An alternative to traditional lower eyelid blepharoplasty
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Tissue-Sparing Lower Blepharoplasty
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"Tissue-sparing" should not be confused with the term "fat preservation," a label has been used (and sometimes misused) with respect to lower blepharoplasty throughout the past decade.
While tissue-sparing lower blepharoplasty is indeed an operation based upon a better understanding of the pathophysiology behind bulging lower eyelids and the perils of disturbing orbital fat, there is more to it. Not only is most orbital fat retained, but the same holds true for the most important portion of the orbicularis (the eyelid's closing) muscle and its nerve supply. Furthermore, the operation is reparative to the orbital septum, the tissue most responsible for allowing orbital fat to protrude in the first place.
With tissue-sparing lower blepharoplasty, the tissues that benefit include not just fat, but also muscle, its nerve supply, and the orbital septum.
There is an even a more substantial benefit, although it is somewhat more conceptual. Not only are these various eyelid tissue layers minimally depleted, but the structural interactions between the eyeball, eyelid, and orbit are less disturbed. Maintaining or even restoring these anatomic relationships is far more important than focusing on only preserving this or that tissue.
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 designed 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 thus restores the bulging tissue (fat rather than intestine) back to its normal anatomic compartment (orbit rather than abdomen) and repairs the overlying barrier that normally holds it back (orbital septum rather than abdominal wall).
With tissue-sparing lower blepharoplasty, the cascade of local anatomic changes associated with disturbing orbital fat by aggressive removal or even repositioning out of the orbit and into the tear trough or onto the upper cheek is avoided.
Similar operations were described in Europe more than ten years ago but have not been used widely. Recent reports have confirmed long-term effectiveness and safety.
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 of these variations, but prefer the skin approach described below:
• 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 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.
• 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 and/or canthal reinforcement are needed, a separate skin incision is still required.
• Risks and potential complications are similar to those associated with standard lower blepharoplasty.
•  Actual surgery photos:
- Skin approach tissue-sparing lower blepharoplasty
- Conjunctival approach tissue-sparing lower blepharoplasty
The primary advantages of tissue-sparing lower blepharoplasty include:
• Orbital fat is not removed.
• The upper orbicularis muscle is not removed and its innervation remains intact.
• The risks of both immediate and long-term hollowness are greatly reduced.
• The risk of lower eyelid droop or collapse due to reduction of support normally provided by orbital fat is greatly reduced.
• The need for canthopexy and orbicularis muscle suspension procedures is greatly reduced, thus avoiding the unnatural wind-swept appearance often associated with such techniques when applied aggressively.
• If excessive lower eyelid skin is present, it may be trimmed without requiring a separate incision.
• Although performed through a skin incision placed just below the lashes, the operation is not the same as or even similar to "transcutaneous lower blepharoplasty," an older form of surgery designed to remove fat from the lower lid and associated with a significant incidence of lower eyelid retraction and hollowness.
The primary disadvantage of tissue-sparing lower blepharoplasty is that it does leave behind a thin scar just below the full length of the lashes. Thus, in patients with relatively mild fat bulging or in those who simply cannot accept the idea of a scar, conservative fat trimming via a transconjunctival approach remains a useful alternative.
As with standard lower blepharoplasty, tissue-sparing lower blepharoplasty is often performed in conjunction with other related procedures:
• If clearly excessive, a tiny strip of skin may be removed from the area just below the lashes.
• If support of the lower lid is clearly deficient (such as in smokers or older patients), it may be strengthened by canthal tendon reinforcement.
• Wrinkles may be softened with a chemical peel.
Tissue-Sparing Blepharoplasty
Overview > Lower Eyelid > Upper Eyelid
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