Key points

Overview

Hamra observed that the youthful eyelid-cheek complex is a single mildly convex line on profile. Aging causes descent of the globe and subsequent pseudoherniation of intraorbital fat, producing a double-convex lower eyelid contour. Aging also causes attenuation and descent of the orbicularis oculi and cheek fat. The inferior and lateral descent of these structures results in an increased distance from the lower lid margin to the inferior aspect of the orbicularis oculi, producing an orbit that appears deeper and wider in diameter. This progressive ptosis and attenuation of soft tissue coverage reveals the contours of the inferior bony orbital rim and is a common feature of patients seeking lower eyelid and midface rejuvenation.

Although early approaches to lower lid blepharoplasty focused more on the excision of fat, it has not been until recently that surgeons have gained an appreciation of the aesthetic benefits of periorbital fat conservation. Over the past 2 decades, there has been an emerging consensus among aesthetic surgeons to refrain from aggressive fat resection during blepharoplasty.

The technique of mobilizing intraorbital fat from the nasal compartment over the inferior orbital rim was first described by Loeb. The goal of this maneuver was camouflage of the nasojugal groove. Hamra subsequently advocated mobilization of fat from all 3 compartments of the lower eyelid to camouflage the infraorbital bony rim. Eder reported a series of more than 200 cases in which the arcus marginalis was released and fat was advanced over the infraorbital bony rim, suturing it to the periosteum of the maxilla and to the suborbicularis oculi fat pad (SOOF). After this maneuver, if an excess of fat was still apparent, it was removed or coagulated.

In patients with orbital fat pseudoherniation and evidence of skeletonization of the infraorbital bony rim, it is generally preferable to advance redundant intraorbital fat and orbital septum over the rim rather than excise fat. This has been the technique of choice in the senior author’s practice for the past decade. Technical pearls and refinements are discussed.

Overview

Hamra observed that the youthful eyelid-cheek complex is a single mildly convex line on profile. Aging causes descent of the globe and subsequent pseudoherniation of intraorbital fat, producing a double-convex lower eyelid contour. Aging also causes attenuation and descent of the orbicularis oculi and cheek fat. The inferior and lateral descent of these structures results in an increased distance from the lower lid margin to the inferior aspect of the orbicularis oculi, producing an orbit that appears deeper and wider in diameter. This progressive ptosis and attenuation of soft tissue coverage reveals the contours of the inferior bony orbital rim and is a common feature of patients seeking lower eyelid and midface rejuvenation.

Although early approaches to lower lid blepharoplasty focused more on the excision of fat, it has not been until recently that surgeons have gained an appreciation of the aesthetic benefits of periorbital fat conservation. Over the past 2 decades, there has been an emerging consensus among aesthetic surgeons to refrain from aggressive fat resection during blepharoplasty.

The technique of mobilizing intraorbital fat from the nasal compartment over the inferior orbital rim was first described by Loeb. The goal of this maneuver was camouflage of the nasojugal groove. Hamra subsequently advocated mobilization of fat from all 3 compartments of the lower eyelid to camouflage the infraorbital bony rim. Eder reported a series of more than 200 cases in which the arcus marginalis was released and fat was advanced over the infraorbital bony rim, suturing it to the periosteum of the maxilla and to the suborbicularis oculi fat pad (SOOF). After this maneuver, if an excess of fat was still apparent, it was removed or coagulated.

In patients with orbital fat pseudoherniation and evidence of skeletonization of the infraorbital bony rim, it is generally preferable to advance redundant intraorbital fat and orbital septum over the rim rather than excise fat. This has been the technique of choice in the senior author’s practice for the past decade. Technical pearls and refinements are discussed.

Anatomy

A detailed anatomic study of infraorbital fat confirmed that the infraocular (below the globe) fat is in fact continuous and not separated into true compartments. Although there are not true separate compartments, the concept of compartmentalization of the infraorbital fat is useful in describing excision of the fat as well as clinical descriptions of fat protrusion. From the surgeon’s perspective, the infraocular fat can typically be divided into 3 areas: (1) nasal, (2) central, and (3) lateral. The inferior oblique muscle divides the nasal from the central fat. The arcuate expansion divides the central from the lateral fat.

de la Plaza and Arroyo proposed the theory that fat protrusion is due to a weakening of the support system of the globe, allowing it to descend and causing enophthalmos and lower lid pseudoherniation. Likewise, Camirand and colleagues believe that weakening of the Lockwood suspensory ligament causes globe descent. This phenomenon presumably causes anterior projection of the infraocular fat, creating pseudoherniated fat pads and relative enophthalmia. It has been previously shown that removing 2.5 cm ³ of intramuscular fat lowers the globe 1 mm and moves the globe backward 2 mm.

Evaluation

The most critical aspect of successful lower lid blepharoplasty is accurate preoperative evaluation. The presurgical consultation includes an examination of visual acuity. All patients are asked about dry-eye symptoms. Other relevant aspects of the past medical history include thyroid disease, glaucoma, hypertension, anticoagulation status (including over-the-counter vitamins and herbal supplements), renal failure, and edema of the extremities. Patients are specifically asked if they have recently undergone other ophthalmologic surgery, including laser vision correction surgery. In such instances, the authors generally delay performing blepharoplasty for 6 months.

Physical examination includes careful evaluation of facial nerve function and determination of the presence or absence of lagophthalmos, Bell’s phenomenon, and lid retraction. The lid distraction test and the lid retraction test are performed. With normal lower lid tone, anterior distraction is limited to less than 10 mm. The lower lid is retracted inferiorly with a finger on the lid-cheek junction; release of the lid from the surface of the globe causes the lid to recoil back into proper position within one eyeblink. The presence of fine skin wrinkles of the lower lid, as well as malar bags and festoons are also noted.

The presence of a negative vector is noted as is the overall symmetry of the malar eminences and maxillae. Negative vector is defined as protrusion of the anterior surface of the cornea beyond the bony rim of the maxilla in the sagittal plane. The presence of negative vector is not a contraindication to this technique. The relative maxillary deficiency observed in these patients often manifests as exophthalmos. Fat transposition lower eyelid blepharoplasty increases the soft tissue covering the inferior bony orbital rim and has the visual effect of reducing the appearance of exophthalmos.

Patient perspective

During a preoperative counseling session, patients are counseled concerning the common risks and complications of blepharoplasty. Patients can experience temporary narrowing of the palpebral fissure due to the skin-muscle flap and postoperative edema, and this is explained. The importance of effective treatment of hypertension is addressed with patients, and the assistance of their primary care physician is sought if required. The authors discuss the possibility of an increase in dryness of the eyes, lower eyelid retraction, persistent visibility of the pseudoherniated fat, and diplopia on upward gaze due to possible injury to the inferior oblique muscle. In general, patients are asked to temporarily discontinue anticoagulant medications if it is safe to do so with respect to their medical comorbidities.