Operations on the lower eyelid
A group of surgical procedures designed to enhance the appearance of the lower eyelids are referred to collectively as “lower blepharoplasty.” Lower blepharoplasty was historically a reduction operation when skin and/or fat were removed to lessen skin redundancy, fat bulges, and wrinkles on the lower eyelids. Modern lower blepharoplasty still involves the removal of fat and skin, but current developments adhere to a tissue-preserving philosophy that may involve the use of fat transfer procedures to replace lost face volume, as well as orbital and sub-orbicularis fat relocation. Hyaluronic acid-based dermal fillers became popular in the early 2000s as an off-label technique for infra-orbital and lower eyelid volumization. Laser energy and light-based treatments on the lower eyelids have made it possible to treat lower blepharoplasty without surgery or to add to incisional blepharoplasty.
Upper and lower transconjunctival blepharoplasty before and after
the patient’s complaints that coincide with anatomical problems found during an examination are addressed by a successful surgical rejuvenation of the lower eyelids. Different surgeons may use different procedures and distinctions. The target endpoint may be attained via a single process or a combination of approaches (e.g., transconjunctival fat manipulation with anterior skin pinch).
The patient is frequently seated when markings are done. A surgical pen is used to outline the steatoblepharon and hollow.
The surgical site is injected with a local anesthetic containing lidocaine and/or bupivacaine combined with epinephrine. In the lower cul-de-sac, topical anesthetic drops are used. It’s possible to use a corneal shield. The preparation is sterile.
The transconjunctival method
The transconjunctival method is one of the most widely utilized procedures for lower eyelid blepharoplasty. This is a fantastic alternative for patients who have protruding lower eyelid fat rather than extra lower eyelid skin. ( There are many methods that can be used , but one of the most common is mentioned below.
Conjunctiva and lower eyelid retractors are used to expose the area, while a desmarres retractor creates an infratarsal incision. The fat pads are more easily seen, and the best place for the incision may be chosen thanks to globe ballooning. Exposure is aided by the placement of traction sutures at the proximal conjunctival edge. Insufficient exposure may require lateral canthotomy and inferior cantholysis. The orbital septum is not broken in order to get straight to the three fat pads in the lower eyelids.
Post-septal fat pads using a transconjunctival technique
In order to be repositioned to areas of concavity inferior to the orbital rim, the orbital fat pads are debulked or mobilized as pedicles. Monopolar or bipolar cautery is used to maintain strict hemostasis. You see, don’t touch the inferior oblique muscle. After making a pocket and removing attachments, fat redraping might happen in the subperiosteal or suborbicularis plane. Internal absorbable sutures or percutaneous sutures are used to hold the fat pedicles in place. Through a transconjunctival incision, the suborbicularis oculi fat (SOOF) can be raised and sutured to the orbital rim periosteum with absorbable sutures. A SOOF lift helps to eliminate the infraorbital hollows and tear trough just like orbital fat repositioning does.
The skin approach (infraciliary)
In order to reach the lateral eyelid crease, an incision is made 1-2 mm beneath the eyelash line or inside of an already-existing infraciliary crease. By crushing the skin with a hemostat without traction on the edge of the eyelid, one can perform a skin “pinch” to assess the degree of redundancy. As an alternative, a skin flap could be made that extends as far as needed to mobilize the area adequately without changing the shape of the eyelid opening. To prevent anterior lamellar deficiency, a moderate amount of skin is excised. To determine how much skin tuck is permitted, the patient is asked to look up and open their mouth. The skin-muscle method allows for more skin and muscle advancement and trimming, either separately or together. The infraciliary incision allows access to the SOOF and orbital fat pads, and both can be reached in the same manner as the transconjunctival approach. Access to the orbicularis muscle and the orbitomalar ligament, which can be raised and suspended to the exterior lateral orbital rim periosteum in order to lift and support the eyelid, is made possible via an infraciliary incison, either complete or lateral. Using the same cut as infraciliary blepharoplasty, lateral canthopexy can also be done to keep the lower eyelid in place or raise it.
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