What is Best Treatment for Lower Blepharoplasty After Steroids in a Young Woman?

After stopping steroids, a 32 years old woman has modest lower lid swelling. Two surgeons agree on a transconjunctival approach, but one recommends fat removal and the other plication of the septum. Which method has the more solid basis of support? Are there reviews of scientific comparisons? Do steroids increase fat or weaken the septum?

Doctor Answers 9

Transconjunctival blepharoplasty with fat removal is safer than septal plication in my opinion

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Transconjunctival lower blepharoplasty for fat removal is a safe widely accepted practice for correction of puffy lower eyelids. Most who use this technique do so because this technique preserves the support of the lower eyelid and does not change the eyelid shape.

Septal plication requires an eyelid incision which risks weakening lower eyelid support. potential complications include excessive shortening of the eyelid which eversion and potentially ectropion, a serious complication of lower eyelid surgery.

My personal opinion is that the transconjunctival approach is safer for you.

Transconjunctival approach is the best approach for fat removal.

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Steroids do not increase fat or weaken the septum of the orbit. Transconjunctival approach is the best approach for fat removal. However, if the eyelids are really very hollow, the lower lid fat can be turned over and used to augment a very hollow lower lid.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Be very careful!

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Although I don't know the extent of your steroid use, I'm concerned that neither surgeon is correct. First, there is almost a cardinal rule in eyelid surgery "don't violate the septum." Scarring of the septum occurs very easily which will result in a pulling down and outward turning of the lid. A very bad outcome. So no plication of the septum!

Next, I'm concerned that you have a tissue bogginess due to the steroids and not fat pseudoherniation. I'm a strong proponant of keeping fat since fat is youth. You may just need a muscle plication which will tighten the lid and push any fat back. You need to be off steroid for a year first. Good luck.

You need to be personally evaluated

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Dear Emma,

A transconjuctival lower blepharoplasty is a highly predictable surgery that can be graded to avoid hollowing the lower eyelid. Septal plication is a much less predictable surgery to the point of being essentially a type of an experiment each and every time it is performed. If you have two surgeons that disagree and you are not committed to either, it is time to seek out some new opinions.

You might consider getting the opinion of some eye plastic surgeons. Given your age and your description of your issue, perhaps you don't even need surgery. Perhaps you would benefit from an arcus marginalis release and preservation of lower eyelid fat.

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

Treatment depends on physical exam

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If bulging fat is the reason for the puffiness, then removal is indicated.  If the septum holding the fat back is weak, then repair of that structure is indicated. Perhaps, based on exam, both will be needed for best result. Steroids, in general, tend to weaken tissues when taken over long periods of time.

Both techniques can create improvement

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Both techniques can create an improvement based on your complaints. The big difference is that the septal plication has more significant risks. The transconjunctival approach will remove the appropriate amount of fat, and in most cases, the septum tightens up by itself. This may be especially true in a 32 yo woman who has stopped steroids. You could also take the risks to plication in a secondary procedure if you are not satisfied with the simpler, safer procedure. Keep in mind that the lower lids have a high complication rate with need for multiple operations. Especially at your age, choose the simplest!

Robert M. Freund, MD
New York Plastic Surgeon
4.8 out of 5 stars 34 reviews

Comprehensive analysis of lower lid swelling necessary

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The anatomical elements that are causing the current look need to be analyzed and reversed. Fat removal works in a small percentage of lower lid surgery where there is no excess skin,no deep lines,no weakness of the lower lid support ligaments.

A classic blepharoplasty will explore the lower eye lid and repair the deformity. The fat is manipulated, the muscle is tighten,the skin is trimmed and the ligaments are fixed if needed. A comprehemsive rejuvenation is better.

Hisham Seify, MD, PhD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 19 reviews

Septum plication would give best result

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Transconjunctival approach is faster, safer, and easier. The problem is the long term result and hollowed look as you age. The fat pocket removal and septum plication will give better and lasting result, but has higher risk of complication. If your surgeon feels confident about the plication, then it will give you better result .

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.8 out of 5 stars 154 reviews

Lower lid blepharoplasty after steroids

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To my knowledge, there is no deifinitve answer to these questions, leaving one to speculate.

We do know that corticosteroids promote the appearance of a Cushingoid facies or round face. We generally attribute this to increase facial fat, but this is merely an educated guess. It could be paritally facial edema due to a mineralocorticoid effect. Furthermore, we know that steroids may weaken or impair healing of soft tissues, but this has not been known to be isolated to the orbital septum.

Plication of the septum with fat preservation via the transconjuctival approach is a challenging operation and difficult to quantify. Fat removal is clearly the more traditional approach, but what happens when the steroids are stopped or aging progresses? The appearance of a hollowed-out eye is a potential.

Both are reasonable options with trade-offs, and I am not certain that there is any one correct approach.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 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.