What are the steps involved in a lower blepharoplasty procedure?

Lower Blepharoplasty Procedure Steps

Lower blepharoplasty is a surgical procedure that requires careful planning and execution to achieve optimal aesthetic results while minimizing complications such as diplopia, ectropion, and bleeding.

Preoperative Assessment

• Comprehensive ocular history: Evaluate for dry eye symptoms, previous eye surgeries, and ocular comorbidities 1
• Visual function assessment: Measure visual acuity with current correction at distance and near 2
• External examination: Assess eyelid position, lashes, lacrimal apparatus, tear function, and pertinent facial features 2
• Ocular alignment and motility: Perform cover/uncover test to identify pre-existing strabismus 2
• Slit-lamp examination: Evaluate eyelid margins, tear film, conjunctiva, cornea, and anterior chamber 2
• Specific lower eyelid evaluation:
  • Lower eyelid position and laxity
  • Presence of fat pseudoherniation
  • Tear trough deformity
  • Malar descent
  • Skin texture changes
  • Festoons or malar bags 3

Surgical Approaches

1. Transcutaneous Approach

Steps:

1. Mark the incision line: Place 2-3mm below the lash line, extending from the punctum to the lateral canthus 4
2. Local anesthesia: Administer 1-2% lidocaine with epinephrine (1:100,000) 5
3. Skin incision: Make the incision along the marked line using a #15 blade or CO2 laser 5
4. Skin-muscle flap dissection: Create a skin-muscle flap by dissecting in the preseptal plane down to the orbital rim 4
5. Fat management:
   • Identify the three fat compartments (medial, central, lateral)
   • Open the orbital septum to expose the fat pads
   • Conservatively excise or reposition fat to address bulging 3, 6
6. Fat transposition (if indicated): Mobilize the medial and central fat pads and secure them to the periosteum to fill the tear trough 6
7. Orbicularis suspension: Suspend the orbicularis muscle to the lateral orbital rim to improve lower lid tone 3
8. Lateral canthal support: Perform lateral canthopexy or canthoplasty to prevent postoperative lid malposition 5, 7
9. Skin excision: Remove excess skin conservatively while avoiding tension 7
10. Wound closure: Close with fine sutures (6-0 or 7-0) 5

2. Transconjunctival Approach

Steps:

1. Corneal protection: Insert a corneal shield or apply lubricant 5
2. Local anesthesia: Infiltrate the lower eyelid and conjunctiva 5
3. Lid eversion: Evert the lower eyelid using a Desmarres retractor 4
4. Conjunctival incision: Make an incision through the conjunctiva 4mm below the tarsus 3
5. Fat identification: Identify and expose the three fat compartments 3
6. Fat management: Conservatively excise or reposition fat pads 3, 6
7. Fat transposition (if indicated): Secure the mobilized fat pads to the periosteum at the tear trough 6
8. Conjunctival closure: Close with absorbable sutures or leave open to heal by secondary intention 3
9. Skin management: If needed, perform a separate skin pinch excision or laser resurfacing 3, 4

Postoperative Care

• Head elevation: Keep head elevated for the first 48-72 hours 1
• Cold compresses: Apply intermittently for the first 48 hours to reduce swelling and ecchymosis 1
• Corneal protection: Use lubricating eye drops and ointment, especially at night 5
• Activity restriction: Avoid strenuous activity for 2 weeks 1
• Suture removal: Remove skin sutures after 5-7 days 5

Complication Prevention

• Bleeding: Ensure meticulous hemostasis using electrocautery before wound closure 1, 7
• Ectropion/retraction: Perform conservative skin excision and provide lateral canthal support 7
• Diplopia: Avoid trauma to the inferior rectus muscle during lower lid dissection 2, 1
• Dry eye: Identify patients at risk preoperatively and use aggressive corneal lubrication postoperatively 5
• Retrobulbar hematoma: Monitor for acute pain, proptosis, or vision changes; this is a surgical emergency requiring immediate intervention 1

Approach Selection

Transcutaneous approach is preferred when:

• Significant skin excess is present
• Orbicularis muscle hypertrophy needs addressing
• Extensive fat repositioning is planned 6

Transconjunctival approach is preferred when:

• Minimal skin excess is present
• Fat is the primary concern
• Patient is younger with good skin tone
• Risk of postoperative ectropion is high 3, 4

By following these systematic steps and selecting the appropriate approach based on patient characteristics, optimal aesthetic and functional outcomes can be achieved while minimizing complications.