Persistent Upper Eyelid Skin

Persistent fullness in the upper eyelid can be a common complaint following primary upper blepharoplasty and is most commonly seen laterally. Anatomically, fullness develops with age due to a tendency of central upper eyelid fat to shift laterally and lateral excess skin’s absence of fixation to the tarsal plate. This can be further exacerbated by decreasing frontalis support of the temporal brow and, infrequently, lacrimal gland prolapse. These anatomical changes need to be considered when evaluating patients for both primary and secondary blepharoplasty. In addition, it is also essential that the surgeon be aware of eyebrow position and function, particularly the potential role of compensatory brow elevation. Dermatochalasis and significant temporal hooding are often compensated for by elevating the forehead in an attempt to maintain maximal vision.

Excess upper eyelid skin following blepharoplasty may be due to a number of factors, including difficulty in judging the extent of skin resection as well as limiting the most lateral extent of the incision. Furthermore, brow ptosis may be the culprit in some cases, and may be the result of preexisting or new-onset brow ptosis, such as can occur following Botox therapy. For this reason, it is important to inquire about the Botox status/history of such patients. Of note, underresection can typically be differentiated from brown ptosis by a true excess of skin folds.

Persistent Upper Eyelid Fat

Upper eyelid preaponeurotic fat lives in one of two compartments, central or medial. The central fat pad tends to atrophy with age, while the denser and more stem cell–rich medial fat pad is an extension from deeper orbital fat and tends to become more prominent with age, even after primary blepharoplasty.

Underresection of upper eyelid fat may be seen following primary blepharoplasty, and is most commonly associated with the medial fat compartment. From a technical perspective, this makes sense, as medial fat is typically more difficult to visualize and dissect during upper blepharoplasty. Although nasal fat can often be distinguished by its unique pale “whitish” color, it is important that surgeons identify and remove any excess fat in this distinct compartment during blepharoplasty.

Interestingly, the recent emphasis on fat preservation techniques in upper blepharoplasty may also be increasing the likelihood of “underresected” fat in upper blepharoplasty procedures. As surgeons grow increasingly concerned with avoiding hollowness and skeletonization, overly conservative results are a possible outcome.

Persistent Lower Eyelid Fat

Persistent lateral compartment fat is among the most common findings requiring secondary lower blepharoplasty. One interesting phenomenon with age is the development of pseudoherniation of lower eyelid fat pads, predominately in the lateral aspect, which may result from globe descent inferiorly and laterally in the orbit. In older patients, specifically, atrophic soft tissue coverage further exacerbates contour irregularities to create a fullness that interrupts what ideally should be a single mildly convex line in the sagittal view that defines the youthful eyelid–cheek complex.

The lower lateral fat pocket is prone to underresection during primary blepharoplasty for reasons similar to those noted earlier, including recent trends in conservative blepharoplasty as well as an anatomical location that is relatively challenging to access and identify, particularly so in the transconjunctival approach. Furthermore, recent approaches favoring fat preservation or transposition may also contribute to the risk of persistent lateral fat. For example, some surgeons now favor medial and central fat repositioning techniques, whereby these compartments are mobilized along with redundant septum and transpositioned into a subperiosteal pocket. Notably, this cannot be accomplished with the lateral fat compartment as it is located just above the Lockwood ligament and lacks adequate mobility to be repositioned.