The lower eyelids are just one component of the management of the peri-orbital facial area. While browlifts and removal of excessive skin from the upper eyelids (upper blepharoplasty) are well known and established anti-aging treatments, lower eyelid surgery has evolved in its techniques over the past decade.
Traditionally, lower blepharoplasty was all about the removal of skin and compartmentalized fat to get rid of bags and loose skin. While immediately effective, some patients suffer long-term consequences of this substractive approach to the lower eyelid with a more aged and skeletonized appearance. Thus such tissue removal does not always create the appearance of youth.
As a result a different approach to the lower eyelid has evolved towards tissue sparing methods, preserving fat and removing less skin. Rather than aggressively removing fat from the three lower eyelid fat compartments (medial, middle and lateral), it is preserved and used as soft tissue fill for the tear troughs and elimination of the lid-cheek junction.
Conversely another approach is to harvest fat from elsewhere in the body and use it as a fat injection technique for filling in the tear trough and eliminating the lid-cheek junction. Because an open lower blepharoplasty technique does not allow for containment of injected fat one, does not see open blepharoplasty combined with fat injections unless it is with a transconjunctival (closed) lower eyelid approach.
The basic manuevers of a fat-repositioning lower blepharoplasty is based on moving vascularized pedicles of fat from the inner (nasal) and middle (central) protruding fat compartments. These stalks of fat are teased out and moved over and below the lower eye socket rim. (inferior orbital rim) They are used to fill in the hollows and lines of the lower eyelid-cheek region. When done through an open approach, the release of the tear trough and orbicularis retaining ligaments can also be done creating a two-pronged treatment of the tear troughs and the line of the lid-cheek junction.
As the technique of fat-repositioning lower blepharoplasty evolved, it was applied through a transconjunctival rather than an open blepharoplasty approach. The desire to not disrupt the orbicularis muscle and decrease the risk of lower lid ectropion was the primary motivation. But not exposing the transferred fat presumably improves their chance of survival as well. But the limited exposure through the inside of the lower eyelid and the difficulty in releasing the orbital ligaments may lead to persistence of the tear trough groove.
While technically challenging, fat repositioning with the transconjunctival approach can be successfully done and encompasses several important technical steps. The plane of dissection is between the orbicularis muscle and the orbital septum, meticulous release of the tear trough and orbicularis retaining ligament, septal windows for nasal and central fat pedicle release and repositioning, securing the fat pedicles over the orbital rim with transcutaneous sutures, free fat graft (from lateral pocket) placed between the two fat pedicles and a pinch external blepharoplasty and skin resurfacing (laser vs peel) if needed.
Lower eyelid rejuvenation that preserves fat produces a better aesthetic result than a traditional subtractive lower blepharoplasty in many cases. Fat transposition through the lower eyelid is technically challenging and can also be done by transconjunctival fat removal combined with external fat injections with comparative results in many cases.
Dr. Barry Eppley
Indianapolis, Indiana