy or cantholysis was not done. Operations fell into three categories: fracture plating alone, 10 (22 percent); split-calvarial bone graft placement with or without plating, 26 (58 percent); and orbital decompression, 9 (20 percent). The overall incidence of ectropion was 6.7 percent (3 of 45). One patient (2 percent) had transient ectropion, and two patients (4 percent) had persistent ectropion, which required surgical correction. Ectropion occurred only in those lower eyelids that had a previous transcutaneous incision (3 of 18 = 17 percent). None occurred in those eyelids that had no prior incision or only a previous transconjunctival incision. The transconjunctival approach without a lateral canthotomy provides safe access to the orbit in eyelids that have not had a previous transconjunctival incision.

Laser Resurfacing of the Periorbital Region

Laser skin resurfacing of the periorbital region can be performed as an isolated procedure, as part of a full-face resurfacing, or as an adjunct to procedures such as transconjunctival blepharoplasty. The two wavelengths in common use are pulsed carbon dioxide and erbium: yttrium aluminum garnet. The principles and techniques of using these lasers for periorbital resurfacing, as well as the practice of combining these wavelengths in sequence, are described. In addition, pre- and postprocedure measures are discussed.

Diplopia following Transconjunctival Blepharoplasty

The resurgence of popularity of the transconjunctival approach to lower eyelid fat removal as a component of cosmetic blepharoplasty has been highlighted by a number of publications in recent years. There has been, however, minimal discussion in the literature of the complications of this procedure. Although the mechanism of muscle injury is similar in transcutaneous and transconjunctival surgery, there is a much more direct route to the inferior extraocular musculature via the latter approach. Herein, we present a series of six patients with diplopia status post-transconjunctival lower eyelid blepharoplasty referred to the Manhattan Eye, Ear, and Throat Hospital for evaluation. Transconjunctival lower lid blepharoplasty was performed as a primary procedure in four patients and as a secondary procedure following transcutaneous blepharoplasty in two patients. Patients were evaluated with ocular examination and orthoptic measurements. Magnetic resonance imaging was obtained in two cases. The inferior rectus and inferior oblique muscles were found to be equally injured in these cases (4 of 6), and the lateral rectus was encountered in one case. Two patients required strabismus surgery to correct their diplopia, whereas four patients improved with observation alone. The possible etiologies of postoperative diplopia following transconjunctival lower lid blepharoplasty are manifold. Mechanisms of extraocular muscle injury may include intramuscular hemorrhage and edema, cicatricial changes within the muscle, and accidental incorporation of extraocular muscle in closure of orbital septum. Avoidance of these complications is probably best achieved through intimate understanding on the part of the surgeon of eyelid anatomy from the transconjunctival perspective. (Plast. Reconstr. Surg. 102: 1219, 1998.)

Lower-eyelid rejuvenation via transconjunctival blepharoplasty and lateral retinacular suspension: A simplified suture canthopexy and algorithm for treatment of the anterior lower-eyelid lamella

A variety of options are now available for the aesthetic rejuvenation of the lower eyelid. The transconjunctival blepharoplasty has become a simpler and more effective alternative in many instances because fat removal can be accomplished without violation of the various anterior eyelid lamella structures to avoid malposition of the lower eyelid. In most situations, however, treatment of the skin and/or muscle is required for maximal improvement and maintenance or enhancement of the lower-eyelid and canthal position as desired. Various forms of canthoplasty have been described to address the need for lower-eyelid support. A new, simplified suture canthopexy, the transpalpebral lateral retinacular suspension, described in this article may avoid many of the pitfalls of traditional canthoplasty with aesthetically improved results. An algorithm for treatment of the anterior lower-eyelid lamella in conjunction with transconjunctival lower blepharoplasty and the lateral retinaculum suspension is also discussed.

Lower lid blepharoplasty-The transconjunctival approach: extended indications.

The transconjunctival blepharoplasty is an elegant and secure technique especially in young people and helps to avoid the hazard of a scar. In older patients, it saves them the possible sequelae such as rounding sclero show or possible ectropion after a classical operation. Because there is no visible scar, the transconjunctival approach respects the integrity of the functional structure of the orbital septum and the orbicular muscle, the active support of the lower eyelid.

Tips to prevent complications with transconjunctival blepharoplasty

Transconjunctival blepharoplasty is a commonly performed procedure. Corneal protection, avoidance of damage to the inferior oblique muscle of the eye, avoidance of hemorrhage from the fat pads, and adequate fat removal are important considerations when transconjunctival blepharoplasty is performed. The described surgical technique provides consistently satisfactory results and avoids the use of cumbersome corneal protectors.

Septal-myocutaneous flap technique for lower lid blepharoplasty.

Lower lid blepharoplasty can present a significant challenge to the facial plastic surgeon. Routine findings of periorbital fat herniation and dermatochalasia of the lower lid are often associated with the presence of more occult findings, e.g., tarsoligamentous laxity and ectropion. Traditional surgical approaches to the aging lower eyelid utilize the skin flap, the skin-muscle flap, and the transconjunctival technique. The limitation of any one of these procedures alone is that of not addressing the multiple problems of the aging eyelid; this may lead to common postoperative problems of lower lid blepharoplasty, including lid retraction, lagopthalmos, scleral show, rounding of the lateral canthus, and ectropion. We present an integrated surgical solution to the functional and anatomical defects of both the anterior and posterior lamellae, and, when indicated, lateral canthal support. The procedure incorporates a small lateral subciliary and lateral canthal incision with a myocutaneous advancement flap developed in a plane deep to the orbital septum, combined with transconjunctival blepharoplasty for removal of herniated orbital fat. It allows for simultaneous management of the multiple defects of the aging lower eyelid and complete restoration of the relevant anatomy, while avoiding the common pitfalls of lower lid blepharoplasty. We present our experience of 64 patients who underwent bilateral combined septal-myocutaneous advancement flap and transconjunctival blepharoplasty. Indications and postoperative results are reviewed. No complications, including scleral show or ectropion, have been noted over the 4-year postoperative period.

Transconjunctival blepharoplasty with simultaneous laser resurfacing

For patients seeking aesthetic rejuvenation of the eyes, transconjunctival blepharoplasty is an effective means of dealing with proptotic lower eyelid fat. For dermatochalasis of infraorbital skin, Ultrapulse carbon dioxide (CO2) laser resurfacing can be used simultaneously with blepharoplasty to “tighten” periorbital skin. This article describes the technique, results, and complications in a series of 101 patients. Histological and electron microscopic study of laser wounding provides an understanding of tissue biophysics unique to human eyelid skin. The entire procedure can be performed with the laser, by starting with a 0.2 mm CO2 laser handpiece to incise the conjunctiva and resect fat, then switching to a computer pattern generator (CPG) for skin resurfacing. Meticulous hemostasis, avoidance of the inferior oblique muscle, and complete fat excision are the mainstays of this procedure. The technique has been extremely safe and free from complications of ocular morbidity, bleeding, ectropion, scleral show, hypopigmentation, skin slough, or scarring. There was one case of herpes simplex. Duration of healing averaged 7 weeks when the CPG was used. In contrast, the single-spot, manual sweep handpiece significantly prolonged erythema to 11 weeks or more. The incidence of hyperpigmentation was 16%, and equal in patients undergoing transconjunctival blepharoplasty with resurfacing and those receiving periorbital laser resurfacing alone. Treatment with hydroquinone cleared all patients. Histological study showed variance in total eyelid skin thickness, from 483 to 1,371 μms with epidermis comprising 63.5 μm on average. The first pass of the laser characteristically exfoliates the epidermis in a clean plane, 60 to 80 μm, with nominal dermal effect. A second pass produces dermal coagulation of approximately 40 μms, sparing adnexal structures. With a second pass of the laser, electron microscopy confirms collagen fibril contraction in the reticular dermis, with a 30% increase in diameter and a 9% contraction in periodicity. At the same level, microvasculature is preserved. Transconjunctival lower lid blepharoplasty, performed with Ultrapulse CO2 laser incision and skin resurfacing, avoids morbidity typically associated with standard subciliary blepharoplasty, and with no increase in ocular or laser-related sequelae. For resurfacing, two passes with the CPG enhances dermal collagen contraction, and dermal viability and collagen contraction are confirmed by microscopic examination. For patients seeking aesthetic rejuvenation of the eyes, transconjunctival blepharoplasty is an effective means of dealing with proptotic lower eyelid fat. For dermatochalasis of infraorbital skin, Ultrapulse carbon dioxide (CO2) laser resurfacing can be used simultaneously with blepharoplasty to “tighten” periorbital skin. This article describes the technique, results, and complications in a series of 101 patients. Histological and electron microscopic study of laser wounding provides an understanding of tissue biophysics unique to human eyelid skin. The entire procedure can be performed with the laser, by starting with a 0.2 mm CO2 laser handpiece to incise the conjunctiva and resect fat, then switching to a computer pattern generator (CPG) for skin resurfacing. Meticulous hemostasis, avoidance of the inferior oblique muscle, and complete fat excision are the mainstays of this procedure. The technique has been extremely safe and free from complications of ocular morbidity, bleeding, ectropion, scleral show, hypopigmentation, skin slough, or scarring. There was one case of herpes simplex. Duration of healing averaged 7 weeks when the CPG was used. In contrast, the single-spot, manual sweep handpiece significantly prolonged erythema to 11 weeks or more. The incidence of hyperpigmentation was 16%, and equal in patients undergoing transconjunctival blepharoplasty with resurfacing and those receiving periorbital laser resurfacing alone. Treatment with hydroquinone cleared all patients. Histological study showed variance in total eyelid skin thickness, from 483 to 1,371 μms with epidermis comprising 63.5 μm on average. The first pass of the laser characteristically exfoliates the epidermis in a clean plane, 60 to 80 μm, with nominal dermal effect. A second pass produces dermal coagulation of approximately 40 μms, sparing adnexal structures. With a second pass of the laser, electron microscopy confirms collagen fibril contraction in the reticular dermis, with a 30% increase in diameter and a 9% contraction in periodicity. At the same level, microvasculature is preserved. Transconjunctival lower lid blepharoplasty, performed with Ultrapulse CO2 laser incision and skin resurfacing, avoids morbidity typically associated with standard subciliary blepharoplasty, and with no increase in ocular or laser-related sequelae. For resurfacing, two passes with the CPG enhances dermal collagen contraction, and dermal viability and collagen contraction are confirmed by microscopic examination.