Lower blepharoplasty II — Step-by-step technique and rationale

Before starting: positioning, anaesthesia and protection

The surgeon stands at the head of the patient, not to one side: from there both lids are seen symmetrically and can be compared as work proceeds. Before any infiltration, topical tetracaine drops are instilled with the eyes closed, anaesthetising the conjunctiva and making the rest tolerable. Infiltration uses articaine with adrenaline and serves two purposes at once: anaesthesia and hydrodissectionThe infiltration itself separates the planes, easing later dissection and reducing bleeding. Wait the seven or eight minutes adrenaline needs to work; starting earlier is the commonest cause of a bleeding field that then forces excessive cautery. The cornea is always protected, with a shell or a tarsal stitch that doubles as traction, and the globe is displaced backwards with the fourth finger to expose the fornix.

Instruments and role allocation

Retroseptal or preseptal?

Retroseptal transconjunctival — sequence

1. 1. Preparation→Topical tetracaine with eyes closed. Globe pressure with the 4th finger, tarsus retracted with Desmarres
2. 2. Anaesthesia→Articaine with adrenaline into the three compartments and conjunctiva; subciliary skin subcutaneously
3. 3. Incision→Conjunctiva continuously; then capsulopalpebral fascia with 3 cuts, one per compartment, where prolapse is greatest on pressure
4. 4. Traction→Prolene stitch in conjunctiva, mosquito hanging over gauze towards the patient’s head
5. 5. Compartments→Retract each pad, anaesthetise, clamp with mosquito, cut with scissors and coagulate the pedicle stump
6. 6. Closure→Only one inverted simple 5/0 Vicryl stitch in the lateral aponeurosis, to prevent ectropion

The three compartments, one by one

The central compartment is approached first because it is the most accessible and orients the rest of the dissection. The medial lies inside the inferior obliqueMuscle crossing between the medial and central compartments; injury produces double vision on upgaze and is paler and more fibrous: it must be sought deliberately, since it is the one most often left residual and later seen as a persistent medial bulge. The lateral is the hardest to find; it is reached by shifting the retractor outward, and in many cases does not need removing. Each pad is handled the same way: retract gently, infiltrate a little more anaesthetic into the pedicle itself, clamp with a mosquito, cut in front of the clamp and coagulate the stump before releasing it. That order is not arbitrary. Release an uncoagulated pedicle and it retracts into the orbit, where the bleeding is no longer accessible: this is the exact mechanism of retrobulbar haematoma.

Subciliary skin pinch and associated peel

With two Adson forceps or bayonet forceps the pinch is performed at the subciliary level and the excess skin resected with scissors. Stretching the cheek skin exposes the incision for coagulation. Closure runs medial to lateral with a running 5/0 prolene, 5/0 silk or 5/0 express catgut suture. Where rhytidosis is also present, an infraorbital 35% trichloroacetic acid peel applied with a cotton bud replaces a larger skin resection with considerably less ectropion risk: it is the preferable alternative whenever the temptation would be to resect more skin. The area turns white and desquamates in the first week; petrolatum once daily for two weeks is indicated.

Fat transposition: what is being done and why

Transposition is not about moving fat somewhere else: it is about filling a groove that is tethered to bone. While the tear trough ligamentFibrous band joining bone directly to skin; while intact, no amount of fat placed above will blur the groove remains inserted, any fat laid over it sits behind the groove and does not correct it. Hence the sequence is always release first, fill second: cautery incision at the septum–periosteum junction, subperiosteal dissection over the rim and release of the retaining ligaments until a real pocket exists. The central compartment fat is lifted off the inferior oblique keeping its vascular pedicle — it is a pedicled flap, not a free graft — and brought into that pocket. Fixation with double-armed 4/0 prolene exiting through the cheek serves to hold it in place while it heals, not to secure it indefinitely, and tension should be just enough for the fat to rest in position: over-tightening produces a visible cheek bulge that takes months to settle.

Fat transposition (preseptal) — what changes

1. Anaesthesia→Add an infraorbital nerve block via the transconjunctival route
2. Incision→Subtarsal conjunctiva, sliding anterior to the septum to the orbital rim; dissect with cotton buds to bone
3. Compartments→Resect medial and lateral. The central is dissected off the inferior oblique and drawn towards the malar without dragging conjunctiva
4. Maxillary pocket→Electrocautery incision at the septum-periosteum junction and subperiosteal dissection releasing the retaining ligaments
5. Fixation→Double-armed 4/0 prolene through the fat with its septum, exiting through the cheek and tied to the required tension
6. Closure→4/0 Vicryl, three inverted stitches in the capsulopalpebral fascia, with particular attention to the lateral one

Subciliary route: why it is the exception, not the rule

The subciliary route is the one most used historically and also the one that has produced the most ectropion. The reason is mechanical: the incision crosses the anterior lamella and, on healing, that lamella shortens and pulls the lid margin down. It is therefore reserved today for the one scenario that justifies it — abundant lax skin together with orbicularis hypertrophy — and always accompanied by three precautions. The incision runs 2 mm from the margin and only to the mid-pupillary line, extending laterally along a natural crease rather than continuing straight. Dissection begins in the subcutaneous premuscular plane for the first few millimetres and only then crosses the orbicularis, leaving a strip of pretarsal muscle intact and preserving its innervation. And closure always includes orbicularis resuspension to the lateral rim periosteum and canthopexy: in this route these are not optional, they are what offsets the traction the scar itself will exert.

Subciliary approach — when and how

1. Indication→Only when there is a large amount of lax skin to resect. Avoided in all other cases
2. Corneal protection→4/0 silk tarsal stitch or protective shell; the stitch also serves for traction
3. Incision→Along the lateral crease from the outer canthus with a cold blade; subciliary 2 mm from the margin, only to the mid-pupillary line
4. Dissection→Subcutaneous premuscular plane with curved Iris scissors; then through the orbicularis to bone
5. Resuspension→Orbicularis fixed to lateral orbital rim periosteum with 5/0 Vicryl: gives an infraorbital lifting effect
6. Closure→Lateral canthopexy, conservative skin resection and simple 6/0 silk stitches

Checks before closing