Modified Transconjunctival Lower Blepharoplasty Method For Asian Eyes
Aging around the eyes is a common concern for many patients, particularly in Asian populations, where anatomical differences can contribute to sunken lower eyelids and an overall tired appearance. Enophthalmia, or sunken eyes, along with ptotic upper eyelids and lower lid deformities, are frequent issues that affect both function and aesthetics. Traditional transconjunctival lower blepharoplasty (TCLB) has been widely used for lower eyelid rejuvenation, but a recent modification to the technique has demonstrated additional benefits, including an eye-opening effect.
This article is based on the research conducted by Takayuki Kubo, titled Eye-Opening Effect Achieved by Modified Transconjunctival Lower Blepharoplasty, published in the Aesthetic Surgery Journal. It explores the modified TCLB approach, detailing its surgical steps, ideal patient selection, advantages over conventional methods, and clinical outcomes.
The Modified Transconjunctival Lower Blepharoplasty Method
Unlike the traditional approach, which mainly focuses on contouring the lower eyelid by removing excess fat, the modified TCLB includes deframing and decompression maneuvers on the lower orbital fat compartments (LOFC) and their supporting structures. These modifications allow for better palpebral fissure height (PFH), improving both the appearance and function of the periorbital region. By carefully addressing the orbital septum and adjacent ligaments, this method enhances eye openness without requiring direct intervention on the upper eyelid.
Surgical Approach
Preoperative Assessment:
Patients are classified based on their lower eyelid symptoms, including prominent eye bags, tear trough deformity, nasojugal grooves, or dark circles.
Hertel exophthalmometry is used to determine the severity of enophthalmia and assess the necessity for surgical intervention.
Anesthesia and Preparation:
Mild sedation is administered to ensure patient comfort.
Local anesthesia (1% xylocaine with epinephrine) is injected into the lower orbital compartment via the conjunctiva.
Incision and Exposure:
A horizontal conjunctival incision is made approximately 5 mm below the tarsus using a radiofrequency probe.
Dissection is carried out inferiorly until the orbicularis retaining ligament (ORL) and arcus marginalis are reached.
The tear trough ligament and ORL are released to expose the orbital septum.
Deframing and Decompression:
The arcuate expansion of Lockwood’s ligament (AELL) is transected to reduce tension in the lower orbital fat pads.
The lateral LOFC is decompressed to allow for a more natural eye projection.
Depending on the patient’s anatomical needs, excess fat is either resected or repositioned to correct hollowing.
Closure and Postoperative Care:
Meticulous hemostasis is performed, and the incision is closed without the need for external sutures.
Ice packs are applied postoperatively to minimize swelling.
Patients are monitored through follow-ups at one, three, six, and twelve months.
Patient Selection
This modified approach is particularly beneficial for patients who present with sunken lower eyelids, enophthalmia, or mild upper eyelid ptosis. Those with significant tear trough deformities and prominent eye bags can also achieve improved aesthetic and functional outcomes with this method. However, patients with severe upper eyelid ptosis (MRD-1 < -0.5 mm) may require additional surgical intervention. Additionally, individuals who have previously undergone upper eyelid surgery or those with a predisposition to excessive bleeding should be evaluated carefully before proceeding with this technique.
Advantages of the Modified Approach
One of the primary benefits of the modified TCLB is its scarless nature, as all incisions are made internally via the conjunctiva. This is particularly important for Asian patients, who are at a higher risk of visible scarring. Additionally, the technique simultaneously enhances both upper and lower eyelid aesthetics without requiring a separate upper blepharoplasty. Unlike conventional TCLB, which often results in postoperative hollowness due to excessive fat removal, this method ensures a more natural contour by redistributing rather than simply excising fat.
Furthermore, the minimally invasive nature of the procedure leads to a shorter recovery period and a lower risk of complications. While conventional approaches may primarily focus on fat removal, this method incorporates anatomical restructuring, yielding longer-lasting and more harmonious results.
Limitations and Considerations
Despite its advantages, the modified TCLB has some limitations. Patients with significant upper eyelid ptosis may not achieve the desired results without additional surgical correction. Furthermore, some individuals may experience temporary hyperpigmentation following the procedure, which typically resolves within three to six months. Given the complexity of the technique, it is crucial that surgeons have a thorough understanding of orbital anatomy to avoid complications and ensure optimal outcomes.
Clinical Outcomes
A study tracking forty patients over a twelve-month period demonstrated a significant increase in PFH, with an average improvement from 8.41 mm to 9.26 mm. Additionally, patient satisfaction rates were high, with 75% of individuals reporting a marked improvement in their eye openness. Complications were minimal, with only a small percentage of patients experiencing transient hollowing (3%), exaggerated tear trough deformities (4.3%), or temporary paresthesia (0.6%).
Conclusion
The modified transconjunctival lower blepharoplasty represents a significant advancement in periorbital rejuvenation. By incorporating deframing and decompression maneuvers, this approach enhances both aesthetic and functional outcomes, offering a more natural and youthful appearance. Its ability to improve eye openness without direct upper eyelid intervention makes it an invaluable technique for surgeons seeking to provide comprehensive periorbital solutions.
Reference:
Takayuki Kubo, Eye-Opening Effect Achieved by Modified Transconjunctival Lower Blepharoplasty, Aesthetic Surgery Journal, Volume 45, Issue 2, February 2025, Pages 126–135, https://doi.org/10.1093/asj/sjae205
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