Eyelid corrections are one of the most common aesthetic operations performed today. The majority of this is due to sliplid treatment with an upper eyelid blepharoplasty. The lower eyelid blepharoplasty with the removal of “tear sacs” is technically more demanding and is performed less frequently. The removal of fat from the lower eyelid can be carried out using two basic approaches:

1. through an incision in the skin below the lashes (transcutaneous).
2. through an incision along the inner surface of the Eyelids (transconjunctival).

The introduction of the transconjunctival technique more than thirty years ago was an important step in the field of eyelid surgery. The procedure seems technically more difficult for the surgeon who operates only occasionally on blepharoplasty. Even today, it is not used by all cosmetic surgeons, even when correctly indicated, for reasons of unfounded respect for the method. Routinely, you still use the side effect richer outer skin access to remove isolated orbital fat from the lower lid. The higher tissue protection of transconjunctival techniques was thoroughly investigated and is considered proven today [1]. In patients with little or no excess skin (the majority), the slightly stretched skin and muscle layer on the lower eyelid will simply return to a normal position after the gentle operation without bulging or wrinkling and will show an excellent cosmetic result. New tissue-conserving techniques also make it possible to retract individual fat areas in order to avoid hollow eyes when fat is extracted too much. With us, transconjunctival blepharoplasty is the surgical procedure of choice if the indication is correct.

History

Transkonjunctival access has been used in eyelid surgery in Europe for 90 years. The first scientific descriptions were made by Bourget in 1928 [3] and Tessier in 1973 [10]. They described this method for blepharoplasties after trauma and deformities. The first descriptions of the technique for aesthetic blepharoplasty were given in the 1970s and up to the end of the 1980s. The publications of Tomlinson [11] and Baylis [2] are to be emphasized here. Only publications by Zarem and Resnick [12, 13] at the beginning of the 1990s with sophisticated technical descriptions and case numbers gave this method greater importance. The first reports of laser-assisted transconjunctival blepharoplasty were made in 1988 by Spandoni and Cain [9].

Fig. 1: Local anesthesia of transconjunctival blepharoplasty.

Early studies of transconjunctival blepharoplasties concentrated on young patients with excess fat without large excess skin. However, the method was quickly extended to older patients with moderate excess skin [12]. It showed excellent results and a reduced incidence of post-operative complications than with the transcutaneous method. In 1993 and 1999 reports of transconjunctival upper eyelid blepharoplasties followed [4, 7], which, however, because of the mostly existing excess skin, only appear to be suitable for a few selected indications.

Fig. 2: Surgitron Dual RF 4.0 from Ellman.

Fig. 3: Wound edges following radio frequency.

Material and Methods

Patients receive extensive sedation from us 30 minutes before the operation in order to shield them from anxiety and nervousness during the operation on the eye, which for them is very impressive. The conjunctiva is also slightly anesthetized by adding 0.5% tetracain solution to the eye. Afterwards, a thorough infiltration of local anesthesia with at least 4-5 ml local anesthetic with adrenaline is performed on both sides. We do not use any hylase additives at all. Infiltration takes place directly through the conjunctives with a 30-gauge needle at an angle of 45°, deep into the lower eye socket and the individual fat compartments (Fig. 1). We use an eyeball protection in the form of plastic eye shields covered with panthenol eye ointment, which is applied to the eye before the operation. After a waiting time for anesthesia and vascular constriction of at least 8 – 10 minutes, the actual operation begins. By default, we use the Surgitron Dual RF 4.0 radio frequency unit from Ellman for the entire operation (Fig. 2). With its high frequency of 4 MHz, it allows cutting virtually “cold” and thus produces excellent wound edges for complication-free wound healing (Fig. 3). This is important because, as described later, the conjunctives are not sutured. The precision of the cut with this device is extraordinary and usually not possible with a conventional scalpel. A bipolar unit for simultaneous hemostasis is also built into the same device. In our practice, we used to perform this operation with pulsed CO₂lasers. However, the equivalent results do not justify neither the tremendously higher technical effort nor the clearer unmanageability of the laser.

Figs. 4 and 5: Incision of the operation.

Fig. 6: Development of the fat compartments.

The lower eyelid is gently retracted by an assistant using a special Desmarres retractor. We open the conjunctiva with the radiofrequency device over almost the entire length of the lid (Fig. 4 and 5). The distance to the edge of the eyelid is approx. 5-8 mm. One can orientate oneself here at a fictitious border, which is formed by cilliare vessels and becomes clearly visible at the conjunctiva during retraction. After the cut the fat presents itself almost spontaneously. After enlargement of the incision with the blunt mobilization scissors, three fat compartments swell out of their capsules, as on the upper eyelid (Fig. 6).

Fig. 7: Patient before transconjunctival blepharoplasty.

Fig. 8: Patient directly post-op after loewer eyelid lift.

Fig. 9: Same patient 4 weeks after surgery.

Depending on the findings, the surgeon must now decide how much fat is removed from the respective compartments. If there is a risk of hollow eyes, the fat can only be tightened by cauterization [9]. The fat is removed by applying a clamp and setting it down with scissors or better, as with us, with the radio frequency device. Blood vessels are coagulated simultaneously. Afterwards, blood vessels are carefully coagulated with the bipolar unit of the device. Then the clamp is released and the fat retracts automatically into the orbit.

Unlike the upper eyelid blepharoplasty, it is absolutely necessary for an optimal cosmetic result to remove the lateral fat sufficiently, otherwise an unsightly bulge on the lower eyelid will occur after the operation on the lateral cantus. After completion of the fat resection, the retractor is removed and the eyelid is replaced. We completely dispense with wound closure, as the incisions primarily grow over on their own without scar distortion. The risk of retrobulbar bleeding with compression and damage to the optic nerve is also lower than with other surgical methods, as bleeding after the operation can escape unhindered through the incision.

Fig. 10: Patient with pronounced infraorbital fat compartments.

Fig. 11: 4 weeks after transconjunctival blepharoplasty.

After the primary operation it is possible to tighten a minor excess of skin on the lower eyelid from the outside. This can be done with a CO₂laser in low-pulse mode or simply also with the radio frequency device with a special headpiece. The skin on the lower eyelid is shrunk by controlled fractionated micro burns. The healing of the skin is uncomplicated when applied correctly and shows excellent results (Fig. 9). The direct postoperative findings of this procedure are shown in Figure 8.

Discussion

Our own experience and literature reports show that transconjunctival blepharoplasty shows excellent results and high safety with the correct patient selection and equipment. In the literature there are no serious differences in the complication rates between the transdermal and transconjunctival surgical variant. However, our personal impression shows fewer and milder side effects during transconjunctival blepharoplasty. The authors Baylis and colleagues described very early that transconjunctival access significantly reduced the number of cases of postoperative ectropion and its further complications, such as dry eyes [2].

The correct choice of patients remains the most important factor for the success of the operation [5]. Suitable patients have little excess skin or muscle tissue, while unsuitable candidates show significant skin excess, eyelid flaccidity and muscle excess. Patients with eyelid flaccidity require other procedures with additional eyelid tightening. Transdermal access is clearly superior here. In our practice, the proportion of men with the desire for blepharoplasty is constantly increasing. The special anatomy must be considered [6]. The trans-conjunctival approach can also be used on the upper eyelid to correct isolated medial fat hernia without excess skin [7]. However, this operation is still a rarely used method today. Transconjunctival access to the lower eyelid may also be considered as revision surgery if too little of the fatty bodies was removed during previous transcutaneous blepharoplasty.