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BLEPHAROPLASTY 101
Preserve and restore

Topic 18 - 1
Tissue-Sparing
Lower Eyelid Blepharoplasty 
lower eyelid orbicularis muscle hypertrophy Lower Eyelids lower eyelid fat removal

While confusingly similar, the term "fat preservation lower blepharoplasty" is sometimes used to indicate repositioning of lower orbital fat onto the upper cheek, a procedure that bears no resemblence to tissue-sparing.


What Does It Mean?

Tissue-sparing lower blepharoplasty is an operation based upon a relatively new theory on the pathophysiology behind bulging lower eyelid fat. The operation is reparative to the orbital septum, a weakness of which is, supposedly, the primary culprit in allowing orbital fat to protrude.

Currently, any benefits are still more conceptual than proven.


Restoration Rather Than Subtraction

Both transcutaneous and transconjunctival lower blepharoplasty are, essentially, subtractive operations designed around removing varying amounts of skin, muscle, and particularly fat.

Tissue-sparing lower blepharoplasty is intended to restore by repairing an anatomic weakness present inside of the eyelid (an orbital septum hernia) that allows normal orbital fat to bulge forward.


Orbital septum hernia shown in cross-section


Much like with an abdominal hernia repair, the operation is thus intended to return the bulging tissue (fat rather than intestine in this case) back into its normal anatomic compartment (orbit rather than abdomen) by strengthening the overlying barrier that normally holds it back (orbital septum rather than abdominal wall).

The goal is to avoid the cascade of local anatomic changes associated with disturbing orbital fat by aggressive removal or repositioning out of the orbit and into the tear trough or onto the upper cheek.

Despite this theoretical benefit, tissue-sparing lower blepharoplasty does come with its own set of real disadvantages. Because the orbital septum and/or capsulopalpebral fascia are tightened, there is a small but definite risk of creating lower eyelid retraction. Other pros and cons can be found in the chart below comparing the three major approaches to lower blepharoplasty.

Similar operations were described in Europe more than ten years ago but have not been used widely. Interest in the procedure worldwide remains limited.

In bold contrast to upper tissue-sparing blepharoplasty, many consider lower tissue-sparing to be a procedure "under development" and thus employ the operation on a limited and highly selective basis. In fact,as we have gained more experience with this operation, we have slowly come to question the validity of its very premise, that an eyelid "hernia" is in play.

In the majority of our patients with lower bagginess, we still favor a minimally-disruptive approach consisting of conservative transconjunctival fat trimming, pinch blepharoplasty, and chemical peel used either individually or in various combinations as indicated.


Technique

Tissue-sparing lower blepharoplasty may be undertaken through either a skin or conjunctival approach and focus on direct repair of the orbital septum, capsulopalpebral fascia, or both. We have used all variations and prefer a skin approach with repair of the fat hernia using the capsulopalpebral fascia rather than the orbital septum as described below and shown photographed in detail on the following pages:

An incision is made through the skin just below the lashes and extends across the length of the eyelid.

The skin is dissected away from the underlying orbicularis muscle.

The orbicularis muscle is opened low in the lid near the orbital bone thus mitigating any negative effect on eyelid support, innervation, or closure.

The orbital septum hernia (fat bulging forward against or through a weakened portion of orbital septum) is identified.

The edge of healthy orbital septum is noted by the green arrow, below which orbital fat can be seen bulging forward against the lower septum's weakened section (hernia).

The nearby and stronger capsulopalpebral fascia is advanced over the the herniated fat and attached to the rim of bone below the eye with sutures.

Bulging fat is thus returned to the orbital compartment rather than being removed.

Same patient following return of fat to the orbit (hernia repair).

When due to anatomic limitations, a small area of temporal fat near the lid's outer corner may sometimes require slight trimming.

While orbital septum hernia repair can also be accomplished through a conjunctival incision (incision hidden on the inside surface of the lid), we have found this approach to be technically more difficult, more invasive, and less forgiving. If skin removal is indicated, a separate skin incision is still required (skin pinch).


Potential Complications

Risks are similar to those associated with standard lower blepharoplasty discussed in Chapter 28. This operation's big advantage is fat preservation rather than operative ease or increased safety. Below is a comparison of tissue-sparing with the two forms of fat removal blepharoplasty:

Skin Approach
Tissue-Sparing


Trans-conjunctival
Fat Removal


Trans-cutaneous
Fat Removal


Orbital fat removed
No
Yes
Yes
Upper orbicularis muscle injured
No
No
Often
Risk of hollowness immediately
No
Yes
Yes
Risk of hollowness over time
No
Yes
Yes
Relative risk of lid retraction
High
Low
Highest
Relative risk of eyelid collapse
No
Possible
Possible
Relative risk of lid shape change
Moderate
Low
High
Canthopexy used routinely
No
No
Yes
Allows removal of excess skin without additional incision
Yes
No
Yes
Visible scar under lashes
Yes
No
Yes
Degree of invasiveness
High
Low
High
For mild fat bulging
Not Currently
Very Good
Avoid
For advanced bulging
Good
Fair
Fair
Precision
Good
Good
Fair
Length of healing
Medium-Long
Short
Long
Chance of future fat bulging
Low
Low
Moderate
Time in surgery
Longest
Short
Long
In use since
Still New
1980s
Pre-1950s
Availability
Limited
Wide
Wide
Cost
Highest
Average
Higher
Relative level of risk
Medium-High
Low
High

Next: Should Fat Ever Be Removed
From The Lower Eyelid?


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