Transconjunctival Lower Lid Bleph

In planning a lower eyelid blepharoplasty, a number of issues are considered:  fat resection or repositioning, transconjunctival or transcutaneous approach, midface advancement, and lateral canthal fixation.  In this video, a transconjunctival approach is performed with fat repositioning.  I often do some type of lateral canthal stabilization, and a trans-upper eyelid canthopexy is performed.  At the conclusion of the case, a 30% TCA peel is performed to improve the skin quality and to try to eliminate fine static wrinkles.

This is Richard Allen at oculosurg.com.  This video demonstrates a transconjunctival lower eyelid blepharoplasty with fat repositioning and a trichloroacetic acid peel.  The needle tip cautery is used to make an incision through the conjunctiva inferior to the inferior border of the tarsus extending from the level of the punctum medially to the lateral canthus laterally.  Dissection is then carried out between the orbicularis muscle and the orbital septum.  I have my assistant help by fixating the orbicularis muscle to aid in exposure.  A 4-0 silk suture is then placed through the cut end of the conjunctiva, lower lid retractors, and orbital septum to provide traction.   The inferior orbital rim is then exposed and the needle tip cautery is used to make an incision through the periosteum.  The freer periosteal elevator is then used to elevate the periosteum from the anterior surface of the inferior orbital rim.  This is performed along the length of the inferior orbital rim and dissection proceeds approximately 2 cm inferiorly.  The orbital septum is then opened laterally.  I prefer to exposed the lateral fat pad first, which I commonly resect.  The remainder of the orbital septum is then opened and the medial and central fat pads are identified.  The inferior oblique is exposed, as it is the landmark that runs between the central and medial fat pad.  Attention is then redirected to the lateral fat pad, and the lateral edge of the central fat pad and medial edge of the lateral fat pad are delineated.  The lateral fat pad is mobilized and clamped.  The fat is resected and the clamp is cauterized with the needle tip cautery.  The fat pad is then released.  The central and medial fat pad are inspected.  Additional lateral fat is resected.  The medial fat pad is mobilized and a portion of it is debulked.  

Attention is then directed to the opposite side and dissection is carried out between the medial and central fat pad.  The lateral fat pad is then debulked.   The medial and central fat pad are inspected and a portion of the central fat pad is resected.  Additional lateral fat pad is debulked.  I am usually pretty liberal with regards to resecting lateral fat.   Attention is then directed to the medial fat pad which is engaged with a double armed 6-0 Prolene suture.  The fat pad will be repositioned into the subperiosteal space and each arm of the Prolene suture is placed into the inferior extent of the subperiosteal space and then placed transcutaneously.  This will allow preservation of volume and effacement of the nasojugal fold (“tear trough”).  The central fat pad is then engaged in the same manner and repositioned similarly, placing the needles in the subperiosteal space.  The repositioning of the fat pads is inspected and confirmed to be in the correct space.   The arms of the sutures are then loosely tied.  These sutures will be removed in approximately one week. 

The repositioning is reinspected.  The transconjunctival incision is then closed with interrupted 7-0 Vicryl sutues.  I commonly performed a trans-upper eyelid lateral canthopexy in lower lid blepharoplasties.   A 4-0 Prolene on a PS-2 needle is introduced through the upper eyelid blepharoplasty incision which then exits the lateral lower eyelid tarsus.  The suture is then turned around and enters adjacent to the exit site.  The suture is directed posteriorly and then anteriorly to exit out of the upper blepharoplasty incision after engaging the superior lateral periosteum.  The suture is tied and the procedure is the completed with a 30% TCA peel.