Joshua Soggi
Introduction
Lower lid blepharoplasty is becoming an increasing popular cosmetic surgery to create a more youthful effect around the eyes. As the normal ageing process takes place this can affect the periorbital region giving the appearance of puffy eyes with dark circles. The transconjunctival approach allows this problem to be rectified without making any external skin incision, allowing for a scar free approach. This has led it to it becoming an increasingly sought-after surgery.
Anatomy
To allow for the understanding of the procedure one first must become familiar with the general anatomy of the periorbital region. The anatomy will be focused on the main structures as a more thorough detail can be found elsewhere in literature.
Looking at the eye directly the lower eyelid is situated just below the limbus, the border between the cornea and sclera. In relation to the lower eyelid itself, this can be separated into three distinct lamellas. The anterior lamella comprises the eyelid skin itself as well as the orbicularis oculi muscle situated underneath. The middle lamella involves the orbital septum whilst the posterior lamella includes the tarsus, lower lid retractors and conjunctiva. When retracting the lower lid and making an incision through the tarsus, this allows access to the retro-septal fat pads which are an important part of a lower lid blepharoplasty. There are 3 main fat pads to be aware of; medial fat pad, central fat pad and the lateral fat pad. The inferior oblique muscle transverses across both the medial and central fat pads. This is an important landmark to note because during a lower blepharoplasty when dissecting to reposition/remove fat pads this is subject to injury if not careful. Continuing laterally we have the arcuate expansion of the inferior oblique muscle which separates the lateral from the middle fat pad (1). In addition to the fat pads discussed there is another one of importance to note; the suborbicularis oculi fat. This is a deeper fatty tissue which can be divided into medial and lateral segments (1).
Indications for the procedure
Some of the most common indications are (1):
- Evident nasojugal grooves marking the appearance of a tired eye
- Lower eyelid dermatochalasis
- Malar mounds/festoons causing a somewhat swollen appearance of the lower eye bag
- Correction of a lower eyelid asymmetry
- Rhytidosis
Preoperative Evaluation
Before the surgery it is imperative that a thorough medical and ophthalmic history is taken during a consultation before a lower blepharoplasty.
A detailed history must be taken which includes:
- Any current medical conditions
- Current medications
- Allergies
- Previous eye surgeries
- Social history
- Ophthalmic drugs as well as asking if they wear contact lenses
Upon initial consultation it is important to understand the patient’s thoughts behind such a procedure and what they expect in terms of improvement. This should not be overlooked because if the patient has unrealistic expectations from the surgery which cannot be delivered then this needs to be addressed from the start. Sometimes it is helpful for patients to describe what they would like to be rectified by looking into a mirror and describing accordingly.
After history taking a physical examination is undertaken which includes the following:
- Visual acuity test
- Direct ophthalmoscopy/Indirect ophthalmoscopy to assess the eye
- Periocular skin examination
- Lower eyelid position and laxity
- Presence of tear trough deformities
- The distribution of fat present under/around the eye
- Infraorbital hollowing
- Signs of any asymmetry
- Canthal tendon laxity
After getting consent from patients, pre-op and post-op pictures are usually taken for comparison (2).
Procedural technique
Whilst we will be taking about the approach in a transconjunctival blepharoplasty, it’s important to note that a transcutaneous approach also exists.
Before the procedure takes place, markings are made with a surgical pen around the eye. These include the three fats pads which were discussed in the anatomy section above, along with any asymmetry which may be noted. This allows the surgeon to know if one side may need more detailed attention than the other. In most cases the markings made are in conjunction with the indication of the surgery in the first place. For example, the outline of an evident lower lid dermatochalasis which is to be rectified.
Transconjunctival blepharoplasty in most cases is done under local anaesthetic however it can also be done under general anaesthesia as-well. First to make it more comfortable for the patient numbing eye drops are administered first before proceeding with local injections. Tetracaine hydrochloride 0.5% is considered a popular choice. A 1% lidocaine can then be injected into the lower lid conjunctiva. The needle is advanced until the bony orbital rim is palpated and then injected as the needle is slowly withdrawn (4).
Once waiting for adequate vasoconstriction, the lower lid is then retracted by double pronged hooks. An incision is then made to the inferior tarsus to gain access the compartments of the fat pads. This fat is then directly visualised by access of radio frequency cautery. This is also used throughout the procedure to ensure good haemostasis from bleeding vessels during dissection. As already mentioned above the inferior oblique muscle runs past the middle and central fat pads. It’s pivotal that this is identified and maintained throughout the procedure. One way which can help the surgeon is the colour of the fat pads themselves. Typically the medial fat pad is whiter than the central and lateral pads helping aid the surgeon visually with the anatomy. Once full access to the fat pads have been established, the surgeon can either remove or reposition the fat according to what will give the patient the best results. This is carefully decided during the pre-operative assessment. After every compartment of fat has been treated, it is then double checked to ensure no active bleeding is taking place. Once satisfied, the retractors are removed and the lower lid is allowed to return to its normal position. The initial incision made through the conjunctiva is not usually sutured and heals on its own within a week. Although, some surgeons do prefer to suture the conjunctiva incision (1, 4).
Post-operative care
After surgery the patient is closely monitored for a couple of hours to ensure there is no active bleeding. It’s also good to reassure the patient that its completely normal for the eyes to have a reduction in vision. This is usually secondary to an antibiotic ointment that is applied into both eyes. Given this as well as the after effects of sedation its essential that someone accompanies the patient from the clinic to their house when being discharged.
Frequent cold compressing and head elevation at 45 degrees during the first 48 hours after surgery is important to reduce swelling (4). It’s encouraged to be continued after the first 48 hours with cold compresses several times a day for a couple of minutes. Some surgeons also encourage patients to sleep upright at a reclining angle of 45 degrees to enhance the recovery period. This can be done comfortably by using several pillows to raise the head.
Eye drops should be provided and can be applied if the eyes feel dry during the day. Sometimes oozing can happen from the operative site which is normal, in which case a sterile gauze can be used to clean the site. Saline solution can also be used to gently clean the area as well.
It is recommended that physical activity is avoided within the first 2 weeks of surgery which can elevate heart rate. If non-absorbable sutures are placed during the surgery then these are usually removed within a week of the surgery date. After this a follow-up consultation is sometimes arranged post-op. It is crucial however that patients are instructed on concerning symptoms that they should contact their surgeon or visit the local A+E department (2).
References
1) Bhattacharjee, Kasturi; Ghosh, Sripurna1; Ugradar, Shoaib; Azhdam, Ariel M. Lower eyelid blepharoplasty: An overview. Indian Journal of Ophthalmology: October 2020 – Volume 68 – Issue 10 – p 2075-2083 doi: 10.4103/ijo.IJO_2265_19
2) Paul O. Phelps, Brett Kotlus, Michael T Yen, Marcus M. Marcet, Cat Nguyen Burkat. Lower Eyelid Blepharoplasty. American Academy Of Ophthalmology: Eyewiki. [cited 2022 Nov 23]. Available from: https://eyewiki.aao.org/Lower_Eyelid_Blepharoplasty
3) Bhupendra C. Patel; Keith Volner; Raman Malhotra. Transconjunctival Blepharoplasty. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
4) Ira D. Papel, John L. Frodel, G. Richard Holt, Wayne F. Larrabee, Nathan E. Nachlas, Stephen S. Park, Jonathan M. Sykes, Dean Toriumi; Roger L. Crumbly, Behrooz A. Torsion, Amir M. Karam. Aesthetic Facial Surgery; Chapter 23 Lower Eyelid Blepharoplasty. Facial Plastic and Reconstructive Surgery, 3rd edition, Thieme 2009. DOI: 10.1055/b-0034-73241