Fat management in upper blepharoplasty:Addition or subtraction blepharoplasties,how and when

BACKGROUND As one of the most common aesthetic surgical procedures carried out today,blepharoplasty should be in the repertoire of every plastic surgeon.The term blepharoplasty encompasses a wide range of techniques and options that must be tailored to the specific defect and patient one has to treat.A sound knowledge of the upper and lower eyelids’anatomy is essential for proper surgical execution.Trends have shifted towards more conservative methods(especially of the fat compartment)and sometimes in combination with augmentation techniques,helping to reach a rejuvenated appearance.AIM To present an overview of the surgical techniques considered for upper lid blepharoplasty and fat pad management,in addition to information on how a surgeon may approach the best treatment for his patient based on current publications in literature.METHODS We searched the literature published between 2013,to 2023 using Medline and Reference Citation Analysis.The database was searched using the keywords“upper blepharoplasty”AND“fat”.Papers without full text/abstracts and reviews were excluded.The search strategy followed the PRISMA.The American Society of Plastic Surgeons guidelines for Therapeutic Studies checklist was used to assess all articles.Two authors individually reviewed each article and rated them for importance and relevance to the topic.A consensus was sought and the most relevant studies.RESULTS After the application of the selection criteria used in our review,13 publications were found to address upper lid blepharoplasty specifically.Three of these studies were reviews and three were retrospective studies.Five publications were comparative studies and a further two were clinical trials.CONCLUSION The tendency of modern surgery is to be conservative,by removing adipose tissue only if strictly necessary and restoring the volume of the upper eyelid in a concept of beauty that espouses a"full"sight.There is no gold standard technique to achieve younger and enhanced eyelids.Long-term prospective comparative studies are fundamental in understanding which path is the best to follow.

Modern blepharoplasty:From bench to bedside

The demand for procedures aiming to rejuvenate the upper third part of the face and the periocular region has increased in the past several years.Blepharoplasty is one of the most frequently performed procedures worldwide to date.Surgery is currently the first choice in order to achieve permanent and effective results;however,it is burdened by potential surgical complications feared by patients.There is an increasing trend in individuals to request less invasive,non-surgical,effective,and safe procedures for eyelid treatment.The aim of this minireview is to present a brief overview of non-surgical blepharoplasty techniques that have been reported in the literature in the past 10 years.Numerous modern techniques that provide a rejuvenation of the entire area have been described.Numerous less invasive methods have been proposed in the current literature and in modern-day routine clinical settings.Dermal fillers are a commonly chosen option for providing enhanced aesthetic results,especially considering that volume loss can be one of the main underlying causes of facial and periorbital aging.Deoxycholic acid use may be considered when the problem is represented by periorbital excess fat deposits.The simultaneous excess and loss of elasticity of the skin can be assessed with techniques such as lasers and plasma exeresis.Furthermore,techniques such as platelet-rich plasma injections and the insertion of twisted polydioxanone threads are emerging as viable methods to rejuvenate the periorbital region.

A Comparative Study in the Outcome of Primary Asian Blepharoplasty with and without Fat Removal

Background: Asian Blepharoplasty (AB) is one of the most commonly performed aesthetic procedures today. Despite the increasing demand for AB and advancements in surgical techniques, creating an optimal upper eyelid crease remains difficult. This study aimed to determine whether removing the preaponeurotic fat pad (PAF) had any effect on the revision surgery rates following primary Asian blepharoplasty. Methods: A retrospective comparative analysis was conducted on patients who underwent primary AB between January 2016 and December 2020. Patients were divided into PAF removed and PAF not removed groups. The outcomes in the groups were compared by the frequency of revision surgery following primary AB using the chi-square test (p Results: The study included 480 patients, 442 (92%) female and 38 (8%) male, and the final outcome was evaluated after 6 months postoperatively. 412 (86%) patients were observed to have PAF pads intraoperatively, while 68 (14%) had minimal/no PAF pads. In total, 115 (24%) patients underwent revision surgery, of whom 31 (27%) had PAF removed, 66 (57%) had PAF not removed, and 18 (16%) had minimal/no PAF noted. When compared to the PAF not removed group, the PAF removed group showed a significantly lower frequency of revision surgery between the two groups of patients (p = 0.0001). Conclusion: In the final outcome, not removing the PAF in primary AB indicated a strong association with an increase in revision surgery. The removal of PAF in primary AB showed a better overall outcome and patient satisfaction.

Management of tear trough deformity with and without tear trough-orbicularis retaining ligament complex release in transconjunctival blepharoplasty: a comparative study

AIM: To evaluate the effect of releasing the orbicularis retaining ligament(ORL) complex of the tear trough combined with the transconjunctival blepharoplasty in the surgical management of tear trough deformity compared with the effect of blepharoplasty alone. METHODS: A prospective, randomized(by closed envelope technique), controlled surgical trial which included 50 patients(100 eyes) with bilateral visible tear trough deformity and lower eyelid fat bulging, was divided into two groups where 25 patients(50 eyes) had tear trough-ORL release with blepharoplasty and 25 patients(50 eyes) didn't. Qualitative and quantitative assessments of tear trough deformity were done at 6 mo postoperatively, achieving grade 0 or 1 of Barton's classification was considered a success. Standardized photographic documentation of each patient was done pre and postoperatively, also assessment of the patients' satisfaction postoperatively was done and ranked as excellent, very good, good or fair. RESULTS: There was statistically significant difference between the two groups in the overall aesthetic results postoperatively regarding the qualitative and quantitative analysis of the tear trough deformity, where patients who had tear trough-ORL complex release had more successful outcomes than those of the second group. CONCLUSION: ORL release should be done in patients with tear trough deformity in order to release the tethering effect of this ligament which causes the prominence of the naso jugal groove.

Surgical outcome and patient satisfaction after Z-epicanthoplasty and blepharoplasty

AIM: To evaluate surgical outcomes of modified Z-epicanthoplasty with blepharoplasty that we previously reported from the patient’s perspective using patient-reported outcome measures(PROMs) and patient satisfaction scores.METHODS: A total of patients(n=180) who underwent the surgery between January 2013 and June 2016 were randomly selected. Standardized patient satisfaction forms(total score, 40) and validated PROMs questionnaires(total score, 12) were sent to patients for completion. PROMs assesses the severity of scarring, pain and asymmetry, as well as functional and appearance issues.RESULTS: All patients were female, ranging from 18 to 35 years old(mean=24). The response rate was 73.3%(n=132). The majority of patients reported good or excellent outcomes based on PROM analysis. Patients reported minimum or non-visible scarring at both the double eyelid surgical scar(85.6%) and the inner canthus(80.3%). Issues concerning function and appearance were minimal as 80.3% reported satisfaction with both domains. Notably, the majority of patients reported either a high or very high satisfaction rate to yield a mean score of 104 out of 120(P<0.05).CONCLUSION: Integration of our modified Z-epicanthoplasty with blepharoplasty produces good outcomes based on PROM results, which shows a positive linear relationship with patient satisfaction scores.

Cosmetic blepharoplasty and dry eye disease: a review of the incidence, clinical manifestations, mechanisms and prevention

Dry eye disease is a multifactorial disease of the ocular surface and can be caused by a variety of iatrogenic interventions,especially ophthalmic surgical procedures.This article reviews the incidence,clinical manifestations,mechanisms and prevention of dry eye disease caused or worsened by cosmetic blepharoplasty,and focus on how to reduce and prevent the occurrence of postoperative dry eye disease and provide the basis for the selection of operation methods and the rational drug during the perioperative period.

Effects of upper lid blepharoplasty on visual quality in patients with lash ptosis and dermatochalasis

AIM：To assess the effects of upper lid blepharoplasty on visual quality.METHODS：Seventy-three eyelids of 39 patients were subjected to upper lid blepharoplasty.Pre- and postoperative contrast sensitivity,visual acuity,vertical palpebral aperture and the degree of lash ptosis were measured.RESULTS：The mean log contrast sensitivities under photopic（P =0.017） and scotopic conditions（P =0.009）were improved after surgery,and these differences were significant.The degree of lash ptosis was also decreased after blepharoplasty（P〈0.001）.CONCLUSION：In our study,a significant increase in contrast sensitivity was found after surgery.These results suggest that upper lid blepharoplasty can be helpful for improving visual quality.

Upper Blepharoplasty Scar and Patient Satisfaction Evaluation in a Plastic Surgery Center in Mexico

Background: Eyes are one of the most important facial features, their appearance being associated with state of mind, age and beauty. Therefore, upper blepharoplasty is one of the most common procedures performed in plastic surgery. Standardized tools allow for measurement of outcomes through patient satisfaction and surgeon experience. Objectives: Our objective was to measure the satisfaction index and scar quality of patients who underwent upper blepharoplasty using the Patient-reported Outcome Measure Questionnaire (PROM-Q) and Patient and Observer Scar Assessment Scale (POSAS). Methods: A retrospective review of patients that underwent upper blepharoplasty in our institution was performed. We included those with a preoperative anthropometric analysis, standardized incision markings (developed in our center), same operative technique and a 3-month postoperative evaluation with PROM-Q and POSAS. The sample for this study consists of 67 patients, all of them operated between January 1 2019 and June 30 2019 at the Department of Plastic Surgery, South Central High Specialty Hospital, Pemex, Mexico City, Mexico. Results: A total of 67 patients were included, 73% female and 27% male. The most frequent indication for surgery was functional visual symptoms. The index of PROM-Q at 3 months demonstrated an increased satisfaction above 90%, and the evaluation with POSAS reported an almost imperceptible scar. Conclusion: Evaluating outcomes with objective tools provides data useful to improve the surgical protocols of patients subjecting to aesthetic procedures.

Lower Blepharoplasty Review, Transcon-junctival vs. Transcutaneous Approach

Currently in lower blepharoplasty, the transconjunctival approach indication has been limited to young patients without skin excess and prominence of bags;in our practice this access has become the preferred technique in most of our cases because it is simpler, faster, prevents bad scarring, produces less orbicularis muscle trauma, and decreases postoperative edema and possible retractions (ectropion) in patients with decreased lower palpebral tone. Objective: To identify important concepts when deciding this approach. Material and Methods: Retrospective review of 177 patients who underwent lower blepharoplasty by a single surgical group. Regarding techniques, the transconjunctival approach was selected in 42% of patients while the transcutaneous technique was preferred in 58%. Results: A lower rate of complications was observed by the transconjunctival approach, with greater patient satisfaction. Conclusions: In our experience, due to its simplicity and less traumatic effect on the patient, the transconjunctival approach is an ideal technique, except in cases where there is lower eyelid weakness and surgical resolution is needed.

Anesthetic injection pain and hematoma occurrence during upper blepharoplasty:Comparison between thin needles and thick needles

Background:Upper blepharoplasty is one of the most commonly performed esthetic surgeries,but injection pain during local anesthesia often disturbs patients.The objective of this study was to identify the pain levels associated with anesthetizing the upper eyelids in blepharoplasty and determine whether injection with thin needles is associated with less pain and bleeding than injection with thick needles.Methods:The study included 50 patients who underwent bilateral upper blepharoplasty.The eyelids were anesthetized using 2%lidocaine with 1:100000 epinephrine.One upper eyelid was randomly injected with a thin needle(26G)and the other with a thick needle(22G).The pain level was scored by patients immediately after the injection of each eyelid using a visual analog scale(VAS)ranging from 0 to 10.The incidence of eyelid hematomas caused by the anesthetic injection was also recorded.Results:The VAS scores in eyelids injected with thin needles were not significantly lower than those in eyelids injected with thick needles(4.0 vs.4.0,P=0.393).The formation of eyelid bruises caused by thin-needle injection was less frequent than that caused by thick-needle injection(16%vs.26%),but there was no significant difference between the two groups(P=0.326).Conclusion:Using thin needles for local anesthesia during upper blepharoplasty could not significantly decrease injection pain or hematoma occurrence compared with that associated with using thick needles.

Revisiting the upper eyelid blepharoplasty advancement flap:adaptation for the repair of full-thickness upper eyelid defects—a case series

A blepharoplasty flap has been previously reported as a useful reconstruction approach for anterior lamellar defects lying between the lash line and the eyelid crease.We herein describe a variation of the blepharoplasty flap and suggest its use as an adjunct in the reconstruction of full-thickness lateral upper eyelid defects.Technique description and retrospective interventional case series.The reconstruction technique was used by an experienced oculoplastics surgeon(ASL)in 3 adults with malignant lesions involving the lateral upper eyelid margin,resulting in a post-excision 50%full-thickness defect between November 2017 and June 2020.The posterior lamella was reconstructed using an ipsilateral free tarsal graft and an inferiorly hinged transposition periosteal flap.The anterior lamella reconstruction was then performed using a local advancement flap utilizing the principles of upper blepharoplasty and Burow’s triangle.Almost full eyelid excursion and full gentle closure were evident at 1–2 weeks follow-up in all three cases.One case later developed 1–2 mm of gentle closure lagophthalmos and was managed successfully with topical lubricants.In all patients,the final eyelid contour and symmetry were adequate,with only minimal scarring,evident already 3 to 4 months postoperative.There were no major complications or need for revisions.The technique described herein highlights the utility of the blepharoplasty flap for lateral,full-thickness upper eyelid defects.This logical variation enables the reconstruction of significant defects using only local tissue,obeying the“like with like”principle,and helps avoid the need for a bridging flap.We provide preliminary evidence of the potential of a good cosmetic outcome of upper lid appearance and contour,together with a fast recovery of appropriate eyelid function.

A practical technique of reverse orbicularis oculi muscle resection with preserved subcutaneous capillary network for double eyelid blepharoplasty

Background: Traditional full-incision double eyelid blepharoplasty has several significant disadvantages, including slow recovery and bilateral asymmetry, which results in high rates of patient dissatisfaction. These problems can be minimized using improved surgical techniques aimed at reducing tissue damage and bleeding, decreasing operation time, and especially at protecting the subcutaneous capillary network during the operation. We therefore aimed to guard the capillary network and reduce intraoperative bleeding using the practical technique of reverse orbicularis oculi muscle resection.Methods: Fifty cases of double eyelid blepharoplasty with traditional full-incision(group A) and 61 cases of reverse double eyelid blepharoplasty with a preserved capillary network(group B) were divided into two groups from October 1 to December 31, 2021 and from March 1 to May 31, 2022, respectively. The orbicularis oculi muscle was removed reversely from the front of the tarsal plate using double eyelid blepharoplasty, and the muscular membrane and subcutaneous capillary network were preserved. The operation time recorded in previous medical records was checked and compared with that of our novel technique. The recovery of double eyelid blepharoplasty was determined at 1, 4, and 12 weeks after the operation and patient satisfaction was also compared with that in previous medical records of patients in group A.Results: The reverse double eyelid blepharoplasty procedure was less complicated and easier to control than the traditional full-incision double eyelid blepharoplasty methodology. The average operation time of the double eyelid blepharoplasty cases with traditional full-incision was significantly greater than that of the cases of reverse double eyelid blepharoplasty with the capillary network preserved(45.68 ± 5.27 min and 31.11 ± 5.58 min,respectively;t=14.018 9, P=0.000 0). Patient satisfaction was 42% and 78.69%, respectively, at 1 week postoperation(χ~2=15.724 8, P=0.000 1), 62% and 90.16% at 4 weeks post-operation(χ~2=12.490 2, P=0.000 4),and 90% and 95.08%, at 12 weeks post-operation(χ~2=1.061 1, P=0.303 0).Conclusion: Reverse double eyelid blepharoplasty with preserved subcutaneous capillary network effectively decreases the operation time and improves post-operative patient satisfaction. It is a double eyelid blepharoplasty method worthy of popularization.

Recurrence of Lower Eyelid Fat Pads (Herniated Fat) after Blepharoplasty: An Analysis of Different Operative Techniques

Background: Aging changes to the lower eyelids and midface include all but not only these changes: pseudoherniated orbital fat, tear trough deformity, lid laxity, and dermatochalasis. Surgical repair often aims at treating redundant skin or orbital fat malposition with a lower eyelid blepharoplasty. In manipulating the inferior orbital fat pads, a surgeon has many options including excision, repositioning, or augmentation with synthetic dermal filler, autologous fat grafts, or acellular dermal allografts [1]. The aim of this study is to find the best approach in preventing fat herniation reccurnce in lower lid blepharoplasty. Methods: The patients in study were classified into three groups depending on the used surgical technique, to test the most effective technique associated with minimal rate of lower fat pad recurrence after surgery. Two of these techniques include a muscular flap suspension from the orbicularis oculae muscle. Results: The two surgical techniques that include orbicularis oculi muscle suspension are associated with no recurrence of lower herniated fat pads after blepharoplasty. Conclusions: The suspension of orbicularis oculi muscle has an important role in enhancing the lower orbital septum and prevents the recurrence of the lower herniated fat pads.

Insights into upper blepharoplasty: Conservative volume-preserving techniques

This editorial commentary critically examines the systematic review by Miotti et al,which discusses the evolving trends in upper lid blepharoplasty towards a conservative,volume-preserving approach.The review emphasizes the shift from traditional tissue resection to techniques that maintain anatomical integrity,paralleling broader trends in panfacial rejuvenation.Miotti et al delve into the nuances of fat pad management,advocating for conservation over reduction to sustain natural contours and improve long-term aesthetic outcomes.This perspective is supported by comparative studies and empirical data,such as those from Massry and Alghoul et al,highlighting the benefits of conservative approaches in terms of patient satisfaction and aesthetic longevity.The review also stresses the importance of surgeon discretion in adapting procedures to diverse patient demographics,particularly in addressing distinct features such as the Asian upper eyelid.However,it identifies a significant gap in long-term comparative research,underscoring the need for future studies to substantiate the safety and efficacy of these minimalist techniques.Overall,Miotti et al.'s work contributes profoundly to the discourse on personalized,conservative cosmetic surgery,urging ongoing research to refine and validate surgical best practices in upper eyelid blepharoplasty.

Modified lower eyelid blepharoplasty improves aesthetic outcomes in patients with hypoplastic malar prominences

Aim: Aging affects the appearance of the eyelids and the surrounding malar region. Blepharoplasty improves the aesthetic appearance of this region, and multiple variants of the procedure have been reported. We here report our technique for modified lower lid blepharoplasty and cheek lift for patients with hypoplastic malar regions, which was introduced after observing prominent lower orbital rims in patients with flat malar prominences after blepharoplasty. Methods: This technique combines standard canthopexy and cheek-lift for rejuvenation of the mid-face with redraping of orbital fat and concurrent sub orbicularis oculi fat pad (SOOF) lift to 'double-breast' the lower orbital margin. Data on 33 patients who had undergone this modified lower lid blepharoplasty was collected retrospectively. Results: Thirty-three patients underwent the modified lower lid blepharoplasty resulting in smooth and youthful appearance of the malar region that was consistent and sustained. No recurrence of V-deformity was observed on a median follow-up of 14 months. twenty-two (66.6%) and 11 (33.3%) patients were pleased and satisfied with postoperative outcomes respectively. Three (9.1%) patients experienced minor postoperative complications and no major complication was observed. Conclusion: The proposed modified lower lid blepharoplasty is a safe and effective alternative to the existing technique with improved aesthetic outcomes and therefore is recommended in patients with flat malar prominences.

Total lower lid reconstruction: clinical outcomes of utilizing three-layer flap and graft in one session

AIM:To report the clinical outcomes of utilizing a three-layer flap and graft in reconstruction of the lower lid in one session.METHODS:Seventeen patients with total or near total lower eyelid defect were included.The defects were reconstructed in three layers.Posterior lamella was reconstructed by using tarsoconjunctival free graft from the ipsilateral upper lid and periosteal flap from lateral orbital rim.Mobilization of residual orbicularis muscle provided a rich blood supply;and the anterior lamella was reconstructed by skin flap prepared from upper lid blepharoplasty as a one-pedicular or bipedicular bucket handle flap.RESULTS:The cause of lower eyelid defect was basal cell carcinoma in 15 patients and trauma in two of them.No intraoperative and postoperative complication occurred.Patients were followed from 10 to 15mo postoperatively.Cosmetic results were favorable in all patients and we had acceptable functional results.Thickness of the reconstructed tissue was a concern in early postoperative period.CONCLUSION:Three-layer lower lid reconstruction in one session is an effective technique for total lower lid reconstruction with minimal complications and acceptable functional and aesthetic outcomes and can be considered as a safe alternative for the preexisting techniques.

Severe Symmetric and Chronic Lower Eyelid Lymphedema in the Setting of Neck Surgery and Psoriasis

Purpose: To present a patient with bilateral severe and symmetric lower lid lymphedema in the setting of previous neck surgery and chronic psoriasis, and to review the potential relationships of neck surgery, irradiation, psoriasis, and rosacea to chronic lymphedema. Design: Single case report with literature review. Methods: A 60-year-old female with long-standing psoriasis presented with a 2-year history of severe, symmetric bilateral lower eyelid edema that developed after total laryngectomy and selective right neck dissection for recurrent Squamous Cell Carcinoma (SCC). 10 years prior she underwent radiation and radical left neck dissection for metastatic disease. Surgical management entailed transcutaneous debulking of the masses combined with ectropion repair and suture tarsorrhaphy. A comprehensive literature review was performed using Pubmed and Medline. Results: Surgical debulking of the soft tissue masses via a transcutaneous incision resulted in significant improvement in the patient’s lymphedema without recurrence at 5 months follow-up. Histopathologic findings were consistent with chronic eyelid lymphedema. Conclusions: Isolated eyelid lymphedema is rare, with many etiologies, and poses a diagnostic challenge. While ophthalmologists are familiar with the ocular manifestations of rosacea such as conjunctivitis or blepharitis, it is important to consider rosacea as an etiology of eyelid lymphedema. Reviewing the history for previous surgery or radiation to the head and neck, or other dermatologic inflammatory disorders is also warranted. Rosaceous lymphedema is typically less severe than in post-surgical/radiation patients, and does not respond well to medical treatment;however, it often shows a favorable response to debulking blepharoplasty surgery, with or without skin grafting. This patient with a history of severe psoriasis and bilateral neck dissections with radiation for SCC also responded well to surgery without recurrence of lymphedema. Therefore, surgical debulking can be considered in these patients with severe eyelid lymphedema as an option to markedly improve visual function and overall cosmetic appearance.

Improved Epicanthus Correction Combined with Double Eyelid Surgery

Objective:To explore the clinical effect of improved epicanthus correction combined with double eyelid surgery.Methods:From February 2019 to February 2020,70 patients with epicanthus who underwent surgical treatment were treated as study participants.The computer 1:1 grouping method was adopted.Thirty-five patients in the reference group were treated with epicanthus correction,and 35 patients in the experimental group were treated with improved epicanthus correction combined with double eyelid surgery.The operation efiect was compared.Results:The satisfaction scores of morphological aesthetics and prognosis recovery in the experimental group were higher than those in the reference group(P<0.05).The recurrence rate of scar hyperplasia and epicanthus in the experimental group was lower than that in the control group(P<0.05).Conclusion:The improved epicanthus correction combined with double eyelid surgery can engender ideal correction effect and reduce postoperative adverse outcomes.Therefore,the combined operation scheme is feasible.

Periorbital rejuvenation in the clinic:A state-of-the-art review

Objective:To provide an overview of the various treatment options available in the clinic to achieve periorbital rejuvenation.Data Sources:Literature review and expert opinion.Conclusions:Periorbital rejuvenation in the clinic can be accomplished through a variety of treatment modalities,including topical therapies,skin resurfacing,and fillers and injectables.Furthermore,some surgical approaches,such as upper blepharoplasties,ptosis,and brow lifts,can be performed in the clinic under local anesthesia with only mild oral sedation.However,the successful execution of such procedures depends on proper patient selection and maximizing patient comfort.

Evaluation and management of acquired ptosis

Periorbital rejuvenation is a common aesthetic goal sought by patients presenting to the plastic or oculoplastic surgeon.For this reason,it is critical that the surgeon understand the functional considerations,such as preexisting blepharoptosis,which will contribute to the ultimate aesthetic outcome.This article will review the anatomy of the normal and ptotic lid and will discuss the approach to diagnosing and characterizing the type and degree of lid ptosis.High-yield surgical techniques for ptosis correction will then be described,including the indications for and steps of each procedure.Finally,the diagnosis and management of common complications that follow ptosis surgery will be discussed.Our main objective is to arm the surgeon with the preoperative and operative planning tools to successfully manage comorbid ptosis and thereby improve blepharoplasty outcomes.