The periorbital area has been shown by experimental eye-tracking studies to be the preferred attention area when judging fatigue and age [3]. Consequently, treatments aimed at the rejuvenation of this area are highly effective in enhancing the appearance of an individual’s face. Lower eyelid bags are one of the degenerative diseases, which always seen in the elderly and even young patients. Prior studies have already reported in 1988 that degeneration of orbital septal fascia, relaxation of orbicularis oculi muscle and skin relaxation could be three predisposing factors to the increased rate of lower eyelid bags [4]. Although there are many methods of lower eyelid blepharoplasty at present, many operators still use the traditional conjunctival procedure to blepharoplasty, resulting in unnecessary palpebral margin incision scar in a small number of patients. and the incision is large and prone to postoperative hematoma, bruising, uneven skin of lower eyelid, diplopia, cyst and granuloma and other complications. And on this basis, we optimized the procedure. We choose a small entry site about 0.1 cm below the inferior tarsal plate by piercing the skin to the depth of subconjunctiva using a 23-gauge needle. This needle-hole can minimize the damage of blood vessels to reduce the probability of postoperative bruising and retroocular edema, maximize the integrity of the lower eyelid tissue, with rapid recovery, good aesthetics and no obvious postoperative adhesion, accompanied by the ideal treatment effect and satisfaction.
The current study is the first, to the authors’ knowledge, which investigated the long-term success and safety of an improved and refined minimally invasive surgical procedure for correction of lower eyelid bags. We are cautioned against overaggressive resection of orbital fat due to the hollow appearance noted in patients undergoing overaggressive lower eyelid blepharoplasty. However, there are always some ways to deal with the pre- or postoperative hollow of lacrimal sulcus, such as conservative resection and transposition of prolapsed orbital fat.
Although there are obviously a variety of causative pathophysiologic mechanisms associated with lower eyelid bags, there is no doubt that a slackening of orbicular muscle tension, lower lid horizontal laxity also secondary to a weakness of canthal support and the weakening of the orbital septum all favor a prolapse of orbital fat [1]. Goldberg also highlight how the presence of bulging orbital fat tissue is the important cause of this condition for a high percentage of patients. Due to the poor elasticity of the skin and the tension of the orbicularis oculi muscle in the elderly, the lack of supporting strength of the orbital septum can easily lead to the herniation of ocular fat [5]. A total of 167 patients with lower eyelid bags were divided into different age groups by CT and the loss of orbital fat was evaluated. The results demonstrated that the loss of orbital fat increased gradually with age [6]. An article showed that the orbital fat of lower eyelid protruded out and the periocular space expanded with the increase of age, leading to the formation of aging state [7]. Another article also considered that with the increase of age, the orbicularis oculi muscle became thinner and the orbital fat protruded out, leading to the formation of lower eyelid bags [8]. These studies suggested a potential role of orbital fat prolapse in the pathophysiology of eyelid bags. This is perceived as a significant problem by patients seeking rejuvenation or aesthetic enhancement of the periocular area and fat transfer is a good surgical option [9-12]. Based on these observations, our clinical cases further confirmed that more than eighty percent of patients with lower eyelid bags have different degree of lacrimal depression, and more than twenty patients would be more obvious after the removal of eyelid bags (Figs.7); Therefore the fat in the orbital septum cannot be removed directly to achieve the purpose of removing the lower eyelid bags in the actual operation, and the filler of autologous fat is necessary.
From our clinical practice, we explored that the pure fat extracted from the lower eyelid bags has a good survival rate by centrifuge at 3000 rpm, 15min. After that, fat is layered into the predetermined depressions of lacrimal sulcus (always in proportion of 80% on the periosteum and 20% under the skin). The follow-up time was 24 hours to 3 months after surgery. The improvement was significantly greater in the observation group, especially after 15 days (Figure 1-3). Immediately after, after 24 hours, 3 and 5 days, 15 days and 3 months by phone or WeChat routine postoperative clinical assessment, evaluation results show that, compared with control group, the observation group China intelligence and clinical improvement is significantly higher than the control group, after 5 days has significant statistical differences between two groups (P < 0.05).The clinical efficiency of the two groups was compared, and it was found that the clinical efficiency of the observation group was significantly higher than that of the control group (P < 0.05).We compared the complications between the two groups and found that there was a significant difference between the two groups (P<0.05).The satisfaction of the two groups was analyzed after follow-up, and the results showed that the satisfaction of the two groups at different follow-up times was compared: 1 day after the operation, the satisfaction of the observation group was 52.5%, and that of the control group was 32.5%, with no statistically significant difference (P > 0.05). The satisfaction of the observation group was higher than that of the control group at 3d and 1 month after surgery, and the difference was statistically significant (P < 0.05).
Based on these observations, it has become the authors’ practice to assess patients with the amount of orbital fat preoperatively for concomitant depression of lacrimal sulcus and to perform resection of prolapsed orbital fat at the time of eyelid bag removal in an attempt to repairing each layer of relaxed eyelid tissue and levelled eyelid buccal groove.
The results of this study showed that in the recovery time of lower eyelid bags skin, satisfaction and the incidence of postoperative complications in the observation group were better than those in the control group, which fully demonstrated the important role of ultra-micro transconjunctival lower eyelid bags removal combined with orbital fat transfer in lower eyelid blepharoplasty. In addition to cardio-cerebral vascular sclerosis, many middle-aged and elderly patients with elevated blood lipids and blood viscosity rely on drugs for long-term treatment, especially drugs for promoting blood circulation and removing blood stasis. The above situations may lead to more blood oozing and bleeding during the operation. Therefore, medical staff must comprehensively consider the actual situation of patients, take preventive measures for various adverse reactions, reduce accidents, and pay attention to avoid cardio-cerebrovascular and other complications during the operation.
The authors have so far treated more than 1000 patients with lower eyelid bags using the described above ultra-micro transconjunctival lower eyelid bags removal combined with orbital fat transfer procedure in ten years. With a low overall complication rate, all the adverse advents that they encountered were mild and temporary. No cases of diplopia, strabismus, blindness or other serious complications were observed in our department. Our analysis of the demographics of cases information revealed that over sixty percent patients were women and that the average age (43 years) was similar to the previously reported case series. This data reflects the high incidence of lower eyelid bags and the growing awareness of this defect among the middle-aged women population.
This study is not without limitations, including its retrospective nature. Furthermore, only patients with of 3 months of clinical follow-up were included in this study. While phone interviews were used to further assess long-term follow-up, the authors acknowledge that this may underestimate the rate of recurrence.