Transconjunctival Retroseptal Lower Eyelid Blepharoplasty for Treatment of the Lid-Cheek Junction Deformity
Johnny T Chang, MD, Erik A Hoy, MD, Patrick K Sullivan, MD
Brown University – Rhode Island Hospital, Providence, RI
Goals/Purpose: 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 both excess lower eyelid fat and the orbicularis retaining ligaments that are the basis for the tear trough and lid-cheek junction deformities. In addition, we frequently perform lateral canthopexy when indicated, and support the lower lid with frost and tarsorrhaphy sutures in the perioperative period. The skin is treated conservatively with skin peels or at most pinch excision when indicated.
Methods/Technique: A retrospective review of consecutive patients who underwent transconjunctival retroseptal lower eyelid blepharoplasty including orbicularis retaining ligament release from 2001 through 2009 was undertaken. To treat the tear trough and lid-cheek junction deformities, the arcus marginalis was dissected off the orbital rim in order to allow subperiosteal access to the orbicularis retaining ligaments. These ligaments were then released, and lower eyelid fat was transposed or grafted into this subperiosteal space in order to prevent reattachment. This fat was secured to the periosteum with an internal running suture, without use of external skin sutures. In order to reduce the risk of ectropion, we frequently performed lateral canthopexies. Frost and tarsorrhaphy sutures were routinely used to reduce the risk of lid malposition and chemosis. Complications including revisions, lid malposition, and ectropion were compiled.
Results/Complications: A total of 335 consecutive patients were reviewed. There was one case of retrobulbar hematoma treated with lateral canthotomy, without postoperative sequelae. Four patients underwent revisional surgery due to under-resection, most commonly in the lateral compartments. There were no cases of lower lid hematoma, seroma, or infection. Most notably, there were no cases of ectropion. Representative pre- and postoperative photographs are presented.
Conclusion: Transconjunctival retroseptal lower eyelid blepharoplasty with orbicularis retaining ligament release and fat transposition is an effective, safe, and reliable method of correcting the tear trough and lid-cheek junction deformities. Based on our experience, three types of patients were identified requiring progressively more extensive procedures. We present our technique, key factors in avoiding problems including ectropion, and a classification system that can be used to guide treatment of these lower eyelid deformities.
