Journal Logo


Transconjunctival Lower Blepharoplasty through Interrupted Incisions

Pechter, Edward A. M.D.

Author Information
Plastic and Reconstructive Surgery: July 2009 - Volume 124 - Issue 1 - p 166e-167e
doi: 10.1097/PRS.0b013e3181a83aa8
  • Free


It is generally accepted that the short- and long-term complications of the transconjunctival approach to lower blepharoplasty are fewer than with skin-muscle flap techniques.1 Nevertheless, problems have been reported with the technique, including lower lid malposition, diplopia, cysts, and granulomas.2–4

Transconjunctival lower blepharoplasty is usually performed through a single incision extending from the medial to the lateral canthal area, although Metzner5 described separate medial and lateral incisions, leaving an intact bridge of tissue in the middle third. I believe the risks of transconjunctival lower blepharoplasty can be reduced even further by performing it through three short interrupted incisions. I imagine others use this technique, but I was not able to find it described in the literature, and that is the reason for this communication.

The technique is as follows. The conjunctiva and cornea are anesthetized with a few drops of 0.5% tetracaine hydrochloride ophthalmic solution. Then, the conjunctiva is infiltrated through a 32-gauge needle with 1 cc of 0.25% bupivacaine with epinephrine 1:200,000. The globe is covered with a lubricated corneal protector. The lower lid is retracted with a Desmarres retractor and holes are made through the conjunctiva over the anticipated positions of the medial, central, and lateral fat compartments with a needle tip cautery, using the lowest effective power setting in a blended mode. The three holes are situated in the lower third of the conjunctiva, at least 5 mm below the tarsal plate, to allow a retroseptal approach to the fat. The incisions are gently spread with fine tenotomy scissors until the capsulopalpebral fascia is identified. The capsulopalpebral fascia is nicked with the scissors, usually resulting in the redundant fat bulging into the wound (Fig. 1). Ballottement of the eye may facilitate this process. The fat pads are gently retracted, infiltrated with a small additional amount of local anesthetic, and amputated with cautery. Even after these maneuvers, the incisions remain quite small and do not require suturing, although they will allow egress of fluid in case of mild postoperative bleeding (Fig. 2).

Fig. 1.
Fig. 1.:
Excess fat in the medial, central, and lateral fat compartments is shown protruding through small incisions in the conjunctiva and capsulopalpebral fascia. MC, medial canthus.
Fig. 2.
Fig. 2.:
Even after fat removal, the three lower eyelid incisions are very small. As a reference, the Desmarres retractor is 15 mm in width.

Transconjunctival fat removal is usually combined with a “pinch” excision of excess lower eyelid skin and occasionally with a light chemical peel using 30% or 40% trichloroacetic acid. Canthopexy is used very rarely.

Although I occasionally struggle to find a fat compartment, usually when I have not been careful enough in placing an incision, I have never had to resort to a full-length transconjunctival incision. The inferior oblique muscle is sometimes visualized through the medial or middle incision, but this is not an objective of the procedure. Chemosis may occur, but I believe it is less likely than with a full-width incision. Similarly, because there is less disruption of lower lid retractors, the small risk of lower eyelid malposition would seem to be reduced even further. Inadequate or excessive fat excision can occur but, again, is no more likely than with a continuous incision. Overall results have been excellent and problems minimal in using this technique for more than 10 years.

Edward A. Pechter, M.D.

Division of Plastic Surgery

University of California, Los Angeles

25880 Tournament Road, Suite 217

Valencia, Calif. 91355-2844

[email protected]


1. Zarem HA, Resnick JI. Minimizing deformity in lower blepharoplasty. Clin Plast Surg. 1993;20:317–321.
2. Ghabrial R, Lisman RD, Kane MA. Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg. 1998;102:1219–1225.
3. Kavouni A, Stanek JJ. Lower eyelid cysts following transconjunctival blepharoplasty. Plast Reconstr Surg. 2002;109:400–401.
4. Fryer RH, Reinke KR. Pyogenic granuloma: A complication of transconjunctival incisions. Plast Reconstr Surg. 2000;105:1565–1566.
5. Metzner DM. Transconjunctival lower blepharoplasty. Perspect Plast Surg. 1990;4:37.

Section Description


Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2009American Society of Plastic Surgeons