What is Lower Blepharoplasty (Transkonjonktival)?

Introduction

Lower blepharoplasty (transkonjonktival) is a surgical procedure designed to improve the appearance of the lower eyelids. It addresses issues such as puffiness, wrinkles, skin laxity, and hollowing under the eyes. Over time, surgical techniques have evolved from simple skin and fat removal to advanced, tissue-preserving methods that focus on restoring volume and maintaining a natural look.

Background

Traditionally, lower blepharoplasty (transkonjonktival) was a reductive surgery in which excess skin and fat were removed. Modern approaches now emphasize tissue preservation and repositioning, which includes fat grafting, orbital fat repositioning, and sub-orbicularis oculi fat (SOOF) lifts. Non-surgical adjuncts such as laser resurfacing, light-based therapies, and dermal fillers are also commonly used to complement surgical results.

Patient Selection

Medical History

A thorough medical and ophthalmic history is taken before surgery, including:

• Current medical conditions
• Medications and supplements (especially anticoagulants)
• Allergies
• Dry eye symptoms
• Previous facial or eyelid surgeries
• Lifestyle factors such as smoking and sun exposure
• Patient goals and expectations

Physical Examination

The preoperative assessment includes:

• Visual acuity and ocular motility
• Tear film and ocular surface evaluation
• Lower eyelid laxity and canthal tendon strength
• Skin type, elasticity, and presence of lesions
• Fat pad prominence and tear trough deformity
• Orbital structure, asymmetry, and globe position

Standardized photographs are taken before surgery.

Indications

Lower blepharoplasty (transkonjonktival) may be recommended for:

• Wrinkles and skin redundancy
• Protruding fat pads (steatoblepharon)
• Tear trough deformity and infraorbital hollowing
• Volume loss in the midface
• Malar bags or festoons
• Lower eyelid asymmetry

Contraindications

Surgery may not be suitable for patients with:

• Unrealistic expectations
• Severe or unstable medical conditions
• Active thyroid-related eye disease
• Uncontrolled dry eye syndrome

Surgical Techniques

Transconjunctival Approach

One of the most common techniques, this approach involves making an incision inside the eyelid. It is ideal for patients with fat prolapse but minimal skin excess. Through this incision, orbital fat pads can be removed, repositioned, or redraped without disrupting the orbital septum. Fat can be redistributed to correct hollowing beneath the orbital rim, and SOOF lifting can also be performed. The incision often heals without sutures.

Infraciliary (Skin) Approach

An incision is made just below the lash line. This technique allows removal of excess skin, fat, and sometimes muscle. It also provides access for SOOF lifting and lateral canthopexy to support the eyelid. Skin closure is performed with fine sutures for minimal scarring.

Additional Procedures

• Canthopexy or canthoplasty for patients with significant lower eyelid laxity
• Fat grafting or implants for volume restoration in hollow areas
• Laser resurfacing or chemical peels to improve skin texture and reduce fine wrinkles
• Vein treatments with ligation, sclerotherapy, or laser for visible veins
• Botulinum toxin injections to soften dynamic wrinkles around the lower eyelids

Postoperative Care

• Cold compresses for the first 48 hours, then warm compresses
• Application of bland ointments, antibiotic, or steroid drops for one week
• Avoiding strenuous activity for several days to weeks
• Follow-up within a week; sutures (if present) are usually removed after 5–7 days
• Patients are advised to watch for signs of bleeding or infection and report them immediately

Complications

While lower blepharoplasty (transkonjonktival) is generally safe, potential complications include:

• Bruising and swelling
• Retrobulbar hemorrhage (rare but serious)
• Chemosis or conjunctival swelling
• Pyogenic granuloma
• Under- or overcorrection of fat removal
• Lagophthalmos (incomplete eyelid closure)
• Diplopia due to inferior oblique muscle injury
• Hypertrophic scarring or suture cysts
• Eyelid retraction due to scarring or septal violation
• Anterior lamellar shortage from excessive skin removal
• Ectropion, particularly in cases with poor canthal support

Conclusion

Lower blepharoplasty (transkonjonktival) is a highly effective procedure for rejuvenating the lower eyelids and restoring a youthful appearance. Modern techniques focus on balancing tissue preservation with volume restoration, ensuring natural and long-lasting results. Careful patient selection, precise surgical planning, and skilled execution are key to achieving optimal outcomes.