Achieving Symmetry in Lower Blepharoplasty Fat Removal

Abstract

These tips will make fat removal in a purely subtractive transconjunctival lower blepharoplasty procedure more symmetric to avoid postoperative surprises. Divide each fat pad flush with the orbital rim and check for residual fat using ballottement of the globe.

Reprinted from Chen WPD, Khan JA, McCord, Jr, CD. Color Atlas of Cosmetic Oculofacial Surgery. Philadelphia, PA: Butterworth Heinemann/Elsevier; 2004. With permission from Elsevier

These tips will make fat removal in a purely subtractive transconjunctival lower blepharoplasty procedure more symmetric to avoid postoperative surprises.

Divide Each Fat Pad Flush with the Orbital Rim: Nasal and Central Fat Pads

Using the symmetric positions of the paired inferior orbital rims as a guide is a key to achieving postoperative symmetry in lower blepharoplasty. When deciding exactly where to transect the herniating lower eyelid fat, use the bony inferior orbital rim as the sole landmark. One can grasp the herniating fat with a hemostat which rests upon the orbital rim, and then one can comfortably proceed with excision of the fat. If piecemeal excision is used to remove the protruding fat, it is important to immediately perform ballottement and see if any more fat easily comes forward past the inferior orbital rim.

Divide Each Fat Pad Flush with the Orbital Rim: Lateral Fat Pad

Positioning a hemostat properly in addressing the fat pad in the tight lateral area requires diligence and experience, especially when it comes to positioning the hemostat. Not uncommonly, there is more fat prolapse immediately following the first excision. Also, there may still be a residual temporal bulge of fat that requires further division of the septum. Diligence and patience are necessary to achieve adequate temporal fat excision (Fig. 58.1).

Fig. 58.1

The lateral fat pad is transected flush with the inferior orbital rim and requires use of a metal desmarres, moist cotton tip, or hemostat as a backstop

Reposition the Eyelid and Ballottement to Look for Any Residual Bulging Fat

The final and important step is balloting. Often one may find residual fat that was overlooked earlier in the procedure. Such fat may not come forward until later in the procedure because it had been constrained by cautery or clamping of the overlying fat.

• Ballottement by applying firm pressure against the globe (Fig. 58.2).

  Fig. 58.2

  

  Finger pressure is applied to the protective shield in order to retropulse the globe and prolapse forward any residual excess fat

• Examine the contours of both lower eyelids.

• Look for any bulging or asymmetry.

• Excise further fat as needed.

• Look for and cauterize any bleeding points.

  • Tug upward on the eyelid to prevent inversion or overriding of the wound.

  • No suture is used.

  • Remove eye shield.

  • Place ointment.

• Reassure patient (Fig. 58.3).

  Fig. 58.3

  

  Appearance at end of procedure