Complications were rare. One patient had a corneal abrasion from inadequate lubrication with the use of the metal eye shield that resolved completely within 24 hours. One patient had a tiny bulge from a small hematoma around the inferior oblique muscle that resolved spontaneously. No chemosis, prolonged swelling, lower eyelid retraction, or ectropion was seen in any patients. Five patients (9 percent) complained of palpability/lumpiness of the grafted fat in the initial postoperative period. All resolved spontaneously within 4 to 8 weeks.
Conventional transconjunctival lower eyelid blepharoplasty techniques are generally effective for younger patients with true eye bag fat excess. When more significant aging changes are present (with prominence of the lid-cheek junction, tissue descent, and skin laxity), many authors prefer the transcutaneous approach, incorporating some form of cheek lift into the procedure.21–27 However, there is a large group of patients with milder aging changes, prominent eye bags, a significant tear trough deformity, and orbital rim indentations that may be treated with the “extended” transconjunctival approaches, with excellent aesthetic results.8,10,14 The transconjunctival approach as described here is a version of the extended technique, using recent understanding of the retaining ligaments and facial soft-tissue spaces of the midcheek to perform the surgery in an effective and anatomically logical manner.
Release of the tear trough ligament is a key maneuver in rejuvenation of the midcheek.19,27–29 The importance of this maneuver may be clearly demonstrated in patients whose appearance becomes “less attractive” when they smile. These are typically patients with hypertrophic orbicularis oculi, small eye bags at rest, and maxillary retrusion. With animation, strong contraction of the periorbital muscles squeezes the retro-orbital fat pads forward and medially against the tightly fixed tear trough ligament, increasing the bulging of the eye bags and prominence of the tear trough deformity. Removal of the eye bags alone, which has the effect of reducing the bulge, offers only a partial solution. With release of the tear trough ligament and orbicularis origins, the tethering effect is significantly eliminated and the dynamics of the smile are changed. This change in vectoring of the action of the orbicularis oculi gives a more relaxed and aesthetically pleasing smile (Fig. 11, below).
The postseptal variant of the transconjunctival approach provides the most direct access to the retroseptal fat pads, making fat excision easier and quicker, and is therefore the preferred approach for techniques that focus on fat excision.6,30–32 In contrast, the preseptal variant is the preferred plane of dissection to access the midcheek.33 The preseptal space (preseptal dissection plane), like other facial soft-tissue spaces in the face, can be bluntly opened to its inferior boundary, formed by the origins of the orbicularis oculi medially and the orbicularis retaining ligament more laterally. Key landmarks, the arcus marginalis and the origins of the orbicularis oculi just inferior to it, are easily located once the preseptal space is fully opened. In addition, the orbital fat pads do not prolapse into the operative field thereby obscuring visibility in this tight area, as tends to be a problem with the retroseptal approach. Significantly, as demonstrated by Schwarcz et al., the retroseptal and preseptal approaches in transconjunctival blepharoplasty have similar low complication rates.34 To preferentially enter the preseptal space, the transconjunctival incision is located farther from the fornix, approximately 2 mm below the tarsus as described above.32
When the preseptal space is fully opened and with the orbicularis under tension, the muscle (and the closely associated tear trough ligament) is released, staying close to the anterior maxilla while applying upward retraction on the tear trough ligament. This is important, as the blood vessels (the angular vein and artery) are located in close relation, on the underside of the orbital part of the orbicularis oculi close to its origin, and therefore need to be lifted out of the way of the dissection.20 The extent of the release is determined preoperatively, by marking the indent of the tear trough deformity and its lateral extension as the palpebromalar groove. With the right eye as a reference, this release usually extends from the 4-o’clock to the 8-o’clock position (Fig. 12). Medially, the release should not extend medial to the 4-o’clock position, as in this area the angular nerve (which innervates the inner canthal orbicularis, glabella, and procerus) and the angular artery and vein become very closely associated with the tear trough ligament and are at risk of injury.35 Release of the more lateral part of the orbicularis retaining ligament, beyond the 8-o’clock position, is rarely necessary.
To prevent reattachment of the ligament to the anterior maxilla and to correct retrusion of the maxilla here, fat excised from the “eye bags” is placed under the tear trough ligament as free fat grafts. Free fat grafting of the excised orbital fat, in contrast to fat flap transposition through the transconjunctival approach,36 has several advantages. An inherent difficulty with the fat flap transposition is matching the two separate but linked objectives of fat bag reduction of the lid with the maxillary augmentation below. In the free fat grafting technique, the surgeon first obtains the correct lid contour by precise removal of the excess orbital fat. Then, separately, excised fat of the appropriate amount is grafted to the precise positions indicated under the tear trough ligament and upper part of the premaxillary space. It is technically easy to perform this even through the 15-mm transconjunctival incision. The free fat grafting approach has been used effectively by Marten in transblepharoplasty corrugator resection surgery in preventing volume loss and reattachment of the divided corrugators.37 The long-term viability of the free fat grafts can be seen in our long-term results.
Patient selection is an important consideration. Figure 6 shows an ideal candidate for this procedure. These are younger patients with aging changes occurring primarily over the medial midcheek, with eye bags, a prominent tear trough deformity, and maxillary retrusion. The wide bizygomatic width, with good support provided by the strong body of the zygoma, is responsible for the minimal descent of the cheek soft tissues, negating the need for a midcheek lift, which is the main advantage of the transcutaneous approach.21–27 In patients with more significant maxillary retrusion (as demonstrated in the patient shown in Fig. 7), additional midcheek augmentation with fat grafting would be needed to give a more profound rejuvenation. Figures 9 and 10 demonstrate the use of this technique in older patients with moderate and significant skin laxity, respectively. As shown here, the procedure delivers a level of results that is very satisfying.
The transconjunctival approach offers a safe access to the lower eyelid. Our extended transconjunctival technique, using the concept of dissecting through the facial soft-tissue spaces of the midcheek with precise release of the retaining ligaments that separate them, is effective in rejuvenating the upper midcheek, with correction of tear trough deformity and eye bags while minimizing bruising, swelling, and downtime.
Patients provided written consent for use of their images.
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