Primary goal: Removal of excess skin, orbicularis muscle, and fat
Anesthesia: Local anesthesia with oral or intravenous sedation
Operation: The skin is incised just below the eyelid margin along its full length and slightly beyond into the lateral canthus. The exposed orbicularis muscle is incised along its length in a similar fashion. A skin-muscle "flap" is lifted off of the underlying orbital septum using blunt dissection with cotton-tipped applicators and sharp dissection with scissors. The skin-muscle dissection extends downward over the entire lower eyelid to a level approximately even with the orbital bony rim. The orbital septum is incised to expose the three fat pockets of the lower eyelid. Excess fat is teased free and clamped. The fat is removed with scissors, and each "stump" is cauterized before allowing it to retract back into the orbit. The patient is asked to open his or her mouth and look upward towards the forehead while the surgeon drapes the skin-muscle flap over the initial incision to determine the amount of "extra" tissue (generally, only a small amount). Any excess skin and muscle are trimmed. The skin edges are closed using sutures.
Variations: Many variations have been suggested, most of which have to do with placement of incisions or level of penetration from one tissue layer to the next. All such adaptations are small attempts to overcome the basic insufficiency of this operation: extensive internal disruption of the eyelid. In patients with markedly excessive skin, only a skin flap may be dissected (rather than skin-muscle), and the orbicularis muscle then entered lower down near the bone (which allows for more skin relative to muscle to be removed when the flap is trimmed).
Advantages: In addition to fat removal or repositioning, excess skin and orbicularis muscle may be removed (which is not possible in "pure" transconjunctival blepharoplasty).
Limitations: There are many problems with this operation, including its highly invasive nature, wide dissection, and extensive violation of the orbital septum. In a modified form accompanied by extra "reinforcement" procedures (canthoplasty), the operation has regained some of its lost luster.
Risks and complications: The incidence of eyelid malposition following lower blepharoplasty undertaken from a skin approach is significantly higher than with transconjunctival surgery. More bruising, more swelling, and slower healing are to be expected.
Comments: "Pure" transcutaneous lower blepharoplasty (that is, without adjunctive procedures such as lateral canthal reinforcement or midface resuspension) is an operation on its way out. The procedure creates a harsher "surgical look" that is no longer in fashion and carries a higher rate of significant complications.
