In the realm of lower blepharoplasty, the transconjunctival approach has emerged as a pivotal technique, revolutionizing the landscape of aesthetic surgery. This method, first introduced by Bourquet in 1923, has undergone significant refinement, with contemporary advancements incorporating carbon dioxide (CO2) lasers to elevate precision and outcomes.

Unveiling the Transconjunctival Approach

The transconjunctival approach, although appearing deceptively straightforward, demands intricate anatomical knowledge of the internal ocular region. The key advantage lies in sparing the orbicularis oculi muscle, mitigating long-term denervation atrophy risks associated with traditional skin-muscle flaps. While seemingly less complex than its transcutaneous counterpart, meticulous hemostasis remains paramount throughout the procedure, addressing the primary risk of bleeding control.

Harnessing the Power of CO2 Lasers

The introduction of CO2 lasers in the late 1980s has marked a paradigm shift in lower eyelid fat pad resection. The exceptional tissue water absorption characteristic of CO2 lasers allows surgeons to execute excisional and incisional procedures while ensuring simultaneous hemostasis. Surgeons today widely adopt CO2 lasers for both standard lower incisional blepharoplasty and transconjunctival approaches, integrating laser resurfacing seamlessly into the surgical process.

Precision in Transconjunctival Approach

For the transconjunctival approach, a strategic injection of 2% lidocaine with 1:100,000 epinephrine sets the stage. The Desmarres retractor facilitates lower eyelid retraction, exposing the inferior fornix. Employing the CO2 laser in continuous wave mode, incising the lower eyelid conjunctiva unveils the inferior orbital fat pads. Two distinctive conjunctival incisions—preseptal and retroseptal—offer surgeons flexibility in reaching the fat while minimizing bleeding and fat extrusion.

Navigating the Dissection Planes

In the preseptal approach, incising 2 mm under the inferior edge of the tarsus enables access to the fat by separating the septum and the orbicularis oculi muscle. Retroseptal dissection, executed 3 to 5 mm under the inferior tarsus edge, provides direct access to the inferior orbital fat without compromising the septum. Careful management of conjunctival vascular arcades is imperative to minimize bleeding.

The Art of Fat Excision with CO2 Laser

A small Desmarres retractor, strategically placed, aids in fat exposure and excision. CO2 laser excision, with simultaneous cautery, ensures precise removal of central and lateral fat pads. The challenging medial fat compartment, bordered by the inferior oblique muscle, demands meticulous attention. Volume checks and evaluation of residual fat bulging guide the surgeon to the endpoint—flush removal down to the inferior orbital rim, often obviating the need for sutures.

Postoperative Considerations and Complications

Postoperative vigilance against retro-orbital hemorrhage, the most dreaded complication, underscores the importance of meticulous surgical technique. While complications such as infection, scleral show, and corneal ulceration may arise, a judicious balance between lipectomy and fat preservation is crucial. The postoperative phase recommends laser or radiofrequency (RF) resurfacing to enhance outcomes and combat fine wrinkles.

Interstitial Lasers: A Cutting-Edge Frontier

In the pursuit of faster, safer alternatives to reduce localized fat deposits, interstitial lasers have emerged as a compelling option. Laser lipolysis, facilitated by pulsed lasers, delivers degeneration of fat cell membranes, vaporization, liquefaction, carbonization, and heat-coagulated collagen fibers. The neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser, operating at 1,064 nm, stands out as a prime example, demonstrating clinical efficacy comparable to traditional transconjunctival lower blepharoplasty.

Safety and Efficacy in Laser-Assisted Lipolysis

Noteworthy studies, such as Zhang et al.'s retrospective review of 128 cases, validate the safety and efficacy of transconjunctival laser-assisted lipolysis. Employing a 1,064-nm Nd:YAG laser with meticulous technique and postoperative care, the procedure showcased results akin to traditional blepharoplasty with minimal downtime and side effects.

Cautionary Notes: Overheating Risks and Surface Temperature Management

As with any advanced procedure, vigilance is paramount. A cautionary report underscores the risks of overheating, emphasizing the need to maintain surface temperatures below 42°C during laser-assisted lipolysis. This preventive measure prevents burns and scarring, ensuring optimal patient outcomes.

Conclusion: Elevating Lower Blepharoplasty to Unprecedented Heights

In the ever-evolving landscape of lower blepharoplasty, the integration of CO2 lasers and interstitial lasers heralds a new era of precision, safety, and efficacy. Surgeons embracing these advanced techniques navigate the delicate balance between innovation and established practices, ensuring that each procedure unfolds as a masterpiece in the pursuit of aesthetic excellence.