When it comes to addressing the aging eye, Andrew Jacono, M.D., a Manhattan, N.Y., based facial plastic surgeon uses a specific algorithm to decide which treatment — or treatments — is right for each patient. Fillers alone in patients with loose skin may be unhappy with results; traditional blepharoplasty could cause the eyes to appear older, not younger, as intended.
See “The Aging Orbit, An Eye for Eyes” for Dr. Jacono’s non-surgical component to to eye rejuvenation.
When it comes to surgery, Dr. Jacono, assistant clinical professor of facial plastic surgery at the New York Eye and Ear Infirmary and the Albert Einstein College of Medicine, uses a specific algorithm to decide which blepharoplasty approach is best for each patient.
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Transcutaneous vs Transconjunctival
Dr. Jacono often chooses the transconjunctival approach for patients in their 30s through 50s, who are only concerned about the loss of volume. For others — especially older patients — he prefers the muscle-flap approach.
"When you do the transconjunctival approach, you're not able to tighten the orbicularis muscle as much, which is an important part of lower eyelid rejuvenation in the older patient. If you do the extended skin muscle-flap approach, the flap releases the attachments of the orbicularis muscle to the tear trough by the orbitomalar ligaments. This allows for greater re-draping of the orbicularis muscle and more significant improvement in the laxity of the lower eyelid. At the same time, the fat pads are moved, so you can accomplish more, especially for those with more significant eyelid aging," he says.
Another reason to choose the transconjunctival approach is if the surgeon is concerned about the risk of post-blepharoplasty lower eyelid retraction, or ectropion. Patients who have prominent eyes and a weak cheek structure, called a negative vector, are at higher risk of this complication, according to Dr. Jacono.
"The transcutaneous approach with the lower eyelid skin-muscle flap has a much higher risk of this complication. So, for patients with poor facial structure and prominent eyes, I will be much more likely to do a transconjunctival surgery, to limit the risk of lower eyelid malposition," he says.
The Fat Pad: Remove or Not?
As Dr. Jacono points out in Dermatology Times, "It's still common practice to remove the fat pad from around the eyes with traditional blepharoplasty," he says. "With or without fat grafting, it still de-volumizes the eyes."
In patients with large fat bags, he believes it makes more sense to perform a lower eyelid fat transposition. Compared with fat grafting, transposed orbital fat is much more predictable and also has a 100% survival rate, as it remains attached to the blood supply in the form of a pedicled vascularized flap, he says. However, to be a candidate for fat transposition, patients must have enough local fat to move. If they don’t, Dr. Jacono says he relies on fat grafting.
Both the transconjunctival and transcutaneous surgical approaches can be used to reach and move the fat pockets in lower eyelids, according to Dr. Jacono. For the transconjunctival approach, from inside of the eyelid, surgeons can use a preseptal or post-septal technique to get to the fallen fat and transpose it to the hollow area, he says.
"After making a transconjunctival incision, you dissect to the orbital rim where an incision is made and the periosteum is lifted under the area of the tear trough. The orbital fat is transposed from its superior location to the inferior tear tough and held into place with transcutaneous sutures while it's healing," he says.
Dr. Jacono usually removes these sutures in five days.
The other way to access the patient's fat pocket it is to make a subciliary external incision (under the eyelashes) and lift skin and muscle, simultaneously in what Dr. Jacono calls this the skin-muscle-flap approach.
“In this method, the skin muscle flap is extended to the area under the tear trough, lifting the flap in a supra-periosteal plane. Because of this, the fat bags can be sutured directly to the periosteum with a dissolvable chromic suture under the flap, so transcutaneous sutures are not necessary,” he says.