Medical

Communication

Biosci. Biotech. Res. Comm. 10(2): 102-107 (2017)

Comparison of two transconjunctival and

transcutaneous approaches in the incidence of scleral

show during lower eyelid blepharoplasty

Hooman Hooshangi

, Mehdi Sezavar

*, Behnam Bohluli

, Farzin Sarkarat

, Fatemeh

Nasrollahi

and Sina Seyedabbaszadeh

Resident of Oral and Maxillofacial Surgery, Islamic Azad University, Dental Branch, Tehran, Iran

Assistant Professor, Department of Oral and Maxillofacial Surgery, Islamic Azad University, Dental Branch,

Tehran, Iran

Associated Professor, Department of Oral and Maxillofacial Surgery, Islamic Azad University, Dental

Branch, Tehran, Iran

ABSTRACT

Despite its effectiveness for the facial rejuvenation, blepharoplasty has been associated with several adverse effects.

One of the most common side effects of this surgery is eyelid malposition and scleral show which is not suitable from

esthetic point of view. Although some techniques have been used for the blepharoplasty of the lower eyelid, the effect

of these techniques has not been de nitely identi ed in the incidence of scleral show. The present study compared

the effects of lower eyelid blepharoplasty with transconjunctival and transcutaneous approaches in the incidence of

scleral show in patients. 22 candidates of the lower eyelid blepharoplasty were studied. The patients had no history

of systemic disease, previous lower eyelid blepharoplasty, trauma or dry eye syndrome. The patients were randomly

assigned in 2 methods of transconjunctival and transcutaneous approaches. The surgeries were perform on 2 eyelids

of the left and right sides and in total, 44 eyelids were subjected to blepharoplasty surgery in both sides of the patients

in 2 approaches. The incidence of scleral show in both modalities was studied 2, 4 and 6 months post-surgery. In this

study, 22 patients were included for eyelid blepharoplasty (44 eyelids). In the transconjuctival approach, 4 males and

7 females with average age of the 57.09 years old were included. For transcutaneous approach, 5 males and 5 females

average age of the 56.18 years old were included. According to the results, no scleral was showed using transconjucti-

val approach after 2 months. Two months after transcutaneous approach only 2 (9%) scleral was observed (P<0.8). No

102

ARTICLE INFORMATION:

*Corresponding Author: sina.seyedabbaszadeh.omfs@gmail.com

Received 11

March, 2017

Accepted after revision 2

June, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

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Online Contents Available at: http//www.bbrc.in/

Hooman Hooshangi et al.

signi cant difference detected in scleral using transconjuctival or transcutaneous operations after 4 months, however

only 2 (9%) scleral was observed using transcutaneous approach (P<0.8). The same results observed after 6 months

follow-up period (P<0.8).Despite insigni cant differences between 2 lower eyelid blepharoplasty approaches regard-

ing the scleral show incidence, using transconjunctival technique was recommended for the lower eyelid blepharo-

plasty in order to decrease the incidence of the scleral show.

KEY WORDS: LOWER EYELID BLEPHAROPLASTY, TRANSCUTANEOUS, TRANSCONJUNCTIVAL, SCLERAL SHOW

INTRODUCTION

Blepharoplasty remains one of the most common con-

temporary facial surgical procedures performed. While

in oculo-facial plastic surgery functional upper eye-

lid blepharoplasty still encompasses the majority of

the specialties procedures, cosmetic upper and lower

blepharoplasty are rapidly increasing in number.The

skin-muscle  ap approach to lower blepharoplasty was

popularized in the 1970s. It remained the most gener-

ally used method because of e fast, effective and widely

applicable (Hidalgo, 2011; Massry and Hartstein, 2012).

Post blepharoplasty treatment of lower eyelid retraction

is challenging (Yoo et al. 2013). Several methods intro-

duced to improve lower eyelid blepharoplasty outcome

(Schwarcz et al. 2016, Kossler et al. 2017).

Transcutaneous lower eyelid blepharoplasty with fat

excision has been the paradigm for addressing the un-

desirable sequelae of the aging eye (Grif n et al. 2014).

This is eyelid contour and no changes in eyelid position

when performed in a conservative fashion. Transcutane-

ous is a time-tested method that achieves satisfactory

cosmetic results (Garcia and McCollough, 2006). The lat-

est evolution of the transcutaneous lower eyelid blepha-

roplasty is a skin  ap or skin muscle  ap method in

which the incision is placed inferiorly to the tarsal mar-

gin (Freeman, 2000). The transconjunctival approach

was primary described in 1924 to the lower orbital fat

and the inferior orbital surface (Korchia et al. 2003).

Transconjunctival lower eyelid blepharoplasty is most

acceptable as a safe and effective method to eliminate

herniated orbital fat from the lower eyelid and avoid-

ing the complications of a cutaneous incision (Belinsky

et al. 2015).

The transconjunctival approach avoids numer-

ous complications of the classic transcutaneous lower

blepharoplasty (Kossler et al. 2017). It is reported

the limitations of the transcutaneous approach was

improved by the transconjunctival approach (LoPiccolo

et al. 2013). The transconjunctival approach has gained

popularity over the transcutaneous approaches because

of its inconspicuous scar and decreased risk of postop-

erative ectropion and scleral show (Salhi and Cordoba,

2015).

Scleral show is one of the main complications of

lower blepharoplasty which may result to manifest as

lack of de nition of the lateral part of the eyes and eye-

lid retraction (Pascali et al. 2015). Lower eyelid retraction

is known for the existence of scleral show (which each

patient stated (Grif n et al. 2014). Scleral show is one of

the most feared complications of lower blepharoplasty

surgery. The attendant scleral show and rounding of the

eye are poorly tolerated by patients from a cosmetic and

often functional stand-point (Grif n et al. 2014). The

surgical correction of postsurgical eyelid retraction can

be challenging as well as frustrating (Yoo et al. 2014).

Despite its effectiveness for the facial rejuvenation,

blepharoplasty has been associated with several adverse

effects. One of the most common side effects of this sur-

gery is eyelid malposition and scleral show which is not

suitable from esthetic point of view. Although some tech-

niques have been used for the blepharoplasty of the lower

eyelid, the effect of these techniques has not been de -

nitely identi ed in the incidence of scleral show. So, the

current study was compared the effects of lower eyelid

blepharoplasty with transconjunctival and transcutaneous

approaches in the incidence of scleral show in patients.

MATERIAL AND METHODS

In a prospective randomized clinical trial, 22 candidates

of the lower eyelid blepharoplasty in patients referred

to two private clinics and Bu Ali hospital at 2015. The

patients had no history of systemic disease, previous

lower eyelid blepharoplasty, trauma or dry eye syn-

drome. The patients were randomly assigned in 2 meth-

ods of transconjunctival and transcutaneous approaches.

The surgeries were perform on 2 eyelids of the left and

right sides and in total, 44 eyelids were subjected to

blepharoplasty surgery in both sides of the patients in

2 approaches. The incidence of scleral show in both

modalities was studied using standard photographs of

patients taken before the surgery and 2, 4 and 6 months

post-surgery. The frequency of the scleral show was sta-

tistically analyzed by exact  sher test in two approaches

in different time intervals.

RESULTS

In this study, 22 patients were included for eyelid blepha-

roplasty (44 eyelids). In the transconjuctival approach, 4

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPARISON OF TWO TRANSCONJUNCTIVAL AND TRANSCUTANEOUS APPROACHES 103

Hooman Hooshangi et al.

Table 1. the demographic information of the patients based on the surgery operation

Sex Location age Following period (month)

Male Female Left Right

Transconjuctival 4 7 11 11 57.09 6

Transcutaneous 5 6 11 11 56.18 6

Table 2. the results of the scleral show at 2-6 months post Transconjuctival or Transcutaneous operation

Follow (2 months) Follow (4 months) Follow (6 months)

scleral show

No Yes No Yes No Yes

Transconjuctival 22 (100%) 0 (0%) 22 (100%) 0 (0%) 22 (100%) 0 (0%)

Transcutaneous 20 (91%) 2 (9%) 20 (91%) 2 (9%) 20 (91%) 2 (9%)

Fisher’s P value <0. 8 <0. 8 <0. 8

males and 7 females with average age of the 57.09 years

old were included. For transcutaneous approach, 5 males

and 5 females average age of the 56.18 years old were

included. Then all patients were followed-up 6 months

for possible scleral show (table 1).

The results of the scleral show at 2-6 months post

transconjuctival or transcutaneous operations are pre-

sented in table 2. According to the results, no scleral was

showed using transconjuctival approach after 2 months.

Two months after transcutaneous approach only 2 (9%)

scleral was observed (P<0.8). No signi cant difference

detected in scleral using transconjuctival or transcuta-

neous operations after 4 months, however only 2 (9%)

scleral was observed using transcutaneous approach

(P<0.8). The same results observed after 6 months fol-

low-up period (P<0.8).

DISCUSSION

Eyelid tone, position and scleral show have been the

most common limiting aspects of lower blepharoplasty.

Dysfunction of the lateral canthal tendon can be caused

by aging, iatrogenic damage, and so on (Sacchidan-

and et al. 2012). Lower eyelid retraction might occur

by dynamic imbalance in the lateral suspension system

of the lower eyelid, lack of elasticity of mid facial soft

tissue and etc. (Oestreicher and Mehta, 2012). Base on

the results of the current study, no scleral was showed

using transconjuctival approach after 2 months. Two

months after transcutaneous approach only 2 (9%) scle-

ral was observed. No signi cant difference detected in

scleral using transconjuctival or transcutaneous opera-

tions after 4 months, however only 2 (9%) scleral was

observed using transcutaneous approach. The same

results observed after 6 months follow-up period. In

this regard, Bernardino et al. (2016) reported there was

improvement in all 16 female and 2 male patients in the

appearance of increased the lower eyelid and reduction

in skin and lateral ligament laxity. Also, eyelid retrac-

tion, ectropion, unaesthetic scars, diplopia and remnant

fat bags were not observed (Bernardino et al. 2016).

During the 1998–2008 in 2400 patients underwent

lower blepharoplasty Transconjunctival blepharoplasty

was the  rst choice for primary eyelid bags. Transcu-

taneous lower blepharoplasty (skin  ap or skin-muscle

 ap procedures) is indicated for the senile eyelid with

excess skin and muscles (Guo et al. 2010).Both transcon-

junctical and transcutaneous approaches is applied for

upper and lower lid blepharoplasty. Even though trans-

cutaneous upper and lower eyelid surgery and transcon-

junctival lower lid procedures are popular with facial

plastic surgeons, transconjunctival upper blepharoplasty

is new technique with limited indications (Jacono et al.

2001). These researchers suggested the transconjunctival

lower lid blepharoplasty as it circumvents the risk of

lower eyelid retraction associated with the transcutane-

ous approach (Jacono et al. 2001). A lower rate of com-

plications reported via the transconjunctival approach,

with greater patient satisfaction (Rancati et al. 2015).

The transconjunctival and approaches were preferred

in 42 and 58 % (Rancati et al. 2015). In transconjunc-

tival versus transcutaneous lower eyelid blepharoplasty

(Netscher et al. 1995) in 6 months follow-up reported 10

consecutive patients presented for blepharoplasty, and

in all patients the transcutaneous subciliary musculocu-

taneous  ap approach was used on the left lower eyelid

and the transconjunctival preseptal approach was used

on the right. No signi cant variance on the 2 sides (0.60

on the left and 0.68 on the right) (Netscher et al. 1995).

No signi cant difference reported in lower eyelid posi-

tion change between the transconjunctival lower blepha-

roplasty with versus without a skin pinch groups. Using

the transcutaneous approach, the presented infection

104 COMPARISON OF TWO TRANSCONJUNCTIVAL AND TRANSCUTANEOUS APPROACHES BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Hooman Hooshangi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPARISON OF TWO TRANSCONJUNCTIVAL AND TRANSCUTANEOUS APPROACHES 105

FIGURE 1. Results of the transconjunctival apporeach (left) and transcutaneous (right)

Hooman Hooshangi et al.

106 COMPARISON OF TWO TRANSCONJUNCTIVAL AND TRANSCUTANEOUS APPROACHES BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

FIGURE 2. Results of the transconjunctival apporeach before and after the surgery

FIGURE 3. Results of the transcutaneous apporeach before and after the surgery

(2%), scleral show (2%) and insuf cient skin resection

(1%) was reported (Hidalgo, 2011). The transconjunctival

approach is an ideal procedure due to its simplicity and

less traumatic effect, except in the lower eyelid weakness

and surgical resolution (Collar et al. 2013). In conclu-

sion, despite insigni cant differences between 2 lower

eyelid blepharoplasty approaches regarding the scleral

show incidence, using transconjunctival technique was

recommended for the lower eyelid blepharoplasty in

order to decrease the incidence of the scleral show.

Hooman Hooshangi et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS COMPARISON OF TWO TRANSCONJUNCTIVAL AND TRANSCUTANEOUS APPROACHES 107

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