Primary goal: Removal of bulging fat
Secondary goals: Fat transfer to hollowed areas
Special anatomy: The "conjunctiva" is the thin clear membrane of tissue that lines the back of the eyelid and then reflects onto the front surface of the eyeball to cover the sclera (the "white").
Anesthesia: Local anesthesia with oral or intravenous sedation
Operative technique: The lower eyelid is gently pulled away from the eyeball using a blunt retractor, while the eyeball is protected with a plastic plate. An electrocautery is used to sweep across the conjunctiva (back layer of the eyelid) along most of its length near its junction with the eyeball. The eyelid fat presents itself through the incision almost immediately. The incision may be enlarged using scissors, and the three fat pockets individually teased out of their capsules and into the surgical field. Most commonly, the fat is then clamped, excised, and cauterized in a piecemeal fashion from each pocket. The surgeon may stop at any time, return the eyelid to its normal position, and asses the operation in progress from the front, thus allowing for excellent precision. At the conclusion of the procedure, the surgeon may choose to close the wound with one or two dissolving sutures, but more commonly no stitches are necessary.
Variations: The surgery may be accomplished with the laser or any other cutting tool. An optional "skin pinch" excision may be added, if indicated (see below), and the orbicularis muscle may be tightened as well through the same skin incision. Less commonly, fat may be redistributed around the orbit or reflected over the orbital rim rather than being removed.
Advantages: The advantages of this operation over transcutaneous (through the skin) lower eyelid blepharoplasty are substantial and include:
• no external scar
• less invasive to middle layers of eyelid, leaving them functionally intact
• no risk of lower eyelid retraction (lower eyelid pulled down)
• no chance of lower eyelid ectropion (lower eyelid pulled away from eye)
• more precise fat sculpting during removal
• less bruising and swelling
• less chance of major orbital bleeding and vision loss
• more rapid recovery
• safer for reoperations in patients who have had previous lid surgery
• no chance of aggravating lid retraction as the midface sags with age
Limitations: The big question to ask about this operation is obvious: if only the fat is addressed, what happens to the skin? In patients with minimal or no excessive skin (the majority), the skin and muscle layers previously extended out over the bulges simply returns to a more normal position with little or no evidence of redundancy or wrinkling. In patients with more significant skin excess, a strip of skin just below the lashes can be undermined and excised ("skin pinch") or the skin can tightened slightly using chemical peel or laser resurfacing over the lower eyelid and upper cheek.
Care and recovery: In general, bruising and swelling are minimal, and recovery is rapid.
Risks and complications: There is a higher risk of temporary conjunctival swelling ("chemosis"), which can make the thin membrane of tissue over the white of the eye look slightly "blistery" for several weeks.
Comments: The introduction of transconjunctival lower eyelid blepharoplasty fifteen years ago represented a giant leap forward in the field of cosmetic eyelid surgery. The procedure is technically more difficult for the "occasional blepharoplasty surgeon" and therefore not embraced by all cosmetic surgeons, some of whom still prefer to use the skin approach as their routine operation on all patients.
