Transconjunctival Lower Lid Blepharoplasty Research Articles

Correction of Tear Trough Deformity with Minced Orbital Fat Grafts During Transconjunctival Lower Blepharoplasty.

The correction of tear trough deformity poses a significant challenge in the context of facial rejuvenation. Our aim was to introduce a technique that corrects tear trough deformity during transconjunctival lower blepharoplasty using minced orbital fat grafts. The medical records of patients who underwent lower blepharoplasty from January 2019 to December 2021 were reviewed. The study included patients with various grades of tear trough deformity, who underwent lower blepharoplasty using minced orbital fat grafts and followed up for at least 6 months. Modified Barton's grading for tear trough depression, patient satisfaction, and postoperative complications were evaluated. A total of ninety-eight patients, with a mean age of 48.07 ± 9.72 years, consisting of 93 (94.9%) females were included in the study. The average duration of follow-up was 7.2 months, ranging from 6 to 13 months. Tear trough depression significantly improved after the operation (preoperative tear trough depression grade mean (SD): 3.11 (0.60); postoperative tear trough depression grade mean (SD): 0.87 (0.66); P < 0.001). 78.5% of the participants reported their outcome as excellent or good, 20.4% reported as fair, and 1.0% (only one patient) reported as no improvement. None of the participants rated their outcome as worsening. No major complication was observed during the follow-up period. Minced orbital fat grafting during transconjunctival lower eyelid blepharoplasty has good effectiveness for correcting tear trough deformity without the risk of major complications. 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 .

Internal Fixation of Redistributed Orbital Fat in Transconjunctival Lower Eyelid Blepharoplasty.

Fat redistribution combined with release of the tear trough ligament in transconjunctival lower blepharoplasty is widely performed to correct lower eyelid bags and tear trough deformities, but suturing the released fat in such a narrow, dissected space remains a challenge. The purpose of this study was to introduce a new surgical technique of internal fixation that advances and sutures the pedicled orbital fat firmly to the midcheek through premaxillary and prezygomatic spaces. Twenty-two patients (age range, 22 to 39 years) with predominant orbital fat prolapse and tear trough deformity without noticeable lower eyelid skin laxity were treated with this method, all of whom had impressive correction of the eyelid bags and tear trough deformities and were pleased with the aesthetic results during an average follow-up of 11.8 months (range, 10 to 14 months). No patient had postoperative hematoma, ectropion, or midface numbness. The maneuver of internal fixation of redistributed orbital fat provides a novel and safe approach to correct eyelid bags and tear trough deformities without additional percutaneous sutures in transconjunctival lower eyelid blepharoplasty. Therapeutic, IV.

Transconjunctival Lower Eyelid Blepharoplasty with Volume Augmentation for Correction of the Lower Eyelid and Cheek Junction.

Aesthetic surgical management of the inferior periorbital region should include an approach to volume augmentation of the midface and infraorbital hollow, reduction of fat pseudoherniation in the lower eyelids, and treatment of the overlying skin. A combined approach using volume augmentation with fat grafting, a transconjunctival approach to the lower eyelid fat pads, and conservative management of the lower eyelid skin can produce optimal aesthetic results while minimizing complications. Fat harvest from the thigh and abdominal region allows for ample grafting material to the lateral cheek, midface, and orbital rim. The treatment paradigm is to restore volume optimally while minimizing fat resection in the lower eyelids. Volume augmentation is used to restore youthful contours, as well as to counter deflation and laxity in the periorbital and midfacial regions.

A new modified internal fixation method of transconjunctival lower blepharoplasty

AbstractIn transconjunctival lower eyelid blepharoplasty with pedicled fat transposition, internal fixation of the septal fat is always the most difficult step. We describe a new modified method that makes this procedure less time‐consuming and specific instruments unnecessary.

The Selection of Facelift Approach on the Basis of Midfacial Ptosis.

Facial aging in the midface has been described to encompass both soft tissue descent and volumetric change. Currently, there is no established and widely accepted grading system for midfacial ptosis. We propose a simplified grading system for midfacial ptosis ranging from mild to severe in terms of Grades I through III. Using this classification system, we describe an algorithm to help select the facelift approach most appropriate for each patient. The sub-superficial musculoaponeurotic system rhytidectomy, deep plane rhytidectomy, and subperiosteal midface lift techniques are described in detail. The nuances of the selection process also include a discussion on the various approaches to the orbital fat, namely a transconjunctival lower lid blepharoplasty with skin pinch versus a lower lid blepharoplasty with fat transposition, as well as the aging neck. Furthermore, we integrate the addition of postoperative adjunctive procedures which include injectables, chemical peels, and dermabrasion to address facial rejuvenation from not only a gravitational aspect but also the volumetric and textural components.

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.

Simple Approach for Internal Fixation of Repositioned Fat Pedicles in Transconjunctival Lower Eyelid Blepharoplasty.

To introduce an easy and effective approach for internal fixation of repositioned fat pedicles in transconjunctival lower eyelid blepharoplasty. Thirty-six consecutive patients underwent fat repositioning transconjunctival lower blepharoplasty from August 2016 to January 2018. After release of the orbicularis oculi muscle and exposure of the intraorbital fat pedicles, a supraperiosteal pocket was dissected. A 6-0 nylon suture was passed through the shaft of a hypodermic needle from the sharp tip, then the hypodermic needle was pierced through the cheek skin about 5 to 8 mm below the orbital rim into the dissected pocket, the hypodermic needle was next pull out and pierced through the same pinhole but different pathways into the dissection pocket again. The hypodermic needle was curved accordingly and passed through the lower surface tissue of the pocket, the needle was then taken out. Two ends of the 6-0 nylon suture were both brought out through the transconjunctival incison. One end of the 6-0 nylon suture was sewed through the free margin of the fat pedicle and tied tightly with the other end. The fat pads were transferred and blended well with midface fat. The severity of tear trough deformity were evaluated according to Barton's grading system by two independent plastic surgeons pre and post-operatively. Tear trough deformity was improved in most cases. There were significant differences in preoperative and post-operative tear trough deformity grades (P < 0.5). All patients recover very well without significant complications. Three patients had transient mild to moderate lumpiness over the tear trough area, which were all resolved spontaneously eventually. One patient complained of retained fat tissue, and a revision surgery was given. In summary, The authors offered a new, simple, and effective approach to help fix the repositioned fat pads in transconjunctival lower lid blepharoplasty.

Transient Inferior Oblique Muscle Palsy Following Transconjunctival Lower Lid Blepharoplasty

Although the inferior oblique (IO) muscle is positioned considerably deep in the orbit, transconjunctival lower lid blepharoplasty may affect it and transient or permanent IO muscle palsy might result. Therefore diplopia should be explained before cosmetic blepharoplasty performed with transconjunctival approach.

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.

Periorbital Phenol-Croton Oil Chemical Peel in Conjunction with Blepharoplasty

INTRODUCTION: Blepharoplasty can restore a youthful appearance to the periorbital region; however, surgery alone is often unable to address the issue of periorbital fine lines and hyperpigmentation. The literature is replete with publications regarding the efficacy of phenol-croton oil peel, yet, there is little specifically addressing peels of the periorbita. We present a series of patients who underwent a peel combined with blepharoplasty, or peel alone, in order to improve fine lines and/or hyperpigmentation. The authors describe their surgical methods and complications with this technique and how it fits into the plastic surgeon’s armamentarium for periorbital rejuvenation. METHODS: A retrospective chart review was done to identify patients who underwent periorbital phenol-croton oil peels performed by a single surgeon (J.E.Z) from 2003-2014. Treatment sequences included: 1) peel alone to treat hyperpigmentation, 2) peel alone to treat fine lines, 3) peel at the time of transconjunctival or pinch blepharoplasty, or 4) peel secondarily after cutaneous blepharoplasty. A standard concentration of 27.5% phenol and 0.105% croton oil was used for all peels. Patient age, Fitzpatrick type, history of prior facial surgery, blepharoplasty type, and ancillary procedures were obtained. Data was managed with RedCap database. RESULTS: We identified eighty-two patients (81 females, 1 male) who underwent a blepharoplasty and phenol-croton oil peel, or a peel alone. Average age was 58.66 ± 8.05 years. Indications for peel were periorbital hyperpigmentation (n=26) and/or fine rhytids (n=63). Fitzpatrick skin type was: I (n=30), II (n=36), and III (n=16). Twenty-five (30.4%) of these patients underwent a periorbital phenol-croton oil peel combined with a blepharoplasty. Blepharoplasty techniques included: upper lid blepharoplasty (n=20), lower lid pinch blepharoplasty (n=8), and/or transconjunctival lower lid blepharoplasty (n=6). Complications of peeling were few and included: residual hyperpigmentation (n=4), prolonged erythema (n=4), and telangectasias (n=2). Twelve patients (14.6%) underwent a second peel for residual rhytids. A typical result is demonstrated in Figure 1.Figure 1: Pre-operative photos of 54 year old female who underwent upper and lower lid blepharoplasty followed by periorbital phenol-croton oil peel.Figure 2: Post-operative photos of 54 year old female one month after phenol-croton oil peel and twelve months after bilateral upper and lower lid blepharoplasty.CONCLUSION: Judicious use of dilute concentrations of phenol-croton oil in the periorbital region can be successfully performed with minimal to no complications. It can be applied as a stand-alone procedure, or as a complement to blepharoplasty surgery. When these techniques are combined there is significant improvement in upper and lower lid laxity, hyperpigmentation, and reduction of fine rhytids. It is a cost effective treatment with long-lasting results.

Chirurgische Behandlung von Festoons

The well introduced surgical techniques of lower lid blepharoplasty can only repair aesthetic problems between the lid margin and the orbital rim. The neighbouring malar area is located outside the orbit and requires specialised procedures to reposition the sunken malar orbicularis muscle (festoon) and the malar fat pad. A small incision at the lateral canthus provides the access to combine three procedures: transconjunctival lower lid blepharoplasty, lateral canthoplasty and malar lift.

Use of Topical Antibacterial and Steroid Ophthalmic Ointment after Transconjunctival Lower-Lid Blepharoplasty for Prevention of Chemosis

Introduction: The transconjunctival approach for lower-lid blepharoplasty has gained increased attention because lower complication rates have been reported than for the transcutaneous approach. However, chemosis, or conjuncti-val edema, may still occur in patients postoperatively. Our study aims to review the rates of postoperative chemosis, and analyze how use of a topical antibiotic- and steroid-containing ophthalmic ointment affects those rates. Materials and Methods: The charts of 100 patients who underwent transconjunctival lower-lid blepharoplasties by one surgeon were retrospectively reviewed and analyzed. The rate of postoperative chemosis was compared between patients who had routine postoperative administration of topical antibiotic and steroid ophthalmic ointment and those who had not. Results: Of the patients received postoperative steroid and antibiotic ophthalmic ointment, 29% developed postoperative chemosis, compared with 30% of patients who did not receive the treatment. Concurrent upper-lid blepharoplasty increased the rate of postoperative chemosis across all patients (OR 3.0; P= .017). Conclusions: Although many surgeons routinely use ophthalmic solutions and ointments with antibiotics and/or steroids after a transconjunctival approach, very little data support this practice. Our study demonstrates that there is no significant difference in the rate of postoperative chemosis when such agents are used routinely after transconjunctival lower-lid blepharoplasty.

63 Intravascular laser blood irradiation of different spectral and frequency range in the correction of hormonal imbalance of patients with bronchial asthma

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.

The “Mini Tarsal Strip” Lateral Canthopexy for Lower Eyelid Laser-Assisted Blepharoplasty—Indications, Technique and Complications in 614 Cases

The aim of this article is to describe the “mini tarsal strip procedure”, a form of lateral canthal tendon plication to tighten the lower lid and give a better apposition of the lower eyelid to the globe. We describe this procedure in the context of transconjunctival lower lid blepharoplasty.

Arcus Marginalis Release II Via Endoscopic Midface-Lift

Tear troughs in combination with midfacial ptosis may be early and synergistic signs of aging. Premaxillary and suborbicularis oculi fat (SOOF) descent decreases soft tissue volume covering the orbital rim, while prolapsing retroseptal fat actually underscores the resulting tear trough shadow. This volume change precedes skin redundancy. Thus, volume redistribution avoiding external skin incisions is the adequate treatment. De la Plaza's transconjunctival lower lid blepharoplasty is a reliable tool for arcus marginalis release. For patients also requiring an endoscopic midface-lift, even the transconjunctival incision for intraorbital fat compartment realignment can be avoided by performing the release of the lower orbita septum via the buccal mucosa incision.

064-4 Plastie de la paupière inférieure associée à une excision cutanée : la technique du pincement revisitée

Aim The aim of this study is to evaluate the safety, effectiveness and aesthetic results of transconjunctival lower eyelid blepharoplasty associated with skin excision using the Pinch Technique. Materials and Methods 58 patients (45 female and 13 male) aged between 32 and 76 showing the following were selected: prominent eyelid fat pads, anterior lamella laxity and normal eyelid tone; all expressed a desire not to change the shape of their eyes. In all patients the position of the lower eyelid in respect to the limbus in the primary position, in up and low gaze, was evaluated. Lower transconjuctival eyelid blepharoplasty associated with skin excision was performed on all patients using the technique described by Rosenfeld. Results In all patients a satisfactory reduction of fat pads and an improvement in skin laxity were achieved; results met patients’ expectations. There were no cases of eyelid retraction either imediately postoperatively or in later follow-ups. Discussion Transconjunctival lower eyelid blepharoplasty has gained in popularity among opthalmoplastic surgeons over the past decade principally because it results in natural appearance and the absence of eyelid retraction. This technique was initially combined with chemical peeling and later with laser resurfacing techniques to achieve an improvement in the skin. These techniques, however, led to complications such as persistent erithema and hyperpigmentation. In our experience, the technique, recently described by Rosenfeld, of associating transconjunctival blepharoplasty with skin excision, makes it possible to correct eyelid fat pads and reshape skin effectively and without complications since it leaves the middle lamella untouched.

Myopic Change After Transconjunctival Blepharoplasty Using Carbon Dioxide Laser: Case Report

The case of a patient who experienced temporary myopic change after transconjunctival blepharoplasty using the carbon dioxide (CO(2)) laser is reported. Transconjunctival lower lid blepharoplasty using the CO(2) laser, one of the most frequent laser procedures performed in aesthetic surgery, is considered to be a safe and reliable approach that does not incur significant complications. This report describes temporary myopia in a 38-year-old woman as a rare complication after this procedure. As for the possible etiology of the postoperative myopia, the authors strongly suspect a temporary mild deformity of the eyeball leading to the change in refraction, including scleral edematization and/or retinal indentation attributable to thermal injury as a result of CO(2) laser irradiation adjacent to the eyeball. The purpose of this case report is to inform others of the complication the authors encountered and to discuss the possible etiology.

Transconjunctival upper blepharoplasty.

Transconjunctival lower lid blepharoplasty now has an established role as an option in rejuvenation of the lower eyelid. Transconjunctival upper lid blepharoplasty, or transconjunctival removal of medial upper eyelid fat, also has a role in rejuvenation of the upper eyelid. However, this is a rather limited role. We have found this approach safe and efficacious as a primary as well as a secondary procedure for removal of excess medial upper eyelid fat. We report on 20 patients who have undergone this operation: 5 as a primary procedure and 15 as secondary. There were no complications, no revisions, and the patients have been uniformly happy with their results.

Expanded Applications for Transconjunctival Lower Lid Blepharoplasty

Expanded Applications for Transconjunctival Lower Lid Blepharoplasty

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.)