Transconjunctival lower blepharoplasty with skin resection and preservation of the orbicularis muscle. The advantage of the transconjunctival technique is the preservation of the orbital septum, middle lamella, and orbicularis muscle innervation. This study aims to assess the results and complications of transconjunctival blepharoplasty with skin resection in the lower eyelid without detachment. The surgical technique is described in detail.
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Transconjunctival lower blepharoplasty with skin resection and preservation of the orbicularis muscle. The advantage of the transconjunctival technique is the preservation of the orbital septum, middle lamella, and orbicularis muscle innervation.
This study aims to assess the results and complications of transconjunctival blepharoplasty with skin resection in the lower eyelid without detachment. The surgical technique is described in detail. There was improvement in all cases in the appearance of increased volume in the lower eyelid, and a decrease in skin and lateral ligament laxity. Late complications such as eyelid retraction, ectropion, unaesthetic scars, diplopia, or remnant fat bags were not observed.
Surgical reintervention was not required in any cases. CONCLUSION: Transconjunctival lower blepharoplasty with skin resection without detachment and with preservation of the orbicularis muscle, with or without canthopexy, is an excellent technique, and is easily reproducible, reliable, and safe, with few postoperative complications in treatment of age-related changes in the lower eyelids. INTRODUCTION Transcutaneous blepharoplasty has long been the most common technique used by surgeons in the approach to fat bags and lower eyelid skin, despite the fact that several authors reported high rates of eyelid malposition and functional deficits using this technique Transconjunctival lower blepharoplasty was first described by Bourget in and popularized by Tessier, who conducted work associated with genetic malformations5.
This technique has been improved over the years and gained greater popularity when authors such as Zarem and Resnick reported that transconjunctival blepharoplasty showed lower rates of postoperative complications than the classic transcutaneous technique6,7. Isolated transconjunctival lower blepharoplasty is highly recommended for young patients with herniated fat bags without skin redundancy, or for revision in secondary blepharoplasty in cases with residual eye bags8,9.
In patients with excess skin in the lower eyelids, in addition to fat bags, the skin can be treated separately through a skin pinch and resection without skin detachment, skin-pinch , maintaining the integrity of the orbicularis muscle, its innervation, and the middle lamella Several authors describe a combined transconjunctival approach for fat bags with the skin pinch technique for the lower eyelid and call this the "no-touch" or "no-flap" technique If required, this surgery can also be complemented with treatments for lateral ligament laxity and adequate palpebral support, such as canthopexy and canthoplasty This combination of techniques is becoming more popular among surgeons, who have observed lower morbidity through the preservation of the middle lamella and innervation of the orbicularis muscle and lower risk of complications related to eyelid surgery as compared to those in the transcutaneous technique The aim of this study was to analyze the results and complications of transconjunctival blepharoplasty with skin pinch and resection in the lower eyelid, without skin detachment, and with preservation of the orbicularis muscle "no-touch technique" in a series of patients with 2 years of postoperative follow-up.
METHOD Eighteen patients who underwent transconjunctival lower blepharoplasty with skin pinch and resection of the lower eyelid, with or without lateral canthopexy, were assessed. The technique used is described in detail. The inclusion criterion was surgical indication for the technique; there were no exclusion criteria. The study was conducted according to the Helsinki Declaration and the patients provided signed informed consent.
The detailed preoperative evaluation included an interview to collect information about past clinical and ophthalmological history, and a physical examination. Lower eyelid tone was also examined by using the snap test, comprised of lifting the eyelid from the eyeball and observing its position. Relevant findings noted in preoperative records included the presence of scleral show, malar hypoplasia, festoons, entropion, ectropion, etc.
The amount and extent of herniated periorbital fat bags and skin excess were also assessed during physical examination for adequate surgical planning. Pre- and postoperative pictures were taken at various angles to document the cases, and informed consent was obtained from all patients before the procedures. Surgical technique The procedures were performed in a hospital environment under general or local anesthesia and sedation.
Corneal protectors were positioned with ophthalmic ointment. Figure 1. A horizontal mm conjunctival incision with retroseptal access was made in the lower tarsal plate, at the level of the second vascular arcade with a delicate electrocoagulation tip.
This approach allows access to the fat bags without breaching the orbital septum. A Desmarres lid retractor was placed and gentle downward pressure was applied to the eyeball by the assistant, exposing the herniated periorbital fat in the following order: medial, median, and lateral Figure 2. Figure 2. A horizontal conjunctival incision and access to the fat bags without injury to the orbital septum. These were independent and previously contained by the orbital septum. The bags were identified, gently grasped with hemostatic forceps, and resected with electrocoagulation, making sure that there was no subjacent bleeding.
It is important to exercise care in order to avoid damaging the lower oblique muscle located between the medial and median fat bags, which would cause diplopia. Hemostasis was then performed and the conjunctiva was brought together without suturing.
The lower eyelid skin was raised using an Adson-Brown forceps. The skin was pinched to create a thin strip of skin alone, close to the ciliary margin Figure 3. The skin was excised with a delicate iris scissors, extending up to 2 to 3 mm laterally to the lateral corner Figure 4. During the resection, it is important to maintain lateral and not anterior tension, in order to avoid excessive skin resection or damage to the orbicularis muscle.
Continuous suturing was performed with a 6. Figure 3. The skin is pinched to create a thin strip of skin alone, very close to the ciliary margin. Figure 4. The skin is excised with a delicate iris scissors, extending up to 2 to 3 mm laterally to the lateral corner. In patients with an indication for canthal support because of lateral tarsal ligament laxity, canthopexy of the lateral retinaculum with muscle suspension was performed without cantholysis.
This procedure was performed with a 5. The needle exits through the incision in the upper eyelid, where it grasps the periosteum and travels in the direction of the skin incision of the lower eyelid. When returned in the direction of the periosteum, the suture grasps the lower branch of the lateral canthal ligament, and then a knot is made with overcorrection of the lower eyelid 1 to 2 mm past the limbus16 Figure 5. This technique is useful for cases of mild to moderate laxity.
Figure 5. Canthopexy of the lateral retinaculum with muscle suspension without cantholysis. Other types of canthopexy or canthoplasty may be performed depending on the eyelid laxity grading; however, in this study, all patients who required ligament reinforcement presented mild to moderate laxity and only underwent this canthopexy technique. After the surgical procedure, the patient was treated with cold compresses, raised head support, eye drops and lubricant gel, prophylactic oral antibiotics, and painkillers.
All patients were discharged from the hospital within 24 hours, and the postoperative follow-up ranged from 1 to 24 months, with an average of In all cases, surgery was performed in association with other procedures, such as upper blepharoplasty UB In one case, secondary surgery was performed due to remnant fat bags primary surgery was performed by a different surgeon.
Primary surgery was performed in the remaining 17 patients. The most common clinical comorbidity was systemic arterial hypertension SAH in 4 patients. One was an active smoker and another was seropositive. Preexisting palpebral changes such as ectropion, entropion, and scleral show were not observed in any of the patients.
Mild to moderate eyelid laxity was observed in 15 patients Severe eyelid laxity cases were not observed. Pre- and postoperative aesthetic evaluation was performed using anteroposterior and profile photos, which revealed satisfactory results in all cases. There was improvement in the appearance of increased volume in the lower eyelid due to herniated fat bags, improvement in skin laxity in the lower eyelid, and improvement in lateral ligament laxity in all cases.
In the early postoperative period, common findings were the presence of corneal abrasion foreign body sensation , lacrimation, and chemosis Temporary periorbital edema and ecchymoses were also observed in In one case, presence of a conjunctival pedicle was observed due to malposition of the conjunctival scar , but was easily excised at the outpatient stage using an anesthetic collyrium.
In two cases Late complications such as eyelid retractions, ectropion, hematoma, infection, rounding of the lateral corner, lacrimal pump dysfunction, conjunctival granuloma, unaesthetic scars, infraorbital emptying tearthrough deformity , diplopia, or remnant fat bags, were not observed. No surgical reintervention was required in any case. Some of the pre- and postoperative results are seen in Figures 6 and 7. Figure 6. A e B: Preoperative. C e D: 60 days postoperative.
Figure 7. The transconjunctival approach associated with skin resection with preservation of the orbicularis muscle, also called the "no touch" technique, has been gaining popularity among surgeons since it also allows access to the fat bags, but with a much lower rate of complications than that in the transcutaneous approach7,8,19, This is due to the preservation of the orbital septum, middle lamella, and the innervation of the orbicularis muscle The motor innervation of the orbicularis muscle of the lower eyelid is through nerve fibers from the zygomatic branch of the facial nerve.
There is no single dominant branch, and adjacent branches have the capacity for collateral reinnervation in the case of partial injury. Studies performed with cadavers indicate that there are 5 to 7 terminal branches that reach the muscle transversely to their parallel course21, or from 3 to 5 branches that reach the muscle perpendicularly Regardless of the anatomy controversy, authors agree that when there is transection or removal of the muscle fibers, there is a partial or complete denervation of the preseptal portion of the muscle above the level of the incision.
This is the main cause of the most common long-term problem in transcutaneous blepharoplasties, i. This is prevented by using the "no touch" technique.
Therefore, the majority of authors now strongly recommend the preservation of the integrity of the orbicularis muscle of the lower eyelid, to prevent complications related to its denervation,19,21, Our study is in agreement with this idea, since in all patients from our sample, no muscle or nerve injury of the lower eyelid was observed, and related postoperative complications were not detected.
Some authors suggest that transconjunctival lower blepharoplasty presents several advantages over the transcutaneous approach, such as lower risk of retraction and ectropion, ease in accessing the middle third of the face if required , decreased surgical duration, and the possibility of combining it with other facial surgeries and skin treatments such as resurfacing with a CO2 laser In our study, the treatment performed on the lower eyelid was exclusively the skin pinch with resection and muscle preservation.
This technique without skin detachment grasps a smaller skin area, decreasing the chances of occurrence of hematomas and scar contracture Furthermore, it minimizes the risks of eyelid malposition since it avoids breaching the orbital septum and middle lamella8. Some studies point out the increased risks of skin necrosis and damage to local lymphatic drainage23 when this technique is used. However, this was not observed in our sample.
In all patients, the skin strip resected was sufficient to obtain a satisfactory aesthetic result. There was no need for reintervention and there were no complaints from patients. Nevertheless, we believe that in cases of greater excess of skin, this technique may not be adequate, and may require a different approach, with either skin or musculocutaneous grafts, and with greater detachment and resection of skin.
In regard to the resected fat bags in the lower eyelid, it is important to avoid overcorrection. Otherwise, there will be risks of causing a tear-through deformity, which is the unaesthetic sinking of the nasojugal sulcus region.
En la actualidad hay dos tipos de blefaroplastias inferiores. De esta manera es posible acceder a la zona donde se encuentra el tejido graso que forma las bolsas y da un aspecto cansado y envejecido al paciente. Este tejido ha crecido durante mucho tiempo pero con la blefaroplastia subciliar es posible eliminarlo de una vez. La blefaroplastia transconjuntival se realiza en el saco conjuntival y el resto de pasos es igual. El resto es igual que en los otros tipos de blefaroplastias.
Blefaroplastia transconjuntival y subciliar