Key Points

• Transconjunctival lower blepharoplasty does not violate normal anatomic tissue planes (orbital septum and orbicualris muscle) as does its transcutaneous counterpart.

•The incidence of lower lid malposition and lateral canthal rounding is significantly less in transconjuncival vs transcutaneous surgery.

•Understanding lower lid anatomy and appropriate incision placement (4–5 mm below tarsus) is critical to attaining successful results.

•Fat can be excised or preserved (repositioned) depending on patient needs.

•Fat repositioning is an advanced technique, performed in a small surgical space.

•A variety of surgical nuances (traction suture, retracting the lower lid, retro-placing the globe) are used to improve exposure during surgery.

•The addition of various adjunctive procedures (canthoplasty, canthopexy, fat grafting, skin excision, etc.), when necessary, may enhance final results.

•An external skin excision or pinch allows fat and skin to be addressed simultaneously.

•When the surgical technique is mastered, patient satisfaction is high, and postoperative complications are infrequent and mostly self-limiting.

16.1Introduction

Lower eyelid rejuvenation is a challenging aesthetic procedure. One of the key elements in lower blepharoplasty is the approach by which the orbital fat pads are identified. There

G.G. Massry (*)

Director, Ophthalmic Plastic Surgery, Spaulding Drive Cosmetic Surgery and Dermatology, Beverly Hills, CA, USA

e-mail: gmassry@aol.com

are two standard ways to access the lower eyelid fat: transcutaneously (through the skin and muscle – see Chap. 15) and transconjunctivally (through the internal portion of the eyelid). Transcutaneous lower blepharoplasty is the more traditional approach to surgery [1, 2]. The skin, muscle, and fat are addressed through a single incision, thereby providing excellent anatomic exposure. However, the transcutaneous approach is fraught with a higher incidence of complications including lower eyelid retraction, ectropion and a rounded canthal angle [3–5]. This is primarily related to lack of eyelid support, overexcision of skin, and violation of the orbital septum (with subsequent scarring) and orbicularis muscle (with subsequent weakness) in accessing the fat pads.

Transconjunctival lower blephroplasty was first described by Bourguet in 1924 [6], but was not brought into mainstream modern cosmetic surgery until Baylis et al. re-introduced the technique in 1989 [7]. With this approach, orbital fat is addressed through an incision on the internal (conjunctival) surface of the eyelid, thereby preserving the integrity of the orbital septum and orbicularis muscle. These are essential steps in preventing lower eyelid malposition [8, 9] as there is less distortion of anatomy and postoperative cicatrization. For this reason, transconjunctival lower blepharoplasty has gained wide acceptance in cosmetic surgery across all subspecialties.

The transconjunctival procedure does not directly address excess skin or muscle or lid laxity when present. It requires additional procedures to do so. However, a simple skin excision, muscle placation, and lid tightening (see Chap. 17) can be added when necessary. We have found that the addition of these adjunctive procedures to transconjunctival surgery does not lead to the same incidence of the lid malposition complications seen with transcutaneous surgery. In the last decade, the advent of volume preservation/augmentation via fat redistribution or grafting has been an important addition to lower lid blepharoplasty and can be added to the surgery to enhance cosmetic results (see Chap. 22 for periorbital fat grafting technique).

In this chapter, transconjunctival lower blepharoplasty will be described in detail. Special attention will be given to the added technique of volume preservation via fat

repositioning. This is our preferred approach to lower lid surgery. An external skin excision and lid/muscle tightening is added when necessary. We have termed this sequence of fat reduction/preservation through a conjunctival incision, and an external skin-only excision the “bilamellar blepharoplasty.” With this technique skin and fat are addressed, while the orbital septum and orbicularis muscle are left undisturbed. We feel this is a safer alternative to transcutaneous surgery when addressing skin and fat in the lower lid.

16.2Lower Eyelid Anatomy

Transconjunctival lower blepharoplasty is performed from the inside of the eyelid. This can make anatomic orientation and surgical maneuvering difficult, as the surgical field is small and tight when compared to the open transcutaneous approach. For this reason, familiarization with lower lid anatomy (Chap. 2) is essential when performing this surgery.

The lower eyelid is divided into three layers or lamellae (Fig. 16.1). The outer or anterior lamella is comprised of the skin and orbicularis muscle. The middle lamella consists of the orbital septum. The posterior, or inner, lamella includes the tarsus and conjunctiva for the first 5 mm of the lid. Below the level of the tarsus, the posterior lamella continues as the lower eyelid retractors and conjunctiva. The tarsus forms the skeleton of the eyelid, giving it both support and flexibility. It is 4–5 mm in height, 30 mm in length, and 1 mm in thickness. It is bound by conjunctiva on its inner surface which abuts the globe, and by orbicularis muscle and skin on its outer surface.

Below the tarsus, the conjunctiva continues as the posterior extent of the lower eyelid to the inferior fornix. The lower eyelid retractors, also called the capsulopalpebral fascia, are

just anterior to the conjunctiva and intimately associated with it. This sympathetically driven muscle (similar to Muller’s muscle of the upper lid) originates from the tendon of the inferior rectus muscle and continues to fuse with the inferior border of the tarsus. Just anterior to the retractors are the fat pads. Anterior to the fat pads and limiting their forward extent is the orbital septum. This is a connective tissue layer originating from the periosteum at the orbital rim (arcus marginalis) and inserting on or fusing with the capsulopalpebral fascia 2–3 mm below the inferior tarsal boarder. A conjunctival incision just below the tarsus will divide the fused conjunctiva and lower lid retractors from the tarsus (Fig. 16.2). This plane is best suited for surgery desired in the postorbicularis fascial plane (avascular plane between the orbicularis muscle and orbital septum) such as addressing the orbital floor in fracture repair or for orbital volume augmentation. As dissection in this plane proceeds anterior to the septum, fat does not prolapse into the field. A transconjunctival incision below the fusion point of the orbital septum and lower eyelid retractors (4–5 mm below tarsus) is the entry point of choice for transconjunctival blepharoplasty as this is a direct route to the fat pads (Fig. 16.3).

There are three fat pads in the lower lid: nasal, central, and lateral. The nasal and central fat pads are divided by the inferior oblique muscle (Fig. 16.4). This muscle originates from the medial orbital floor and courses superolaterally to insert on the posterior globe. Careful attention must be given to avoid injury to this muscle. The central fat pad is separated from the lateral fat pad by the inferior arcuate ligament (Fig. 16.5).

The separation of the central and temporal fat pads by the arcuate ligament can often be seen clinically by asking a patient to look up. The same is typically not true of the nasal and central fat pads as they tend to override the inferior oblique muscle and blunt this separation (seen when performing surgery) (Fig. 16.6).

Fig. 16.6 (a) Patient photograph in upgaze demonstrating continuous nasal/central fat prominence, with an indentation (arrows) where the arcuate ligemant can be seen clinically to divide the central and temporal fat pad. (b) Surgical photograph demonstrating central fat pad overriding oblique muscle. This is why a clinical demarcation between the nasal and central fat pads (as opposed to the central and temporal fat pads) is typically not apparent

16.3Eyelid Analysis/Preoperative Evaluation

As mentioned previously, to appropriately perform lower blepharoplasty, the surgeon may need to address excess or damaged skin, redundant and/or lax muscle, eyelid laxity, and displaced fat. In addition, volume deficits, involutional changes, and anatomic variations may also be present. The difficulty with surgery lies in correcting these deficiencies when support of the eyelid (including the effect of gravity) is typically against the surgeon. This is clearly not an easy task, and is the reason that surgeons have found lower blepharoplasty to be so challenging. As a result, it is important to understand the various factors which support and act against maintaining eyelid position (see below) [9]. This will provide a framework for planning appropriate surgery including the addition of adjunctive procedures necessary to attain the best possible outcomes.

The factors which support the lower lid (maintain height and position) include the following:

•Tendons: The medial and lateral canthal tendons act as a sling, maintaining lower lid height and keeping the lower lid abutted against the undersurface of the globe.

•Ligaments: There are retaining ligaments which fixate the eyelid and cheek soft tissue to the boney facial skeleton.

•Muscle: The orbicularis muscle which tonically elevates the lid with its sphincter action.

•Volume: Both soft tissue (fat) and hard tissue (bone) promote stabilization of facial structures including the lower eyelid.

The factors which reduce lower lid support (allow the lid

to fall) include the following:

•The lower lid retractors, which like the orbicularis muscle, are in a tonic state of activity.

•Normal involutional changes. With age, canthal tendon and ligamentous laxity, loss of soft tissue and boney volume, and reduced muscular support all promote eyelid laxity and retraction

•Gravity: As lid support decreases with age, and gravity is constant, the equilibrium shifts to retraction.

The preoperative assessment should focus on the factors

above. If only slight fat prominence is present (as with younger patients) a stand-alone transconjunctival blepharoplasty is appropriate. If, in addition, there is excess skin with good lid tone, a skin-only excision (or pinch) is added (bilamellar approach). If eyelid tendon laxity is present or muscle tone is reduced, a lid tightening procedure and/or muscle plication should be performed (Chap. 17). If significant volume deficit exists, fat preservation (see surgical section below), fat grafting (Chap. 22), or synthetic filler (Chap. 25) may be considered. If the midface retaining ligaments are deficient, re-suspension via midface lifting is added (Chap. 20).

If the surgery is to be performed under local anesthesia only (no sedation), a cotton pledget (from cotton-tip applicator) soaked in Tetracaine is placed in the inferior fornix for 10 min prior to anesthetic injection. This maneuver usually renders the conjunctival injection of anesthetic solution painless.

After giving time for hemostasis and anesthesia to take place, the lower lid is displaced inferiorly with the index finger of your nondominant hand while the second finger of the same hand lightly retroplaces the globe. This maneuver elevates and exposes (balloons forward) the incisional site on the transconjunctival surface of the lid (Fig. 16.8). The free dominant hand is utilized to make an incision 5 mm below the tarsus to directly enter the fat compartment of the lower lid (Fig. 16.9). An electrocautery unit (Valleylab, Boulder, CO) with the Colorado tip microdissector (Kalamazoo, MI) or surgical scissors can be used to make this incision. As described in the section on eyelid anatomy, the orbital septum attaches to the capsulopalpebral fascia 2–3 mm below the tarsus. An incision above this area should be avoided as it enters the preseptal space. A dissection in this plane would require violating the orbital septum to identify

16.4Surgical Technique

(With or Without Fat Preservation in the Subperiosteal Plane)

The eyelid is infiltrated transconjunctivally with 2 mL of 1% xylocaine with 1:100:000 epinephrine. If fat repositioning is planned, the tear trough (area to which fat will be repositioned) is marked preoperatively (Fig. 16.7). The tear trough is infiltrated with 1–2 mL of the same local anesthetic. We typically only reposition nasal and central fat. If there is a prominent lid/cheek junction depression lateral to this (orbitomalar groove), we prefer fat grafting (see Chap. 22) to this area.

Fig. 16.7 The tear trough (nasojugal groove) is demarcated with a solid line. This area will undergo fat repositioning. The orbitomalar groove and lateral brows (demarcated with dotted lines) will undergo fat grafting

and manipulate the fat pads. An incision below this attachment point will enter the postseptal or retroseptal space, provide direct access to the fat pads, and maintain the integrity of the orbital septum. This is a critical point as all attempts should be made to leave the orbital septum intact and avoid middle lamellar cicatrix.

The conjunctiva and retractors are then engaged with a 4–0 Silk suture which is secured to the head drape under tension (Fig. 16.10). This traction suture protects the globe, exposes the surgical field, and brings the fat pads forward (again via retroplacement of the globe). An insulated Desmarres retractor is used to retract the remainder of the lower eyelid (tarsus/orbicularis muscle and skin) inferiorly, further exposing the surgical field. It is important that the lip of the Desmarres retractor hits bone (orbital rim). If soft tissue (skin/muscle) gets trapped between the lip of the retractor and bone, it is possible to inadvertently lacerate this tissue and violate the skin.

By depressing the undersurface of the retractors, the fat pads balloon forward. In cases of fat excision only, all three fat pads are excised in a piecemeal fashion until they are flush with or just above the orbital rim (Fig. 16.11). In cases of fat preservation, the nasal fat pad is elevated with a small toothed forceps (0.5 mm Castroviejo). On occasion, it is necessary to amputate the tip of the fat pad to free it from overlying connective tissue elements Once the fat pad is identified, it is bluntly dissected free of surrounding attachments to the inferior oblique muscle, orbital rim, and the caruncle, to expose it in its entirety (Fig. 16.12). This may require some sharp dissection. We prefer the Colorado tip microdissection needle (Kalamazoo, MI) for dissection as it results in minimal bleeding, and obviates the need for clamping fat before cutting it which can be cumbersome and time consuming. Once the nasal fat pad is free, the Desmarres retractor is moved centrally to identify the central fat pad. Again blunt and sharp dissection is used to free the fat pad from the

oblique muscle and orbital rim. When this is accomplished, it is critical to assure that there are no further attachments of fat to the muscle so that restriction of muscle movement is averted after the fat is repositioned. The nasal and central fat pad should be engaged with forceps and pulled in successive fashion to slide the fat freely under the muscle (Fig. 16.13). I call this the “inverse shoe shine sign” as it resembles shining a shoe in an inverted fashion. The lateral fat pad is conservatively

excised or cauterized flush with the orbital rim as with standard fat excision blepharoplasty.

When the fat pedicles are free of all connective tissue attachments, they will move freely in all directions and are ready to be repositioned. The purpose of repositioning the fat is to fill (implant effect) the depression at the suborbital rim space (tear trough). If there is a long and thick pedicle, a portion may need to be trimmed and debulked to prevent overfilling

and postoperative prominence. Conversely, if the pedicle is long and thin, the fat pad may be folded onto itself in order to increase the volume effect.

A Ragnell rake is used to inferiorly displace the eyelid from the orbital rim. This step is difficult with a Desmarres retractor as it is too wide and does not allow adequate visibility of the orbital rim. A blunt cotton-tip applicator and/or a Freer Elevator can be used to displace all suborbicularis oculi fat (SOOF) and muscle tissue elements off the orbital rim periosteum for approximately 3 mm below the arcus marginalis. I then incise the periosteum, just below the arcus, to bone (Fig. 16.14). The extent of the periosteal incision should match the area of the tear trough to be filled. It is imperative to maintain a blood-free field when creating the subperiosteal pockets. During this step, the edges of the attached periosteum limit elevation of tissue and visibility of the dissected pocket. With this reduced view, bleeding can severely limit progress.

A Freer Elevator is used to create the subperiosteal pockets. The dissection begins with the medial pocket whose lateral extent is the infraorbital neurovascular bundle. The nasal extent of the dissection is limited, as bleeding is typically encountered in this area. A second subperiosteal pocket (central) is then created lateral to the neurovascular bundle. Typically the central dissection dives down corresponding to a depression in the bone in that area. It is important to maintain this inferior plane of dissection, or more bleeding will occur. At this point, epinephrine soaked cotton pledgets (1:10,000 epinephrine) may be placed in the subperiosteal pockets for hemostasis. The traction suture is then released, and the transconjunctival incision on the opposite side is initiated. By the time the opposite side subperiosteal pockets are exposed, excellent hemostasis has been achieved on the initial side.

After the epinephrine-soaked pledgets are removed, the pockets are irrigated and a 4–0 prolene suture on a PS-2 (long) needle is passed through the inferior aspect of the tear trough transcutaneously and retrieved within the internal

surgical space. The suture is passed to and fro through the fat pad (Fig. 16.15) and finally passed out from the internal wound to the outer skin. The prolene suture is tied over a cotton bolster. The knot should be taut but not too tight. The tighter it is, the more the fat may strangulate and lead to lymphedema and fat atrophy postoperatively. Also, for the fat to create its fullness over the bone, it should be allowed to recess slightly and fill the space in three dimensions. Too tight a suture will prevent this. The same step is repeated for the central fat pad. With the fat securely repositioned, the surgical view should demonstrate the implant effect of the fat, as it overrides the bone and possibly the inferior oblique muscle (Fig. 16.16).

The traction suture is released and the conjunctiva allowed to reoppose. Forced duction testing is performed. If forced ductions are not free, the wound is re-explored until all restriction is released. We now rarely perform forced ductions as we have found that appropriate lysis of connective tissue elements prevents restriction. At the conclusion of the case, the lid is in the appropriate position with the trough filled and the bolsters evident (Fig. 16.17).

Any adjunctive procedures (canthoplasty, fat grafting, etc. – refer to appropriate chapters) are now added if necessary. If excess skin exists, a pinch or simple excision is performed, and the wound is closed with a running 6–0 plain or fastabsorbing gut suture.

To reduce postoperative bruising and swelling, a pressure tape can be applied for the first week after surgery. I prefer 3M Microfoam tape (St. Paul, MN) applied over Mastisol (Ferndale Laboratories, Ferndale, MI) on the skin. The tape is secured from the lower lid angled towards the temple. When suture bolsters are present, a slit is cut on the tape to allow for the bolsters. This was suggested to me by Jonathan Hoenig, MD, and I have found it to significantly reduce healing time.

Figures 16.18–16.21 demonstrate examples of patient’s appearance before and after surgery.