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Achieving Symmetry in Lower

Blepharoplasty Fat Removal

Jemshed A. Khan

These tips will make fat removal in a purely subtractive transconjunctival lower blepharoplasty procedure more symmetric to avoid postoperative surprises.

Divide Each Fat Pad Flush with the Orbital Rim—Nasal and Central Fat Pads

Using the symmetric positions of the paired inferior orbital rims as a guide is a key to achieving postoperative symmetry in lower blepharoplasty. When deciding exactly where to transect the herniating lower eyelid fat, use the bony inferior orbital rim as the sole landmark. One can grasp the herniating fat with a hemostat which rests upon the orbital rim, and then one can comfortably proceed with excision of the fat. If piecemeal excision is used to remove the protruding fat, it is important to immediately perform ballottement and see if any more fat easily comes forward past the inferior orbital rim.

Divide Each Fat Pad Flush with the Orbital Rim—Lateral Fat Pad

Positioning a hemostat properly in addressing the fat pad in the tight lateral area requires diligence and experience, especially when it comes to positioning the hemostat. Not uncommonly, there is more fat prolapse immediately following the first excision. Also, there may still be a residual temporal bulge of fat that requires further division of the septum. Diligence and patience are necessary to achieve adequate temporal fat excision.

Reposition the Eyelid and Ballottement to Look for Any

Residual Bulging Fat

The final and important step is balloting. Often one may find residual fat that was overlooked earlier in the procedure. Such fat may not come forward until later in the procedure because it had been constrained by cautery or clamping of the overlying fat.

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Chapter 48 Achieving Symmetry in Lower Blepharoplasty Fat Removal 149

Figure 48.2. Finger pressure is applied to the protective shield in order to retropulse the globe and prolapse forward any residual excess fat.

Figure 48.3. Appearance at end of procedure.

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Hemostasis in Lower Blepharoplasty

Erin L. Holloman and Sterling S. Baker

The lower eyelid transconjunctival blepharoplasty can be performed safely, especially if the anatomy is clear. Avoid the prominent marginal arteries below the inferior border of the tarsus if possible. Carefully trim away fat that presents itself. There is usually a large vessel coursing through the nasal fat pads. The vessel, not cut, will not bleed. Try only sculpting away globules of lower lid fat, always avoiding the vessels, instead of clamping the fat paids and cauterizing excessively.

Absolute hemostasis in this area before closing is always in the surgeon’s favor. The palpebral conjunctival incision does not have to be sutured closed as long as the eyelid is repositioned correctly.

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50

The Treatment of Festoons in

Lower Blepharoplasty

Sheri L. DeMartelaere, Todd R. Shepler, Sean M. Blaydon, Russell W. Neuhaus, and John W. Shore

Festoons or “malar bags” are thought to be involutional attenuation of the skin and underlying orbital orbicularis oculi muscle. Edema often accumulates in this area. Standard blepharoplasty techniques will not address festoons, if present, and may make them worse for a time due to persistent edema in this area.

In severe cases of festoons, one approach is direct excision (Figures 50.1 and 50.2). This approach needs to be entertained with caution as the result is a visible scar and frequently there is prolonged postoperative edema, often requiring 6 months or more to resolve. Any lower eyelid laxity, steatoblepharon, and dermatochalasis must be addressed first, otherwise one risks lower lid retraction and/or ectropion postoperatively. Thus, this is often a staged procedure, with the first step being lower eyelid blepharoplasty with correction of any lower eyelid laxity via standard horizontal lower lid tightening (HLLT) procedures. Lower eyelid retraction should also be addressed and may require a lower eyelid spacer graft, SOOF, or mid-face lifting. Three to 6 months later, the remaining festoons can be directly excised with local advancement

ap repair. The incision is made at the crease at the inferior edge of the festoons (marked with patient upright). The skin is then undermined superiorly to the lash line of the lower eyelid, draped, and trimmed to t the defect. Preoperative (Figure 50.3) and postoperative (Figure 50.4)

results can be excellent.

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51

Fat Repositioning in Lower

Blepharoplasty: Less Is More

Sheri L. DeMartelaere, Todd R. Shepler, Sean M. Blaydon, Russell W. Neuhaus, and John W. Shore

Techniques in lower eyelid blepharoplasty have moved to “less is more.” We have moved away from fat excision and have a better appreciation for “fat enhancement” in our goal to soften any tear trough deformities and to minimize the hollow orbit appearance. More emphasis is now being placed on fat repositioning and elimination of the bony prominence of the inferior orbital rim. Fat repositioning is particularly useful in those patients with moderate medial and central fat prolapse, but with a hollow tear trough deformity. There has to be enough orbital fat in order to reposition it over the orbital rim. In patients where there is a prominent tear trough deformity but a paucity of anterior fat, a tear trough implant may be more appropriate to build up the bony support. Fat repositioning over the inferior orbital rim may be inadequate to fill in the hollowness if there is significant descent of the SOOF and/or malar fat pad. In these cases a lower eyelid blepharoplasty may need to be combined with a mid-face or SOOF lift to adequately deal with the contour defects.

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52

Fat Repositioning in Lower Lid

Blepharoplasty: General Principles

Guy Ben Simon and John D. McCann

In young people the eyelid–cheek complex is a single smooth convex pro le. Aging causes descent of the globe and pseudoherniation of intraorbital fat, producing a double convex or tear trough deformity on the eyelid profile and a nasojugal groove at the medial aspect of the lower eyelid. With advancing age this depression appears more prominent because of attenuation and descent of the orbicularis oculi and cheek fat, resulting in skeletonization of the orbital area and revealing the topographical contour of the inferior orbital rim. Simple removal of orbital fat can result in a hollow appearance of the lower eyelid.

Preservation of the lower orbital fat is a new concept in facial rejuvenation, designed to prevent the hollow appearance that may follow the removal of excess fat in lower eyelid blepharoplasty. Such preservation creates a smooth transition to the malar eminence, blending nicely into the upper face. Aging causes progressive exposure of the underlying skeletal anatomy in the periorbital area, unlike in the lower facial area, where thicker soft tissue continues to cover bony landmarks.

The basic surgical technique includes release of the arcus marginalis and advancing of the subseptal fat beyond the infraorbital rim and underneath the orbicularis muscle. The fat pedicles are temporarily externalized to the midface by suturing. They can be placed in the subor supra-periosteal planes, with no apparent effect on aesthetic results.

This technique camouflages the lower orbital rim anatomy and provides more youthful rejuvenation of the midface.

Other methods suggested to correct tear trough deformity include orbital fat removal, fat injections or grafts, and alloplastic cheek implants.

In general, transconjunctival fat repositioning results in leveling of the tear trough deformity, a smooth contour of the lower eyelid, and high patient satisfaction.

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