Overview of Lower Lid Transconjunctival Blepharoplasty

Lower eyelid blepharoplasty is a type of cosmetic surgery that helps to fix signs of aging around the eyes, such as too much skin on the eyelid, a loose eyelid, or misplaced fat around the eye. Basically, there are two main methods for this surgery—a transcutaneous approach and a transconjunctival approach.

This piece mostly focuses on the details of the transconjunctival method of lower lid blepharoplasty. This is a great option for patients who have fat pushing out from under the eyeball, appearing like it’s herniating, and have good, firm, stretchy skin.

Surgeons who specialize in cosmetics today need to understand when to use this surgery, what to keep in mind before carrying out the operation, how to do the surgical method, and any possible complications that might be linked with the transconjunctival lower lid blepharoplasty. This will help them to get the best results and make their patients happy.

Anatomy and Physiology of Lower Lid Transconjunctival Blepharoplasty

The lower eyelid has a few distinct features. It should appear to rest at the bottom of the eye, with its lowest point a little to the side of the pupil. There should be a crease about 1 or 2 millimeters below the lash line at the inner corner, and about 5 millimeters at the outer corner.

The lower eyelid is made up of several layers. The outer layer consists of your skin and the muscle around your eye. The middle layer includes a sheath for the eye muscles and a fibrous plate (tarsal plate) for firmness. The innermost layer includes structures that help in the movement of the eyelid and the inner lining of the eyelid.

There are fat pads under the eye that help keep its shape. These pads are broken up into three sections- on the nose side, in the middle, and on the temple side. Each section has different characteristics, and they are best seen when the patient looks upwards. There are muscles and tissues that separate these fat pads. There’s also an excess of fat below the outer edge of the eye socket rim that provides extra support.

The muscle around your eye, the orbicularis oculi muscle, has two parts. One part is near the fibrous plate of the lower eyelid and the other part spans from the lower edge of this plate to the edge of the eye socket. This muscle attaches just below the rim of your eye socket, contributing to a facial feature known as the tear trough.

As we age, certain changes happen to the lower eyelid and to the middle part of the face. For example, there can be excess skin, pseudoherniated orbital fat which occurs due to weakening of the orbital septum and attenuation of the orbicularis oculi muscle, and a double-convex pattern of the eyelid-cheek transition that appears due to fat herniation and sagging of the cheek tissue. Moreover, there can be a relative backward displacement of the eye socket rim compared to the lower eyelid, known as a negative vector, and loose eyelid that is observed using certain tests. Malar bags, lax skin and orbicularis muscle that appear as bag-like structures, may also develop below the eye socket rim.

Why do People Need Lower Lid Transconjunctival Blepharoplasty

The best patients for a type of eyelid surgery known as transconjunctival lower lid blepharoplasty are those with excess fatty deposits in their eyelids (a condition known as steatoblepharon) and very little to moderate loose or saggy skin on their lower eyelids. This surgery can also help people with a prominent hollow area under their eyes, often referred to as tear trough deformity.

Currently, when performing eyelid surgery, doctors prefer to keep as much natural fat as possible. This can be achieved through repositioning or augmenting the fat during the procedure. However, in cases where a patient has steatoblepharon but no tear trough deformity, it might be better to take out some of the fat.

A transconjunctival approach, which involves making an incision inside the lower eyelid, may particularly benefit other groups of patients. These include people who tend to develop excessive scarring, those who have already undergone eyelid surgery, or those who have a condition called pseudoproptosis. This condition can make it appear as though the eyeball is protruding from the socket and could possibly result in more of the white part of the eye, or sclera, becoming visible after the surgery.

When a Person Should Avoid Lower Lid Transconjunctival Blepharoplasty

There are certain situations where doctors advise against using a transconjunctival approach, a kind of eye procedure:

– Active blepharitis: An eye condition where the edges of the eyelids become red and swollen.

– Dry eye syndrome or orbitopathy (eye disease) that hasn’t been diagnosed: In these cases, the person should see an eye doctor for further examination.

– If the person has had certain types of eye surgery (like laser epithelial keratomileusis or photorefractive keratectomy), they should wait at least six months before considering this procedure.

– Smokers may have imbalances in their tear film (a thin layer of tears on the surface of the eyes), causing diseases that affect the surface of the eye. They should address these issues before considering surgery.

– If the person is taking blood thinners, they should stop taking them two weeks before surgery to prevent excessive bleeding during the procedure.

– Certain substances, such as niacin, echinacea, and kava, can increase the risk of developing diseases that affect the surface of the eyes, so their use should be discussed with the doctor.

Equipment used for Lower Lid Transconjunctival Blepharoplasty

Before the Surgery

The patient will be marked for surgery with a surgical marker. An anesthetic, such as 1% lidocaine with epinephrine 1 to 100000, will be administered to numb the area that will be operated on. The skin will be cleaned with an antiseptic, like a diluted solution of povidone-iodine, which is safe for use around the eyes. To add more protection, a corneal shield may be put in place along with some eye lubrication. If the patient is given a local anesthesia, eye drops of 0.5% topical tetracaine hydrochloride will be given before the protective corneal shields are put on.

During the Surgery

Small retractors, like Desmarres, will be used to enhance visibility of the surgical area. A cautery device with a fine-tip will be used to control bleeding. Fine tissue forceps (Bishop) and small scissors (Westcott) will be used for delicate tissue handling and cutting. Cotton-swap applicators and elevators (tools to lift or move tissues), like Freer or Cottle, will also be used. Sutures (stitches), which could be 5-0 nylon or prolene, 5-0 vicryl, and 6-0 fast absorbable gut sutures, will be used to close the wound. Lastly, a bolster, a piece of supportive material, might be used for extra wound support.

After the Surgery

The patient’s eyes will be treated with an antibiotic ointment to prevent infection. Ice packs can be used to alleviate swelling and discomfort.

Who is needed to perform Lower Lid Transconjunctival Blepharoplasty?

There are a few key people involved in your surgery such as the anesthesiologist, scrub technician, operative nurse, and surgical assistant. Each of these individuals has a very important role to play. The anesthesiologist is a specific type of doctor who is responsible for giving you medicine to make sure you don’t feel any pain during the operation.

The scrub technician helps in preparing for the surgery by arranging all the necessary tools and equipment, and they ensure they are properly cleaned and sterilized. They work directly in the operating room and assist the surgeon during the procedure.

The operative nurse helps to oversee the entire procedure and ensures everything goes smoothly. They’re responsible for taking care of you throughout the surgery and ensuring your comfort and safety.

Lastly, the surgical assistant is an extra pair of hands for the surgeon. They help to hold structures out of the way, manage any bleeding that may occur during the operation, and help with stitching you up after the surgery.

All of these people work together to make sure your surgery goes as smoothly and safely as possible.

Preparing for Lower Lid Transconjunctival Blepharoplasty

For proper documentation of your condition, your doctor will take a series of five photographs of your head while you’re sitting upright, not making any facial expressions. They will also take close-up pictures of your eyes in different positions: closed, open, looking upward and sideways.

Your doctor will then mark certain areas on your face, like the infraorbital fat pads (the area of your cheek just below your eye), the tear trough (the hollow area that runs from the inner corner of your eye diagonally towards your nostril), and the area where the infraorbital nerve is (a nerve that gives sensation to the cheek, lower eyelid, upper lip and gums). If they plan to also remove a small amount of skin, they will mark a small 2 to 3 mm area along the edge of your lower eyelid where the skin will be pinched and removed.

Although the surgery to remove excess skin and fat from the eyelids (known as “transconjunctival blepharoplasty”) can be carried out using just local anesthesia (where only a specific area of the body is numbed), it’s generally recommended to use general anesthesia (where you’re put into a deep sleep and feel no pain) or intravenous (IV) anesthesia (medication given through a vein to help you relax or sleep) to keep you comfortable during the procedure.

Before the procedure begins, you’ll be given a single dose of antibiotics through an IV line to help prevent any infections. The site to be operated on is then numbed by injecting local anesthesia along the lower edge of your eye socket and the marked areas on your face.

The use of eye shields during the surgery is up to the surgeon’s preference. These shields protect your eyes and ensure that no foreign substances enter while the procedure is being performed.

How is Lower Lid Transconjunctival Blepharoplasty performed

In this article, we outline the key steps involved in a specialized type of eyelid surgery, called a transconjunctival lower lid blepharoplasty with fat transposition. This procedure is primarily meant to reduce the appearance of undereye bags.

Initially, the surgeon makes a small cut in the lower part of the clear, thin tissue lining of the eye called conjunctiva. The way the surgery is performed from this point can vary. Some surgeons may choose to make the cut closer to the piece of tissue inside the eyelid, known as the tarsus. They then work upon the area in front of a connective tissue layer, known as the septum. Alternatively, the surgeon may decide to position the cut a bit further away, and work behind the septum. Both approaches are considered safe and have similar potential risks.

To protect one’s eye and guarantee a good workspace, the surgeon then holds the cut tissues in place using a suture and a tiny instrument that draws back the tissues.

Next, the surgeon prepares a pocket for fat repositioning. They make a little cut through a bone-connecting tissue just below the eye socket. A special surgical tool is used to lift the tissue over the upper jawbone. The surgeon takes extra caution not to damage the eye nerve located close to the area. The extent of how far this pocket needs to be made can depend upon the extent of fat repositioning involved. The surgeon may also release a ligament that helps hold the eye in place.

The fat under the eye is then addressed. If the surgeon took the approach closer to the tarsus, they make another small cut at the septum’s lower edge to expose the fat pads. The protruding fat is then cautiously cut away and preserved to prevent damage and ensure good blood supply.

Following this, the surgeon shifts this fat into the prepared pocket. They use stitches across the “tear trough” (the hollow area extending from the corner of your eye diagonally toward your nose). These stitches are then anchored in place.

The surgeon may either let the initial cut in the eye lining heal naturally or they might loosely close it with dissolvable sutures.

Depending on the person’s needs, the surgeon might add onto the procedure to achieve the best results. They might remove excess skin from the lower eyelid and tighten the eyelid’s sagging area. They could also use varying methods to smooth out the transition from the eyelid to cheek, apply treatment to improve thin skin around the lower eyelid or use injections and fillers to better enhance volume around the mid-face.

Possible Complications of Lower Lid Transconjunctival Blepharoplasty

One major benefit of the transconjunctival surgery approach (a surgical technique to correct conditions like “droopy” eyelids) compared to the transcutaneous method (another kind of surgery) is that it can result in fewer problems afterwards. These problems might include incorrect eyelid positioning and visible scarring. However, a surgeon performing this procedure needs to really understand the potential issues that could arise related to it.

Some problems can pop up right after the surgery.

– There could be tiny scratches on the front surface of the eye, known as corneal abrasions. These could be avoided by using eye shields and being careful not to pass surgical tools directly over the eyes.
– There’s also a slim chance of bleeding around the eyes, called orbital hemorrhage. It’s a rare but potentially serious issue, which could impact one’s vision if not treated right away. Doctors would need to rapidly identify and treat it, often using specific medications or even an additional minor procedure.
– Infections could happen but can usually be treated quickly with antibiotics applied directly to the eye or taken orally.

Then, some issues may come up a bit later.

– Following the operation, the eyelids might not sit in the correct position. This could occur if there’s damage to certain layers of the eyelid. Initial treatments could include eyelid massages and taping but may eventually require another surgery to correct the position.
– Lagophthalmos could occur as a result of a nerve injury, which can lead to reduced muscle tone and hence, potential exposure of the cornea. The first line of treatment involves keeping the eyes well-lubricated, but further steps may need to be taken if the issue persists.
– Ectropion, or the turning outwards of the eyelid, can happen if the front layers of the eyelids get shortened. To prevent it, doctors typically use a minor procedure to support the lower eyelid position where interference pressure builds up.

Eyelid muscle injury can lead to strabismus, a condition where the eyes are not aligned correctly. It can typically be managed without surgery, and exposure of the cornea can be avoided with regular eye lubrication.

Lastly, some issues emerge further down the line.

– Changes in eyelid height and shape can occur due to changes in the layers of the eyelid.
– Thick, raised scarring might be present if skin is pinched during the surgery.
– Changes in skin color on the eyelid could also occur.

What Else Should I Know About Lower Lid Transconjunctival Blepharoplasty?

A transconjunctival lower lid blepharoplasty is a surgery that gives the area around your eyes, also known as the periorbita, a younger and more refreshed look by removing or shifting excess fat often referred to as pseudoherniated fat. To get the best results from this procedure, it is important for doctors to thoroughly evaluate the patient and create a detailed treatment plan based on the individual’s anatomy. This method ensures that the procedure is safe, reliable, and produces satisfactory results.

Frequently asked questions

1. What are the potential risks and complications associated with a transconjunctival lower lid blepharoplasty? 2. How will the surgery be performed and what techniques will be used? 3. What are the expected outcomes and recovery time for this procedure? 4. Are there any alternative treatments or procedures that I should consider? 5. Can you provide before and after photos of previous patients who have undergone transconjunctival lower lid blepharoplasty?

Lower Lid Transconjunctival Blepharoplasty is a surgical procedure that can address various changes that occur in the lower eyelid and middle part of the face as a person ages. It can help remove excess skin, fat, and improve the appearance of bag-like structures. The procedure can also correct issues such as a negative vector and loose eyelid.

You may need Lower Lid Transconjunctival Blepharoplasty if you have certain eye conditions or have had specific eye surgeries. It is advised against if you have active blepharitis, undiagnosed dry eye syndrome or orbitopathy, or if you have had certain types of eye surgery within the past six months. Smokers may also need to address imbalances in their tear film before considering this procedure. Additionally, if you are taking blood thinners, you may need to stop taking them two weeks before surgery to prevent excessive bleeding. Certain substances like niacin, echinacea, and kava can also increase the risk of developing eye surface diseases, so their use should be discussed with your doctor.

You should not get a Lower Lid Transconjunctival Blepharoplasty if you have active blepharitis, undiagnosed dry eye syndrome or orbitopathy, have had certain types of eye surgery within the past six months, are a smoker with imbalances in your tear film, are taking blood thinners, or are using substances that can increase the risk of eye diseases.

The recovery time for Lower Lid Transconjunctival Blepharoplasty can vary, but generally, patients can expect to experience swelling and bruising around the eyes for about 1-2 weeks after the surgery. During this time, it is recommended to use ice packs to alleviate swelling and discomfort. Patients may also be prescribed antibiotic ointment to prevent infection and should avoid strenuous activities for a few weeks.

To prepare for Lower Lid Transconjunctival Blepharoplasty, the patient should follow certain guidelines. These include stopping the use of blood thinners two weeks before the surgery, addressing any tear film imbalances caused by smoking, and discussing the use of certain substances with the doctor. Additionally, the patient should inform the doctor about any eye conditions, previous eye surgeries, or dry eye syndrome.

The complications of Lower Lid Transconjunctival Blepharoplasty include corneal abrasions, orbital hemorrhage, infections, incorrect eyelid positioning, lagophthalmos, ectropion, strabismus, changes in eyelid height and shape, thick raised scarring, and changes in skin color on the eyelid.

Symptoms that require Lower Lid Transconjunctival Blepharoplasty include excess fatty deposits in the eyelids (steatoblepharon), little to moderate loose or saggy skin on the lower eyelids, and a prominent hollow area under the eyes (tear trough deformity). Additionally, patients who tend to develop excessive scarring, have previously undergone eyelid surgery, or have pseudoproptosis (a condition where the eyeball appears to protrude from the socket) may also benefit from this procedure.

There is no specific information provided in the given text about the safety of Lower Lid Transconjunctival Blepharoplasty during pregnancy. It is always recommended to consult with a healthcare professional, such as a surgeon or obstetrician, before undergoing any surgical procedure during pregnancy. They can provide personalized advice based on the individual's specific circumstances and medical history.

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