The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

A single tie is placed on the lateral canthal suture to set the correct tension as the
lower lid assumes its desired position. Before completing the knot, lower lid laxity
is once again evaluated with a pair of fine pickups. At this point, the lower lid should
have a normal distraction of 1 to 2 mm, and it should allow some upper and lower
displacement without restriction. If this is the case, the canthopexy knot is com-
pleted. When the lid is too tight and does not permit displacement above the lower
limbus with the pickups, the knot should be loosened.
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Part VI  Eyelid Surgery
Patients who have significant lid laxity with lid distraction greater than 6 mm, or
those with persistent intraoperative lid laxity after canthopexy, require lateral can-
thotomy and canthoplasty. Lateral canthoplasty is performed after canthotomy of
the inferior limb of the lateral canthal tendon, followed by cantholysis, which allows
mobilization of the lower lid. Before the lid is transposed over the lateral orbital rim,
2 to 3 mm of full-thickness horizontal lid shortening is performed to correct signifi-
cant lid laxity. A 4-0 Mersilene suture is used for lateral canthoplasty and is placed

through the edge of the tarsal plate from inferior to superior, ensuring vertical align-
ment while controlling lash rotation. The mattress suture is then placed along the
posterior aspect of the lateral orbital rim periosteum at the appropriate level ac-
cording to eye prominence and is tied in a surgeon’s knot. The desired amount of
tension created by the lateral canthoplasty should allow 1 to 2 mm of lid distraction
away from the globe, and the lid should be easily mobilized over the cornea. Over-
tightening of the lateral canthoplasty should be avoided to minimize lid malposition.
The lateral commissure is then reconstructed with a 6-0 plain catgut suture placed in
the gray line to prevent postoperative lateral canthal webbing. To re-create a normal-
appearing lateral commissure, the suture is placed in the posterior aspect of the upper
lid gray line and the anterior aspect of the lower lid gray line to allow the upper lid
to slightly overlap the lower lid in a normal anatomic relationship.
925
Chapter 30  Lower Eyelid Blepharoplasty
After lateral canthal support is achieved, the skin-muscle flap is redraped in a supe-
rior lateral vector. A triangle of excess skin and muscle is resected according to the
amount that overlaps the lateral extent of the lower blepharoplasty incision.
The orbicularis muscle flap is then resuspended to the lateral orbital rim at the level
of the lateral canthus using a 4-0 Vicryl suture, which is placed as a three-point quilt-
ing suture from the incised edges of skin and muscle to the periosteum along the in-
ner aspect of the lateral orbital rim to recreate the normal concavity associated with
the lateral orbital raphe. Similarly, interrupted absorbable sutures are placed in the lat-
eral cut edge of the orbicularis flap to the lateral orbital rim periosteum and tem-
poralis fascia to resuspend the orbicularis under appropriate tension. Resuspension
of the orbicularis provides additional lower lid support as well as elevation of the
SOOF over the inferior orbital rim, anatomically blending the lid-cheek junction and
giving it a smoother look.

Nasal fat pad
Nasal fat pad transposed
Levator labii superioris muscle
Orbital rim
Levator labii superioris
alaeque nasi muscle
Minimal skin and muscle are resected parallel to the lower lid margin to minimize
the risk of lid malposition. A small strip of orbicularis is removed from the skin
muscle flap to avoid a redundant layer overlying the preserved pretarsal orbicularis.
Tension-free closure is then performed in the skin muscle edges with a 6-0 fast-
absorbing catgut suture.
Adjunctive Techniques
Treatment of the Tear Trough Deformity
926
Part VI  Eyelid Surgery
The tear trough hollow can be corrected during a standard lower blepharoplasty.
When releasing the orbitomalar ligament along the infraorbital rim, the surgeon per-
forms additional preperiosteal dissection and release of the tear trough. This dis-
section is performed with low-power electrocautery and should be limited to pre-
vent injury to the buccal branch of the facial nerve, which is located medial to the
tear trough at the level of the angular artery. If the levator labii superioris alaeque

nasi muscle twitches with the electrocautery, this may be a sign of overdissection
near the buccal branch. After release of the tear trough, the nasal fat pad is trans-
posed and secured with a 6-0 Vicryl suture into the periosteum. It is important to
remember that aggressive transposition of the nasal and central pads can impair in-
ferior oblique function and result in diplopia. Fat grafting from excised orbital fat
can also be used to fill this space.
Postoperative Care
927
Chapter 30  Lower Eyelid Blepharoplasty
At the end of the procedure, a 6-0 nylon suture can be placed as a temporary tarsor-
rhaphy along the gray line lateral to the limbus. Another option is to place a tem-
porary Frost suture in the lower lid margin lateral to the lateral limbus and either
suturing to the eyebrow or suspending to a Steri-Strip above the eyebrow. These tech-
niques will reduce corneal exposure in the immediate postoperative period and min-
imize chemosis. These sutures are removed at the first postoperative visit 5 to 7 days
after surgery.
Postoperatively the patient’s head should remain elevated to reduce edema and oph-
thalmic pressure. An ice pack or cold compresses should be applied to the eyelids for
48 hours. The eyes should remain lubricated at all times with saline drops during the
day and lubricating ointment at night. Lagophthalmos can be caused by periorbital
edema; if this occurs, it resolves spontaneously in 1 to 2 weeks. In these cases eye-
drops and ointment are essential to prevent corneal abrasions and exposure prob-
lems. Before discharge the patient’s vision should be evaluated and documented. Any
signs of corneal irritation or decreased visual acuity require careful ophthalmologic
evaluation, including slit-lamp examination with the use of fluorescein eyedrops to
evaluate the cornea. Patients are asked to avoid the use of contact lenses and any eye-
lid makeup on the suture lines for 2 weeks after blepharoplasty.

Persistent postoperative chemosis can be treated with liberal application of oph-
thalmic ointments and steroid eyedrops. Use of these eyedrops should be limited to
2 weeks to avoid the risks associated with prolonged treatment. Severe chemosis that
herniates through the palpebral fissure requires more aggressive management with
liberal use of ophthalmic ointment, topical steroids, patching the eye closed for 24
to 48 hours, conjunctivotomy, or tarsorrhaphy.
Mild lid malposition may contribute to lagophthalmos and corneal exposure, which
may require bandage contact lenses to protect the cornea and conservative massage
of the lower lid margin until the patient has passed the critical 6-week postopera-
tive period, which corresponds with the peak inflammatory phase of healing. Lower
lid ectropion or persistent lid malposition after a 6 week period of conservative man-
agement may require surgical intervention including placement of a posterior lamella
spacer graft and lateral canthoplasty.
Outcomes
Lower blepharoplasty can no longer be considered a routine operation. Surgical tech-
niques have evolved and are today significantly more sophisticated than in previous
decades. Careful preoperative evaluation is the initial step toward creating a specific
and comprehensive treatment plan for each patient based on individual findings and
desired outcome. Patients who have medical or anatomic characteristics known to
be factors predictive of poor outcome should be considered high-risk patients who
require alternative procedures to minimize complications. Once assessment and plan-
ning are complete, blepharoplasty procedures should be performed with precision.
Emphasis is placed on maintaining the preoperative shape of the palpebral fissure
with particular attention to maintaining lower eyelid position. Lateral canthal sup-
port, most commonly with lateral canthopexy, represents a very important step in
the technique to maintain lid shape and reduce the risk of lower lid malposition or
postoperative round-eye syndrome. The tradeoff, which should be discussed with
the patient before surgery, is that the lower lid may appear tight, and this could last
2 to 3 weeks after surgery. The natural S-shaped curve of the lower lid and the palpe-
bral aperture are preserved after healing is complete.
Complications associated with lateral canthoplasty have been minor and primarily
include canthal angle webbing or asymmetry that requires surgical revision. The risk
of frank ectropion is significantly minimized with the use of lateral canthal support.
In addition to minimizing the risk of complications, maximizing the aesthetic result
is directly related to management of both periorbital fat compartments, the orbicu-
laris muscle, and SOOF. Elevation of the skin muscle flap and release of the orbito-
928
Part VI  Eyelid Surgery

929
Chapter 30  Lower Eyelid Blepharoplasty
malar ligament mobilize the SOOF, which is elevated with the orbicularis muscle.
Using the orbicularis muscle as a sling with secure lateral orbital fixation is the key
to maximizing the aesthetic appearance of the infraorbital region. This can be per-
formed safely based on the anatomy of the lower eyelid. The posterior lamella (tar-
soligamentous sling) has a separate point of periosteal fixation from the anterior
lamella (skin-muscle flap). These basic principles, founded on anatomy, are the two
key points in maximizing surgical outcome after lower blepharoplasty. Adherence to
these basic principles significantly contributes to achieving the overall goal.
Complications
Lower Lid Malposition
Lower lid malposition is the most common surgical complication after transcuta-
neous lower lid blepharoplasty and includes lid retraction, scleral show, and ectro-
pion. The incidence of this complication varies from 5% to 30% in the literature.
Lower lid malposition not only detracts from the aesthetic results but can also lead
to functional problems such as exposure keratopathy. The most common etiologic
factor is vertical deficiency of the anterior or posterior lamella in patients with pre-
existing tarsoligamentous laxity. Care should be taken to avoid excessive skin and
muscle resection. Patients associated with increased risk include those with lower
lid laxity, prominent eyes, negative vector, negative canthal tilt, and preoperative
scleral show. To avoid this complication, some have suggested less-invasive approaches
to the lower lid, such as the transconjunctival lower blepharoplasty. Although more
conservative, this technique does not eliminate the risk of lower lid malposition. In
addition, most patients who consult for lower lid rejuvenation need removal of ex-
cess skin and muscle, which is a limitation of the transconjunctival approach. The
treatment of postoperative mild lower lid malposition is conservative, with postop-
erative massage, the use of tape to hold the lower lid in position, and eye lubrica-

930
Part VI  Eyelid Surgery
tion. If conservative treatment fails to improve the position of the lower lid after
6 weeks, surgical revision with canthopexy or canthoplasty with or without the use
of spacers is recommended. Drill hole canthal anchoring is often needed, because
there might be a lack of adequate periosteum for suture fixation. Severe postoperative
lower lid malposition causing functional problems or corneal exposure requires im-
mediate correction to avoid exposure keratopathy.
The addition of routine lateral canthal anchoring provides an anatomic solution for
decreasing the risk of lower lid malposition after transcutaneous blepharoplasty. In
a review of our 10-year experience with routine lateral canthal support in 264 pri-
mary cosmetic transcutaneous lower lid blepharoplasties, we reported ectropion in
0.8%, lower lid retraction requiring revision in 2.7%, and mild lower lid retraction
(1 mm or less) that resolved with massage in 6.1%. Patients who needed revision
were treated with secondary canthoplasty; three patients required posterior lamella
spacer grafts.
Causes of Postblepharoplasty Lower Lid Malposition
 Lower lid laxity
 Middle lamellar scarring
 High risk patients
 Posterior lamellar scarring
 Excessive skin removal
 Damage to pretarsal orbicularis muscle
 Excessive muscle removal
 Untreated hematoma
Chemosis
Chemosis is the most common nonsurgical complication after lower blepharoplasty,
occurring in up to 12% of patients undergoing the procedure. It is a transudative
edema of the bulbar or fornical conjunctiva and is characterized by visible swelling
of the conjunctiva.

Patients may experience epiphora, irritation, foreign body sensation, and mild vi-
sual alteration. In a lower blepharoplasty, the causes include conjunctival desicca-
tion from exposure, regional edema, and lymphatic stasis resulting from local trauma.
Chemosis usually presents in the first postoperative week. The median duration is
approximately 4 weeks and can range from 1 week to 3 months.
Prevention is the most important treatment in chemosis management, and it starts
in the operating room. The use of lubricated corneal protectors, preventing prolonged
eye exposure and dryness with frequent moisturizing of the eyes, and minimizing
trauma can all help reduce its incidence. If significant chemosis is seen intraopera-
tively, it can be treated with an immediate conjunctivotomy with a pair of small scis-
sors. A temporary tarsorrhaphy suture can be placed lateral to the lateral limbus to
reduce postoperative chemosis.
Postoperative treatment of chemosis starts by keeping the eyes lubricated with wet-
ting drops and ophthalmic lubricants. Ophthalmic steroid drops (tobramycin/
dexamethasone [Tobradex; Alcon]) are also helpful. If the irritation does not resolve,
an eye patch to the affected eye with the use of an ACE bandage at night can be used.
In more severe cases (lasting more than 2 weeks), especially if lagophthalmos is pres-
ent, a conjunctivotomy or tarsorrhaphy should be considered.
931
Chapter 30  Lower Eyelid Blepharoplasty
This patient presented with postoperative chemosis that prolapsed through the eye-
lids during closure, causing lagophthalmos. A conjunctivotomy of the prolapsed con-
junctiva with the patient under local anesthesia was performed in an office setting.

This patient, seen before and immediately after a conjunctivotomy with the use of a
local anesthetic in the office, shows an almost complete resolution of her chemosis.
Visual Changes
Visual changes such as diplopia are generally temporary and can be attributed to
edema. The most common extraocular muscle damaged in lower blepharoplasty is
the inferior oblique muscle, which is located between the nasal and central fat pads
and can be inadvertently injured during fat manipulation. Conservative treatment is
recommended; normal vision is usually regained when the muscle edema subsides.
Vision loss can also occur; it is discussed in Chapter 28.
Other Complications
Epiphora is usually a transient problem that can resolve spontaneously in days; it is
most commonly caused by edema distorting the lacrimal canaliculi. If persistent,
punctal eversion can be corrected by excising and closing an ellipse of conjunctiva
below the canaliculus, producing inversion. The same effect can be obtained by ap-
plying cautery below the lacrimal canaliculus on the conjunctival side to produce
contraction and inversion of the punctum.
Corneal abrasions can be prevented by constant corneal lubrication, the use of oc-
ular protectors, and avoiding prolonged exposure of the cornea. Dry-eye syndrome,
infection, and hematoma may occur; these are discussed in Chapter 28.
932
Part VI  Eyelid Surgery

Results
The following cases represent a variety and continuum of patients who demonstrate
age-related changes of the eyelids and periorbital region.
933
Chapter 30  Lower Eyelid Blepharoplasty
This patient, with early signs of aging confined to the upper and lower eyelid with ex-
cess skin, muscle, and fat, is shown before and after upper and lower blepharoplasty.
This woman, with a tear-trough deformity of the lower eyelid, shows improvement
after release of the orbitomalar ligament, orbicularis, and levator labii superioris,
along with fat transposition into the tear trough.

This patient had prominent eyes, with a Hertel measurement greater than 18 mm;
she is shown after a blepharoplasty with canthopexy to support the lower eyelid,
thus minimizing the risk of lower lid malposition.
934
Part VI  Eyelid Surgery
This woman underwent lateral canthopexy and lateral canthoplasty; her lower lid
shape and lateral canthal position were maintained.

This closeup view of the lateral canthus after lateral canthopexy and lateral cantho-
plasty demonstrates the natural appearance of the lateral palpebral aperture and
commissure.
935
Chapter 30  Lower Eyelid Blepharoplasty
This woman, with significant signs of midfacial aging, is shown after upper and lower
blepharoplasty combined with subperiosteal midface elevation.

This patient underwent bilateral lower blepharoplasty. Her tear trough deformity
was corrected by orbitomalar ligament release and repositioning of the nasal and
central fat pads.
Concluding Thoughts
As concepts of aging evolve and new techniques are developed, operative approaches
to blepharoplasty continue to be refined, thereby producing a more natural, youth-
ful eyelid appearance. The stigmata of surgery can be minimized, along with the risk
of complications, by proper preoperative assessment and meticulous surgical tech-
nique. Appreciation of the underlying anatomy, along with the indications and lim-
itations of techniques used to correct the anatomic changes that occur with aging,
form the basis of a sound surgical approach that ensures favorable results.
Clinical Caveats
 Preoperative evaluation should include the lower lids and midface.
 This technique for lower blepharoplasty is an anatomically based procedure that
requires familiarity with periorbital anatomy.
 Preoperative recognition of high-risk patients is essential; this can be achieved with
systematic clinical evaluation.
 Patients at high risk for lower lid malposition include those with prominent and
deep-set eyes, lower lid laxity, a negative canthal tilt, and a negative vector.
936
Part VI  Eyelid Surgery

 Modifications of the surgical technique are performed based on the extent of the
age-related changes present in the eyelids and periorbital region.
 Lower blepharoplasty using a skin-muscle flap can be safely performed with min-
imal risk of denervation of the pretarsal orbicularis muscle.
 Release of the orbitomalar ligament is an important part of lower lid blepharo-
plasty to resuspend the orbicularis and elevate the SOOF to achieve a smoother
transition of the lid-cheek junction.
 Routine lateral canthal anchoring is required to minimize the risk of postbleph-
aroplasty lid malposition.
 Modest lower lid laxity with less than 6 mm of lid distraction is managed with
lateral canthopexy.
 Significant lower lid laxity of 6 mm or more of lid distraction is managed with
lateral canthoplasty.
 Lower lid malposition is the most common surgical complication after lower lid
blepharoplasty. Chemosis is the most common nonsurgical complication after
lower lid blepharoplasty.
937
Chapter 30  Lower Eyelid Blepharoplasty
Annotated Bibliography
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Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation.
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individual combinations of the orbital anatomic influences cause the variations in the
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eyelid retraction or ectropion should have an additional surgical procedure to support the
lower eyelid and lateral canthus. Suspending the lateral canthus by surgically altering
the lateral canthal tendon is a proven technique that can provide support for the lower
eyelid, but a technique of this complexity may be unnecessary for most patients. The
authors investigated the attachments of the lateral canthus to the lateral orbital rim and
found that the most commonly appreciated attachment between the eyelids and the lat-
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lateral canthus also is attached to the orbital rim at a more superficial level through the
septum orbitale. This superficial fascial plane may be modified and used as a structure to
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Part VI  Eyelid Surgery

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940
Part VI  Eyelid Surgery

Transconjunctival Blepharoplasty

FOAD NAHAI
CHAPTER 31

942
Part VI  Eyelid Surgery
Evolution of Technique
In an effort to minimize the risks associated with the open or transcutaneous skin-
muscle approach to blepharoplasty, there has been renewed interest in the transcon-
junctival approach. Originally described by Bourguet in 1928, the transconjuncti-
val approach was reintroduced in 1973 by Tessier for removal of fat from the lower
eyelid and treatment of congenital deformities and trauma. This approach was later
popularized for the removal of lower lid fat by Baylis et al, by McCord and Moses
in the oculoplastic literature in the 1980s, and by Zarem and Resnick in the plastic
surgery literature in the early 1990s. These surgeons emphasized the safety of this
technique and the significant reduction in complications it offered, with almost com-
plete elimination of lid retraction and its consequences. My personal experience, re-
ported in 1995 and again in 2010, confirmed the safety and efficacy of this approach
for removal of fat from the lower eyelid. Over time, interest in transconjunctival
blepharoplasty waned as the focus shifted to amelioration of aging of the lid-cheek
junction with an emphasis on fat redraping and the transpalpebral approach to mid-
face elevation. Today, however, the transconjunctival approach is again attracting
attention and gaining in popularity, not only for fat removal from the lower eyelid but
also for fat redraping, fat redistribution, and a transconjunctival gateway to the mid-
face. In 1999 we described the transconjunctival approach to the medial or nasal fat
pocket of the upper eyelid.
Advantages
In addition to the obvious benefit of significantly decreasing complications, the other
advantage to this technique is that there is no visible scar. Lid retraction and its con-
sequences—exposure, round eye, scleral show, and ectropion—have all but been
eliminated with this approach. Baylis et al reported no lid retraction, as did Zarem
and Resnick. A personal review of 300 consecutive blepharoplasties between March
1992 and March 1996 (portions of which were published in 1995) included 120
transconjunctival blepharoplasties and 180 transcutaneous blepharoplasties. The
overall complication rate for the transconjunctival group was 5% and for the trans-
cutaneous group 13%. In the transconjunctival group there was no lid retraction,
and in the transcutaneous group 3.3% had lid retraction. The revision rate for the
transcutaneous group was 2.2%, and for the transconjunctival group it was 1.6%.
The complication rates were similar in primary and secondary blepharoplasties.

Disadvantages
Resection of excess skin and muscle is not possible through this approach, although
the addition of a pinch excision adds a viable option for dealing with the excess skin.
Access for redraping and redistribution of periorbital fat and access to the midface
are possible through this approach, but it is not as straightforward as the open ap-
proach. In the upper eyelid, only the nasal fat pocket can be approached through
the conjunctiva, which limits its role to removal of fat from that pocket only.
943
Chapter 31  Transconjunctival Blepharoplasty
Transconjunctival and Transcutaneous Blepharoplasties:
Complications (March 1992–March 1996)
Transconjunctival
Transcutaneous
Complication
(N  120)
(N  180)
Surgical revision
2 (1.6%)
4 (2.2%)
Exposure
0
8 (4.4%)
Subconjunctival hematoma
2 (1.6%)
4 (2.2%)
Infection
0
2 (1.1%)
Granuloma
2 (1.6%)
0
Scleral show/ectropion
0
6 (3.3%)
Overall
6 (5%)
24 (13%)
Transconjunctival and Transcutaneous Blepharoplasties:
A Personal Series of 300 Patients (March 1992–March 1996)
Transconjunctival
Transcutaneous
Primary blepharoplasty
101 (84%)
145 (80%)
Secondary blepharoplasty
19 (16%)
35 (20%)
Mean follow-up
3 yr
3 yr
Range
2-4 yr
2-4 yr

Management of Fat in the Eyelids
944
Part VI  Eyelid Surgery
Fat
excision
No fat
manipulation
Fat
grafting
Fat
redraping
49%
38%
9%
4%
LOWER LID BLEPHAROPLASTY
UPPER LID BLEPHAROPLASTY
Lateral
pocket
Medial/nasal
pocket
76%
24%
Over the years there has been considerable change in our management of periorbital
fat. Gone are the days of the skin-muscle-fat excision blepharoplasty. It was through
this evolution of fat management around the eye in the late 1990s that transcon-
junctival fat removal became less popular in general, and I chose it with significantly
less frequency in my practice. My current management of lower lid fat is presented
in the graphs and includes the following:
 Redraping
 Preservation
 Excision
 Augmentation
Even in the upper eyelid, I am preserving fat rather than resecting, especially in the
lateral pocket.

Indications
Fat management, especially in the lower eyelid, is now customized to each individ-
ual. I base my options for fat management on the amount of fat present and an eval-
uation of the lid-cheek junction. If the patient has little if any aging of the lid-cheek
junction with true excess fat, I prefer resection of fat. If the patient has no excess
fat, the fat pocket is not opened. If the patient has aging of the lid-cheek junction
and sufficient fat for redraping, redraping or redistribution of that fat is the proce-
dure of choice. In patients who require improvement of the lid-cheek junction and
do not have an adequate volume of lower lid fat, augmentation with autologous fat
or a dermis graft is necessary.
945
Chapter 31  Transconjunctival Blepharoplasty
For individuals with excess lower lid fat and little or no lid-cheek junction change,
the postseptal transconjunctival approach is an ideal operation with safe, easy fat re -
moval from all compartments. It is also a good operation for patients with excess fat
and fine skin wrinkling and in those with apparent excess skin in whom fat removal
will result in redraping of the excess skin into an acceptable contour with elimination
of the skin laxity. Laser resurfacing and peels have been advocated for skin tighten-
ing after transconjunctival fat removal to deal with the excess skin; however, I have
found that skin excision is best for handling the excess skin. The combination of
transconjunctival fat removal and skin excision through skin-pinch blepharoplasty
is a suitable alternative to the transcutaneous skin-muscle flap blepharoplasty in se-
lected patients. For candidates for redraping or redistribution or augmentation of
the periorbital fat, the preseptal transconjunctival approach allows access to the peri-
orbital fat, retroorbicularis oculi fat, and midface. This approach does not afford
the same easy access and visualization of the transcutaneous approach.
LOWER LID FAT MANAGEMENT
LID-CHEEK
JUNCTION
Periorbital fat
Normal/youthful
Plan: Lower lid blepharoplasty
Fat management
Without midface lift
Aged/descending
Plan: Lower lid blepharoplasty
Fat management
Transpalpebral midface lift
Augment
Excise
No fat manipulation
Insufficient
Normal or sufficient
Excess
Periorbital fat
Augment
Redrape and resect if needed
Redrape
Insufficient
Normal or sufficient
Excess

946
Part VI  Eyelid Surgery
Preoperative Assessment
A complete medical history is taken. We ask about hypertension and medications
that affect bleeding. A careful ophthalmologic history is then obtained. The patient
is asked about any history of eye problems or operations, specifically inquiring about
glaucoma and Lasik procedures, symptoms of dry-eye syndrome or irritation, whether
he or she wears glasses or contact lenses, and any family history of eye problems,
especially glaucoma.
The examination includes an evaluation of the lower lid skin, muscle, fat, and lid-
cheek junction. Lid tone should be assessed with the pinch and traction tests.
Schirmer’s test is done on a selective basis, as indicated. Although I routinely mea-
sure every patient’s eyes with the Hertel ophthalmometer, it may not be as vital to
do so for patients undergoing transconjunctival procedures.
Upper Eyelid
Pertinent Anatomy
The only fat compartment to herniate in the upper eyelid is the medial compart-
ment. The other compartment is retained anatomically, does not herniate, and can-
not be exposed through the conjunctiva.
Only nasal or medial fat herniates

We consider the upper eyelid to be divided into tarsal and orbital portions at the
level of the supratarsal fold, which is located 3 to 5 mm above the upper border of
the tarsal plate in whites and much lower in Asians. It is formed by the fusion of the
levator aponeurosis, orbital septum, and fascia on the deep surface of the orbicu-
laris oculi muscle. This fused layer acts as a sling and holds up the periorbital fat so
that the excess fat drapes over the fold rather than herniating below it.
947
Chapter 31  Transconjunctival Blepharoplasty
This sling is lower laterally and much higher nasally, thus allowing herniation of the
nasal fat pocket below it. The other structure of importance here is the levator
aponeurosis. The lateral horn of the levator is much lower than its medial horn.
These two factors combined allow transconjunctival access to the nasal or medial
fat pocket without risk of injuring or involving the levator aponeurosis.
Levator palpebrae
superioris muscle
Postseptal fat
Müller’s muscle
Orbicularis oculi muscle
Orbital
portion
Tarsal
portion
Superior tarsus
Brow fat pad
Orbital septum
Levator
Superior tarsus
Levator
aponeurosis
Levator
Superior tarsus
Levator
aponeurosis
“Sling”

The medial or nasal fat lies medial to the levator aponeurosis and below its medial
horn. The lateral temporal or central upper eyelid fat pocket lies anterior to the le-
vator aponeurosis and is inaccessible through the transconjunctival approach. The
medial or nasal fat is usually pale yellow or white. It contains more sensory fila-
ments, branches of the supratrochlear nerve, and more blood vessels, branches of
the superior ophthalmic artery. The fat of the lateral central or temple compartment
is much more yellow in color and has sensory fibers and vascular branches of the
supraorbital nerve and artery.
Transconjunctival Approaches
Only the nasal fat pocket can be approached through the medial conjunctiva below
the medial horn of the levator aponeurosis through the so-called bare area described
by Guerra et al.
Preoperative Planning
The transconjunctival approach is suitable for a primary and secondary procedure for
removal of excess medial upper eyelid fat. The best candidates for this procedure
have excess fat limited to the nasal pocket with little or no true skin excess. In my
experience, most of these patients have undergone previous blepharoplasties, with
remaining excess fat in the medial or nasal pocket.
Markings
With gentle pressure on the globe, I look for the maximum bulging of the medial fat
pocket and place a small mark on the skin.
948
Part VI  Eyelid Surgery
Central fat pad
Junction of superior tarsus
and levator aponeurosis
Medial fat pad

Operative Technique
Anesthesia
Local anesthesia is my choice if fat removal is the only procedure to be performed.
If it is combined with other facial rejuvenation procedures, I prefer general anesthe-
sia. Before injection of the local anesthetic, 1 to 2 drops of topical tetracaine anes-
thetic are placed on the eye. The local anesthetic, 0.5% lidocaine with epinephrine,
1:200,000, is infiltrated transcutaneously and through the conjunctiva. If the patient
is under general anesthesia, the lidocaine-epinephrine mixture is injected for its vaso-
constrictor effect, but the tetracaine is not necessary.
Incision
A corneal protector is placed over the eye. The medialmost part of the upper eyelid
is retracted; I prefer to use a Blair retractor. The “bare area” is immediately exposed
and an incision made in the conjunctiva with Colorado tip needle electrocautery.
This incision is kept in the medialmost part of the upper eyelid and should not extend
laterally beyond the bare area, where it may injure the levator aponeurosis and risk
postoperative ptosis. Once the incision is made, I take a pair of fine blunt-tipped
scissors and spread the blades. The nasal fat pocket immediately comes into view.
Fat Excision
949
Chapter 31  Transconjunctival Blepharoplasty
The medial fat pocket is then easily teased and delivered through the incision, where
it is trimmed with the electrocautery. The endpoint is reached when there is no bulging
medially in the upper eyelid with gentle pressure on the globe.

950
Part VI  Eyelid Surgery
Closure
The conjunctival incision is always left open.
Postoperative Care
The patient’s head is elevated, and ice packs are placed on the eyelids.
Results
The transconjunctival approach for removal of fat in the upper eyelid has been free
of complications in our hands, specifically no eyelid ptosis. There have been no revi-
sions, and patients have been consistently pleased.
This middle-aged woman underwent an endoscopic brow lift, transconjunctival re-
moval of fat from the upper eyelids, a lower lid blepharoplasty with transpalpebral
midface lift and neck lift, and laser resurfacing of the forehead. She is seen 12 months
postoperatively. No skin was removed from the upper eyelids; the improvement seen
in the upper lids resulted from the endoscopic brow lift and excision of fat from the
medial fat pocket.

This woman in her early fifties had had a previous coronal brow lift. She underwent
an endoscopic brow lift with transconjunctival removal of fat from the nasal pocket
of the upper eyelids. The upper eyelids are improved as a result of the transconjunc-
tival removal of fat from the nasal pocket and the endoscopic brow lift. There was
no skin excision from the upper eyelids.
951
Chapter 31  Transconjunctival Blepharoplasty
This 50-year-old woman underwent an endoscopic brow lift, transconjunctival re-
moval of fat from the upper eyelids, lower lid blepharoplasty, and a face and neck
lift. She is shown 3 years after surgery. No skin was removed from the upper eye-
lids. The medial upper lid improvement that resulted from transconjunctival fat re-
moval is most evident in the split-face view.

Lower Eyelids
Pertinent Anatomy
An understanding of the anatomic relationships between the fat pockets and other lid
structures is the key to this approach. It should be remembered that the outer lamella
of the lower eyelid is composed of the skin and orbicularis muscle. The middle lamella
is the orbital septum, and deep to it is the periorbital fat; the posterior lamella be-
hind the orbital fat is made up of the lower lid retractors (capsulopalpebral fascia)
and conjunctiva.
Orbital Fat Pads
952
Part VI  Eyelid Surgery
The orbital fat pads are bounded anteriorly by the
orbital septum. The septum is attached inferiorly
to the arcus marginalis and fuses superiorly with
the lower lid retractors. The orbicularis muscle and
skin are anterior to the septum. The orbital fat pads
are bounded superiorly and posteriorly by the
lower lid retractors. The lower lid retractors arise
from the terminal muscle fibers and tendons of the
inferior rectus muscle. They fuse with the orbital
septum 5 mm below the inferior tarsus and insert
on the tarsal plate. The posterior lower lid retrac-
tors are applied very close, in fact quite adherently,
to the lower lid conjunctiva.
Conjunctiva
Orbital septum
Orbital fat
Infraorbital rim
Central
compartment
Inferior oblique
muscle
Medial
compartment
Lateral
compartment
Arcuate expansion of
inferior oblique muscle
The inferior oblique muscle lies within the orbital fat and is the only eye muscle at
risk during blepharoplasty. The muscle originates along the anterior medial orbital
floor, passing posteriorly and laterally beneath the globe separating the medial and
central fat pockets.

The Compartments
The central compartment is separated from the lateral compartment by the arcuate
expansion of the inferior oblique muscle, which inserts into the orbital rim anterolat-
erally. The inferior oblique muscle separates the central and medial fat compartments.
Transconjunctival Approaches
953
Chapter 31  Transconjunctival Blepharoplasty
Transconjunctival Approaches
The preseptal approach allows:
The postseptal approach allows:
 Fat removal
 Fat removal only
 Fat redistribution
 Access to midface
The preseptal incision is placed:
The postseptal incision is placed:
 Below the tarsal border
 In the fornix 4 to 5 mm below the tarsal border
 At the level of the upper arcade
 At the level of the lower arcade
Transconjunctival approaches to the lower eyelid are either preseptal or postseptal.
Each approach has its own advantages and limitations. The postseptal approach
only allows fat removal. The preseptal approach allows access for fat removal and re-
distribution, along with access to the midface and orbital rim.
Preseptal
incision
Postseptal
incision
Preseptal
approach
Postseptal
approach

954
Part VI  Eyelid Surgery
Orbital
septum
Orbicularis
muscle
The preseptal approach permits access to the fat pads through the orbital septum
and allows access to the orbital rim, retroorbicularis fat (ROOF), and the midface
without any involvement of the orbicularis muscle or skin. The incision is made
along the lower tarsal border, 1 or 2 mm below the lid margin. This incision extends
through the conjunctiva lid retractors and capsulopalpebral fascia. The space be-
hind the orbicularis is then entered, and the dissection is continued deep to the or-
bicularis but anterior to the orbital septum. This dissection is continued down to the
orbital rim, and the arcus marginalis is easily released, affording access to the mid-
face. Access to the fat requires resection or incision of the orbital septum.
Postseptal Approach
Transconjunctival blepharoplasty by the postseptal approach permits access to the or-
bital fat through an incision in the conjunctiva and lid retractors/capsulopalpebral
fascia without any disruption or involvement of the skin, muscle, or orbital septum.
The incision is usually made in the conjunctiva of the inferior fornix, 4 or 5 mm be-
low the tarsal border at the level of the lower conjunctival vascular arcade.
Preseptal Approach

Preoperative Planning
The best candidates for transconjunctival fat removal or redraping are those with
excess fat and little if any real skin excess. The combination of transconjunctival fat
removal and skin-pinch excision is a suitable procedure in some patients. Fat redrap-
ing is appropriate for patients with aging of the lid-cheek junction with little or no
real skin excess.
Markings
With gentle pressure on the globe, the skin is marked directly over each bulging com-
partment. If fat redraping is planned, the nasojugal groove and lid-cheek junction
are marked.
Operative Technique
The ideal candidate for the postseptal approach is a patient with bulging lower lid fat
compartments with no real excess skin. The ideal candidate for the preseptal ap-
proach has aging of the lid-cheek junction with no real skin excess.
Anesthesia
The choice of local versus general anesthetic is the same as described previously for
the upper eyelid.
Postseptal Approach: Incisions
955
Chapter 31  Transconjunctival Blepharoplasty
The globe is protected with a corneal protector. Stay sutures of 5-0 Prolene are placed
medially and laterally through the conjunctiva of the inferior fornix. These two su-
tures are then pulled upward, facilitating the dissection and also affording extra pro-
tection to the globe. A Blair retractor or traction sutures are then placed in the lower
lid margin.

956
Part VI  Eyelid Surgery
Lower Arcade
The incisions are made with the electrocautery, 4 to 5 mm below the lid margin at
the level of the lower arcade.
I prefer to make two separate conjunctival incisions: one medially over the medial
fat compartment and the second laterally over the central and lateral compartments.
These two incisions leave an intervening bridge of conjunctiva over the inferior
oblique muscle in an effort to minimize the risk of injury to the muscle during fat
removal. A single continuous incision affords better exposure without significantly
increasing the risk of muscle injury.
Lower arcade
4-5 mm below
tarsal border
Incision

Once the conjunctiva and the adherent lower lid retractors and capsulopalpebral
fascia have been incised, the fat compartments may not always be readily visible.
957
Chapter 31  Transconjunctival Blepharoplasty
If the fat is not readily visible, gentle spreading with fine, blunt-tipped scissors will eas-
ily expose the fat. The central and lateral fat compartments are more easily identified
than the medial fat compartment. I have found that resection of the central fat facili -
tates identification of the medial fat. It should be kept in mind that the inferior oblique
muscle separates the central and medial fat pockets, whereas the arcuate expansion
of the inferior oblique muscle separates the central and lateral compartments.

Once the fat is exposed, I like to deliver the fat through the incisions to assess the
amount to be resected.
958
Part VI  Eyelid Surgery
The exposed fat is then removed in a careful, graded fashion with the coagulator
and Colorado tip needle. The endpoint is reached when the remaining fat is flush
with the infraorbital rim when gentle pressure is applied on the globe.
Closure
No closure is required if two separate incisions are made. If a single, continuous in-
cision is made, the wound is sutured.

Preseptal Approach: Incisions
959
Chapter 31  Transconjunctival Blepharoplasty
One continuous, long incision is made just below the tarsal border. This is facilitated
by retracting the tarsal plate upward and inferiorly with Blair retractors or through
the placement of stay sutures in the lid margin. The incision is made with the elec-
trocautery and a Colorado tip needle.
Once the incision has been made, stay sutures are placed along the inferior margin
to facilitate exposure. The dissection is continued through the conjunctiva and lower
lid retractors, exposing the orbital septum on the deep surface and the orbicularis
on the superficial side of the incision. A Desmarres retractor is then placed deep to the
orbicularis and pulled downward.

Exposure and Redistribution of Fat
960
Part VI  Eyelid Surgery
Dissection is continued deep to the orbicularis but superficial to the orbital septum,
downward toward the orbital rim. The arcus marginalis is released, and dissection
may continue into the midface as needed. The orbital septum is then opened and the
fat compartments exposed, trimmed if necessary, and then the fat is mobilized over
the orbital rim.
Retainment of this fat over the rim is achieved through transcutaneous sutures. My
preference is 6-0 catgut, tied over a small pledget of Xeroform if needed. The suture
is introduced through the lower lid skin at the lid-cheek junction according to the
preoperative markings.

The suture traverses the skin and orbicularis muscle.
961
Chapter 31  Transconjunctival Blepharoplasty
It is then placed through the mobilized periorbital fat below and then back through
the orbicularis and skin.

962
Part VI  Eyelid Surgery
Several sutures are placed and tied over the pledgets if needed, once the last suture has
been placed. The conjunctival incision is then closed with an intraconjunctival su-
ture so that there will be no exposed sutures that could irritate the cornea.
Postoperative Care
The patient’s head is elevated, and ice packs are placed on the eyelids.
Results
This young woman in her early thirties underwent transconjunctival removal of fat
from the lower eyelids. The dark circles were ameliorated by the application of hy-
droxyquinone skin bleach. Her postoperative result is shown several months after
the procedure.

Transconjunctival fat removal with erbium laser resurfacing was performed on the
lower eyelids of this young woman in her forties. She is shown 1 year and 3 years
postoperatively. She demonstrates an average to below average result because the
aging of the lid-cheek junction has not been addressed through the transconjunctival
removal of fat from the lower eyelid. An alternative approach would have been pre-
septal conjunctival fat redraping over the lower lid–cheek junction.
963
Chapter 31  Transconjunctival Blepharoplasty

This 70-year-old man requested improvement of the fat bags in the lower eyelid. He
wanted a simple procedure with minimal recovery. Transconjunctival postseptal re-
moval of fat from the lower lid was done. The result shown several months later
demonstrates satisfactory reduction of the fat bags, although the aging of the lower
lid–cheek junction and aging skin have not been addressed.
964
Part VI  Eyelid Surgery

Outcomes
The transconjunctival approach to upper and lower eyelid blepharoplasty has been
relatively trouble free. Complications involving exposure and lid retraction are ex-
tremely rare. Recovery is rapid with little risk of chemosis. Postoperative swelling is
minimal compared to transcutaneous approaches.
Injuries to the levator aponeurosis in the upper eyelid resulting in ptosis have not
been reported. Although injury to the inferior oblique muscle during transconjunc-
tival lower lid blepharoplasty has been reported, it is very rare, and I have not per-
sonally encountered it. Although the muscle is always at risk when resecting fat from
the central and medial pockets, I do not think that this risk increases with the
transconjunctival approach.
Concluding Thoughts
The transconjunctival approach remains a safe and effective method for eyelid re-
contouring, lid-cheek blending, and periorbital rejuvenation. The approach offers
little in the way of orbicularis muscle reshaping, skin removal, or lid anchoring.
Modifications such as the skin pinch and approaching the orbicularis and canthus
through the upper eyelid have been described, thus extending the indications for this
approach.
965
Chapter 31  Transconjunctival Blepharoplasty

966
Part VI  Eyelid Surgery
Clinical Caveats
Upper Lid
 Only the nasal fat pocket can be approached through the conjunctiva.
 Lateral extension of the conjunctival incision should be avoided because it may
damage the levator aponeurosis.
 Ideal candidates are individuals with fat herniation of the nasal fat pocket with
no real skin excess.
Lower Lid
 The preseptal approach allows fat excision, fat redistribution, and access to the
midface.
 A postseptal approach allows fat removal only.
 The inferior oblique muscle separates the medial and central fat compartments.
 A preseptal approach with fat redistribution is technically challenging.
 Ideal candidates have excess fat with no real excess skin.
Annotated Bibliography
Pacella SJ, Nahai FR, Nahai F. Transconjunctival blepharoplasty for upper and lower eye-
lids. Plast Reconstr Surg 125:384-392, 2010.
The authors review this technique, including anatomy, indications, and surgical ap-
proaches. They conclude that this remains a safe and effective technique for the treat-
ment of periorbital aging.
Upper Lid
Guerra AB, Metzinger SE, Black EB. Transconjunctival upper blepharoplasty: a safe and ef-
fective addition to facial rejuvenation techniques. Ann Plast Surg 48:528-533, 2002.
The authors performed 42 bilateral transconjunctival upper blepharoplasties in patients
undergoing facial and eyelid rejuvenation. They introduced the term “bare area.” The
CO2 laser was used concomitantly for treating fine rhytids and tightening loose upper
eyelid skin. They found the procedure to be an effective method for removing medial
upper eyelid fat with minimal complications.
Januszkiewicz JS, Nahai F. Transconjunctival upper blepharoplasty. Plast Reconstr Surg
103:1015-1018; discussion 1019, 1999.
This is our original description of the transconjunctival approach for removal of excess
fat in the medial pocket of the upper eyelid. We reported that this was safe and effica-

cious as a primary or secondary procedure. Our initial experience in 20 patients (5 pri-
mary and 15 secondary) revealed the following: no complications, no revisions, and the
patients were uniformly pleased with their results.
Lower Lid
Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedi-
cles into a subperiosteal pocket. Plast Reconstr Surg 105:743-748; discussion 749-751,
2000.
Rejuvenation of the lower eyelid complex is based on the principle that the contour
changes that characterize aging involve not only prolapse of orbital fat but also descent
of the cheek tissues, resulting in accentuation of the orbital rim and tear-trough groove.
When a deep groove is present along the orbital rim in the area of the tear-trough de-
formity, it is advantageous, rather than removing orbital fat, to reposition the fat over
the orbital rim through the opened arcus marginalis onto the superior face of the max-
illa. The author describes orbital fat repositioning through a transconjunctival approach
and follows 24 patients after orbital fat repositioning. It was found that although the
fat pedicle undergoes some variable resorption, the viability of the graft, the texture and
contour of the repositioned fat after a healing period of 1 to 2 months, and the excel-
lent patient acceptance are indicative of the viability of orbital fat repositioning.
Jones GE, Trimble-Bried J, Nahai F. Transconjunctival blepharoplasty: a clinical experience.
In Perspectives in Plastic Surgery. St Louis: Quality Medical Publishing, 1995.
This article describes our technique for transconjunctival fat removal and a comparison
of complications with the transcutaneous approach. The overall complication rate was
5.3% with the transconjunctival approach and 12.7% with the transcutaneous approach.
Exposure problems and lid retraction were 0% with the transconjunctival approach and
7% with the transcutaneous approach.
McCord CD, Shore JW. Avoidance of complications in lower lid blepharoplasty. Ophthal-
mology 90:1039-1046, 1983.
In an article devoted to avoidance of lower lid malposition, the authors describe the
tightening of the tarsoligamentous sling in combination with a lower lid blepharoplasty.
As an alternative method, they also describe postseptal fat removal from the lower eye-
lid. They describe this as “the fornix removal of fatty pads from the lower eyelid—the
‘behind-the-lid’ blepharoplasty.” This alternative method significantly reduced or even
eliminated the risk of lid retraction. They recommend this method for patients with ex-
cess fat in the lower eyelid and tight skin.
Zarem H, Resnick JI. Expanded applications for transconjunctival lower lid blepharoplasty.
Plast Reconstr Surg 88:215-220, 1991.
Initial reports on the transconjunctival approach for lower lid blepharoplasty have fo-
cused on the young patient with isolated fat prominence. The authors describe their ex-
perience with transconjunctival lower lid blepharoplasty. They also discuss indications,
which were expanded to include patients with apparent skin excess, and outcomes.
967
Chapter 31  Transconjunctival Blepharoplasty

Suggested Readings
Upper Lid
Guerra AB, Berger A, Black EB, et al. The bare area of the upper conjunctiva: a closer look
at the anatomy of transconjunctival upper blepharoplasty. Plast Reconstr Surg 11:1717-
1722, 2003.
Kamer FM, Mingrone MD. Experience with transconjunctival upper blepharoplasty. Arch
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Lower Lid
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Part VI  Eyelid Surgery

Lower Eyelid Pinch Blepharoplasty

LORNE K. ROSENFIELD
CHAPTER 32

When I examined my own results, I observed, not as infrequently as I would have
liked, two particular stigmata of a less than perfect result at the lower eyelid. First,
lasting mild scleral show was evident, often preceded by weeks of overly optimistic
eyelid taping. This 55-year-old woman, shown preoperatively and 1 year after a tra-
ditional skin-muscle lower blepharoplasty, exhibits this telltale postoperative sign
of scleral show.
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Part VI  Eyelid Surgery
T
he lower eyelid blepharoplasty embodies a classic surgical paradox worth re-
visiting: the more one performs a particular surgery, the more respect it may
command. Whereas ignorance may be bliss, knowledge can be quite motivating. Any
surgeon who has critically assessed his or her skin-muscle flap lower blepharoplasty
results would heartily agree with this statement.
Second, residual crêpey skin was identified, most often after treatment of prodigious
fat herniation. This 48-year-old woman, shown preoperatively and 1 year after a
traditional blepharoplasty, exhibits this “untreated” redundant skin.
I was compelled by these discomfiting observations to seek an effective solution—a
modified procedure that would at once ensure optimal correction of the eyelid de-
formities and yet maintain normal eyelid posture. And so was born the pinch bleph-
aroplasty series. My personal experience, reported in 2005, confirmed the safety and
efficacy of this approach.

Although the true incidence of eyelid malposition after a traditional muscle flap bleph-
aroplasty is not well defined, the plethora of articles on the subject attests to its per-
sistence. Scleral show has been ascribed to multiple causes: excess skin removal, un-
treated eyelid laxity, denervation of the orbicularis muscle, and scarring of the outer
or middle lid lamellae. This postoperative problem may be considered subtle and in-
deed is often not even acknowledged, but it represents what could also be seen as a
glaring example of the “operated” look that we should all strive to avoid. As for the
excess skin left behind postoperatively, this problem has been equally neglected in
the literature.
Evolution of Technique
There have been many efforts to reduce the incidence of eyelid malposition follow-
ing traditional blepharoplasty. As documented by Zarem and Resnick, one approach
has been to forego the skin incision entirely, thus preserving the integrity of the outer
and middle eyelid lamellae, and to approach the eyelid instead through the conjunc-
tiva only. Although the incidence of scleral show may be less with this approach,
there can be a greater chance of untreated excess eyelid skin.
In another effort to avoid the skin incision and still treat the skin, skin resurfacing
with a chemical peel or laser, in conjunction with a transconjunctival approach, can
indeed reduce the incidence of scleral show. However, unless the skin redundancy is
modest and the entire face is treated, resurfacing may not adequately treat the skin
redundancy and can otherwise produce distracting lines of demarcation. Addition-
ally, if these therapies penetrate too deeply, undesirable changes in eyelid posture
may still occur.
With a skin-muscle flap, a relatively conservative resection of the skin has always
been advocated, regardless of the extent of redundancy. Indeed, it is often impres-
sive how little skin is actually removed despite such an aggressive flap dissection.
And of course, in a patient with more significant excess skin, this conservatism has
surely led to inadequate treatment.
Another adjunctive technique to a blepharoplasty is the canthopexy, particularly in
a patient with a lax eyelid. There is no question that this repair helps reduce the in-
cidence of lid malposition, but the results have been frustratingly inconsistent. We
have all seen scleral show after a traditional blepharoplasty despite the addition of a
canthopexy, even when applied prophylactically. An inadequate canthopexy, coupled
with overaggressive skin resection, and the inciting factors of muscle denervation
and middle lamellar scarring, probably explain this inconsistency. The deliberate
preservation of a wider orbicularis strip of muscle, when conducting a skin-muscle
flap approach, may be salutary but has clearly not proved to be the complete answer.
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Chapter 32  Lower Eyelid Pinch Blepharoplasty

The idea of pinching the excess skin from the lower eyelid is not a new one; in 1973
Parkes et al were the first to suggest the technique. This description, which predated
the transconjunctival approach, attenuated its potential benefits by also describing the
division of the underlying orbicularis muscle to retrieve the excess fat.
Then in 1992 Dinner et al published a case report on the ultimate combination of
the skin pinch with the transconjunctival approach in a “no flap” technique. Ristow,
in 1994 in Mimis Cohen’s textbook, included the concept of a direct skin resection
with a measured and marked resection.
My impetus to revisit and refine a pinch blepharoplasty came from a personal com-
munication with Glenn Jelks in 2000. The solution became even more lucid when
our decades-old standard approach to the upper eyelid blepharoplasty was consid-
ered: we “pinch” the eyelid excess to determine the extent of the excision while ob-
serving the effect on the eyelash and brow posture. Why not apply the same simple
metric to the lower eyelid? So was born the “pinch blepharoplasty” series.
Advantages
My personal experience of more than 400 pinch blepharoplasties confirms that this
approach is indeed capable of producing better, more consistent results than the tra-
ditional skin-muscle flap technique. This variation offers two distinctive advantages:
more crêpey skin can be safely removed, and an aesthetic eyelid posture is secured.
This rewarding marriage of goals is primarily the result of the inherent accuracy of
the pinch technique. The approach enables the surgeon to assess and define in real
time the prospective skin resection as well as carefully evaluate its effect on eyelid
posture. The pinch technique avoids a heavy skin-muscle flap, which can otherwise
create both worrisome vertical traction and more swelling. Additionally, the pinch
blepharoplasty eliminates the usual violation of the orbicularis muscle and orbital
septum, an action that could lead to denervation, scarring, and poor eyelid posture.
Another possible reason for the improved results is the often seen amelioration of
the eyelid-cheek groove with a more youthful vertical shortening of the eyelid, per-
haps secondary to the effacing effect of the significant skin resection.
These benefits translate into a more adaptable and consistent blepharoplasty. This
advantage is seen particularly and most gratifyingly in morphologically challenging
patients with a negative vector and poor lid posture; older patients with poor lid
tone; patients with extensive skin or festoons; and younger patients with primary
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Part VI  Eyelid Surgery