Transconjunctival blepharoplasty is the management of lower eyelid structures via the conjunctival approach and is applied, usually, to the cosmetic improvement of the lower eyelid using this approach. The transconjunctival approach is often also used for reconstructive surgery. The very essence of this surgical procedure implies that there is no skin incision made when addressing the deeper structures of orbital fat, ligaments, and orbital septum. However, there are times when some degree of skin and tendon manipulation will be necessary during the transconjunctival blepharoplasty. We will discuss the reasons for specific manipulations in the transconjunctival blepharoplasty.
Types of transconjunctival blepharoplasty:
In all of the above procedures, chemical peels, erbium, or CO2 laser, or any other skin ablation modality may be used to improve skin laxity, irregularities, wrinkles, and lesions.
In this article, we will concentrate on the indications, assessment, marking and performing the pure transconjunctival blepharoplasty.
A detailed discussion of lower eyelid anatomy is available elsewhere, but here we concentrate on the important structures that apply when performing the transconjunctival blepharoplasty.
Normal Lower Eyelid Position:
The lower eyelid position is at or just above the inferior limbus. The eyelid sits snug against the globe. This position is a result of normal anatomical and physiological factors: the medial and lateral canthal tendon integrity, normal orbicularis tone and attachments, normal pliable skin and a normal tarsal plate. If there is disruption of any of these structures, lower eyelid retraction, canthal dystopia or ectropion may occur.Furthermore, even if these structures are normal, any excessive distracting, downward force can cause lower eyelid malposition. With scarring or shortage of the lower eyelid skin, an ectropion or retraction may occur. Middle lamellar scarring (can involve the orbital septum and retractors) can result in lower eyelid retraction. Scarring or loss of part of the tarsus can result in an ectropion or entropion. Injury to the facial nerve or orbicularis muscle can result in lower lid ectropion and retraction, and disruption of the medial or lateral canthal tendons can similarly cause a lower eyelid malposition.
The lower eyelid is supported medially by the medial canthal tendon and laterally by the lateral canthal tendon. At the tarsal plate level, the eyelid has a bi-lamellar structure with an anterior lamella of skin and orbicularis muscle with a suborbicularis fascial plane with minimal fat. The posterior lamella comprises of the tarsus (which measures 1 mm in thickness and 5 to 6 mm in height) and conjunctiva. Below the level of the tarsal plate, the eyelid may be considered as having a tri-lamella structure with anterior lamella consisting of skin and orbicularis muscle, the middle lamella comprising of the orbital septum and to a degree, the lower eyelid retractors (called the capsulopalpebral fascia) with fat interposed between the septum and the retractors. The posterior lamella may be considered as consisting to a degree, of the lower eyelid retractors and the conjunctiva. The lower eyelid retractors are analogous to the upper eyelid retractors (levator palpebrae superioris and it aponeurosis): the lower lid retractors arise from the inferior rectus muscle, envelope the inferior oblique muscle and proceed to insert into the inferior border of the tarsal plate and orbital septum. The equivalent of Muller's muscle is a less defined muscle present just behind the capsulopalpebral fascia, often called the inferior tarsal smooth muscle. Similar to the Whitnall's ligament in the upper eyelid, there is Lockwood's ligament which is attached laterally to the Whitnall's tubercle and inferolateral orbital rim and medially to the inferomedial orbital rim. Analogous to the upper eyelid post-levator aponeurosis fat pad, the lower eyelid has two additional thin layers of fat, the inter-lower eyelid retractor fat pad lying between the two layers of the lower eyelid retractors and post-lower eyelid retractor fat pad lying between this and the conjunctiva. Whitnall’s tubercle is 3 to 4 mm inside the orbital rim and just above the horizontal axis. Into this tubercle insert several structures: lateral canthal tendon, orbital septum, Lockwood’s ligament, Whitnall’s ligament, deep head of orbicularis muscle and the check ligaments of the lateral rectus muscle.
The orbital septum attaches at the orbital rim, except inferolaterally where it inserts anteriorly forming a recess (of Eisler). The lateral orbital fat, therefore, drapes over the inferolateral orbital rim into this recess and this portion of the fat may be missed in the resection. The orbital septum attaches to the inferior border of the tarsal plate. The septum is thinnest over the medial fat pad. It has a thickening which goes inferolaterally called the arcuate expansion, which separates the central and lateral fat pockets. The thought is that the purpose of this dense arcuate expansion is to retain the fat within the orbit.
The inferior oblique muscle separates the medial and central fat pads. However, there is usually an isthmus of fat over the inferior oblique belonging to one or both of these fat pads so during surgery, if one wants to see the inferior oblique muscle, one has to tease this fat off the inferior oblique muscle. The central and lateral fat pads are separated by the arcuate expansion, a thickening in the orbital septum.
Transconjunctival blepharoplasty is undertaken to improve the appearance of lower eyelids. Specifically, it aims at reducing or effacing the bulges created by the medial, central and lateral fat pads. The procedure, in its purest form, is indicated in the younger patients who have isolated prominence of these fat pads without significant lower eyelid laxity, without skin or orbicularis redundancy, and without festoons. The patient should not have significant nasojugal or malar grooves or cheek ptosis.
There is no functional improvement obtained with a transconjunctival blepharoplasty in the majority of patients. An exception is an occasional patient who has such prominent steatoblepharon that it obstructs their inferior visual fields, or whose spectacles cannot sit in the correct position because of the prominent eyelid fat pads. In such cases, functional lower blepharoplasty is indicated.
Contraindications to a pure transconjunctival blepharoplasty exist if any of these are present:
Relative contraindications include:
Within a "Plastics" surgical instrument set, the following instruments are specifically necessary for the reasons stated:
Transconjunctival blepharoplasty is generally performed under sedation in a surgical theatre. Although the procedure may be performed with straight local anesthesia in the surgical office, many practitioners choose to have proper suction, lighting, cautery, and sedation anesthesia to allow the surgeon to concentrate on the procedure. A good assistant is also vital to allow adequate exposure of the surgical field.
Every patient should have a vision examination before surgery. Basic assessment of the tear film, for evidence of lid margin and meibomian disease, is imperative.
When assessing any cosmetic patient, it is important to ask exactly what improvement the patient wishes to see. This can be done with the patient looking into a mirror, and, where necessary, with the help of a clinical photograph on a big screen. Younger photographs are reviewed, as are previous surgical procedures. As chemosis is one of the commonest complications of transconjunctival blepharoplasty, the patient should have an examination for evidence of conjunctival solar damage and conjunctivochalasis.
Sequential assessment performance:
Skin: the eyelid and surrounding skin are examined for effects of sun exposure, rhytids, laxity, and festoons. The skin turgor and tone undergo assessment, as are any vessels, pigmented lesions, or evidence of chronic edema. A history of use of continuous positive airway pressure (CPAP) machines is taken on every patient as this predisposes patients to malar edema. Preoperative evidence of malar edema (with or without festoons) is a predictor of almost certain postoperative fluid and swelling in this region. Skin redundancy is assessed by the patient looking up and pinching the skin; then the patient opens their mouth at the same time, and the pinch test is repeated. These are all subjective tests which have to take into consideration any midfacial ptosis, solar elastosis, globe position, and prior surgery.
Lower eyelid position:
The lower eyelid position should be at or just above the inferior corneal limbus. This position varies racially as well as depending upon the position of the globe (relative enophthalmos or exophthalmos). The position of the lower eyelid margin in relation to the limbus should be measured and documented as an inferior scleral show in millimeters if the lower eyelid is retracted. Causes of lower eyelid retraction include prior lower eyelid surgery or trauma, thyroid disease, solar elastosis, relative proptosis and certain cicatrizing diseases like chemical burns, pemphigoid and Stevens-Johnson syndrome.
Tests for lower eyelid laxity:
The lateral canthal tendon insertion is 2 mm above that of the medial canthal tendon. In the presence of lateral canthal laxity, this lateral canthal attachment of the canthal tendon stretches (or disinserts in extreme cases) and the lateral canthal position is then at the same position or lower than the medial canthal tendon. The normal distance between the lateral eyelid commissure and the lateral orbital wall is 2 to 3 mm in an adult. Any increase is an indication of stretching or detachment of the lateral canthal tendon; the lateral upper and lower eyelid angle becomes more curved ("C" shaped instead of "V" shaped). Normal lateral canthal position is about 15 degrees above the medial canthal position.
The prominence of the medial, central and lateral fat pads is noted. The associated nasojugal and malar grooves undergo assessment.
The surface of the cornea is normally at the same position as the most prominent position of the cheek. If the cheek is recessed, it is a negative malar angle. This angle may predispose the patient to postoperative lower eyelid retraction after any of the lower blepharoplasty procedures. The cheek position and it's relation to the cornea should be assessed in every patient. The cheek prominence also varies with age and the degree to which the cheek may need to be lifted to provide support to the lower lid. In the presence of a negative malar angle, there may be a limitation to the degree to which a purely transconjunctival blepharoplasty is performable.
The ophthalmologist or the oculoplastic surgeon may fail to assess the degree to which jowls are present when a patient presents for a lower blepharoplasty. In the presence of prominent jowls, there can be a secondary effect on the skin of the lower and midface, with resultant downward pull of the lower eyelid. In such patients, care must be taken not to worsen the support normally provided by lower eyelid fat pads as subsequent lower lid retraction will occur.
It is important to recall that patients presenting with "baggy lower eyelids" will always have worse swelling the first hour or so after waking up when they are tired and after salty meals. Through the rest of the time, the degree of "puffiness" or "bagginess" will vary. Therefore, there is no one distinct degree of procedure that may be necessary.
Patients should be marked sitting up. The outlines of the three fat pads are marked, and a topographical marking is made over the individual pads, together with notes if one pad or side needs more or less attention. Careful attention is paid to the nasojugal groove and the malar groove. In most patients undergoing straight transconjunctival blepharoplasty, these grooves will not be prominent. The presence of prominent nasojugal and malar grooves indicate for different surgical procedures. Sometimes, subtle grooves may be present: these should be marked in case they need filling with the patient's own fat or fillers, during or after a transconjunctival lower blepharoplasty.
A transconjunctival blepharoplasty may be performed under straight local anesthesia injections or with the use of sedation or even general anesthesia. The local anesthetic injection should be in the region of the lateral canthus, the lower eyelid, and transconjunctivally into the three fat pockets. About 2 cc of 2% lidocaine with 1:100,000 epinephrine per side is appropriate.
Retraction and Incision:
A plastic corneal shield should be placed over the cornea to protect the cornea, maintain ocular surface moisture and also prevent bright lights from distressing the patient. The lower eyelid is retracted using the smallest available Desmarres retractor: this allows the surgeon access to the inferior fornix. Under traction, an incision is made in the conjunctiva about 6 mm below the inferior tarsal border. However, other levels of making incisions have also been presented. A little pressure on the upper eyelid and globe is helpful, which makes the fat come forward into the inferior fornix, showing the bulge where the incision is made. Although it is increasingly popular for surgeons to use the CO2 laser or the unipolar cautery to cut the conjunctiva, other surgeons prefer to make the incision with a blade and Westcott scissors to avoid collateral heat injury to the conjunctiva.
We have shown that the lower conjunctiva and retractors may be placed on traction using a 4-0 silk suture on a hemostat when performing this surgery: it helps to expose the fat pads better and also protects the cornea.
Removal of fat:
Again, pressure on the upper eyelid and globe will make each fat pad more prominent. The medial, central and lateral fat pads are opened via the transconjunctival approach, and judicious removal of the fat is carried out with careful attention to obtaining hemostasis. Although some surgeons clamp the fat in a hemostat and excise the fat, others prefer to remove fat using an "open sky" technique and cauterize vessels as needed. There are prominent vessels in the orbital fat but especially so in the medial fat pad. These require careful cauterization. No forward traction is placed on the fat as this runs the risk of over-excision of the orbital fat.
The central fat pad is deeper (more inferior) than a surgeon may think. It is often necessary to palpate the inferior orbital rim and incise the tissues just above to obtain access to the central fat pad.
The lateral fat pad is the one that is most frequently inadequately removed by inexperienced surgeons. Furthermore, the lateral fat pad needs to be exposed with proper lateral lower eyelid traction and may have a firmer fascia over it than the medial fat pad. Again the relevant fat pad reductions are performed based upon the preoperative assessment. Where necessary, pedicles of fat or free fat grafts may be used during surgery if the nasojugal and malar grooves require attention.
When assessing the degree of fat reduction, it helps to have iced gauze which may be used to press on the eyelids to reduce edema related to surgery and local anesthetic injections. By balloting the globe, one can get a dynamic impression of the prominence or otherwise of the lower lid fat. Of course, it need not be stressed that the appearance of lower eyelid fat pads tends to be more apparent when the patient is sitting up and also when tired or first thing in the morning. With the patient lying down, the fat "falls back," and therefore surgical judgment is needed when performing this surgery. Conservative removal of fat and repositioning, sometimes with septal release to treat associated grooves is a useful technique.
The traction suture is removed, and the area of surgery is examined once more looking for any bleeders. One or two buried 6-0 catgut sutures may be used to close the conjunctiva although it is also acceptable to leave the wound open to allow egress of any fluids. The wound closes very nicely with or without sutures. It is important not to apply ointment into the inferior fornix as granulomas may occur if the lanolin in the ointment gains access to the deeper tissues.
Some surgeons prefer not to patch the eyes after transconjunctival blepharoplasty. Ice packs are placed over a moist gauze or face cloth. Topical antibiotic ointment may be applied to the outer and inner corners of the eyes.
It is common to observe the patient for a minimum of 30 minutes after surgery and examine the surgical site for any hematoma or bleeding as well as assess the patient's vision before considering discharge to home.
The patient is discharged with instructions to ice the eyelids on-and-off for the following 24 to 48 hours. Topical antibiotic eye ointment is prescribed and applied twice a day. If laser or a TCA peel have been used on the skin, appropriate moisturizing is instituted. The patient is asked to sleep with two to three pillows for the first two to three nights. The patient may bathe/wash the very next day but is informed that there will be some blurry vision, especially when using the ointment. Artificial tears may be used as needed. Strict instructions are given to the patient to call the emergency number of the surgeon if there is any undue pain, bleeding or change in vision.
Complications of the transconjunctival blepharoplasty include:
Transconjunctival blepharoplasty is a useful procedure with proper patient selection. With an absence of any visible incisions, the results are very gratifying. Although there is a tendency for surgeons to want to simplify lower blepharoplasty, a proper anatomical and physiological approach to assessing and planning of lower eyelid blepharoplasty is vital.
With a purely cosmetic procedure such as a transconjunctival blepharoplasty, it is vital that the surgeon ensures that a complete and detailed examination has been performed to avoid complications. This procedure, in particular, is dependent upon the surgeon's skills as an accomplished examiner and diagnostician. The ophthalmology nurse familiar with the procedure should assist in follow up evaluation and monitoring the patient for complications. [Level V]
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