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Topic 17 - 1
Lower Blepharoplasty:
Main Surgical Approaches
browplasty photo   transconjunctival lower blepharoplasty

"When a lot of remedies are suggested for a disease, that means it cannot be cured."

-- Anton Chekhov

Cosmetic reshaping of the lower eyelid can be accomplished using a surprisingly diverse assortment of very different surgical approaches, each of which is described in the next several chapters. Some doctors prefer one particular approach; some prefer quite another. What follows is an overview with links to more details:


Lower Eyelids are Harder

Regardless of which technique is employed, achieving a flawless outcome with lower blepharoplasty is less likely than with upper blepharoplasty. Why?

• Gravity and the weight of the cheek

• The difficulty of gauging how much fat to remove or reposition

Transcutaneous lower blepharoplasty

Transcutaneous means "across the skin." The term has particular importance in blepharoplasty when used to indicate how an eyelid surgeon approaches the deeper orbital fat during removing of lower lid fat bags. Older forms of lower blepharoplasty still in wide use employ a transcutaneous approach.

Popular since the 1950s, this version of lower blepharoplasty is based upon a skin incision made just below the lashes and extending most of the way across the eyelid and then slightly past the outer corner. From there, the dissection is carried into the eyelid's interior, where, depending upon the patient's findings, the rest of operation occurs.

Because of the operation's invasive nature and internal scarring, there is a high rate of significant complications, the most common of which is lower eyelid retraction, or a pulling down of the lower eyelid after blepharoplasty.

The transcutaneous approach is sometimes referred to as the "anterior" or "skin approach" to lower eyelid blepharoplasty.

Learn more about transcutaneous lower blepharoplasty >

Before and After Photos
Lower Blepharoplasty

Transconjunctival lower blepharoplasty

Tranconjunctival means "across the conjunctiva," which is the name of the tissue layer covering the back or inside surface of the eyelids. When orbital fat to be removed during lower eyelid blepharoplasty is approached through an incision made along the lid's inside surface, the operation is known as transconjunctival lower blepharoplasty.

Transconjunctival lower blepharoplasty offers many advantages over the transcutaneous approach with respect to safety and precision. The same type of incision can be employed to significant advantage in many other types of cosmetic and reconstructive eyelid and orbital plastic surgery operations.

The transconjunctival approach is sometimes referred to as the "posterior" or "conjunctival approach" to lower eyelid blepharoplasty.

Learn more about transconjunctival lower blepharoplasty >

Arcus marginalis release

Arcus marginal release is a confusing term used to describe a cosmetic lower eyelid operation in which socket fat beneath the eyeball is moved out of the orbit and over the rim of bone to try to fill in an upper cheek depression, or tear trough. To accomplish this, the arcus marginalis (the name for a localized rim of thickening where the eyelid's orbital septum attaches to the orbital bone) must be disinserted from its attachment. The operation is more intuitively described by the term "lower eyelid fat repositioning."

Learn more about arcus marginalis release blepharoplasty >

Tissue-sparing lower blepharoplasty

Tissue-sparing lower blepharoplasty reduces lower lid bulging without removing fat, thus reducing the chance of immediate or later hollowing so common with the other methods noted above. While the operation holds great promise, it is still evolving.

The reason fat may bulge in the lower eyelid is only seldom because it has grown excessive. Instead, an internal hernia allows orbital fat to push forward against a weakened orbital septum. By repairing the hernia, the fat can be returned to its natural position inside the orbit instead of needing to be removed, thus greatly decreasing the risk of both immediate and long-term hollowness.

Learn more about tissue-sparing lower blepharoplasty >

Pinch lower blepharoplasty

Pinch blepharoplasty is a minimally-invasive technique for removing only skin from the lower eyelids. A forceps is used to pinch the eyelid skin into an elevated ridge just below the eyelashes. The ridge is then excised with scissors and the raw edges sutured.The procedure avoids the extensive dissection and some of the potential problems associated with the classic transcutaneous approach.

While this deceptively simple procedure is often described as avoiding the risk of pulling down or rounding the lower lid margin, this is not entirely correct. If overdone, it can indeed alter the shape of the eye.

As pinch blepharoplasty deals only with the lid's excess skin, it is often accompanied by transconjunctival fat removal and/or canthopexy to more fully address additional cosmetic or functional issues.

Learn more about pinch lower blepharoplasty >

Adjunctive procedures

Several add-on procedures can be used to enhance the outcome of any of these main surgical approaches. Operations like canthopexy and laser or chemical skin resurfacing can be undertaken to address associated problems like wrinkling or a diminished structural support system.

When seeking cosmetic lower eyelid surgery, it's a mistake to think of these surgical approaches as equal with respect to safety, recovery time, and immediate and long-term outcomes.

Next: Transconjunctival Lower

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