Transcutaneous Lower Lid Blepharoplasty with Fat Resection
This is Richard Allen at the University of Iowa. This video demonstrates a transcutaneous lower lid blepharoplasty with excision of fat pads.
A 4-0 silk suture is placed through the lower lids at the level of the meibomian gland orifices to provide traction during the case.
A subciliary incision is then made extending from the lateral canthus to the punctum.
Dissection is then carried out between the orbicularis muscle and orbital septum towards the inferior orbital rim.
This patient complained mostly of puffiness of the lower lids without a prominent tear trough, therefore fat resection rather than transposition will be performed.
The inferior orbital rim is palpated and the fat pad are mobilized after dissecting through the orbital septum.
The medial, central, and lateral fat pads are identified and mobilized. The medial fat pad is then conservatively excised.
The inferior oblique runs between the medial and central fat pad and it is important not to damage this structure.
This patient had a tendency to bleed, so it was decided to clamp the fat pads prior to excision with a hemostat, followed by cutting the fat pads and then cauterizing. I don't typically do this unless I am having significant bleeding from the fat. Either monopolar or bipolar cautery can be used.
Attention is then directed to the lateral fat pad which is also conservatively excised, using the hemostat to prevent bleeding. Some people believe that clamping the fat may cause tearing of a posterior orbital vessel. I share this concern, but I think this would only happen if significant traction were placed on the fat.
The same procedure is then performed on the right side.
A subciliary incision is made followed by dissection between the orbicularis muscle and orbital septum to the inferior orbital rim.
The orbita septum is opened and the fat pads are mobilized.
These fat pad can be conservatively excised again by clamping the fat followed by excision by scissors, followed by hemostasis. In a patient with a prominent tear trough, one would transpose the fat rather than resecting it.
This patient has significant lower lid laxity, and therefore a lateral tarsal strip will be performed.
Due to the fact that a transcutaneous incision likely increases your risk of post-operative eyelid malposition, it is reasonable to stabilize the eyelid by tightening it.
The strip is shortened and then sutured to the lateral orbital rim at the level of whitnalls tubercle with a double armed 4-0 mersilene suture.
This is performed on each side.
The subciliary incision can then be closed with a running 5-0 fast absorbing suture or your skin suture of choice.
At the end of the case, the eyelids are in good position. The fat pads are shown here to demonstrate symmetrical excision.