INTRODUCTION

The upper eyelid fat is divided into nasal (medial) and central (pre-aponeurotic) fat pads by the superior oblique muscle tendon and the medial horn of the levator aponeurosis.[12]

The whitish nasal fat pad is similar in appearance to intraconal orbital fat, whereas the central fat pad is more yellow in color and similar in appearance to the body adipose tissue. The nasal fat pad contains more connective tissues and less carotenoids, compared with the central fat pad explaining the difference in their gross appearance. The nasal fat pad may be an excellent source for free fat grafting due to its progenitor cell composition.[345]

The upper eyelid nasal fat pad is often prolapsed with aging. There is an apparent increase in the volume of the upper eyelid nasal fat pad and a decrease in the volume of the central fat pad with advancing age due to the overall atrophic changes of the central fat pad.[2]

The upper eyelid nasal fat pad bulge is a common cosmetic problem creating a tired and unsightly appearance that requires nasal fat removal for upper eyelid rejuvenation. The upper eyelid blepharoplasty is one of the commonest esthetic surgeries for upper eyelids. Traditional blepharoplasty includes removing the medial fat pad by opening the entire horizontal length of the eyelid. This requires an incision of the entire length of the eyelid.[46,7]

This cohort aims to investigate the efficacy of the small incision technique in the management of the upper eyelid solitary nasal fat pad bulge.

PATIENTS AND METHODS

Patient selection

this is a prospective study of 43 eyes of 24 patients who underwent small incision upper blepharoplasty for the treatment of solitary nasal pad fat bulge between May 2020 and November 2021.

Inclusion criteria

at least 18 years of age patients with upper eyelid solitary nasal pad fat bulge.

Exclusion criteria

upper eyelid dermatochalasis, upper eyelid blepharoptosis, central fat pad protrusion, and other orbital or eyelid disease.

Patient evaluation

All patients underwent a comprehensive ophthalmic examination, visual field test (VFT), and periorbital evaluation at baseline, 1 week, 3 months, and 6 months after the surgery.

• •

  The periorbital evaluation includes assessment of globe position, palpebral fissure size and shape, upper eyelid position and symmetry, brow position and symmetry, skin assessments, Bell’s phenomenon, and facial nerve function.[8]

• •

  Grading of the nasal fat bulge: A scale of 0–3 was used to grade the volumetric appearance of the fat pads, with 0 being the lowest and 3 being the highest.[59]

• •

  Duration of surgery from the time of the incision to the closure of the wound is measured by a stopwatch in minutes.

• •

  Patient satisfaction evaluation:

  • 1.

    Global Aesthetic Improvement Scale (GAIS)[10];

  • 2.

    Blepharoplasty Outcomes Evaluation (BOE): Six items are scored on a 0–4 scale, with 0 being scored for the most negative response and 4 being scored for the most positive response. Dividing the total score by 24 and multiplying by 100 yields the scaled instrument score. This range is 0–100, with 0 representing the least patient satisfaction and 100 representing the most patient satisfaction.[11]

• •

  Photography: All pre-operative and post-operative photographs were taken under standard positioning and lighting including frontal views of the eyes extending from above the eyebrow to the upper margin of alar groove, within preauricular hairlines in primary, up, and down gazes [Figure 1].[1213]

Close

Figure 1

Left: (A) baseline photograph of the left eye with nasal fat pad bulge, (B) 6-month post-operative photograph, and (C) 2-year follow-up photograph. Right: surgical technique: (A) small incision 4 mm in the nasal eyelid crease, (B) blunt dissection of orbicularis muscle toward nasal fat pad, (C) nasal fat pad isolation and excision, and (D) wound closure

Export to PPT

RESULTS

DISCUSSION

The upper eyelid fat pads show unique behavior and differential volume changes with advancing age. The orbital septum and orbital fat relaxation aggravate sagging, leading to a fatigued tired appearance. The reduction of the nasal fat pad improves a tired eyelid appearance.[4]

The standard blepharoplasty procedure involves removing excess skin, preserving the central fat pad, and conservative removal of the nasal fat pad yields good results and high patient satisfaction. The open sky blepharoplasty approach involves traditional long horizontal upper eyelid incision to visualize the different fat compartments of the upper eyelid. This approach is not necessary to successfully and completely excise lone nasal fat pad bulge.[417,18]

Our small incision blepharoplasty procedure shows good cosmetic results and patients’ satisfaction in the treatment of either primary or secondary lone medial fat bulge cases.

Our study adopted a small incision blepharoplasty procedure which is similar to a stab incision technique of Barbarino et al.,[7] who concluded that the stab incision procedure for upper medial fat pad removal is a safe, effective, and time-efficient surgery yielding an aesthetically pleasing result. Both procedures adopt the same principle; minimally invasive techniques without skin excision to cover the slight concavity and minimize the skin closure tension should decrease the chance of medial canthus scarring. Small incision procedure follows the same pre-operative and post-operative precautions for a traditional blepharoplasty and intraoperative meticulous orbital fat removal and hemostasis.[1920]

Barbarino et al. applied a stab incision through the skin, muscle, and septum, whereas in our cohort, a skin incision followed by blunt dissection of the nasal orbicularis muscle toward the nasal pad of fat was done.

Traditional bilateral upper eyelid blepharoplasty with fat removal required approximately 1 h. Barbarino et al.[7] reported that the stab procedure for medial fat pad removal took approximately 5–10 min. The mean operative time in our cohort was 11.7 ± 1.9 min.

Our procedure belongs to tissue and orbital fat excision techniques which may lead to a high crease, large tarsal platform and a generally hollow upper sulcus. Nasal fat repositioning in upper blepharoplasty can be a useful adjunct to traditional surgery as a preventative measure for post-operative superior sulcus depression and hollowing, minimizing the volume-deficient results. Fat repositioning-related complications included ptosis, pseudo-Brown syndrome, and excessive swelling.[921,22]

The medial fat pad prolapse can be easily diagnosed by inspection only. Vaidya et al.[6] reported patients with malignant lymphoma mimicking the medial fat pad prolapse, highlighting the importance of rubbery and hard mass palpation for the diagnosis.

The limitations of this study include short follow-up interval and absence of the control group.

Although our nasal fat excision with small incision upper blepharoplasty and nasal fat repositioning upper blepharoplasty techniques has different indications, further studies, with longer follow-up, are needed to more critically assess eyelid volumetric changes.

CONCLUSION

Our cohort highlights the efficacy of small incision upper blepharoplasty in the treatment of upper eyelid solitary nasal pad fat bulge, providing a safe, short-timing, and effective option.