Rather, in most situations, Steven Fagien, M.D., recommends combining conservative resection along with procedures to bolster the orbicularis oculi muscle and lateral retinaculum while avoiding lid malposition.
The issue of how one treats a patient with bags of the lower lids has stimulated significant controversy, says Dr. Fagien, an aesthetic oculoplastic surgeon based in Boca Raton, Fla."The traditional treatment for that problem has been simply to resect the fat. That's been done for over 100 years," he says. But now, Dr. Fagien says, "We're in an age of preservation. The pendulum has swung to the point where some people are stating that fat should never be removed — it should always be repositioned or replaced."
"But the ultimate goal of aesthetic surgery is to make people happy with the results. I have seen many patients on whom methods to tighten the orbital septum (without fat excision) as the main ingredient to lower eyelid rejuvenation have resulted in either undercorrection or eyelid malposition," Dr. Fagien says.
And most cosmetic surgeons who perform a lot of eyelid surgery realize that fat "repositioning" in many instances is not likely in and of itself to make patients happy because the aging of the periorbital area is a more complex problem, he adds.
Downfalls of time
Specifically, Dr. Fagien says, "The integrity of the soft tissues — the ligaments, muscles and skin — fail with time."
Skin becomes less elastic; ligaments, attenuated and stretched, he says.
"The soft tissues, including the muscles, aren't firmly adherent to the bone anymore," he says.
Therefore, Dr. Fagien explains, "So-called repositioning, implanting or injecting fat then becomes a relatively small component of what's necessary to make eyelids look better or younger. Most cases require conservative resection of fat (always avoiding a hollow or depleted appearance) to contour the lower eyelid."
Additionally, he says that, while fat repositioning may represent a component of what's needed, repositioning actually is a poor term for what's done.
"What surgeons do when they call it repositioning is to put fat where it's actually never been. Transposing or translocating — taking fat and putting it elsewhere — are probably better terms," Dr. Fagien says.
Fat's stay-at-home tendency
More importantly, he says cosmetic surgeons' ability to transpose fat is limited.
Dr. Fagien explains, "The reason transposition often does not work is because we're trying to move fat that comes from a deeper source in the orbit to an area that blends contour problems more anteriorly than one visualizes through the eyelid."
One can also attempt to suture this fat in place, but because it's still attached to its original location (deeper into the orbit), he says, "Problems can arise from these distraction techniques, and ultimately, most of it will eventually migrate back to where it was from."