Refining transcutaneous lower blepharoplasty: Key steps for minimizing complications

Abstract

PURPOSE:

Lower blepharoplasty carries the risk of significant, long-lasting complications if not performed correctly. The aim of this study is to explore the outcomes, patient satisfaction, and complications of transcutaneous lower blepharoplasty, with a particular focus on key aspects of the surgical technique that enhance favorable results and minimize adverse effects.

METHODS:

A retrospective chart review of a primary lower transcutaneous blepharoplasty series conducted over a 2-year period was performed. Patients with a history of prior eyelid surgery were excluded. Preoperative demographic and morphological data, surgical techniques, the need for additional procedures, and complications were evaluated from patient charts and standardized photographs taken before and after surgery by an independent observer.

RESULTS:

A total of 265 patients underwent successful transcutaneous lower eyelid blepharoplasty (LLB), yielding satisfactory outcomes with high patient satisfaction during a median follow-up of 120 days. Increased scleral show occurred in 3 patients (1%), of those two underwent lower lid retractor release with lateral canthal support. Early intralamellar scarring requiring repeated 5-fluorouracil injections occurred in 5 patients (1.9%). No other complications were noted. No patients were dissatisfied with the final outcome.

CONCLUSION:

Transcutaneous LLB, which incorporates component steps including controlled skin resection, preservation of orbicularis muscle innervation, preseptal orbicularis suspension, and canthal support (when necessary), has demonstrated improved outcomes with exceptionally low complication and revision rates.

INTRODUCTION

The lower eyelids are among the first areas to exhibit signs of aging, including wrinkles, sagging, undereye bags, tear-trough deformities, and dark circles.[1] As a result, lower eyelid blepharoplasty (LLB) has become one of the most frequently requested and commonly performed surgeries worldwide.[2,3,4,5,6] LLB can be performed using either transcutaneous or transconjunctival techniques, and the choice between them remains a subject of ongoing debate. The high rate of unfavorable outcomes following transcutaneous LLB, particularly when performed by noneyelid experts, has prompted many oculoplastic surgeons to move away from this technique. As a result, the transconjunctival approach to LLB has gained increasing popularity in recent decades. This method directly addresses the herniated fat while aiming to minimize postoperative complications such as eyelid retraction, ectropion, and skin scarring, which are often seen with the transcutaneous approach.[7,8,9,10] However, while the transconjunctival approach effectively addresses certain aging concerns, it does not fully resolve all aspects of lower eyelid aging, such as excess skin, anterior lamellar laxity, orbicularis hypertrophy, and lid contour deformities.[10,11] These issues often require additional procedures, including pinch skin excision, skin flap techniques, or resurfacing through laser treatments or chemical peels.[10,12,13,14]

Fat transposition through a transconjunctival incision is particularly challenging due to the anterior restriction of the lid margin, which hinders the manipulation of fat into the midface.[15] Furthermore, transconjunctival blepharoplasty does not always ensure the preservation of septal integrity. The disruption of the septum has long been recognized as a key factor contributing to intralamellar scarring and lower eyelid retraction.[16]

In turn, other surgeons have re-embraced the transcutaneous approach, combining it with strategies designed to minimize postoperative lid malposition and improve overall outcomes. In this study, we review 265 consecutive cases of transcutaneous LLB performed by the senior author. We report on outcomes, patient satisfaction, and complications, with a particular focus on specific aspects of the surgical technique that contribute to favorable results and minimize adverse effects.

METHODS

This retrospective study included all patients who underwent transcutaneous LLB performed by a single oculoplastic surgeon (A.A.S.) at Majesty Hospital in Riyadh, Saudi Arabia, between January 2022 and December 2023. Patients with a history of prior periocular surgeries, permanent fillers in the periocular area, who had their fillers dissolved within 1 week, or those with <3 months of postoperative follow-up were excluded. Informed consent for the procedure and the use of facial photographs for publication was obtained from all patients and is documented in the files. The study received approval from the institutional review board and adhered to the ethical principles set forth in the Declaration of Helsinki.

Demographic data, including age and gender, as well as information on associated eyelid procedures, intraoperative complications, and postoperative complications (such as scleral show, ectropion, eyelid swelling, chemosis, scarring, and extraocular muscle injury), were collected. Scleral show was present when the lower eyelid was inferior to the lower limbus during forward gaze.

Subjects’ satisfaction

A structured questionnaire was used to assess patient satisfaction and perceptions regarding the procedure at the final follow-up visit. The questionnaire included the following three key questions: (1) “Would you advise anyone to undergo the same procedure?” with response options: Yes/No; (2) “Have you thought about repeating the surgery?” with response options: Yes/No; and (3) “How satisfied are you with the overall outcome?” with response options: Dissatisfied, Satisfied, or Very satisfied.

Surgical technique

All procedures were conducted in an outpatient setting under local anesthesia with monitored sedation.

Preoperative skin markings

Accurate skin marking should be performed in a sitting posture before the administration of anesthesia. The process begins with marking an infraciliary line, placed 1 mm below the lash line, ensuring that it does not extend medially beyond the punctum. Next, a nontoothed forceps is used to pinch redundant skin for excision. It is important to exercise caution with skin resection, especially from medial to lateral limbus, and to be extremely cautious when working medially to the medial limbus. In addition, regions planned for fat repositioning or excision are also carefully marked.

The Full face is then cleansed with an antiseptic solution. The marked excess of skin was excised with precaution to leave the pretarsal orbicularis oculi (OO) muscle intact. The OO muscle incision was precisely controlled to preserve at least 6 mm of the pretarsal OO muscle, while ensuring that the incision did not extend beyond the medial limbus line. This helps preserve the motor innervation of the pretarsal segment of OO muscle. Suborbicularis blunt dissection was then performed using cotton-tipped applicators and a blunt-tipped Freer periosteal elevator, advancing through the preseptal plane toward the orbital rim. Once the orbital septum was exposed, it was incised to reveal the underlying fat pads. Depending on the patient’s anatomical needs, excess fat was either excised or repositioned to achieve a smoother contour at the junction of the lower eyelid and cheek. When fat repositioning was performed, it was typically transposed over the infraorbital rim in the preperiosteal plane and secured with 6/0 monocryl sutures approximately 8 mm below the infraorbital rim. The lateral fat pad was excised in all cases.

Orbicularis oculi suspension

The edge of the preseptal OO muscle was then sutured using a 5-0 monofilament suture, positioned about 1 mm below the orbital tubercle at the lateral orbital margin.

Lateral canthal support

Following this, a lid distraction test was conducted. If the distraction was <5 mm, the lid was closed without additional intervention. If the distraction exceeded 10 mm, lateral canthoplasty was performed. For cases where the distraction measured between 5 and 10 mm, a lateral canthopexy was performed.

The incision is meticulously closed using 6-0 Prolene running suture, to promote optimal healing and minimize scarring [Video 1]. After closure, an antibiotic ointment is applied to the incision site, and the eyelid is gently compressed with cool saline-soaked gauze to reduce swelling and bruising.

Postoperative care

The patient is advised to keep their head elevated and apply cold compresses for the first 48 h to minimize swelling and antibiotic ointment is continued for 1 week to prevent infection. The patient is monitored for complications such as hematoma, infection, or eyelid malposition. Sutures are typically removed within 8–10 days, and most swelling and bruising resolve within 10–20 days.

Statistical analysis

Data analysis was conducted using Statistical analysis was conducted using IBM SPSS Statistics software, version 30.0.0 (IBM Corporation, Armonk, New York, USA) Continuous variables were reported as means and medians, whereas categorical variables were summarized as frequencies and percentages.

RESULTS

A total of 265 patients’ records were retrospectively analyzed to assess outcomes following transcutaneous LLB. The mean age of the study population was 54.6 ± 10.6 years old (range: 22–84 years of age), and 84.9% were female.

Concurrent upper eyelid blepharoplasty and browplasty procedures were performed on 177 patients (66.8%), and 17 patients (6.4%), respectively. Median follow-up time was 4 months (range: 3–18 months) [Table 1].

Table 1.

Patient’s characteristics and operative management

Characteristics	n (%)
Age (years old)
Mean	54.6±10.6
Range	22–84
Sex
Men	40 (15.1)
Women	225 (84.9)
Fat
Excision	53 (20)
Transposition	213 (80)
Lateral canthal support
Canthopexy	177 (66.8)
Canthoplasty	2 (0.8)
Concurrent upper blepharoplasty	177 (66.8)
Concurrent browplasty	17 (6.4)

Subjects’ satisfaction

Regarding patient satisfaction, 98.5% (261/265) of participants reported that they would advise others to undergo the same procedure. Only, 1.9% (5/265) considered repeating the surgery. Notably, all participants reported being very satisfied or satisfied with the overall outcome and none were dissatisfied [Figure 1].

Figure 1.

Bilateral transcutaneous lower blepharoplasty. (a and b) Preoperative anteroposterior and oblique views showing moderate fat prolapse, tear trough deformity and mild dermatochalsis of the lower eyelids in a 45-year-old female. (c and d) 3-month postoperative views following transcutaneous lower blepharoplasty with fat transposition

Postoperative complications

Postoperative scleral show occurred in 3 patients (1%). Among these, two underwent lower eyelid retractor recession, while one was satisfied with the result and chose not to pursue further treatment [Figure 2]. Six patients (2.3%) experienced clinically significant eyelid edema, and two patients (0.8%) developed mild postoperative hematomas, all of which resolved completely with observation. No other complications were noted [Table 2].

Figure 2.

Postoperative increased scleral showing preoperative picture of a 30-year-old female who underwent transcutaneous lower blepharoplasty (a). This patient also underwent upper eyelid blepharoplasty at the time of surgery. She developed lower eyelid retraction with no evidence of anterior lamellar shortening or intralamellar scarring, and no improvement with massage (b). Postoperative view following transconjunctival lower eyelid retractor recession, showing significant improvement in lower eyelid retraction (c)

Table 2.

Postoperative complications and revisions

Complications	n (%)
Eyelid hematoma	2 (0.8)
Clinically significant eyelid edema	6 (2.3)
Prominent scar	None
Increased scleral show	3 (1)
Ectropion	None
Lower lid retractor release + canthoplasty	2 (0.8)
5-fluorouracil injection	5 (1.9)

Reoperation

In addition to the two cases in the transcutaneous group that required corrective surgery for postoperative lid retraction, 5 patients (1.9%) received 5-FU treatment for early postoperative fibrosis detected on upward traction test [Table 2].

DISCUSSION

Traditionally, the transcutaneous technique has been considered the gold standard for lower lid blepharoplasty, as it addresses anterior lamellar laxity and provides direct visualization and optimal access to the orbital septum and fat pads. While the results are generally good, lower eyelid malposition occurs in 15% to 20% of cases,[17] and other esthetic complications such as orbital hollowing and rounding of the ocular aperture have also been reported.[18]

Postblepharoplasty lower eyelid malposition can range from increased scleral show and eyelid retraction to severe ectropion. The causes of these issues are multifactorial, including translamellar scarring, unaddressed horizontal lid laxity, and overresection of skin. Yoo et al.[19] identified three additional contributing factors: orbicularis weakness, inferior eyelid/orbital volume deficit, and negative-vector eyelids.[18] Orbicularis weakness was present in 87% of their case series of postblepharoplasty lid retraction. This weakness has been shown to contribute to lower eyelid malposition following facial nerve injury or surgical trauma, including blepharoplasty.[19]

Cumulative anatomical knowledge and recent advancements have guided improved surgical outcomes, particularly in avoiding postoperative malposition and reducing complication rates. In the present study, the rates of postoperative complications and reoperations were substantially low, with high patient satisfaction, reflecting the safety and efficacy of our technique. We believe that the following key steps are essential for achieving optimal results in transcutaneous LLB.

Predetermined skin resection

A key decision in LLB is determining whether the skin should be removed and how much to remove to achieve the best possible outcome for the patient. The authors base this decision on preoperative evaluation. The amount of skin to be removed is determined beforehand using the forceps pinch technique, similar to that used in upper blepharoplasty, allowing for the removal of excess skin with confidence and preventing overzealous excision. While some surgeons prefer to remove excess skin at the end of the procedure, we believe this approach can be inaccurate due to tissue edema.

Preservation of pretarsal muscle and minimizing orbicularis trauma

Our understanding of the innervation of the lower pretarsal orbicularis has refined over the years, paralleling the evolution of lower blepharoplasty techniques. Before the turn of the millennium, it was believed that the lower eyelid OO muscle was primarily innervated from the lateral periorbital region. However, in the early 2000s, it was proposed that the lower pretarsal OO is innervated by two nerves: one penetrating the muscle from its inferior aspect and traveling in a suborbicularis plane perpendicular to the muscle fibers (the zygomatic branches of the facial nerve) and the angular nerve (the buccal branch), which enters horizontally from the medial periorbital region. Based on this anatomical concept, the transcutaneous blepharoplasty incision was thought to inevitably transect the vertically entering nerve. Despite this, the transcutaneous approach has remained popular, with ongoing reports showing no signs of denervation, even though these nerves seem more likely to be transected during surgery. Through high-quality anatomic and electrophysiologic studies, McCord et al.[20] showed that the subciliary approach to lower blepharoplasty does not cause weakness of the orbicularis. Their findings revealed that a small medial portion of the muscle, innervated by the buccal branch of the facial nerve, is the part responsible for maintaining lower eyelid tone and support. Since these nerve and muscle fibers are located inferior and medial to the transcutaneous incision and surgical dissection, they are unlikely to be disturbed during the procedure. This theory was widely accepted in the field until Choi et al.[21] published their observations on the facial nerve supply to the OO around the lower eyelid. Through fresh cadaver dissections of 50 hemifaces, they discovered that vertical submuscular nerves at the lower eyelid, originating from the infraorbital foramen, are all sensory nerves. They also noted that the motor nerve supply is concentrated at the medial palpebral corner.[21] Based on these findings, the authors of the present study advocate for preserving a minimum of 6 mm of pretarsal OO inferior to the eyelid margin, not extending medial to the medial limbus.

To minimize muscle trauma, we prefer performing blunt dissection in the suborbicularis plane using cotton-tipped applicators and a blunt Freer periosteal elevator. This technique helps reduce intraoperative bleeding, muscle damage, and intralamellar scarring. In addition, by avoiding monopolar electrocautery, which can cause collateral thermal injury to muscle tissue or its innervation, we further reduce the risk of postoperative orbicularis weakness and lamellar scarring.

More recently, Choi and Kim[22] supported this approach, outlining a safe zone for the lower blepharoplasty muscle incision. If followed, this safe zone preserves the pretarsal motor supply and prevents muscle atrophy. They also identified a danger zone in the infraorbital area for the transblepharoplasty midface approach, where surgeons must be particularly cautious to avoid damaging motor nerve trunks, especially when using electrocautery.[22]

Preseptal orbicularis suspension

This step has dual effects; first, it helps stabilize the position of the lower eyelid and reduce lid laxity by changing the direction of force on the lower eyelid to the upper-lateral direction.[23] This can eliminate the need for horizontal lid-tightening procedures at the lateral canthus particularly in mild-to-moderate cases.[23] Second, it can effectively address skin wrinkles and nasojugal grooves and correct fat prolapse by exerting external pressure on the orbital septum and fat-improving contour improvement.[23,24]

Canthal support

A critical step during transcutaneous blepharoplasty is to assess tarsoligamentous laxity and address this problem if present. Preseptal orbicularis suspension can reduce this laxity to some extent. Residual laxity can by fixed with additional lateral canthopexy or canthoplasty based on the degree of laxity.

The lower lid should sit at the inferior level of the pupil. In those patients with a negative vector or negative canthal tilt, the lid should sit at the superior edge of the pupil.[25,26] Some authors recommend the routine use of prophylactic lateral canthal tightening procedures in all cases of transcutaneous blepharoplasty;[25,27] however, we did not find this necessary.

Cases with early intralamellar fibrosis were treated with postoperative fluorouracil (5-FU) injections to modulate wound healing. 5-FU has been shown to reduce scarring and regulate wound healing in cutaneous dermatologic procedures, glaucoma filtration surgery, and eyelid and periorbital surgeries. Previous studies have specifically demonstrated the effectiveness of 5-FU injections in preventing and treating postoperative scarring and eyelid retraction following blepharoplasty.[28,29,30]

CONCLUSION

Traditional approaches to LLB primarily focus on the excision of skin, muscle, and fat through skin or skin-muscle flaps. While effective for many patients, these methods can lead to long-term complications, ranging from subtle changes in eye shape to frank lower eyelid malpositions. Consequently, oculoplastic surgeons have increasingly favored transconjunctival techniques, though these may not fully address all signs of lower eyelid aging.

In this context, we share our experience with transcutaneous LLB, aiming to minimize complications. This study highlights several key technical steps – including predetermined skin resection, preservation of muscle innervation, orbicularis suspension, and canthal support when necessary – that, when incorporated into transcutaneous blepharoplasty, result in high patient satisfaction and reduced postoperative complications.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.