Transconjunctival Approach to Resection of Lower Eyelid Herniated Orbital Fat

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CHAPTER 14 Transconjunctival Approach to Resection of Lower Eyelid Herniated Orbital Fat

Allen M. Putterman

The transconjunctival approach to removal of herniated orbital fat is the preferred method of treatment in patients who have only herniated orbital fat with minimal or no evidence of dermatochalasis (excess skin) and no hypertrophic orbicularis oculi muscle. This technique is also especially advantageous for:

• Younger patients with large amounts of herniated orbital fat.

• Patients who have had previous blepharoplasties in whom an external approach might lead to eyelid retraction or ectropion.

• Patients with lower eyelid retraction secondary to thyroid disease in whom hard-palate grafts are required (Chapter 18).

• Patients with wrinkled or minimally excessive lower eyelid skin in whom plication of the lateral canthi or laser resurfacing of lower eyelid skin is useful (see Chapter 15).

If there is horizontal lower eyelid laxity, this procedure can be easily combined with a horizontal eyelid tightening through a tarsal strip procedure (see Chapter 1).

Many patients want this approach done because it eliminates external scarring and produces less ecchymosis; however, it has been my experience that many patients develop conjunctival chemosis and slight redundancy and wrinkling of skin compared with those who were treated with the external approach. Therefore, I find that more frequently I am combining this approach with a lower eyelid skin flap dissection and excision with orbicularis tightening.

A contraindication to this procedure is with patients with minimal lower eyelid fat, inferior orbital rim or nasojugal hollowing and depression. In these patients, fat repositioning or cheek–midface lifting are indicated (Chapters 17 and 19).

Allen M. Putterman

Surgical technique

The transconjunctival procedure is performed with the patient under local anesthesia. Two percent lidocaine (Xylocaine) with 1 : 100,000 epinephrine is injected subcutaneously at the center of the lower eyelid just beneath the lashes. An additional anesthetic agent is injected into each fat pad. To inject the anesthetic into the nasal, central, and temporal fat pad, the surgeon inserts a 25-gauge, 0.8-cm needle just above the inferior orbital rim and directs it downward slightly until it penetrates its entire length (0.8 cm). The barrel of the syringe is withdrawn to make sure that no blood has been entered, and approximately 0.5 ml of the agent is injected into each of the three fat pads.

A 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superficial tarsus at the center of the eyelid. The surgeon pulls the eyelid downward with a traction suture as the assistant everts the lower eyelid over a small Desmarres retractor to expose the inferior palpebral conjunctiva. Additional anesthetic is injected subconjunctivally over the inferior palpebral conjunctiva across the eyelid. Topical tetracaine is instilled over the eye, and a scleral lens is placed over the eye to protect it. Two percent lidocaine with epinephrine is also injected subcutaneously over the center of the upper eyelid, and a 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superficial tarsus to pull the upper eyelid upward.

A Colorado needle or disposable cautery (Solan Accu-Temp, Xomed Surgical Products, Jacksonville, FL) is applied to the inferior palpebral conjunctiva. The Colorado needle or cautery are used to cut conjunctiva from the medial to temporal end of the eyelid halfway between the inferior palpebral fornix and the inferior tarsal border (Fig. 14-1). The surgeon grasps the inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent, more superior edge with forceps and the assistant pulls the Desmarres retractor downward (Fig. 14-2

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