It is critical to identify the major aging effect that is bothering the patient. In our practice, we have found the majority of patients to be most bothered by the worsening of the nasojugal folds ("tear troughs") under the eyes. This can occur in younger patients, but is usually seen in older patients, becoming more prominent with facial aging due to midface descent and septal weakening. This causes the accentuation of the "fat bags" below the area of nasojugal hollowness.
Peel vs. removal
Most patients benefit from lower eyelid tightening and elevation via a lateral canthopexy, fat sculpting and repositioning as compared to removal of excess skin of the lower eyelids. To improve lower eyelid wrinkles, we recommend a lower eyelid TCA peel (25 percent to 35 percent), which is safer than skin removal and also helps with pigmentary changes.
Through a transconjunctival incision placed approximately at the midpoint between the inferior border of tarsus and the conjunctival fornix, the septum can be accessed. We use a four-prong retractor to facilitate the access followed by the use of a Desmarres retractor once the conjunctival incision has been made.
In cases with a prominent "tear trough" deformity, opening the septum and fat capsules should be done inferiorly at the orbital rim so that the fat will drape inferiorly and help fill the "tear trough."
We have not found a need to suture the fat pads inferiorly, but an integral component is release of the pre-periosteal attachments at the inferior orbital rim. This is best accomplished by blunt dissection and elevation of skin and the underlying tissues with the combination of Stevens scissors and a Sayer periosteal elevator. This release is carried below the rim (about 1 cm), which will help allow the fat to drop and fill in the "tear trough" deformity. Undermining laterally and release of the orbital malar ligament — combined with upper blepharoplasty dissection for elevation of the lateral canthus, lateral lower eyelid orbicularis, and, if needed, suborbicularis ocli fat lift (SOOF) — provides opportunity for more aggressive midface elevation.
Less is more
Fat removal should be conservative and usually only involves the more superior fat that prolapses after the capsules are opened.
In younger patients and those with minimal fat, we only reposition and do not advise fat sculpting. However, excessive lateral fat pads must be more aggressively sculpted as the lower eyelid trough deformity is usually least pronounced laterally. After ensuring there are no sites of active bleeding, the conjunctiva is closed in the midline with a single 6-0 plain gut suture to avoid conjunctival adhesions.
Excess lower eyelid skin removal, if needed, is usually performed as a secondary procedure. The vast majority of patients do not require skin removal. The combination of TCA peel and lower eyelid fat repositioning with lateral canthopexy and/or lateral SOOF and midface elevation provide an excellent aesthetic result and has high patient acceptance with few risks.
About the authors: Drs. Burroughs and Anderson practice at the Center for Facial Appearances, Salt Lake City.