Eye-opening effects caused by modified transconjunctival lower blepharoplasty

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A modified transconjunctival lower blepharoplasty (TCLB) performed to address lower eyelid symptoms also benefits the upper eyelid with improved results,¹ according to Takayuki Kubo, MD, PhD, who is a plastic surgeon in private practice in Tokyo.

Aging changes affect both the upper and lower eyelids, such as thinning of the periobital skin resulting in droopy upper eyelids or wrinkles. The lower eyelids can become baggy (anterior herniation of the lower orbital fat compartment [LOFC]), and tear trough deformities, nasojugal grooves, and dark circles can develop,^2-4 according to Kubo.

He explained that cutting-edge surgeries have traditionally been performed to treat the signs of aging on the lower lids, making oculoplastic surgery one of the most common procedures performed by facial aesthetic surgeries.^5-7 However, TCLB is becoming a high-profile surgery because it is minimally invasive.⁸In particular, scar-free surgery is favored in Asian populations, because this skin type is more susceptible to postoperative scarring.^9,10

Enophthalmia is a more complex symptom defined as an abnormality of the sunken globe in the orbital socket caused by age-related attenuation of the supporting tissues inside the lower orbit that¹¹ shows not only a typical aging appearance but is also believed to cause pseudoblepharoptosis or dermatochalasis, Kubo said.

His aim in the study under discussion was to assess the effect of a modified TCLB procedure that added deframing and decompression maneuvers to the LOFC and its support structures to obtain better results for both the lower and upper lids.

TCLB assessment and results

Forty patients (36 women) with lower eyelid symptoms were treated using the modified TCLB and followed at 12 months postoperatively. The palpebral fissure height (PFH), defined as the distance between the upper and lower eyelids in vertical alignment with the pupillary center, was measured preoperatively and 12 months postoperatively from three-dimensional photographs. The changes in the measurements were compared to validate the postoperative eye-opening effect, and the excised fat from each LOFC was weighed.

Kubo reported the changes in the mean preoperative right and left eye PFHs at the follow-up examination. The mean preoperative PFH for both the right and left eyes was 8.41 mm. Postoperatively, the respective measurements were 9.26 and 9.21 mm, differences from baseline that reached significance (P<0.01).

The total excised LOFC was 0.43 grams for the right and 0.42 grams for the left eyes. The largest amount of fat was excised bilaterally from the lateral LOFC.

Kubo concluded, “The results after the modified TCLB clearly demonstrated increased eye-opening ability and marked resolution of observable symptoms. A modified TCLB performed to treat lower lid symptoms also offers improved results for the upper lid. These effects can result from the deframing and decompression of the LOFCs to acquire anatomic relevance in the orbit with sufficient resection of the lateral LOFC, creating more space for the globe to settle back into the desired position. This results in corrected enophthalmia and associated ptotic upper lid. Therefore, priority should be given to performing the modified TCLB in patients seeking resolution of symptoms in both lower and concurrent minor upper lids.”

References:

1. Kubo T. Eye-Opening effect achieved by modified transconjunctival lower blepharoplasty. Aesthet Surg J. 2025;45:126–135; https://doi.org/10.1093/asj/sjae205

2. Stutman RL, Mark A. Codner tear trough deformity: review of anatomy and treatment options. Aesthet Surg J. 2012;32:426-440. doi: 10.1177/1090820X12442372

3. Wong CH, Hsieh MKH, Mendelson B.The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg. 2012;129:1392-1402. doi: 10.1097/PRS.0b013e31824ecd77

4. Vrcek I, Ozgur O, Nakra T. Infraorbital dark circles: a review of the pathogenesis, evaluation and treatment. J Cutan Aesthet Surg. 2016;9:65-72. doi: 10.4103/0974-2077.184046

5. Atiyeh B, Hakim CR, Oneisi A, Ghieh F, Chahine F. Surgical correction of tear trough deformity (TTD) with orbicularis retaining ligament release and volume augmentation for periorbital rejuvenation: review of the literature. Aesthetic Plast Surg. 2023;47:199-214. doi: 10.1007/s00266-022-03183-0

6. Majidian M, Kolli H, Moy RL. Transconjunctival lower eyelid blepharoplasty with fat transposition above the orbicularis muscle for improvement of the tear trough deformity. J Cosmet Dermatol. 2021;20:2911-2916. doi: 10.1111/jocd.13978

7. Akşam E, Karatan B. Periorbital aesthetic surgery: a simple algorithm for the optimal youthful appearance. Plast Reconstr Surg Glob Open. 2019;7:e2217. doi: 10.1097/GOX.0000000000002217

8. Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty. Technique and complications. Ophthalmology. 1989;96:1027-1032. doi: 10.1016/s0161-6420(89)32787-4

9. Chike-Obi CJ, Cole PD, Brissett AE. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg. 2009;23:178-184. doi: 10.1055/s-0029-1224797

10. Huang C, Wu, Z Du Y, Ogawa R. The epidemiology of keloids. In: Textbook on Scar Management: State of the Art Management and Emerging Technologies [Internet].Chapter 4.Springer, New York; 2020;29:doi: 10.1007/978-3-030-44766-3_4

11. Camirand A, Doucet J, Harris J. Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid fat pads. Plast Reconstr Surg. 1997;100:1535-1546. doi: 10.1097/00006534-199711000-00026