Transcutaneous Lower Eyelid 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, there is a bit of skin redundancy, and a transcutaneous approach will be performed.  Due to the increased risk of lower lid malposition with a transcutaneous approach, a lateral canthal stabilization procedure is almost always performed.

This is Richard Allen at oculosurg.com.  This video demonstrates a transcutaneous lower lid blepharoplasty with fat repositioning.  A 4-0 silk suture is placed through the lower eyelid at the level of the tarsus to provide traction during the case.  The needle tip cautery is the used to make a subciliary incision through only the skin extending from the level of the punctum medially to the lateral canthus laterally.  Dissection is then carried out between the skin and the orbicularis muscle to the level of the inferior border of the tarsus to preserve the pretarsal orbicularis muscle.  Dissection is then directed through the preseptal orbicularis muscle and a plane is developed between the orbicularis muscle and the orbital septum.  Dissection proceeds to the inferior orbital rim.  The periosteum is then incised with the needle tip cautery along the length of the inferior orbital rim. 

The freer periosteal elevator is used to elevate the periosteum from the inferior orbital rim inferiorly for approximately 2 cm.  The orbital septum is the opened laterally to expose the lateral fat pad.  The lateral fat pad is mobilized.  I almost always debulk the lateral fat pad.  A hemostat is used to clamp the fat pad and the fat pad is debulked with Westcott scissors.  The clamp is then cauterized with the needle tip cautery to prevent bleeding.  Additional cautery is performed to sculpt the fat pad.  The orbital septum is then opened medially to expose the medial and central fat pad.  The medial and central fat pad are separated and the inferior oblique muscle is exposed.  The medial fat pad is then mobilized.  A portion of the central fat pad is clamped and debulked.  A portion of the medial fat pad is clamped and debulked.  The medial fat pad is then engaged with a double-armed 6-0 polypropylene suture.  The suture is then placed through the inferior extent of the subperiosteal pocket.  The suture is then placed transcutaneously to exit inferior to the marked nasojugal fold (tear trough).  The other end of the suture is placed in the exact same manner.  Repositioning of the fat pad will result in effacement of the nasojugal fold.  Attention is then directed to the central fat pad.  It is engaged with a double-armed 6-0 polypropylene suture.  Each end of the suture is placed through the inferior extent of the subperiosteal pocket and then transcutaneously.  The repositioning and placement of the fat pads are then confirmed.  The sutures are then tied.  These sutures will be removed at the one week followup.  The repositioning of the fat pads is again inspected. 

In transcutaneous lower blepharoplasties, stabilization of the lower lid is mandatory.  In this case, a canthopexy is performed with a double-armed 5-0 polypropylene suture.  Each arm is placed through the lateral lower eyelid tarsus and exits the blepharoplasty incision.  The periosteum of the superior lateral orbital rim is engaged with the needle prior to exiting the blepharoplasty incision.  Tightening the suture demonstrates the effect of the technique.  The suture is then tied.  Attention is then directed to the excision of the skin.  This should be very conservative.  I usually excised at most 5 mm in height of skin, which is less medially and more laterally.  The skin is draped over the eyelid and the excess skin is marked.  This is then excised with Westcott scissors.  This will be closed with interrupted 5-0 fast absorbing sutures.

Attention is then directed to the contralateral side where the procedure is performed in the exact same manner.  A subciliary incision is made and dissection is carried out between the skin and the pretarsal orbicularis muscle.  Dissection is then performed through the presepctal orbicularis muscle and a plane is developed between the orbicularis muscle and the orbital septum to the inferior orbital rim.  The periosteum is incised and then elevated from the inferior orbital rim.  The lateral fat pad is mobilized and conservatively debulked.  The central and medial fat pads are mobilized, exposing the inferior oblique muscle.  A portion of the central and medial fat pads are debulked.  The fat pads are then repositioned into the subperiosteal pocket with a double-armed 6-0 polypropylene suture.  The repositioning of the fat pads is confirmed and the sutures are then tied.  The positioning of the fat pads is reinspected.  The lateral canthopexy is performed to ensure stabilization of the lower eyelid.  The excess skin is conservatively marked and excised.  The subciliary incision is then closed with interrupted 5-0 fat absorbing sutures.  At the conclusion of the case, antibiotic ointment is placed over the incisions and into the eyes.  The patient will follow up in approximately one week.