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LOWER BLEFAROPLASTY WITH FAT PADS REPOSITIONING: CASES SERIES

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LOWER BLEFAROPLASTY WITH FAT PADS REPOSITIONING : CASES SERIES

•INTRODUCTION: The periorbital area plays an important role in facial expression, but it unfortunately demonstrates some of the early signs of aging, and properly performed blepharoplasty is one of the most rejuvenating procedures in facial surgery. Techniques evolved and procedures were described to improve the aesthetic appearance of the eyelids and decrease the rate of complications. Some authors argue that the removal of herniated periorbital fat can lead to skeletonization of the orbital border and worsen the signs of aging of the eyelid. In view of this fact, fat repositioning techniques gained importance in the aesthetic treatment of the periorbital region, aiming to increase the volume of the orbital rim, as well as filling the nasojugal groove ( tear through).
•PURPOSE: To illustrate the lower blepharoplasty with fat pads repositioning, as a consolidated surgical modality and effective in the aesthetic treatment of the lower eyelids.
•MATERIALS AND METHODS: This is a descriptive observational study, based on review of charts and photographic documentation, of patients submitted to inferior blepharoplasty with repositioning of fat pads, in the Hospital das Forças Armadas and in the private practice of the main author, between January 01, 2017 to December 31, 2018 totaling 27 cases.
•SURGICAL TECHNIQUE

  The procedures were performed in a hospital setting under local anesthesia. Infiltration: lidocaine solution 2% and epinephrine 1: 100,000, initiated in the topography of the infraorbital nerve, followed by infiltration of the entire lower eyelid and lateral portion of the superior orbital rim. the procedure, the anesthetic block was reinforced at the moment of manipulation of the fat pads.

  Incision: subciliary was with myocutaneous flap and dissection in the avascular plane anterior to the septum orbital border. Release of the orbicularis oculi origin from the orbital border superficially to the periosteum and up to 5 mm to release the tear through.

  Fat pads dissections : medial and central were dissected leaving a pedicle and then transposed to the deformity level and sutured into the periosteum with 5-0 Nylon. Resection of the lateral was chosen, since it is slightly more fixed in relation to the others, which implies a more limited transposition.

  After completing the first stage (treatment of fat pads and nasojugal sulcus), the procedures of canthal support were performed. Canthopexy was done as follows: through the superior blepharoplasty incision, or through a small super-lateral incision, a 5-0 nylon cord was passed, transferring the superficial lateral canthal ligament and a lateral segment of the inferior tarsal plaque. The wire was returned to the entry point at the super-lateral orbital rim through a needle, suturing it into the periosteum at pupil level. It is very important that the traction to raise the lateral corner lies flat below the orbicularis muscle and follows the curvature of the lower eyelid, avoiding the separation of the eyelid border of the eyeball. About 1 to 2 millimeters of the lower limb should be covered.

  Finally, after the skin excision was delimited, the skin was resected exclusively, preserving the muscular portion of the myocutaneous flap, followed by suturing of this orbicularis muscle strap to the periosteum of the orbital rim in a slightly super-lateral vector. The skin suture was performed with 4-0 nylon, intradermal suture.

  In the postoperative were prescribed antibiotic, anti-inflammatory and analgesic, as well as lubricating eye drops and ophthalmic ointment. Patients received resting guidelines, use of sunglasses for eye protection against trauma and radiation, and use of cold compresses for 72 hours. The stitches were removed between 5-7 days, at which point local lymphatic drainage began. Weekly returns were established in the first month, and a return to 90 and 120 days.

•RESULTS: Of the total number of patients (27 cases), 23 were female and 4 were male. All with ages between 50 and 75 years. The degree of satisfaction was excellent in 22.22%, very good in 44.45%, good in 25.93%, poor in 7.4%, according to the interview with each patient. No postoperative haemorrhage was observed. As complications, recurrence / persistence of fat pads was observed in 1 patient (3.7%), prolonged edema greater than 30 days in 2 patients (7.4%), scleral show in 2 patients (7.4%), chemosis in 1 patient (3.7%) and ectropion in 1 patient (3.7%). Cicatricial retraction occurred in the cantal area in 1 patient (3.7%), where the scarring of the lower and upper blepharoplasty was closer.
•CONCLUSION:. Blepharoplasty is an important surgery for facial rejuvenation, which brings aesthetic benefits when well performed. The different access routes and complementary procedures tend to guarantee a high degree of patient satisfaction. Fat pads repositioning  aims to ensure a better filling of the nasojugal groove (tear through) and lower risk of skeletonization of the inferior orbital border. The technique does not bring significant increase of the surgical time, brings satisfactory results.  
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