SAN DIEGO In recent years, the transconjunctival approach to lower blepharoplasty has become a popular alternative to the traditional transcutaneous approach, but which technique is best?
The answer "is not entirely clear," Hayes B. Gladstone, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.
"The transconjunctival approach to lower blepharoplasty is safe, but edema and wrinkled skin are the two most common complications," said Dr. Gladstone, director of the division of dermatologic surgery in the department of dermatology at Stanford (Calif.) University.
"It also seems that with the transconjunctival approach, an adjunct procedure such as laser resurfacing or chemical peels is an important consideration," he said.
Reported advantages of the transcutaneous approach are that it provides easy access to the skin, the fat pads are usually well visualized, and it removes excess skin, he said. The reported disadvantages of this approach include risk for eyelid malposition, risk for ectropion, and the fact that it leaves a visible scar.
Reported advantages of the transconjunctival approach are that it leaves no scar and it poses a decreased risk for eyelid malposition as well as ectropion. Reported disadvantages include difficult access to the skin, less visualization of all fat pads, potential for inferior oblique injury, and the fact that "it doesn't address excess infraorbital skin," he said.
Dr. Gladstone conducted a metaanalysis of the transcutaneous and transconjunctival approaches to lower blepharoplasty based on relevant studies published in the medical literature from 1970 to the present. He evaluated components of the studies that concerned complications, patient satisfaction, and physician assessment.
The studies he reviewed included 4,460 patients who underwent transcutaneous lower blepharoplasty and 3,438 patients who underwent transconjunctival lower blepharoplasty.
Edema occurred in 18% of patients who underwent the transconjunctival approach, compared with 0.2% of those who underwent the transcutaneous approach. In addition, 11% of patients in the transconjunctival group experienced wrinkling, compared with 2.4% of patients in the transcutaneous group.
Dr. Gladstone also observed that 32% of patients who underwent the transconjunctival approach required an adjunctive procedure such as laser resurfacing or chemical peels, compared with 1.5% of patients who underwent the transcutaneous approach.
The patient assessment of lower blepharoplasty "was not clear" in studies of the transcutaneous approach, he said.
Among patients who underwent the transconjunctival approach, more than half (52%) described being satisfied by the procedure, while only 29% described their results as excellent. "They wouldn't even consider that they had excellent results, which I think is a problem when you're doing a cosmetic procedure," Dr. Gladstone commented.
He was not able to quantify physician assessment of the two approaches from the studies he reviewed.