Overview of Transconjunctival Blepharoplasty
Transconjunctival blepharoplasty is a type of surgery used to modify the lower eyelid’s structures. It’s a procedure that’s often used to improve the appearance of the lower eyelid area. The surgery is done through the inner lining of the eyelid (the conjunctiva), so no skin cuts are involved. The surgery mainly focuses on going deep to modify the fat, ligaments, and orbital septum– the thin, tough membrane enclosing the eye socket. However, there may be times when some changes to the skin and tendons may also be necessary during the surgery.
There are different types of transconjunctival blepharoplasty, each with a specific purpose and depending on the patient’s needs:
- Pure transconjunctival blepharoplasty
- Transconjunctival blepharoplasty with tightening of eye corner using canthopexy or canthoplasty (surgical procedures to correct an abnormal eye position)
- Transconjunctival blepharoplasty combined with tightening of the eye corner and small portions of skin removal
- Transconjunctival blepharoplasty with changes to the ligament near the eyeball and transfer or adding of fat, eye corner tightening, with or without skin removal
- Transconjunctival blepharoplasty with skin-muscle flap (a technique rarely used now, but there are specific cases where it’s the best approach)
- Transconjunctival blepharoplasty along with reposition or lifting of midfacial tissue through an incision near the temple (also known as a “hammock lift”)
For any of the procedures mentioned, some people may undergo extra treatments to address skin looseness, unevenness, wrinkles, and other skin concerns. These can include chemical peels, laser therapies, or other methods to remove the outer layers of the skin.
This article will focus on explaining when the pure transconjunctival blepharoplasty is used, how it’s assessed, marked, and carried out.
Anatomy and Physiology of Transconjunctival Blepharoplasty
The lower eyelid is a fascinating piece of anatomy that plays a key role when it comes to a medical procedure called transconjunctival blepharoplasty. This is a surgery mainly done to remove or reposition excess fat in the lower eyelid, which can help with the appearance of ‘bags’ under the eyes.
Normally, the lower eyelid is located right at or slightly above the bottom edge of the colorful part of your eye (the iris). It fits closely against the eye, kept in place by various factors such as the overall tone and integrity of certain eye muscles and tendons, the flexibility of the skin around your eye, and a part known as the tarsal plate, which gives the eyelid its structure. If any of these elements are damaged or functioning improperly, it can cause the eyelid to be out of place or cause discomfort. Too much pulling down can also cause the eyelid to move away from its natural position. Skin shortage or scarring can result in the lowering or outward turning of the eyelid. Injuries to the nerves or muscles can also lead to similar problems.
The lower eyelid is complex and has multiple important structures that help it function. It’s mainly kept in place by two tendons, one on the inside corner (medial canthal tendon) and one on the outside corner (lateral canthal tendon) of your eye. It features multiple layers of tissue – skin, muscle, fat (orbital septum), and a thin layer known as the conjunctiva. It also relies on bands of tissue known as retractors, which help control the position of the eyelid. There are also additional fat layers in the lower eyelid that contribute to its structure.
The important part to note for this surgery’s context is the orbital septum, a thin sheet of tissue in the front of the eye socket, which holds back fat to stop it from pushing forward into the lids. However, the septum can sometimes let the fat through, which forms the ‘bags’ under the eyes.
Therefore, understanding the structure and function of the lower eyelid is crucial when it comes to transconjunctival blepharoplasty. This helps the surgeon to operate more effectively while causing minimal discomfort to the patient.
Why do People Need Transconjunctival Blepharoplasty
Transconjunctival blepharoplasty is a type of surgery performed to enhance the look of the lower eyelids. The primary aim is to lessen or remove the puffiness caused by fat pads located in the inner, middle, and outer parts of the lower eyelids. This procedure is particularly suitable for younger patients who have noticeable puffiness from these fat pads but don’t have sagging lower eyelids, excess skin or muscle around the eyes, or puffy bags under the eyes. It’s also suitable for those not having noticeable indentations or sagging in the cheeks.
In general, this procedure doesn’t improve eye function for most patients, since it’s mostly done for aesthetic reasons. However, there may be occasional instances where patients have such excessively puffy eyelids (a condition known as steatoblepharon) causing a hindrance to their lower field of vision or even preventing the correct positioning of spectacles. In these scenarios, the surgery has a functional benefit and is thus recommended.
When a Person Should Avoid Transconjunctival Blepharoplasty
There are certain conditions where a specific type of eyelid surgery, known as a pure transconjunctival blepharoplasty, might not be suitable for some people. These include:
When there is too much skin in the eyelid area; if a person has poor skin quality in their lower eyelids due to sun damage; if their eyelid muscles are overly large or bulky which is known as orbicularis redundancy or hypertrophy; or saggy bags under the eyes, often called festoons.
Other reasons can also be if the lower eyelid is not tight enough, this is known as lower eyelid laxity; a condition where the eyelid becomes very relaxed and can easily flip inside out, commonly known as floppy eyelid syndrome; a condition where the eyelid is folded outwards, referred to as ectropion; or if the lower eyelid is pulled down which is termed as lower eyelid retraction.
The unsuitable conditions also include when the outer part of the eye corner is in an abnormal position, known as lateral canthal dystopia; if there is a noticeable groove in the lower eyelid or cheek area; or significant sagging of the cheek, medically referred to as cheek ptosis.
In addition, there are some conditions that don’t outright prevent the surgery, but might make it more complicated or risky. This can include protruding eyes, often known as proptosis; or a negative malar angle, which refers to the angle of the cheekbone in relation to the rest of the face.
Equipment used for Transconjunctival Blepharoplasty
Within a surgical tool set for plastic surgeries, certain instruments are crucial for specific reasons:
A small Desmarres retractor and a four-pronged rake with blunt ends are needed for pulling down the lower eyelid. Using wider retractors can limit the visibility for the surgeon. The blunt ends of the rake help to pull back skin gently without causing unnecessary injury.
It is reasonable to use an electrocautery unit with a sharp needle-like tip for making cuts. An alternate is a radio-frequency device; however, this might not stop bleeding as effectively as an electrocautery unit, and could cause more heat damage to surrounding tissues.
Many surgeons prefer to create cuts with a type of scissors known as Westcott scissors. They may also use these scissors or another type called Stevens scissors to help expose and work with fatty tissue. They might use a tool called bipolar cautery during the procedure, which is less likely to cause burns than another type known as a monopolar unit.
A 4-0 silk suture is used to pull back the conjunctiva, the clear tissue covering the front of the eye, to make it easier for the surgeon to work.
Q-tips are used for gentle blotting to stop minor bleeding.
Bipolar cautery, frozen gauze or sterile ice packs are used during surgery. And to protect the cornea, the clear front surface of the eye, during eyelid surgery, a plastic corneal shield is used.
Who is needed to perform Transconjunctival Blepharoplasty?
A type of eye surgery called ‘transconjunctival blepharoplasty’ is usually done in a proper hospital operation room. It can be performed in a regular doctor’s office using local anesthesia (which numbs the operation area), but many doctors prefer to have it done in an operating room because it provides the right conditions and equipment. This includes strong lighting, special surgical tools, and overall better conditions. This setting allows the doctor to fully focus on the operation. It’s also necessary to have a skilled assistant during the surgery. They make sure the doctor has a clear view of the area they’re working on.
Preparing for Transconjunctival Blepharoplasty
Before any surgical procedure on the eyes, a thorough eye exam is crucial. This includes checking the natural moisture or ‘tear film’ of your eyes, and looking out for any signs of eyelid or surrounding gland issues.
The doctor will also want to understand exactly what you’re hoping to improve with surgery. This is often done with the help of a mirror and sometimes also photos. If you’ve had any previous surgeries or younger photos, these will be reviewed too. The doctor will examine your eyes for any signs of damage from sun exposure as this can increase the chance of complications after surgery.
Next, the skin around your eyes is checked. The doctor will look for signs of sun exposure, wrinkles, sagging, and swelling. If you regularly use a device like a CPAP machine for sleep apnea, this is important to mention as it can cause puffiness under the eyes. Any excess skin and the overall health and strength of the skin will be assessed too.
The position of your lower eyelid is also checked. Ideally, it should sit just above the bottom of your cornea (the transparent front layer of your eye). However, this can vary depending on your eye shape and any previous surgeries.
Several tests are performed to check if your eyelid is too loose. For example, the doctor may pull your lower eyelid away from your eye and then let go, to see how quickly it returns to its normal position. If it doesn’t ‘snap’ back quickly, this might suggest laxity or looseness in the lower eyelid.
Additionally, the position of the corner points of the eye (your ‘canthi’) will be measured as well. The punctum, or small hole at the corner of your eye, is also observed when the lids are moved for any indication of laxity. Swollen or tightened punctum can indicate laxity along with other complications.
The ‘fat pads’ in your eyelids will also be looked at, as well as any dips or hollows that might have formed due to them. Aspects of the mid-face such as the cheek prominence are evaluated too, this is because a recessed cheek might lead to complications after eyelid surgery.
Lastly, if you have sagging skin in the lower part of your face or “jowls,” this will be taken into account when planning your surgery. Prominent jowls can pull down the skin of the lower face and eyelid, which doctors need to be careful about, or it might lead to lower eyelid retraction after surgery.
How is Transconjunctival Blepharoplasty performed
If you have “puffy” or “baggy” lower eyelids, you may notice that the swelling is worse when you first wake up, when you’re tired, or after you eat salty food. The severity of the puffiness can change throughout the day, which means the type of treatment you might need can vary as well.
In preparation for this eye procedure, the doctor will make special markings on your eyelids. This helps them identify particular areas fat deposits, also known as fat pads. If there are any grooves or wrinkles on your lower eyelid that may need to be filled, the doctor will take note of these too.
The procedure, known as transconjunctival blepharoplasty, can be done using a local anesthetic which is injected into the lower eyelid. Sometimes, sedation or even general anesthesia might be used.
To protect your eye during the surgery, a plastic shield will be placed over your cornea (the clear front part of your eye). Using a small tool, the doctor will then make a cut inside your lower eyelid to access and remove the fat pads contributing to your baggy eyelids. The doctor will be careful not to injure any nearby tissues and blood vessels while performing this procedure.
In addition to removing fat pads, the doctor may also use small amounts of your own fat or fillers to fill in any slight depressions on your lower lid. This is determined based on the markings made before the procedure.
Upon completion of the procedure, the doctor will remove the traction sutures (the thread holding the tissue in place), and will stitch up the incision made in the conjunctiva (clear tissue covering the white part of your eye). They may choose to not stitch the wound depending on the situation. The goal here is to ensure that any fluid can leave the surgery site, aiding in your eye’s recovery.
After the procedure, you will receive specialized care instructions that include applying ice to your eyelids and using an antibiotic ointment to prevent infections. It is important to follow these instructions to ensure proper healing after the surgery.
The team will want to monitor you for at least half an hour after the surgery to check your vision and ensure there’s no bleeding or other issues. You will also receive clear instructions on how to reach your health care provider if there are any problems when you get home.
Fediveriding down on what your doctor observed before the procedure, he or she may recommend different follow-up steps.
Possible Complications of Transconjunctival Blepharoplasty
After undergoing a specific type of eyelid surgery called transconjunctival blepharoplasty, some people might experience complications. These could include:
* Chemosis: This is a condition where the membrane that covers your eye swells up.
* Infection: This happens when harmful bacteria or other microorganisms enter the body, often causing inflammation.
* Bleeding: This is any blood loss from the tissue in or around the eyes.
* Residual prominence of fat pads: This means there might be remaining visible fatty tissue around the eyes.
* Lower eyelid retraction: This is a condition where the lower eyelid is pulled down and away from the eye.
* Excessive fat removal: A situation where too much fat is eliminated from around the eyes during surgery.
* Neuropraxia: This term refers to a temporary loss of nerve function without damage to the nerve itself.
* Trauma to extraocular muscles: Damage could occur to the muscles around the eye that control its movement, particularly the inferior oblique muscle.
* Double vision: Seeing two images of a single object.
* Loss of vision: In rare cases, there could be a partial or total loss of sight.
What Else Should I Know About Transconjunctival Blepharoplasty?
Transconjunctival blepharoplasty is a type of eye surgery that can be very beneficial for the right patients. This procedure doesn’t leave any visible scars, so the end results can be quite rewarding. However, it’s critical not to oversimplify this type of surgery. It’s very important for doctors to do a thorough check of your eye’s structure and function before planning lower eyelid blepharoplasty to ensure the best possible results.
