Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution

We read with great interest the article entitled “Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution” by Wong and Mendelson in which the authors described the use of a transconjunctival approach to release the tear trough ligament and the orbicularis retaining ligament to correct the tear trough deformity and graft the excised fat.1 Giving a fatigued and tired appearance, especially in young people, tear trough deformity is nowadays a relevant cosmetic issue. Even in the absence of significant fat pads, it may emphasize their presence in the lower eyelid, as in cases reported by the authors in Figures 9 and 11. With the aging process, the face follows a vertical vector, flattering the typical convexities of the young age. The separation of the adjacent adipose tissue compartments, rather than the decrement of the adipose volumes of the face, points out the transition between contiguous areas such as the eyelid and the cheek, interrupting the contour profile of the middle face. This region is rich in highly efficient anchoring structures, including the tear trough ligament, which strongly connect the dermis of the lower eyelid with the periosteum. These ligaments, defining a hollow in the inferomedial part of the orbital region, highlight, at the same time, the presence of the fat pads even when minimal. In some cases, fat excision during lower eyelid blepharoplasty could worsen the overall appearance of the orbital area, underlining, if present, the crescent aspect of the eye. In these cases, we maintain that correction of the tear trough deformity is the main issue and, in the absence of fat pad herniations, the release of the tear trough ligaments could reduce the tired aspect of the face, facilitating the reunion of the adjacent fat compartments, recontouring a more youthful profile.2–5 In our experience, the intraoral approach may represent a valid access with which to reach the tear trough ligament directly, sparing the orbicularis muscle and reducing at the same time the risk of hematomas. The infraorbital nerve block with local anesthesia makes the procedure completely comfortable for patients. Through the intraoral access, the cannula reaches the supraperiosteal plane directly, avoiding the orbicularis muscle and decreasing the risk of hematomas. A blunt cannula releases the tear trough ligament with a gentle twisting movement and, when necessary, a fat graft or a filler decreases the hollow appearance of the deformity. Attention to avoiding damage to the infraorbital nerve is mandatory. In very selected cases, this procedure can be extremely efficient and, at the same time, less aggressive, with a short downtime, enrolling also nonsurgical populations. (See Video, Supplemental Digital Content 1, which shows execution of the intraoral technique for correction of the tear trough in a young patient, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users,