Is Nasal Area Fat Pad Removal Possible without cutting muscle? (Photo)

One of my questions was how to avoid permanent dry eye and although there have been several different opinions the one I'm finding to be a common answer is to avoid cutting the muscle. I have loose skin that needs removal but there is also a fat pad in the corner, from what I read the fat lies below the muscle. Is the only way to fix that spot to cut the muscle & take the fat out? Is that section of muscle an area that can produce permanent dry eye? I'm assuming tests will follow before surgery.

Doctor Answers 7

Importance of the medial upper eyelid fat pad

This is a common concern in my patients before this type of surgery.  There a couple of ways in which one can access the fat pockets of the upper eyelid without compromising the function of the muscle.  One can either approach the fat pad transconjunctival (not very popular as many surgeons do not commonly perform this procedure) or they can approach the fat pad through small button hole incisions in the muscle.
That being said, lets look at your case.  You have significant fullness to the upper eyelids and you would actually benefit from removing some muscle along with skin conservatively.
The muscle does possess a function of helping with the tear blanket, but dry eyes from removing muscle is less of a concern than dry eyes resulting from removing too much skin (a condition called lagophthalmos).
Make sure that you consult with a Board Certified Facial Plastic Surgeon.
I hope that this helps.

Jacksonville Facial Plastic Surgeon
5.0 out of 5 stars 25 reviews

Upper and lower eyelid fat pad removal

The primary goal of upper eyelid surgery is to remove hooding excess skin, and a small amount of fat closest to the nose. For patient who have dry eyes, no muscle strip is taken.
The primary goal of lower eyelid surgery is to remove a conservative amount of fat in the 3 fatty compartments on the lower lids through a trans-conjunctival approach on the inside of the lower lids. If there is any excess skin present, a pinch technique is used to remove excess skin on the lower lids from the outside. The muscle is never violated on the lower lids.
For many examples, please see the link below to our eyelid surgery photo gallery

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 143 reviews

Dry Eye and Blepharoplasty

It is very uncommon to have dry eye in a well performed upper eyelid surgery. From your photos, it appears that you need skin, muscle and fat removed to improve the shape of your upper eyelid. Unless you have a predisposing condition, cutting the muscle will have little effect on your procedure. Muscle tone is more important in the lower eyelid approach. 

You should see a board certified plastic surgeon in your area to get a formal opinion through and in-person consultation.

Best of luck,
Vincent Marin, MD
San Diego Plastic Surgeon

Vincent P. Marin, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 46 reviews

There is help out there for you.

I understand what you are looking for.  Frankly I would feel more comfortable giving you advise if I could personally examine you and better understand your issues and concerns.  Dr Blaydon is basically stating the party line.  However removal of orbicularis oculi muscle creates a risk of injuring the motor nerves to the orbicularis oculi which blinks the upper eyelid closed.  For many patients, this weakening of the closure mechanism does not produce a significant dry eye.  However it most definitely does cause permanent dry eye is some finite percentage of individuals.  A skin only blepharoplasty can be done that leave the muscle intact across most of the upper eyelid can be performed and this will reduce the risk of dry eye.  At the same time a button hole removal of nasal fat can be performed.  To be honest with you, I think an open approach provides a better aesthetic outcome.  You are trading that for a reduced risk of dry eye.  The trick is to find a surgoen who will perform this type of upper blepharoplasty.

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

Nasal Fat Pad Removal

Most surgeons do remove a small portion of the thin orbicularis muscle that lies under the skin when performing blepharoplasty surgery.  This does not usually weaken eyelid closure, but can slightly in some cases. However, orbicularis muscle can be left intact removing skin only.  There is a little more bleeding, but is my preferred approach if the patient does not have a lot of fat across the eyelid.  This maintains good lid closure.
However, to remove the nasal fat pad, a small amount of orbicularis in this area needs to be either divided or removed to excise the fat pocket in this area.  This really should not affect lid closure at all.  The opinions to avoid cutting the muscle is really about avoiding excising muscle when excising skin and I would agree with these opinions.  I think a conservative skin only excision blepharoplasty (no underlying muscle) with minimal dividing of nasal orbicularis to remove the more prominent nasal fat pads will be safe and will leave you with good lid closure.

Sean M. Blaydon, MD, FACS
Austin Oculoplastic Surgeon

Diminishing Lower Lid Bags and Hollows Nonsurgically

Although surgery seems to be the intent here, I would just like to offer an alternative, completely nonsurgical approach to consider for improving the appearance of lower lid bags and hollowness of the upper inner cheek (near the nasal bridge)--as seems to be the case here from the photo provided.

Many of the changes we typically encounter in the lower lids with the passage of time--namely tear trough deformities, hollows and bags, result from shrinkage, shriveling, and a downward descent of the once robust, heart-shaped fat pad that sat immediately under the lower lids and extended out toward the temples, inward toward the root of the nose, and downward about half-way to the angles of the mouth. The loss of this volume and its downward displacement in the direction of the jaw (due to weakening of the supporting ligaments and the downward pull of gravity) elongates the lower lid to several times its narrow youthful width and leaves it somewhat sunken. In addition, like a balloon having lost its air after being fully inflated for a long while, the skin of the lower eyelid fails to snap back to its youthful smoothness, and instead remains crinkled and baggy.

Today, we can attempt to address these problems nonsurgically with the injection of fillers and volumizing agents to restore the volume to the lower lids and recontour them, mask the bags, and diminish the darkish discoloration.

A variety of have been tried for these purposes. My personal favorites for dealing with tear troughs--for providing overally smoothness, shape and lift-- are the recently approved Belotero Balance and Restylane L. When more cheek support and buttressing are needed for the lower eyelid, the upper inner cheek immediately below may be supplemented with with Perlane L, known for its lifting capacity.

In my experience, while more prominent bagging may be improved considerably with this approach, some degree pf bagging typically persists following treatment. On the other hand, for mild to moderate bags, it usually takes about five minutes to treat each lower lid with immediate that typically evoke a "Wow!" response from patients when they look in the mirror.

While minimal bruising, tenderness, swelling and redness may occur following treatment in this delicate region, these are usually temporary and disappear spontaneously within one to seven days. Most people can return to work or social activities immediately or the following day and coverup may be used if desired.

Nelson Lee Novick, MD
New York Dermatologic Surgeon
4.9 out of 5 stars 29 reviews

Best way to do belpharoplasty

  • For the upper lids, removing skin, a few muscle fibers and the excess fat will give you a nice result,
  • For the lower lid, to avoid the muscle, the fat can be trimmed and repositioned from the inner eyelid - doing surgery under not through the muscle.
  • Blepharoplasty can cause dry eyes - it will usually improve in 6 weeks, longer in some people.
  • People with auto-immune problems or a naturally dry eye, may find their eyes permanently affected

Elizabeth Morgan, MD, PhD
Atlanta Plastic Surgeon
4.6 out of 5 stars 43 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.