Excess and unwanted skin and fat above the upper and lower eyelids is one of the most common concerns of patients desiring cosmetic surgery of the eye lids. The surgical procedure performed to reverse these age-related changes of the eyelids is called blepharoplasty. Blepharoplasty surgery helps restore a more energetic and youthful appearance, and is an excellent procedure under local injections of anesthesia with or without sedation, or in some cases general anesthesia can be used.
In upper eyelid blepharoplasty, a fine incision is made in the pre-existing crease above each eye. A crescent of excess skin and muscle is then removed, as well as all fat (puffiness) that is present. The incisions are then closed with fine stitches, which are removed in one week. In the lower lids, the fatty deposits are typically repositioned (to prevent a hollow look) or removed from the inside of the lid so that no external incision is made. In some instances, when there is excess skin that needs to be removed, a skin pinch is performed with an incision placed under the lashes so as to avoid a conspicuous scar. As with the upper lids, fine stitches are used to close the incision.
The typical post-operative recovery period (the time necessary for bruising and swelling to resolve) after cosmetic eyelid surgery is 14 days. It is important to avoid strenuous activity for the first week after surgery, but one can return to work during this time if desired. Antibiotic eye drops are generally prescribed for several days after surgery, and patients cannot wear contact lenses for approximately two weeks after surgery, as the eyelids may be stiff and sore. Makeup can be worn after 10-14 days, and the resultant fine scars, which follow the natural contour of the eyelid, tend to fade in about two to three months.
- Excess, baggy eyelid skin that in severe cases may interfere with vision (may be covered by insurance).
- Bags and/or dark shadows under the eyes, frequently caused by excess skin or fat in the lower eyelid which interferes with the patients sight.
- Sometimes a browlift is indicated and performed at the same time.
- Incisions are made where the natural crease exists in the upper lid and below or behind the eyelash line in the lower lid. Excess fat and/or skin are removed or repositioned and, if needed, the muscles are tightened.
- The procedure normally takes only one to two hours for upper and lower eyelids. Frequently it is done in conjunction with the “anti-gravity” midfacelift or endoscopic browlift.
- To minimize swelling after eye lid surgery, the head needs to be elevated for several days following surgery.
- Following surgery, discomfort is minimal and easily controlled by oral medication.
- Swelling and bruising subside over a few weeks.
- Sutures are removed in seven days.
- A fresher, more rested appearance.
- Eyelids no longer interfere with vision for better sight.
Frontal of a female patient following traditional transconjunctival removal of lower eyelid herniated orbital fat with resultant tear-trough deformity (nasojugal fold).
Frontal of a patient with midface decent and a double-convexity contour deformity (lower eyelid herniated orbital fat convexity followed by the cheek/malar mound convexity).
One year post operative photograph demonstrating improvement in lower eyelid contour following lower eyelid transconjunctival fat repositioning and an endoscopic sub-periosteal midface lift. An endoscopic brow lift and upper blepharoplasty were also performed.
Fat granuloma of the right lower eyelid following fat repositioning.
B, Right (oblique), before (left) and after (right). A 55-year-old-woman with dermatochalasis and herniated lower eyelid fat. Before (left) and 1 year post-operatively (right) following lower eyelid transconjunctival fat repositioning, endoscopic brow lift and bilateral upper blepharoplasty. Notice the improvement of the lower eyelid contour and tear-trough deformity.
A, Frontal of before (left) and after (right).
B, Left (oblique), before (left) and after (right). A middle-aged woman with brow and midface ptosis, dermatochalasis and herniated lower eyelid fat. Before (left) and 20 months post-operatively (right) following lower eyelid transconjunctival fat repositioning, endoscopic brow and midface lift and bilateral upper blepharoplasty.
Frontal of before (left) and after (right). A 38-year-old female complaining of “a deep groove under her eyes and heavy upper eyelids.” The before photo on the left reveals minimal herniated lower eyelid fat with a moderate tear-trough deformity. Following lower eyelid transconjunctival fat repositioning and an upper blepharoplasty, the after photo on the right shows improvement of the tear-trough deformity.
Frontal of before (left) and after (right).
Right Frontal Close Up, before (left) and after (right). A 35-year-old male complaining of “deep groove below my eyes.” The before photo on the left demonstrates minimal to no visible herniated lower eyelid fat with a moderate tear-trough deformity, especially of the right eye. Following lower eyelid transconjunctival fat repositioning, the hollowness is improved.
Over the last decade, lower transconjunctival blepharoplasty has become the method of choice by facial plastic surgeons for treatment of lower eyelid herniated fat due to the reduced rate of complications and to the hidden incision (1, 2). The primary complications of the transcutaneous approach are lower lid retraction with scleral show, lower lid ectropion and rounding of the lateral canthal angle (3).
Traditionally, lower eyelid herniated fat is removed which may cause a sunken or hollow lid appearance, especially in patients with a tear-trough deformity. A tear-trough deformity or nasojugal fold is usually caused by the inferior descent of the cheek (malar mound) with age or an anatomic bony deficiency of the maxilla, producing a depression at the medial inferior orbital rim (4) (Figure 1). Additionally, the midface descends creating a double-convexity contour deformity (lower eyelid herniated orbital fat convexity followed by the cheek/malar mound convexity) (Figures 2a & 2b). Fat preservation in the lower eyelid, which was originally described in 1996, may prevent some of these contour irregularities (5). We define fat repositioning as the subperiosteal repositioning of the medial and central lower lid herniated orbital fat into the nasojugal fold. The lateral orbital fat pad may be repositioned into the lateral inferior orbital region if needed.
Advantages of fat repositioning include the prevention and/or improvement of the tear-trough deformity and treatment of the herniated orbital fat. The disadvantages of fat repositioning are the steep learning curve and potential complications such as diplopia due to injury of the inferior oblique muscle, fat granulomas, prolonged edema and rarely, soft tissue irregularities.
Candidates for fat repositioning include patients with:
- Lower eyelid herniated fat
- Presence of a tear-trough deformity
- Acceptance of the possible risks and complications
- Realistic expectations
Often this technique is used to soften moderate to severe tear-trough deformities in patients with minimal to no herniated fat since fat may be released once the septum is opened. In addition, a lower eyelid skin pinch may be performed in patients with excess skin in the lower lid and adequate lower lid tone. Often, lower eyelid fat repositioning is combined with a subperiosteal midface lift to completely rejuvenate the lower eyelid – cheek region.
The transconjunctival fat repositioning procedure is performed with the patient under local or general anesthesia. With the patient in the supine position, a surgical marker is used to mark the nasojugal groove. One drop of tetracaine ophthalmic solution is instilled in each eye. One per cent lidocaine (Xylocaine) with 1:100,000 epinephrine is injected into the lower conjuctival surface and subcutaneously and subperiosteally over the inferior orbital rim nasal to the nasojugal fold. With the use of a Desmarres retractor, the lower conjuctival was exposed. The preseptal approach involves a transconjunctival incision at the inferior edge of the tarsus using a Colorado needle (Figure 3). The incision is carried through the lower eyelid retractors with care not to injure the tarsus. A preseptal dissection (Figure 4) is performed bluntly with surgical Q – tips.
A 4-0 black silk traction suture is placed through the posterior conjuctival flap to protect the cornea and to aid with exposure of the fat pads. With slight pressure on the globe, the medial fat is identified. With the Colorado needle, a buttonhole is made in the septum exposing the medial fat pad. The fat is made into a pedicle for repositioning by thinning and elongating the fat with careful dissection of the surrounding fibrous attachments. The base of the pedicle is kept intact to ensure the viability of the fat pad. While grasping the fat pad with forceps, blunt dissection is performed using Q – tips and/or scissors between the fat pad and the inferior oblique muscle to make sure that the fat pad is not adherent to the inferior oblique muscle (Figure 5). This maneuver prevents tethering of the muscle to the fat pad while repositioning. During the entire dissection, meticulous dissection and hemostasis helps prevent injury to the inferior oblique muscle.
If the central fat pad is to be repositioned, the same procedure described above is performed with one caveat. Fibrous attachments between the medial and central fat pads need to be released with blunt and/or sharp dissection to prevent tethering of the fat pads to the inferior oblique muscle. Following this maneuver, both fat pads are grasped with forceps and a “see-saw” movement is made allowing free movement of the fat pads from the inferior oblique muscle (Figure 6). The lateral fat pad is usually excised or may be used for repositioning if indicated.
For the repositioning portion of the procedure, a Jaeger plate is placed over the fat pads and the inferior oblique muscle. A Senn retractor is used to retract the lower eyelid and the orbicularis oculi exposing the inferior orbital rim and arcus marginalis (Figure 7). Using the Colorado needle, an inferior orbital rim incision is made through the periosteum approximately 2 millimeters inferior to the arcus marginalis. The medial border of the incision is immediately lateral to the medial puncta. The lateral border of the incision on the inferior orbital rim is approximately above infraorbital nerve but may extend to the lateral rim if repositioning is to be performed with the lateral fat pad. A freer elevator is used to elevate a non-constricted subperiosteal pocket along the inferior orbital rim from the infraorbital nerve to the medial/inferior aspect of the nasojugal fold.
A 4-0 polypropylene suture on a FS-2 needle is passed through the skin medial to the nasojugal groove and retrieved in the subperiosteal pocket (Figure 8). Next, the suture is placed through the medial fat pad pedicle while the pedicle is splayed-out (Figure 9), into the subperiosteal pocket and finally, exiting the skin just inferolateral to the location of the first suture. The suture is used to “pull” the pedicle towards the distal aspect of the medial subperiosteal dissection, in essence, bringing the pedicle “through” the tear-trough deformity while making sure that the fat pedicle is splayed-out and not “bunched”. Once again, care is taken to make sure that the inferior oblique muscle is free from the fat pedicle. The polypropylene suture is gently tied down over a cotton bolster. The central fat pad is repositioned inferolateral to the medial fat pad with the same suture technique (Figure 10). The subperiosteal pocket is irrigated and platelet rich plasma (if used) is sprayed into the pocket. Forced ductions are performed to confirm absence of inferior oblique muscle tethering. There should be no movement on the fat pedicle as the globe is rotated. This procedure is repeated on the contra-lateral side. If a lower eyelid skin pinch is to be performed, a frost stitch may be used if mild laxity of the lower eyelid is diagnosed preoperatively. If moderate to severe lower eyelid laxity is present, a lower eyelid tightening procedure should be performed. Following the procedure, check both sides for symmetry. An antibiotic-steroid ophthalmic ointment is placed in each eye.
The patient is instructed to apply cold compresses to the eyes for 48 hours. For 1 week, patients are instructed to maintain a semi-upright position when sleeping or resting. An antibiotic-steroid ophthalmic drop is used for 5 days since chemosis in not uncommon. Artificial tears are used frequently throughout the day for 5 days. A steroid dose pack is prescribed as needed.
A cursory eye exam checking for diplopia, gross visual acuity, edema and chemosis is performed on the first post-operative day. On day 5, the polypropylene suture is removed and the repositioned fat is checked for symmetry. The patients may resume full activities after 3 weeks.
The complications from fat repositioning are generally the same for a transconjunctival blepharoplasty except that the potential risk for diplopia due to injury of the inferior oblique muscle, fat granulomas, prolonged edema and soft tissue irregularities are higher. Diplopia is usually transient due to edema, while persistent diplopia will need evaluation by our ophthalmology colleagues. Although rare, a fat granuloma (Figure 11) may be treated conservatively with intralesional steroids, or if needed, more aggressively with local excision. Prolonged edema (persistent for more than 6 weeks) may be treated with oral steroids and ultrasound.
Since January 2001, we have performed fat repositioning procedures in more than 100 patients with no visible fat reabsportion. This procedure has the advantage of addressing the herniated fat while preventing lower eyelid hollowness and/or improving the tear-trough deformity.
Fat repositioning may be combined with one or more of the following procedures:
- Endoscopic subperiosteal midface lift
- Transcutaneous skin pinch
- Transconjunctival orbicularis oculi excision
As with any new procedure, thorough knowledge of the current literature and anatomy and observation of this procedure by an experienced surgeon should prelude your attempt in lower eyelid transconjunctival fat repositioning.
- Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty: technique and complications. Ophthalmology 1989; 96:1027-32.
- Goldberg RA, Lesner AM, Shorr N, Baylis HI. The transconjunctival approach to the orbital floor and orbital fat: a prospective study. Ophthalmic Plast Reconstr Surg 1990; 6:241-46.
- Baylis HI, Goldberg RA, Groth MJ. Complications of lower Blepharoplasty. In: Putterman AM, editor. Cosmetic oculoplastic surgery: eyelid, forehead, and facial techniques, 3rd edition. Philadelphia: WB Saunders; 1999. p. 429-56.
- Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthalmic Plast Reconstr Surg 1996; 12:77-88.
- Hamra ST. The role of orbital fat preservation in facial aesthetic surgery: a new concept. Clin Plast Surg 1996; 23:17-28.
Paul S. Nassif, M.D., F.A.C.S. is a world-renowned facial plastic and reconstructive surgeon whose work has been featured on numerous international and national television and print media. He has been featured on such programs as NBC World Nightly News with Tom Brokaw, ABC World News Tonight with Peter Jennings, CBS’ The Early Show, CNN, MSNBC, E!, EXTRA!, VH1, BBC, The Learning Channel and Discovery Health. Dr. Nassif has also been quoted in such publications as the New York Times, Associated Press (world-wide), The Wall Street Journal, USA Today, and Los Angeles Times among others.
For a complete list of his media work, go to the Media section.