Discussion: Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution

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The authors Wong and Mendelson present their experience with transconjunctival lower eyelid blepharoplasty using a case series of 54 patients. They describe an extended approach that offers better results by addressing the tear trough deformity and smoothing the lid-cheek junction. Although similar less invasive transconjunctival approaches have been described,1,2 the authors provide an excellent detailed description of the underlying anatomy and technique. This presep tal approach includes releasing the palpebral and orbital origins of the orbicularis oculi from the orbital rim, and releasing the “tear trough ligament” medially and the orbicularis retaining ligament laterally. To more easily enter the preseptal space, the incision is lowered 2 mm below the tarsus. The most significant difference from the traditional approach, however, is the ability to transpose or perform fat grafting in an open technique directly under the tear trough ligament. This provides the advantage of improved visibility and direct control of volume compared with closed fat grafting, which has been associated with increased complications.3
This is a particularly timely article because of the growing interest in nonsurgical and surgical techniques for lower lid rejuvenation. In the style to which we have become accustomed from Dr. Mendelson’s group, there is an excellent description of the anatomy of the tear trough and the inferior orbital area. The tear trough deformity is the concavity that runs diagonally below the medial canthus, and it is a major contributor to lower lid aging. What is termed the tear trough ligament in this article has also been described as the orbital malar ligament4 and the orbicularis retaining ligament.5 This structure is a true osteocutaneous ligament originating from the periosteum, and it is located between the preseptal and orbital portions of the orbicularis oculi muscle. The orbital portion of the muscle is in the same plane as the superficial musculoaponeurotic system. The ligament, like other retaining ligaments of the face, inserts into the dermis.6 Patients with a visible tear trough deformity often have a paucity of subcutaneous tissue in this area, which makes the addition of volume critical for an aesthetic correction of the hollowing. Lower blepharoplasty techniques with a skin-muscle flap or transconjunctival fat removal often make the tear trough worse because the volume deficit is not addressed or orbital fat is overresected without release of the tear trough. Figures 1 and 2 show excellent representations of this anatomy. The article thus describes an extended transconjunctival approach that can be used to treat the tear trough deformity and, according to the authors, has the added advantage of less recovery time. Of note, patients in this case series had a mean follow-up of 10 months, with a 5 percent revision rate and a low complication rate. There were no cases of chemosis, prolonged swelling, eyelid retraction, or ectropion.
It is worth noting, however, that even an “extended” transconjunctival blepharoplasty does not address lower lid laxity, prominent eyes, or canthal position. This is demonstrated in Figure 10 in an older male patient with preoperative scleral show and orbital hollowing. Although the tear trough was improved with the extended transconjunctival approach, use of this technique resulted in rounding of his eye shape, imparting a “surprised” or “startled” appearance. Preservation or creation of lower lid shape is critical in all blepharoplasty techniques. A change in the eyelid shape can, and often does, occur after less invasive transconjunctival blepharoplasty. The complications include postoperative scleral show and ectropion. Therefore, it is often helpful to analyze the shape of the eye before and after surgery, particularly the shape of the lateral scleral triangle.

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