16.1 Patient History Leading to the Specific Problem

The patient is a 53-year-old woman who presented following an upper lid blepharoplasty elsewhere 2 years prior to presentation. She expressed concerns for an “unnatural” appearance. She felt that she looked “overoperated” and was seeking correction of the appearance of her upper eyelids.

16.2 Anatomic Description of the Patient’s Current Status

The patient’s upper orbits have a hollowed-out appearance. The hollowing is most apparent medially, producing an A-frame deformity. The skeletonized nature of her deformity accentuates the visibility and prominence of her superior orbital rim. This results in an overall aged and deflated appearance despite her initial goals of looking younger from a blepharoplasty (Fig. 16-1).

16.3 Analysis of the Problem

Overresection is a relatively common problem after traditional blepharoplasty due to traditional concepts that emphasize resection of excess skin, muscle, and fat. Laxity and gravitational descent will cause excessive hanging and bulging of tissues in most patients who present for blepharoplasty, but deflation is also a major component of periorbital aging. These bulging tissues often mask the loss of volume, and thus during resection of the apparent “excess” tissue, the surgery contributes to an even greater loss of volume. This only exacerbates the continued deflation that occurs with further aging and increases the risk of skeletonization of the orbit and development of a hollowed-out cadaveric appearance.

The following elements lead to formation of the undesired deep excavation of supraorbital area:

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  Overresection of medial and central fat pads will create a central hollow.

  
  
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  Overresection of preseptal orbicularis muscle will expose superior orbital rim.

  
  
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  Overresection of lower fat pads will reduce total amount of fat in the orbit, allow eyeball to sink down, and translate to upper hollowness indirectly.

Avoidance of overresection of volume, which often corresponds to fat, should be a priority in any operation. The surgeon’s goal should be to address the apparent excess of tissues while remembering deflation is a central characteristic of the aging eye. If the surgeon pursues a fat resection approach, one technique that may be helpful to avoid overresection is to press on the globe during the operation to allow preaponeurotic fat to bulge. The end point of fat resection should not extend beyond the point of resecting preaponeurotic fat back into the orbit. The surgeon should distinguish excess fat that delivers itself from fat that needs to be surgically manipulated and pulled, and focus on excising the former.

Fat preservation approaches have also been described to avoid overresection. One method uses bipolar coagulation (BICO) to reduce the pseudoherniation of bulging fat. The technique simply makes a small incision through skin and preseptal orbicularis muscle to expose the orbital septum and underlying fat. BICO is then applied to the septum to cause shrinkage and disappearance of bulging subseptal fat analogous to “hernia repair.” Of note, the authors do not strictly rely on bipolar instruments for this technique, but do feel that coagulation in general can be a valuable means of camouflaging such bulges without traditional resection of fat.