The resurgence of popularity of the transconjunctival approach to lowe
r eyelid fat removal as a component of cosmetic blepharoplasty has bee
n highlighted by a number of publications in recent years. There has b
een, ha however, minimal discussion in the literature of the complicat
ions of this procedure. Although the mechanism of muscle injury is sim
ilar in transcutaneous and transconjunctival surgery, there is a much
more direct route to the inferior extraocular musculature via the latt
er approach. Herein, we present a series of six patients with diplopia
status post-transconjunctival lower eyelid blepharoplasty referred to
the Manhattan Eye, Ear, and Throat Hospital for evaluation. Transconj
unctival. lower lid blepharoplasty was performed as a primary procedur
e in four patients and as a secondary procedure following transcutaneo
us blepharoplasty in two patients. Patients were evaluated with ocular
examination and orthoptic measurements. Magnetic resonance imaging wa
s obtained in two cases. The inferior rectus and inferior oblique musc
les were found to be equally injured in these cases (4 of 6), and the
lateral rectus was encountered in one case. Two patients required stra
bismus surgery to correct their diplopia, whereas four patients improv
ed with observation alone. The possible etiologies of postoperative di
plopia following transconjunctival lower lid blepharoplasty are manifo
ld. Mechanisms of extraocular muscle injury may include intramuscular
hemorrhage and edema, cicatricial changes within the muscle, and accid
ental incorporation of extraocular muscle in closure of orbital septum
. Avoidance of these complications is probably best achieved through i
ntimate understanding on the part of the surgeon of eyelid anatomy fro
m the transconjunctival perspective.