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 of the eye).
Anesthesia: Local anesthesia with oral or intravenous sedation
Operation: The lower eyelid is retracted away from the eyeball, 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. The eyelid fat presents through the incision almost immediately. The incision may be enlarged using scissors and the three fat pockets teased out of their capsules and into the surgical field. Most commonly, the fat is clamped, excised, and cauterized in a graded 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, although 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, 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 include:
• no external scar
• less invasive to middle layers of eyelid
• no risk of lower eyelid retraction or ectropion
• more precise fat sculpting during removal
• less bruising and swelling
• less chance of major orbital bleeding
• more rapid recovery
• safer for second operations
Limitations: In patients with minimal or no excessive skin, any skin previously bulged out over the fat simply returns to a more normal position with little or no evidence of redundancy or wrinkling. In patients with more significant skin excess or skin damage, a strip of skin just below the lashes may be undermined and excised or the skin can tightened slightly using chemical peel or laser resurfacing over the lower eyelid and upper cheek.
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 “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.
