23 Lower Eyelid Blepharoplasty - Facial plastic surgeon in San Diego

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276 II Aesthetic Facial SurgeryFig. 23.6 Transconjunctival approach to lower eyelid fat pockets.Simultaneous eversion of the lower eyelid and ballottement of theglobe produces a bulge of orbital fat that helps to guide the dissection.(From Baylis HI, Long JA, Groth MJ. Transconjunctival lowereyelid blepharoplasty: technique and complications. Ophthalmology1989;96:1027.)found that this is usually not necessary and may lead tounnecessary bruising.The upper lid is placed over the globe to protect it. Either aguarded needle-tip bovie on a low setting or a no. 15 bladeis used (others prefer a laser) to make the transconjunctivalincision 2 mm below the inferior edge of the inferior tarsalplate. This inferior tarsal edge appears gray through theconjunctiva. The medial aspect of the incision is in line withthe inferior punctum. The incision is carried just 4 to 5 mmshy of the lateral canthus.Immediately after the transconjunctival incision ismade, a single 5–0 nylon suture is placed in the conjunctivaclosest to the fornix and used to retract the posteriorlamella over the entire cornea (Fig. 23.8). Mosquitossnapped onto the patient’s headwrap are used to hold thesutures under tension. The conjunctiva acts as a naturalcorneal protector and the superior retraction allows foreasier plane dissection. The two skin hooks are then carefullyremoved and a Desmarres retractor is now used toevert the free edge of the lower lid (Fig. 23.9).The distance of the transconjunctival incision fromthe inferior edge of the inferior tarsal plate determineswhether one will approach the orbital fat preseptallyor postseptally. 16 We usually utilize the preseptal approach;therefore, our incisions are always 2 mm below the tarsus.The preseptal plane is an avascular plane between theorbicularis oculi and the orbital septum. 22 Because the orbitalseptum is still intact while the preseptal plane is beingdeveloped, orbital fat does not bulge into one’s view. Thevisualization obtained is closely similar to the orientationone is used to having when performing a skin–muscleQ1IncisionAfter waiting a full 10 minutes for vasoconstriction tooccur, the lower lid is gently retracted by an assistant usingtwo small, double-pronged skin hooks (Figs. 23.6 and 23.7).Fig. 23.7 The needle-tip bovie is poised to initiate the incision. (A cornealprotector, or upper lid skin, is used for protection when the actual incisionis made.)Fig. 23.8 Retraction suture in place; cotton-tipped applicator spreadsincision site.
23 Lower Eyelid Blepharoplasty 277Fig. 23.9 Desmarres retractor exposes orbital septum.flap blepharoplasty. The orbital septum will still have tobe opened to access the orbital fat below (Fig. 23.10).Others prefer the postseptal approach to the orbitalfat. 19 To directly access the fat pads the conjunctiva isincised 4 mm below the inferior border of the inferiortarsal plate and directly toward the anterior edge of theinferior orbital rim. The big advantage of this method is thatthe orbital septum is kept completely intact. Proponentsfor this technique state that the intact orbital septumadds to the support of the lower eyelid. One disadvantageis that the orbital fat immediately bulges into one's view.Care must be taken not to incise close to the conjunctivalcul-de-sac to avoid the risk of synechiae. 16 Also, the viewfrom the direct approach is one to which most facial plasticsurgeons are less accustomed.After the 5–0 suture retraction and Desmarres retractorare in place, the preseptal plane is developed with a combinationof blunt dissection with a cotton swab and sharpdissection with scissors. It is mandatory to maintain a drysurgical field. Therefore, a bipolar cautery, “hot loop,” ormonopolar cautery is used to cauterize any bleeders.The medial, central, and lateral fat pads are each individuallyidentified through the septum with the help ofsome gentle digital pressure on the conjunctiva coveringthe globe. The orbital septum is then opened with scissors.Using forceps and a cotton-tipped applicator, the excess fatis carefully teased above the orbital rim and septum. Caremust be taken to remove only the excessive and herniatedfat because the eyes may take on a hollowed-out appearancefollowing excessive fat excision. The ultimate goalis to achieve a lower eyelid contour that forms a smooth,gentle concave transition between it and cheek skin.A 30 gauge needle is then used to inject a small amountof local anesthetic into the excess fat (Fig. 23.11). The bipolarcautery is used to cauterize across the fat stalk. Whenone is sure the entire stalk has been cauterized, scissors areused to cut across the cauterized area. Others, notably Cook,reduce fat volume with electrocautery, minimizing surgicalexcision. Many surgeons feel that the lateral fat pocketshould be explored initially because its volume contributionbecomes more difficult to assess after removal of its adjacentand interconnected central fat pad. 11,23 After excessfat has been removed from each compartment, the field isexamined to make sure there is no bleeding. Although CO 2laser fat excision has been advocated based on the advantagesof hemostatic efficiency, precision, and reduced tissuetrauma, the increased costs, requirements for highly trainedpersonnel, and additional laser precautions have led us andothers to abandon laser incisions for lower lid surgery. 24,25Fig. 23.10 Fat appearing through orbital septum.Fig. 23.11 Fat of medial compartment, partially excised.
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23 Lower Eyelid Blepharoplasty - Facial plastic surgeon in San Diego

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