Transconjunctival Lower Blepharoplasty through Interrupted Incisions

Sir: It is generally accepted that the short- and long-term complications of the transconjunctival approach to lower blepharoplasty are fewer than with skin-muscle flap techniques.1 Nevertheless, problems have been reported with the technique, including lower lid malposition, diplopia, cysts, and granulomas.2–4 Transconjunctival lower blepharoplasty is usually performed through a single incision extending from the medial to the lateral canthal area, although Metzner5 described separate medial and lateral incisions, leaving an intact bridge of tissue in the middle third. I believe the risks of transconjunctival lower blepharoplasty can be reduced even further by performing it through three short interrupted incisions. I imagine others use this technique, but I was not able to find it described in the literature, and that is the reason for this communication. The technique is as follows. The conjunctiva and cornea are anesthetized with a few drops of 0.5% tetracaine hydrochloride ophthalmic solution. Then, the conjunctiva is infiltrated through a 32-gauge needle with 1 cc of 0.25% bupivacaine with epinephrine 1:200,000. The globe is covered with a lubricated corneal protector. The lower lid is retracted with a Desmarres retractor and holes are made through the conjunctiva over the anticipated positions of the medial, central, and lateral fat compartments with a needle tip cautery, using the lowest effective power setting in a blended mode. The three holes are situated in the lower third of the conjunctiva, at least 5 mm below the tarsal plate, to allow a retroseptal approach to the fat. The incisions are gently spread with fine tenotomy scissors until the capsulopalpebral fascia is identified. The capsulopalpebral fascia is nicked with the scissors, usually resulting in the redundant fat bulging into the wound (Fig. 1). Ballottement of the eye may facilitate this process. The fat pads are gently retracted, infiltrated with a small additional amount of local anesthetic, and amputated with cautery. Even after these maneuvers, the incisions remain quite small and do not require suturing, although they will allow egress of fluid in case of mild postoperative bleeding (Fig. 2).Fig. 1.: Excess fat in the medial, central, and lateral fat compartments is shown protruding through small incisions in the conjunctiva and capsulopalpebral fascia. MC, medial canthus.Fig. 2.: Even after fat removal, the three lower eyelid incisions are very small. As a reference, the Desmarres retractor is 15 mm in width.Transconjunctival fat removal is usually combined with a “pinch” excision of excess lower eyelid skin and occasionally with a light chemical peel using 30% or 40% trichloroacetic acid. Canthopexy is used very rarely. Although I occasionally struggle to find a fat compartment, usually when I have not been careful enough in placing an incision, I have never had to resort to a full-length transconjunctival incision. The inferior oblique muscle is sometimes visualized through the medial or middle incision, but this is not an objective of the procedure. Chemosis may occur, but I believe it is less likely than with a full-width incision. Similarly, because there is less disruption of lower lid retractors, the small risk of lower eyelid malposition would seem to be reduced even further. Inadequate or excessive fat excision can occur but, again, is no more likely than with a continuous incision. Overall results have been excellent and problems minimal in using this technique for more than 10 years. Edward A. Pechter, M.D. Division of Plastic Surgery University of California, Los Angeles 25880 Tournament Road, Suite 217 Valencia, Calif. 91355-2844 [email protected]