Fat/tissue Sparing Blepharoplasty

Orbital hollowness is frequently a complication with traditional blepharoplasty. Fat sparing blepharoplasty addresses this issue by tightening the orbital septum and pushing orbital fat back into it's anatomical position. I would like to hear opinions on why fat sparing blepharoplasty is not more widely practiced. Would it be appropriate to use this procedure in cases with only mild orbital fat prolapse, and where the main issue is mid face descent? thank you for your answers

Doctor Answers 9

Fat Sparing Blepharoplasty

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With each passing year I find myself performing less 'invasive' lower lid surgery (i.e a formal lower blepharoplasty) and more lower lid rejuvenation by means of structural fat grafting.  The reality of aggressive lower lid surgery - which involves some combination of skin excision, fat pad reduction and/or fat pad transposition, orbicularis (muscle) redraping and excision, and canthal support (to hold up the lateral aspect of the lower lid while everything heals) - can easily create an 'operated' appearance.  Every experienced blepharoplasty surgeon understands quite well that the lower lid can be very unforgiving, and that an 'operated' appearance can be produced despite the best efforts of even the most skilled hands.

Patients with full cheekbones and excellent lower lid support usually do very well with a traditional lower blepharoplasty, although if I feel that I can produce an equivalent result by means of fat grafting and a modest amount of skin excision I will certainly choose the less invasive (and quicker recovery) fat grafting option.  Patients with poorly projecting, flat cheekbones in which lower lid support is lacking, on the other hand, are at significant risk for post-blepharoplasty complications and that obvious 'operated' lower eyelid appearance.  These patients are often best served by structural fat grafting to camouflage the hollowness and create some lower lid support.
Adding fat definitely improves lower lid support, and it often reduces the amount of lower lid skin excision that is required to produce an improved lower lid appearance and a blended lower lid / cheek junction.  I frequently see patients who have previously undergone a blepharoplasty procedure in which an excessive amount of upper and/or lower lid fat has been removed, and they invariably report that since that surgery they feel that they look tired, older, and even ill.  For patients with post-blepharoplasty hollowness, the only way to restore a healthy and more youthful appearance is to restore the missing soft tissue volume, and this can reliably be accomplished by means of structural fat grafting.
Structural fat grafting is a procedure in which small amounts (less than 0.1 cc at a time) of fat are carefully introduced in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each micrograft, new blood vessels are able to grow into the grafted fat, allowing it to persist indefinitely. If this process of blood vessel ingrowth (neovascularization) does not occur, then the transferred fat cannot truly be considered a 'graft' and is instead just another temporary 'soft tissue filler' that is broken down and reabsorbed over several weeks.  Fat grafting requires specialized training and specialized surgical instruments, as well as patience and meticulous attention to detail on the part of the surgeon. When performed properly, permanent and natural-appearing aesthetic enhancements can be achieved.
Because the lower lid tissues tend to be quite thin, a conservative approach is an absolute necessity for fat grafting of this area.  If one overfills the lower lid  /cheek junction, and most of the fat persists, then the patient ends up with unnatural fullness that needs to be corrected.  I tell patients that our plan will be to add fat until an ideal contour is achieved and then we have to let it heal and see how much persists.  Because the amount of fat that survives is variable, some patients require a second and rarely even a third fat grafting procedure to reach the desired endpoint of improvement.  As fat grafting can be performed as an office procedure under mild oral sedation, and fat grafting recoveries are brief compared to traditional lower blepharoplasty surgery, supplemental fat grafting procedures are easily accomplished.

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Eyelid Surgery

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The reason more fat sparing surgeries are not done is that most people we see need less, not more fat.  We spare fat when necessary, avoid the hollow look, but most are visiting us to remove the fat, not to leave it in.

Vivek Bansal, MD
Danville Plastic Surgeon
4.9 out of 5 stars 26 reviews

Fat Sparing is Part of Properly Contouring

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A thoughtful analysis is always a key element to a successful operative  plan.

There are many approaches to adjust volume and contour around the eye and properly blend the lids with adjacent structures, especially the orbital rim and upper cheek.

Paul C. Zwiebel, MD
Denver Plastic Surgeon
4.7 out of 5 stars 45 reviews

Respecting eyelid fat during blepharoplasty

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Excellent question!!  I have been preaching fat preservation during blepharoplasty surgery for years.  I have quite a few patients that come to me to get that hollow eye look repaired after having a blepharoplasty elsewhere.  Blepharoplasty surgery has made more advances over the last 2 decades then any other cosmetic surgery procedure.  There are many options surgeons have to address patients with, it is no longer cookie cutter remove skin and fat.  Now we can sculpt with fat or filler, transpose the fat while releasing the arcus marginalis.  This transposed fat can be placed in different tissue layers as well,  and the incision could be made behind or in the front of the eyelids.  So to answer your question, not everyone needs the same surgery and luckily we have many different oftions to address the different anatomical concerns patients have. 

Robert Schwarcz, MD
New York Oculoplastic Surgeon
4.5 out of 5 stars 23 reviews

Adding volume to lower eyelid grooves may look better than removing lower eyelid fat.

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I read your comment, and agree that removal of lower eyelid fat may lead to an operated, hollow appearance. For this reason, I hardly ever remove lower eyelid fat. In my practice, Silikon-1000, an off-label filler for permanent results is preferred to fill lower eyelid grooves.

With upper blepharoplasty, I usually do not remove fat either. I will typically remove only a skin and muscle strip.

Regards from NJ.

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 435 reviews

Fat Transfer and Grafting in Lower Blepharoplasty

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Simply stated, we tend to lose facial fat and volume as we age.  In my practice I save virtually all of the fat from the lower eyelid and in most cases transpose this into the hollow tear trough under the eye.  I do leave this on the pedicle to preserve blood supply and insure a healthy graft that remains over time.  Sometimes I will actually use facial fat transfers from abdominal fat liposuction to add additional volume to the lower eyelid.  I personally believe that facial volume should be preserved in all cases, especially in the area of the tear trough near the nose.

Todd Christopher Hobgood, MD
Phoenix Facial Plastic Surgeon
4.9 out of 5 stars 57 reviews

Fat removal in lower eyelid surgery

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Every patient is different. Some I remove some fat if it bulges, some I release the arcus marginalis to free the depressed line along the lower lid cheek junction. and some I remove some skin.  It really depends upon the individual.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Lower blepharoplasty options

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The answer depends on the invdividual patient and his/her eyelid anatomy.  The treatment needs to be invidualized.  Some have significant buldgy lower eyelid fat pad, which requires removal.  Some may benefit with fat transposition (moving the buldgy fat inferiorly to fill up the hollow area). Some benefit from fat or filler injection.  Some may benefit from lower eyelid skin tightening.  A combination of any of these options may be needed.

Mehryar (Ray) Taban, MD, FACS
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 91 reviews

The procedure you are referring to is called arcus marginalis release.

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Traditional lower blepharoplasty or cosmetic lower eyelid surgery is performed through a skin incision below the lower eyelid lashes and may extend out into a lower crows feet line. The incision is typically deep enough to open the septum, a layer of connective tissue that separates the orbital contents from the more anterior eyelid. Just behind the septum is orbital fat which is the remove by the surgeon. Closure is the completed by excising "excess" lower eyelid skin. This type of surgery is associated with a number of post-surgical changes including a pulled down, dog eyed look with increased scleral show and a hollow lower eyelid. My website feature a number of articles on how we go about fixing these issues. Unfortunately surgeons still use this method. The often rationalize their continued use of this method. However there is not much to recommend this type of surgery.

In the mid 1980s oculoplastic surgeons developed and popularized the transconjunctival approach to rejuvenation the lower eyelid. This surgery was preformed from behind the lower eyelid avoiding the skin incision and the complications that result from scaring and damage to the motor nerves that are damaged by surgery. If skin needed to be removed, it could be done by removing a pinch of skin just below the eyelashes. The problem with this procedure is that lower eyelid fat is often not the actual aesthetic issue. Instead, the apparent herniated lower eyelid fat is an not the issue. Generally the lower eyelid fat is visible because of midface descent. Midface ptosis is related to facial skeletal structure, laxity of ligaments at the top of the cheek, and even the volume of deep facial fat.

Recognizing that fat removal in the lower eyelid can cause lower eyelid hollowing irrespective of the surgical approach, in the 1990s eyelid specialists introduced and popularized preservation of lower eyelid fat. This procedure is know as arcus marginalis release. Typically surgery is performed behind the lower eyelid transconjunctivally. The fat is mobilized. The arcus marginalis which is the name for where the septum fused with the connective tissue that covers the cheek bone. So it is not accurate that this procedure tighten the septum. A pocket is dissected at the top of the cheek and the lower eye fat is tucked into these pockets as living grafts. This bit of fat provides volume at the top of the cheek filling in the lower eyelid hollow. Overall, for the right person surgery improves fullness of the lower eyelid and benefits the lower eyelid hollow. The key is that this benefit is better for some individuals than others. Patient selection is really too complex to discuss here. However this is the task of the experienced eyelid surgeon. The procedure is fussy so not all surgeons are comfortable offering this surgery.

Fillers have proven to be a very good alternative to these surgeries for many individuals. It is important to understand that a personal assessment by the cosmetic surgeon is critical in determining what is best for you in their hands.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.