Transconjunctival Lower Blepharoplasty
3 December 2019 onur
The outer surface of the lower eyelid is covered with skin, and the envelope covering the inner surface is called the “conjunctiva”. Transconjunctival lower blepharoplasty is a surgical approach in which we cross the back layers of the eyelid with an incision on the inner surface of the lower eyelid and reach the fat bags under the eyes.
In this approach, we can only deal with fat. Fat can be removed or spread into the tear trough under the eye. Since no incision is made on the skin during surgery, there will be no externally visible scar. Its scar-free nature is one of the key advantages of this method. Another advantage is that complications such as the lower eyelid pulling down (retraction/scleral show) or turning outward (ectropion) due to excessive skin removal or exaggerated healing on the surface where the skin is taken are rarely seen in this technique. Since there are no sutures, there is no need to remove them. Patients generally recover faster than open eyelid surgery. In addition, swelling and bruising are less common, but there are of course exceptions.
In this technique, since no incision is made on the skin, excess skin cannot be removed, and the looseness/sagging/wrinkling of the skin cannot be corrected. Therefore, this technique is a suitable method for patients at the young age group, where there is no loosening of the skin yet, but the under-eye bags due to congenital skeletal structure become evident at a relatively early age. We typically perform this surgery in the late 20s and 30s, but the transconjunctival approach is a surgical technique that we use frequently in older ages. This approach may be preferred in the elderly patient group, especially male patients, whose bags are prominent and who are at high risk for postoperative lower eyelid complications.
It is frequently required to combine transconjunctival lower eyelid surgery with microfat tissue transfer under the eye. Since the bags under the eyes herniate forward before the surgery, they act like a mass that takes up space under the eyelid. At some point, this mass starts to act like a Pilates ball that supports the lower eyelid from below. Herniated under-eye fat pads camouflage the bone structure, which is often backward/weak compared to the eyes. In the transconjunctival approach, when we reduce the bags under the eyes, this space empties and a state of relative collapse appears under the eye around month 6. The microfat tissue procedure is performed to support the superficial fat pad called SOOF, which covers the bone and softens the transition from cheek to under-eye.
It is not required to transfer fat tissue during the surgery. This can always be done later in clinical conditions. At that point, the decision should be made according to the length of the expected process of recovery from the procedure. If not combined with fat tissue transfer, the operation site heals much faster and it is possible for the patient to return to social life typically within 5-7 days. When combined with fat tissue transfer, this period can be extended up to 10-14 days.
It would be no exaggeration to say that the transconjunctival approach requires microsurgery training. Manual precision should equal that in microsurgery. Most of the time we work with the help of magnifying glasses. The reason for this precision is the necessity to see the vascular network surrounding the under-eye fat pads and to work without bleeding those vessels. When these vessels bleed, they may cause stiffness, minor asymmetries and adhesions in the under-eye tissues that last for 3-6 months. Almost all of these are temporary in nature, but we still do not want an operation that is expected to heal in 1-2 weeks and causes trouble for the patient up to 1-2 months. Therefore, it is not an operation that every surgeon can perform. Unfortunately, the transconjunctival approach is not an operation that is included in the curriculum of every plastic surgery education institution and is thus not performed by many plastic surgeons. I try and explain this approach at congresses to contribute to its dissemination. That is because this surgery provides clear and measurable results.
In the last 5 years, under-eye fillers have become very popular and have been used in an off-label manner. Practitioners have sprung up, filling the left and right side of the bag to camouflage huge under-eye bags. These are completely wrong. Why? Because a person who knows the formation mechanisms of under-eye bags also knows that they cannot be removed with fillers. On my blog, I have a relevant post titled “How are under-eye bags formed and how should they be treated?” I suggest you take a look at it.
If you are complaining about under-eye bags, if you know that you had them even when you were a child, if people around you ask silly questions such as “Are you so tired? Have you had alcoholic beverages? Did you abuse any substances?”, if there is not an evident skin or muscle relaxation in your lower eyelid, if evident wrinkles and skin folds have not formed, then you may be a suitable candidate for transconjunctival lower eyelid surgery.
Take good care…
… of yourself and your beauty.