Transconjunctival lower lid blepharoplasty with fat reposition
This is Richard Allen at the University of Iowa. This video demonstrates a lower lid blepharoplasty with transposition of the medial and central fat pads through a transconjunctival incision.
A 4-0 silk suture is placed through the lower lid at the level of the meibomian gland orifices to provide traction during the case. A trans-upper eyelid canthopexy will also be performed to stabilize the lower lid.
A pinch excision has been marked and this is incised with the 15 blade. This should not extend medial to the medial limbus.
Skin without orbicularis is excised.
A transconjunctival incision is then made with the needle tip cautery extending from the punctum medially to the lateral canthus laterally.
Dissection is then carried out between the orbicularis muscle and orbital septum to the inferior orbital rim.
Once the inferior orbital rim is identified, dissection is carried out inferior to the inferior orbital rim with a freer periosteal elevator in a preperiosteal plane.
4-0 silk suture is then placed through the edge of the conjunctiva to provide traction during the case.
The fats pads are then identified by dissecting through the orbital septum.
The medial and central fats pads are mobilized; between the two runs the inferior oblique muscle.
The lateral fat pad is mobilized and this fat pad is usually conservatively excised.
However, in this patient, the medial and central fat pads will be transposed over the inferior orbital rim in order to fill out the tear trough.
A 4-0 prolene suture is placed through the skin and orbicularis and retrieved.
The suture then engages the medial fat pad and then place back through the orbicularis muscle and skin. This results in transposition of the medial fat pad over the orbital rim.
The same is done to the central fat pad.
These sutures are tied over a bolster and then taken out at the one week follow up.
Unfortunately in this video the trans-upper eyelid canthopexy is not well visualized. Therefore, the transconjunctival incision is closed with a 7-0 vicryl suture. The pinch exicision of skin is closed with interrupted 6-0 prolene suture.