Transconjunctival Retroseptal Lower Eyelid Blepharoplasty with Treatment of the Lid Cheek Junction While Avoiding Ectropion
Johnny Chang, MD, Erik A. Hoy, Patrick K. Sullivan, MD.
Brown University - Rhode Island Hospital, Providence, RI, USA.
Lower eyelid blepharoplasty is a technically challenging procedure that carries significant risk of adverse outcomes including ectropion.
Our technique most importantly avoids disruption of the middle lamella with a transconjunctival retroseptal approach to the lower eyelid fat compartments and lid cheek junction. Through this incision alone, we can safely and effectively address the arcus marginalis, and lower lid retaining ligaments when necessary. A skin pinch technique for removal of excess lower eyelid skin is used when indicated.
The purpose of this study was to
1. To delineate the findings requiring orbital fat resection, arcus marginalis release and draping of fat over the infraorbital rim, or selective fat injection in the lower lid.
2. Use what we have learned to help surgeons optimize results while avoiding the possible complications of lower eyelid surgical procedures.
A retrospective chart review was conducted of 335 consecutive patients who underwent correction of lower eyelid deformities using a transconjunctival approach addressing the lid cheek junction abnormalities when indicated through the same incision. To treat tear trough and lid-cheek junction contour deformities, the arcus marginalis was dissected off the inferior orbital rim, the lower lid / cheek retaining ligaments were released as needed, and fat was redraped inferiorly to fill the contour abnormality, prevent reattachment and recurrence. In select patients the fat was internally sutured in place to the undersurface of the periosteum overlying the orbital rim.
A total of 58 patients underwent fat grafting to the tear trough region. Frequently a lateral canthopexy was performed to reduce the risk of postoperative ectropion. Delayed intraoperative snap test was an indicator for lateral canthopexy. In every patient, a modified tarsorrhaphy suture was temporarily placed to decrease the risk of chemosis. From a review of the electronic medical records demographic data, presense or absence of complications, and the manner of securing transposed fat in the lower lid was collected.
In total, 335 patients were retrospectively reviewed. No patients developed postoperative ectropion. Four patients returned to the operating room for additional fat removal. Hematoma, seroma, and cellulitis were also not encountered. This measured technique specifically designed to treat each anatomic deformity resulted in effective and safe aesthetic rejuvenation of the lower lid-cheek junction. Representative pre- and postoperative photographs are presented.
Transconjunctival retroseptal lower eyelid blepharoplasty with redraping and internal suture fixation of vascularized fat is a safe, reliable, effective, and durable method of correcting lower eyelid and lid-cheek junction deformities. No ectropion was encountered in 335 patients over the last 8-years using these techniques, judicious use of lateral canthopexy, and perioperative Frost and tarsorrhaphy sutures.
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