Table 1. Open in new tab Transcutaneous...

LLB Technique

Transconjunctival LLB

Transcutaneous LLB

Indications

Steatoblepharon (with mild to moderate lower eyelid laxity)
History of:
- Hypertrophic scarring
- Reoperation (blepharoplasty)
- Pseudoproptosis

Skin and muscle laxity (with or without fat prolapse)
Repairing orbital floor zygomatic-maxillary complex fractures

Contraindications

Active blepharitis
Unrecognized dry eye syndrome
Unrecognized orbitopathy
History of:
- Refractive procedures
- Smoking
- Taking niacin, echinacea, kava, or anticoagulants^52,53

Similar to other elective and/or aesthetic surgical procedures⁵⁴

Complications

Insufficient lipectomy (2.7%), bleeding (1%), and corneal ulcer (1%)⁵⁵
- Early
Corneal abrasions
Orbital hemorrhage: may require lateral canthal release and/or medications (eg, mannitol & steroids)
Infections: requires topical and/or systemic antibiotics
Chemosis: resulting from canthopexy and canthoplasty.⁵⁶ A temporary tarsorrhaphy suture at the level of the lateral limbus of the iris for at least 3 days is suggested.⁸
- Intermediate
Eyelid malposition:
- Lower lid retraction: managed by lid massage and upward taping or surgical revision for persistent cases (>3 months)
- Lagophthalmos: due to injury to the zygomatic branch of the facial nerve; results in reduced orbicularis tone and exposure keratopathy
- Ectropion
Strabismus
Corneal exposure
Epiphora
- Late
Changes in eyelid height and contour
Dermal pigmentation^6,57
Suturing complications:
- Inflammation, suture abscess
- Pyogenic granuloma
- Eyelid retraction
Risk of ointment granulomas in sutureless techniques⁵⁸

Bleeding (1%), corneal ulcer (1%), infection (2%), scleral show (2%), and insufficient skin resection (1%)^55,59
External scarring^60,61
Vision loss: commonly caused by retrobulbar hemorrhage. Requires emergent hematoma evacuation and cauterizing the offending vessel, with lateral canthotomy and inferior cantholysis.⁶² Medical treatment alone may not be effective.
Temporary complications (managed by topical treatments):
- Diplopia
- Dry eye
- Corneal abrasion
Lower lid malpositioning^57,63-65
- Scleral show
- Lid retraction
- Ectropion: caused by eyelid laxity, overzealous skin excision, denervation of the orbicularis oculi, or contractile scarring that everts the lash line and gray line away from the globe. Only found in 0.4% of patients.^48,66

Table 1.

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Transcutaneous and Transconjunctival Lower Lid Blepharoplasty (LLB): Comparison of Indications, Contraindications, and Complications

LLB Technique	Transconjunctival LLB	Transcutaneous LLB
Indications	Steatoblepharon (with mild to moderate lower eyelid laxity) History of: Hypertrophic scarring Reoperation (blepharoplasty) Pseudoproptosis	Skin and muscle laxity (with or without fat prolapse) Repairing orbital floor zygomatic-maxillary complex fractures
Contraindications	Active blepharitis Unrecognized dry eye syndrome Unrecognized orbitopathy History of: Refractive procedures Smoking Taking niacin, echinacea, kava, or anticoagulants^52,53	Similar to other elective and/or aesthetic surgical procedures⁵⁴
Complications	Insufficient lipectomy (2.7%), bleeding (1%), and corneal ulcer (1%)⁵⁵ Early Corneal abrasions Orbital hemorrhage: may require lateral canthal release and/or medications (eg, mannitol & steroids) Infections: requires topical and/or systemic antibiotics Chemosis: resulting from canthopexy and canthoplasty.⁵⁶ A temporary tarsorrhaphy suture at the level of the lateral limbus of the iris for at least 3 days is suggested.⁸ Intermediate Eyelid malposition: Lower lid retraction: managed by lid massage and upward taping or surgical revision for persistent cases (>3 months) Lagophthalmos: due to injury to the zygomatic branch of the facial nerve; results in reduced orbicularis tone and exposure keratopathy Ectropion Strabismus Corneal exposure Epiphora Late Changes in eyelid height and contour Dermal pigmentation^6,57 Suturing complications: Inflammation, suture abscess Pyogenic granuloma Eyelid retraction Risk of ointment granulomas in sutureless techniques⁵⁸	Bleeding (1%), corneal ulcer (1%), infection (2%), scleral show (2%), and insufficient skin resection (1%)^55,59 External scarring^60,61 Vision loss: commonly caused by retrobulbar hemorrhage. Requires emergent hematoma evacuation and cauterizing the offending vessel, with lateral canthotomy and inferior cantholysis.⁶² Medical treatment alone may not be effective. Temporary complications (managed by topical treatments): Diplopia Dry eye Corneal abrasion Lower lid malpositioning^57,63-65 Scleral show Lid retraction Ectropion: caused by eyelid laxity, overzealous skin excision, denervation of the orbicularis oculi, or contractile scarring that everts the lash line and gray line away from the globe. Only found in 0.4% of patients.^48,66

LLB Technique	Transconjunctival LLB	Transcutaneous LLB
Indications	Steatoblepharon (with mild to moderate lower eyelid laxity) History of: Hypertrophic scarring Reoperation (blepharoplasty) Pseudoproptosis	Skin and muscle laxity (with or without fat prolapse) Repairing orbital floor zygomatic-maxillary complex fractures
Contraindications	Active blepharitis Unrecognized dry eye syndrome Unrecognized orbitopathy History of: Refractive procedures Smoking Taking niacin, echinacea, kava, or anticoagulants^52,53	Similar to other elective and/or aesthetic surgical procedures⁵⁴
Complications	Insufficient lipectomy (2.7%), bleeding (1%), and corneal ulcer (1%)⁵⁵ Early Corneal abrasions Orbital hemorrhage: may require lateral canthal release and/or medications (eg, mannitol & steroids) Infections: requires topical and/or systemic antibiotics Chemosis: resulting from canthopexy and canthoplasty.⁵⁶ A temporary tarsorrhaphy suture at the level of the lateral limbus of the iris for at least 3 days is suggested.⁸ Intermediate Eyelid malposition: Lower lid retraction: managed by lid massage and upward taping or surgical revision for persistent cases (>3 months) Lagophthalmos: due to injury to the zygomatic branch of the facial nerve; results in reduced orbicularis tone and exposure keratopathy Ectropion Strabismus Corneal exposure Epiphora Late Changes in eyelid height and contour Dermal pigmentation^6,57 Suturing complications: Inflammation, suture abscess Pyogenic granuloma Eyelid retraction Risk of ointment granulomas in sutureless techniques⁵⁸	Bleeding (1%), corneal ulcer (1%), infection (2%), scleral show (2%), and insufficient skin resection (1%)^55,59 External scarring^60,61 Vision loss: commonly caused by retrobulbar hemorrhage. Requires emergent hematoma evacuation and cauterizing the offending vessel, with lateral canthotomy and inferior cantholysis.⁶² Medical treatment alone may not be effective. Temporary complications (managed by topical treatments): Diplopia Dry eye Corneal abrasion Lower lid malpositioning^57,63-65 Scleral show Lid retraction Ectropion: caused by eyelid laxity, overzealous skin excision, denervation of the orbicularis oculi, or contractile scarring that everts the lash line and gray line away from the globe. Only found in 0.4% of patients.^48,66

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