Lateral Fat Pad Research Articles

The Origin and Course of the Blood Supply to the Lower Eyelid Orbital Fat: Anatomical Study and Clinical Significance.

The aim of this study is to investigate the origin and course of the orbital fat arterial supply in the lower eyelid using traditional anatomy and three-dimensional computed tomography (CT). Twenty-seven cadaver heads were infused with mercury sulfide contrast media through the ophthalmic artery, maxillary artery, transverse facial artery, and facial artery. CT images were obtained after contrast agent injection, three-dimensional CT scans were reconstructed, and the cadaver heads were dissected. Forty-five qualified hemifaces showed that the orbital fat arterial supply in the lower eyelid originates primarily from the inferomedial muscular trunk (IMT) of the ophthalmic artery and the orbital branch of the infraorbital artery. The medial branch of the IMT terminated at the medial fat pad (35.6%) or the orbital floor (64.4%). The lateral branch terminated at the inferior oblique (IO) muscle (28.9%) or the central and lateral fat pads (17.8%). In 53.3%, the lateral branch extended to the anterior part of the lateral fat pad and terminated in the orbital wall or the zygomaticoorbital foramina. The orbital branch of the infraorbital artery coursed between the orbital floor and the orbital fat, providing supply to the IO muscle, inferior rectus (IR) muscle, nasolacrimal duct, and orbital fat. This study elucidated the origin and course of the orbital fat arterial supply in the lower eyelid, which may help to avoid reducing the blood supply of the orbital fat pedicles during surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Supraperiosteal fat repositioning with midface lift in lower eyelid blepharoplasty: an 18-year experience.

To assess the clinical outcomes of fat repositioning via supraperiosteal dissection with midface lift for correction of tear trough deformity in a large Asian patient population. Retrospectively review 1152 Asian patients who underwent fat repositioning to the supraperiosteal plane with a midface lift between 2005 and 2022. Surgical technique, postoperative course, and complications were recorded. At the 6-month postoperative follow-up, the degree of patient satisfaction was assessed. A total of 2304 eyes from 1152 patients with an average follow-up of 10 months. These procedures were performed using a transforniceal approach in 185 patients (16%) or a transcutaneous skin excision approach in 967 patients (84%). Among the patients who underwent the transcutaneous technique, seven individuals (0.6%) experienced effective treatment of lower lid ectropion through lateral tarsal strip procedures. Nine patients (0.7%) required revision surgery to address the remaining lateral fat pad due to inadequate lateral orbital fat excision during the initial procedure. At the 6-month follow-up, most patients reported a high level of satisfaction, with 800 patients (78%) expressing extreme satisfaction and 196 patients (19.1%) reporting satisfaction with the improvement in their appearance. No one reported facial numbness, lower eyelid or cheek paralysis, newly developed diplopia or granuloma formation. The procedure of fat repositioning involving supraperiosteal dissection and a midface lift, whether performed using a transforniceal approach or a transcutaneous skin excision approach, in lower eyelid blepharoplasty proves to be a secure and auspicious surgical technique for rectifying tear trough deformity and attaining a pleasing aesthetic outcome.

Single access upper blepharoplasty and lower lid lateral fat pad removal: A proven technique with low recurrence rate

The transconjunctival approach is commonly performed in lower lid blepharoplasty so as not to violate the orbicularis oculi muscle integrity and avoid additional scars. This technique does not, however, permit easy access to the lateral fat pad (LFP). As upper and lower blepharoplasty are frequently combined in our clinical practice, the removal of LFP via upper blepharoplasty is a surgical approach that we found most applicable with good outcomes. A prospective review of 47 consecutive bilateral combined upper and lower blepharoplasty cases using a single access technique was conducted; patient outcomes and the occurrence of any complications were recorded, in addition to preoperative and postoperative measurements between standardized anatomical landmarks. Forty-seven patients were included in our study. Postoperative measurements showed a decrease of both lateral cantus to inferior orbital border distance and horizontal width of LFP. Good esthetic outcomes and patient satisfaction with surgical results were achieved in the majority of patients. The single access upper blepharoplasty and lower lid LFP removal technique can improve esthetic outcomes in lower blepharoplasty. The advantages are many; a low risk of missing the lateral pad, ease of achieving a uniform contour of lower eyelid; short lower transconjunctival incision, minimizing complications associated with an intra-conjunctival scar. This technique, based on cadaveric anatomical studies, has been found to be safe and is of great utility to those patients requiring upper and lower lid blepharoplasties.

Addition of "Septal Window" to Lower Blepharoplasty for the Management of Fat of the Lower Eyelids.

The most common reason for dissatisfaction and reoperation in lower blepharoplasty patients is persistent bulging of the lateral fat pad. This compartment contributes the most to fat herniation and yet is the most commonly overlooked. The addition of a septal window, a small opening of the septum on the most prominent part of the lateral fat compartment, helps with precise removal of lateral fat and allows for additional fat excision after septal reset without disrupting the arcuate expansion. Our lower blepharoplasty approach includes 1) a subcilliary incision; 2) aggressive lateral fat excision through a septal window; 3) central and medial fat excision, transposition, and septal reset; 4) canthopexy; 5) orbicularis oculi muscle suspension; and 6) no dissection of orbicularis oculi medially and no skin resected medially to avoid lid retraction. We performed a retrospective review of all lower blepharoplasty cases by a single surgeon over 10 years. Demographics and operative outcomes were queried. There were 224 cases, 90% were women with a mean age of 58.2 years. The most common postoperative occurrences were eyelid edema, malar edema, and chemosis, all of which were self-limiting. Two patients needed additional removal of lateral fat of their lower eyelids.Two patients had lid retraction, one of which had a previous facial nerve palsy and the other did not have a canthopexy and developed transient unilateral lid retraction that resolved with conservative treatment. Resumption of full activities and exercises at 6 weeks was typical. The septal window facilitates aggressive resection of the lateral fat pad and additional fat excision after septal reset to create a smooth lid-cheek junction. In our practice, it is a critical component of a successful lower blepharoplasty.

Lower eyelid transconjunctival blepharoplasty with fat repositioning: outcomes and complications

The lower eyelid changes with aging include atrophy of the orbital septum with subsequent forward herniation of orbital fat, descent of the sub-orbicularis oculi muscle fat, ptosis of the orbicularis oculi muscle, weakening of the orbito-malar ligament and the development of laxity of the eyelid skin, the tarsus and the canthal tendons. In this article we aim at describing our experience of using a modified lower lid blepharoplasty with fat repositioning in patients with lower lid fat prolapse and tear trough deformity. A retrospective, non-randomised non-comparative interventional consecutive case series of patients seeking surgical treatment. Patients underwent surgery between April 2010 and October 2019 by a single surgeon (BL). Patient demographics, clinical examination, preoperative and postoperative clinical photography, outcomes and complications were recorded. Follow-up was initially at 2 weeks and finally at 16–20 weeks. Outcomes were recorded as subjective improvement and degree of patient satisfaction. A total of 150 patients were recruited in the study period. The mean age at the time of surgery was 49. One hundred forty-one (94%) patients were very satisfied with the final outcome of their surgery, 5 were satisfied and 4 were dissatisfied. One patient developed a bilateral lower lid infection requiring abscess drainage. Seventeen other patients experienced minor complications in the postoperative period, including 2 with a unilateral lower lid infection requiring oral antibiotics, 3 with a temporary inferior oblique palsy, 1 with temporary unilateral infraorbital nerve dysfunction, 3 with residual prolapses of the lateral fat pads, 1 with a medial lower lid lump, 2 with a conjunctival granuloma, 2 with a temporary medial ectropion, 1 with persistent unilateral lower lid oedema, 1 with persistent bilateral lower lid oedema and 1 with unilateral lower lid retraction. We report a high patient satisfaction with a low rate of significant complications following our modified lower lid transconjunctival blepharoplasty with fat repositioning. Level of evidence: Level III, therapeutic study

Effectiveness of remold eyelid structure method of blepharoplasty for thickening eyelid

Objective To explore the method and efficacy of using Y flap formed to remold double eyelid structure of blepharoplasty for thickening eyelid. Methods A total of 97 cases of single eyelids and thickening eyelid were treated with surgery, to release the space before tarsus fascia and levator palpebrae aponeurosis to form a continuous interspace of the orbicularis oculi muscle. Then joint fascia was reconstructed to format Y flap, on which both sides of the levator aponeurosis and orbital septum fascia were tightened and the redundant fat and fascial organization removed. The lateral fat pad under the orbicular muscle were wedge-shaped sheared along the orbital margin after double eyelid was formed. Few patients presented acrimal glands prolapse, which suspended to return the lower margin of the orbital bone. Finally according to the upper eyelid anatomy suture each layer of incision was closed. Results The 97 cases underwent surgical treatment and the incisions were healed by first intention, in which 3 cases had slight skin ptosis at the lateral double crease due to the conservative tissue removal and 2 cases had the double eyelid width asymmetry due to the tissue was removed unevenly. They were adjusted satisfiedly 3 months later. All cases were followed up for more than 3 months and acquired satisfactory improvement and beautification. Incision was healed hiddenly. Conclusions This method can be used to tease and adjust the upper eyelid levels clearly and completely, which makes redundant tissues removed in place and double eyelid located accurately. By this method single eyelid combined thickening eyelid could be solved aestheticly at the same time and get a natural, popular and natural shape. Key words: Blepharoplasty; Slitting up method; Remodled eyelid structure; Thickening eyelid; Blepharoplasty

A modified mini-incisional technique for double-eyelid blepharoplasty

Background Double-eyelid blepharoplasty is one of the most popular cosmetic surgeries in Asia. Objective To introduce a modified mini-incisional technique to form a double eyelid. Methods A total of 372 patients (325 women, 47 men) were involved in the study between July 2008 and August 2014. Their age ranged from 16 to 34 years, with a mean age of 24 years. All patients underwent the modified mini-incisional upper blepharoplasty. In the technique, four 2 mm incisions were made along the designed fold. The orbicularis muscle overlying the levator aponeurosis was removed. The removal of the lateral fat pad was completed accordingly. The medial fat pad was also removed if necessary. Suture was used to fix the skin to pretarsal fascia along the double-eyelid line. The double-eyelid crease was formed after the operation. Results The follow-up period was three to 12 months (mean nine months). Most of the double eyelids were natural. During the follow-up period, 92% (342 of 372) patients were satisfied with the blepharoplasty. The most common complications were swelling within first week after the operation, which subsided spontaneously. Asymmetries occurred in 17 patients; six patients had multiple eyelids and seven patients experienced shifting of the fold. These were corrected six months after the operation. Disappearance of the fold was not observed. The scars of the stab incision became invisible after one full year of recovery. No other severe complications were found. Conclusion The four mini-incisional blepharoplasty technique was successful for the formation of a natural-appearing and long-lasting double eyelid. Except for individuals with obvious skin redundancy, patients with a single eyelid are suitable candidates for the technique.

A modified mini-incisional technique for double-eyelid blepharoplasty.

Double-eyelid blepharoplasty is one of the most popular cosmetic surgeries in Asia. To introduce a modified mini-incisional technique to form a double eyelid. A total of 372 patients (325 women, 47 men) were involved in the study between July 2008 and August 2014. Their age ranged from 16 to 34 years, with a mean age of 24 years. All patients underwent the modified mini-incisional upper blepharoplasty. In the technique, four 2 mm incisions were made along the designed fold. The orbicularis muscle overlying the levator aponeurosis was removed. The removal of the lateral fat pad was completed accordingly. The medial fat pad was also removed if necessary. Suture was used to fix the skin to pretarsal fascia along the double-eyelid line. The double-eyelid crease was formed after the operation. The follow-up period was three to 12 months (mean nine months). Most of the double eyelids were natural. During the follow-up period, 92% (342 of 372) patients were satisfied with the blepharoplasty. The most common complications were swelling within first week after the operation, which subsided spontaneously. Asymmetries occurred in 17 patients; six patients had multiple eyelids and seven patients experienced shifting of the fold. These were corrected six months after the operation. Disappearance of the fold was not observed. The scars of the stab incision became invisible after one full year of recovery. No other severe complications were found. The four mini-incisional blepharoplasty technique was successful for the formation of a natural-appearing and long-lasting double eyelid. Except for individuals with obvious skin redundancy, patients with a single eyelid are suitable candidates for the technique.

Recreating the Lateral Footprint of Obese Patients in Immediate Silicone Implant Breast Reconstruction Using an Elongated Teardrop Incision

Sir:FigureIn the naïve ptotic large breast, in the subgroup of obese patients, there is often a lateral fat pad extension of the breast toward the posterior axillary line. The main difference between a naïve large breast and a reconstructed one is the projection of the breast. The conus of the breast is transformed from a ptotic breast into a protruding one. This transformation extenuates the lateral fat pad extension and obliterates the lateral breast footprint with poor aesthetic result. We address this problem with the elongated teardrop incision. Between February and December of 2010, we performed this technique on 13 immediately reconstructed breasts. The mean age of the patients was 50.2 years. The mean body mass index was 29.4 kg/m2. The incision is continued laterally as far as necessary (Fig. 1) but never beyond the posterior axillary line. The extension of the surgical incision toward the axilla facilitates the general surgeon's work and enables a convenient approach to the axilla during axillary lymph node biopsy. The lateral fat pad is excised with all the layers down to the axilla and the serratus anterior muscle. The skin flaps are reflected, and tacking sutures are positioned to obliterate any dead space and to align the lateral skin flaps to the lateral border of the pectoralis major.Fig. 1: A 72-year-old woman with a body mass index of 30.5 kg/m2 underwent mastectomy because of invasive ductal carcinoma after lumpectomy on her right breast. The weight of the amputated breast was 720 g. (Above) Preoperative views show lateral fat pad extension of the breast. (Below) Postoperative views show elongated teardrop incision that was continued toward the midaxillary line, with good definition of the lateral footprint of the breast.The mean weight of the amputated breasts was 610 g. In all patients, anatomical silicone implants were used (range, 755 to 440 cc). None of the patients suffered from skin flap necrosis or device failure. One patient had minor slough of the surgical scar that was treated conservatively. Creation of an aesthetically pleasing breast in obese women has been a challenge for plastic surgeons worldwide.1 Blondeel et al. discuss this issue comprehensively in a series of articles beginning in 20092 describing the three-step principle: the footprint, conus, and skin envelope. The footprint essentially infers to the outline of the breast on the chest wall. The position of the footprint may vary from one woman to another, usually not extending as far as the midaxillary line in the aspect of its lateral border.3 Nevertheless, in obese patients, accessory lateral fat pad might be found extending through the axilla to the back. In these patients, a sufficient aesthetic result after immediate breast reconstruction with silicone implants is more challenging and at times difficult to accomplish.4 Few articles regarding the lateral fat pad have been published.5 The elongated teardrop incision enables us to address the lateral footprint violation. One must not forget that elongating the incision produces a longer scar that is more difficult to conceal. The patient must be informed of this before the operation and agree to it. In our experience, the aesthetic result overwhelmed the disadvantage of an extended incision. We portray a sound surgical technique for recreating the lateral footprint of an immediately reconstructed breast with a silicone implant resulting in a good aesthetic outcome. Gil Grabov-Nardini, M.D. Joseph Haik, M.D. Oren Wissman, M.D. Eran Millet, M.D. Eyal Winkler, M.D. Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Fat repositioning via supraperiosteal dissection with internal fixation for tear trough deformity in an Asian population

To investigate the efficacy and complications of fat repositioning via supraperiosteal dissection with internal fat-flap fixation for tear trough deformity in an Asian population. This study is a retrospective chart review. From June 2005 to May 2010, 212 patients with lower eyelid fat prolapse and tear trough deformity underwent fat repositioning via supraperiosteal dissection with internal fat-flap fixation. Postoperative complications were recorded, and the degree of outcome satisfaction was obtained at the 6-month postoperative follow-up. In total, 142 patients underwent transconjunctival fat repositioning, and 70 received the transcutaneous approach for redundant lower lid skin and tear trough deformity. The level of satisfaction 6 months after the operation was high: 152 patients rated their experience as very satisfied (71.7%), 54 as satisfied (25.5%) and six as acceptable (2.8%). None reported being dissatisfied or unhappy. No diplopia or evidence of granuloma formation in the lower eyelid or check area was noted. Four patients who suffered from significant ecchymosis and conjunctival chemosis with corneal exposure were managed with lubricants and resolved spontaneously. Three patients who underwent the transcutaneous approach and excess skin excision had the complication of lower lid ectropion; they received lateral tarsal strip procedures with good results. Three patients required revision to remove the residual lateral fat pad because of inadequate lateral orbital fat excision during the initial procedure. Fat repositioning via supraperiosteal dissection with internal fat-flap fixation is a safe and effective method to create a youthful midface appearance for Asians with tear trough deformity.

Lower Eyelid Rejuvenation with Skin/Skin-Muscle/Fat Repositioning Techniques

A preoperative examination of the cosmetic patient considering lower eyelid blepharoplasty is essential. The preoperative examination allows the patient to express his or her concerns and desires and allows the physician to establish a healthy physician-patient relationship, which is vital in the treatment of the patient. The preoperative examination also allows the physician to explain the surgery and possible complications. As opposed to the aging patient with severe dermatochalasis and orbital fat prolapse, the cosmetic patient considering lower eyelid blepharoplasty often has specific areas of the eyelids to address. It is important for the surgeon to identify these areas and understand exactly what the patient wishes to accomplish with the surgery. One patient may wish to diminish the prominence of the central and lateral fat pads, whereas another may wish to reduce redundant lower eyelid skin. It is often helpful to have the cosmetic patient hold a hand mirror and point out to the surgeon exactly the areas of concern. Both anterior and posterior approaches to the lower eyelid exist. The anterior approach to lower eyelid blepharoplasty is made through an infraciliary skin incision, and most patients require excision of excess skin, orbicularis oculi muscle, and fat. In these patients, a skin-muscle flap is removed. If only loose and redundant skin is present, a skin flap with resection of the redundant skin is performed. If only excess fat needs to be removed, a skin-muscle flap is raised, excess fat is removed, and little or no excess skin or muscle is removed.

Transconjunctival sub-orbicularis oculi fat (SOOF) pad lift blepharoplasty: a new technique for the effacement of nasojugal deformity.

Transconjunctival sub-orbicularis oculi fat (SOOF) pad lift blepharoplasty: a new technique for the effacement of nasojugal deformity.

Operative Technique For Transconjunctival Lower Blepharoplasty

In the past 3 years, more than 125 patients have undergone primary and secondary lower blepharoplasty by the transconjunctival method. The ability to adequately remove fat with this approach has been impressive. Exposure of the central and medial fat compartments is excellent. The lateral fat pad area is not as easy to visualize, and care must be taken to assure that adequate fat removal is achieved. Although one might suspect that postoperative conjunctival irritation could be a problem with this procedure, this has been notably absent in our patient population. In addition, there have been remarkably few patients with dry eye complaints following transconjunctival lower blepharoplasty. The question of skin resection must also be addressed. Currently, we believe that the majority of patients seeking improvement of the lower eyelids benefit most by a transconjunctival blepharoplasty without skin resection (Figs. 3 and 4). When there is obvious skin excess, we believe that it is best approached by removing the fat through the transconjunctival incision and then removing skin with a simple skin flap or skin pinch technique. This must be done considerably more conservatively than has been recommended in the past, to retain a natural palpebral fissure. Secondary skin removal, if necessary, is a straightforward procedure that can be readily done under local anesthesia at a later date. Transconjunctival lower blepharoplasty has not been associated with prolonged (exceeding 1 month) lower lid retraction problems in any of our patients. The technique is easy to learn but does require some experience with the anatomy. The technique should become the basic procedure for correction of excess fat in the lower eyelids.

Central (third) fat pad of the upper eyelid

A clinical study on the surgical anatomy of the upper-eyelid fat pads was performed on 55 consecutive patients who underwent a blepharoplasty. It was confirmed that the periorbital fat is encapsulated in compartments and that the number of fat pads varies. In 56% of the cases there were two fat pads and in the 44% three fat pads in the upper eyelid. The third fat pad is anatomically and histologically an accessory medial extension of the lateral fat pad. However, for the sake of clarity, the term central fat pad of the upper eyelid is proposed as a denominator of this structure. The purpose of this article is to make the less experienced surgeons aware of variations in the configuration of the periorbital fat and to remind them that after two fat pads are removed from the upper eyelid there might still be a third.

Induction of glutamine synthetase and transient co-expression with carbamoylphosphate synthetase in hepatocytes transplanted into fat pads of syngeneic hosts

Isolated rat hepatocytes were transplanted into the interscapular and both anterior lateral fat pads of hepatectomized syngeneic rats. At various time points following transplantation, the fat pads were removed, fixed and embedded in paraffin. Serial sections were stained for glutamine synthetase (GS) and carbamoylphosphate synthetase (CPS) using specific antisera and the PAP technique. The initially low fraction of GS+-heptatocytes remained low up to the fourth day, then increased strikingly up to almost 100% and declined gradually after the 14th day. In contrast, the number of CPS+-cells declined continuously to about 30% after 28 days. If the animals were exposed to CCl4 prior to the isolation of the hepatocytes in order to reduce the number of GS+-cells in the initial cell suspension similar results were obtained and no difference in the probability of the colony formation was noted between this and the normal hepatocyte suspensions indicating that the appearance of the GS+-phenotype was not due to a selective survival of these cells. Analysis of the staining intensity of the transplanted hepatocytes revealed the appearance of two populations of GS+-hepatocytes, one with a strong and one with a weak staining, during the course of formation of larger nodules, while only a single weakly stained population could be discerned with respect to the staining for CPS. These results demonstrate that all hepatocytes or at least their descendents can be induced to express GS by the environmental conditions of the fat pads, and that GS and CPS can be co-expressed with an apparently reciprocal relationship.

Functional upper eyelid anatomy as applied to aesthetic blepharoplasty

The paper reviews significant anatomic details of the upper eyelid important in performing upper lid aesthetic blepharoplasty. Included are descriptions of the obicularis oculi muscle, the preaponeurotic fat pads, the lateral fat pad, and the lacrimal gland. Current concepts regarding the insertion of the levator palpebrae superioris muscle and its role in creating the upper lid sulcus and fold are discussed. Application of these anatomic considerations in performing upper lid aesthetic blepharoplasty is suggested.

Resection of the prominent lateral fat pad during upper lid blepharoplasty.

The presence of a lateral fat pad beneath the orbicularis muscle, which overlies the lateral orbital rim, is described in patients who have marked bagginess of the upper lid and a bulky hood of tissue extending well beyond the lateral canthal region. This fat is separate from the fusiform central fat pad and lies superficial to the orbital septum. Resection of a strip of orbicularis muscle and the underlying lateral fat pad, in addition to the routine removal of central and medial fat pads, provides an enhanced appearance and complete correction of the lateral hood in such individuals.