Lower blepharoplasty II — Step-by-step technique and rationale
Retroseptal transconjunctival, preseptal fat transposition and subciliary approach: full sequence, instruments and the reason behind each step.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Surgeon positioned at the patient’s head. Topical tetracaine drops before infiltrating.
- Retroseptal for simple resection; preseptal when transposing fat into the tear trough.
- Inverted 5/0 Vicryl stitch in the lateral aponeurosis: this is the manoeuvre that prevents ectropion.
- The fat pedicle is always coagulated before release: retroseptal bleeding is the serious complication.
Instruments and role allocation
| Stage | Primary surgeon | Assistant |
|---|---|---|
| Conjunctival approach | Jaeger retractor + Colorado-tip electrocautery | Desmarres retractor |
| Subciliary skin pinch | Two Adson forceps or bayonet forceps + Converse or Iris scissors | Traction and haemostasis with cotton buds |
Retroseptal transconjunctival — sequence
- 1. PreparationTopical tetracaine with eyes closed. Globe pressure with the 4th finger, tarsus retracted with Desmarres
- 2. AnaesthesiaArticaine with adrenaline into the three compartments and conjunctiva; subciliary skin subcutaneously
- 3. IncisionConjunctiva continuously; then capsulopalpebral fascia with 3 cuts, one per compartment, where prolapse is greatest on pressure
- 4. TractionProlene stitch in conjunctiva, mosquito hanging over gauze towards the patient’s head
- 5. CompartmentsRetract each pad, anaesthetise, clamp with mosquito, cut with scissors and coagulate the pedicle stump
- 6. ClosureOnly one inverted simple 5/0 Vicryl stitch in the lateral aponeurosis, to prevent ectropion
Details that prevent problems
- The lateral compartment is hardest to find and sometimes does not need removing.
- Medial and central are separated by the inferior oblique: identify it before retracting.
- The septal opening is not sutured: only the lateral aponeurosis.
- Haemostasis with cotton buds before considering the field finished.
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 (preseptal) — what changes
- AnaesthesiaAdd an infraorbital nerve block via the transconjunctival route
- IncisionSubtarsal conjunctiva, sliding anterior to the septum to the orbital rim; dissect with cotton buds to bone
- CompartmentsResect medial and lateral. The central is dissected off the inferior oblique and drawn towards the malar without dragging conjunctiva
- Maxillary pocketElectrocautery incision at the septum-periosteum junction and subperiosteal dissection releasing the retaining ligaments
- FixationDouble-armed 4/0 prolene through the fat with its septum, exiting through the cheek and tied to the required tension
- Closure4/0 Vicryl, three inverted stitches in the capsulopalpebral fascia, with particular attention to the lateral one
Subciliary approach — when and how
- IndicationOnly when there is a large amount of lax skin to resect. Avoided in all other cases
- Corneal protection4/0 silk tarsal stitch or protective shell; the stitch also serves for traction
- IncisionAlong the lateral crease from the outer canthus with a cold blade; subciliary 2 mm from the margin, only to the mid-pupillary line
- DissectionSubcutaneous premuscular plane with curved Iris scissors; then through the orbicularis to bone
- ResuspensionOrbicularis fixed to lateral orbital rim periosteum with 5/0 Vicryl: gives an infraorbital lifting effect
- ClosureLateral canthopexy, conservative skin resection and simple 6/0 silk stitches
On skin suture in the subciliary approach
6/0 silk in simple stitches is preferred: its similarity to the eyelash hair itself makes it less bothersome for the patient than other sutures in this location. And a general caution for this approach: skin resection must be deliberately conservative, because this is where the cicatricial ectropion that later forces reoperation is generated.
References
- 1.Nassif PS. Lower blepharoplasty: transconjunctival fat repositioning. Facial Plast Surg Clin North Am. 2005;13(4):553-559.
- 2.Gurtner GC, Neligan PC, editors. Plastic Surgery. Volume 2: Aesthetic Surgery. 4th ed. Edinburgh: Elsevier; 2018.
Related specialty: Blepharoplasty