Dermatochalasis Treatment: Upper Blepharoplasty with Orbicularis and Fat Resection For Durable Results
- Admin
- 1 hour ago
- 5 min read
Upper blepharoplasty is the gold-standard procedure for the treatment of dermatochalasis. While skin-only excision remains the most common technique, some surgeons perform additional removal of the orbicularis oculi muscle and preaponeurotic or nasal fat pads to address excess tissue and improve eyelid contour.
The study by Viscardi & Giordano (2025) aimed to compare outcomes between skin-only upper blepharoplasty and combined excision of skin, orbicularis, and fat pads in a reconstructive setting. A total of 386 patients treated at Turku University Hospital from January 2015 to June 2017 were included.
Combined Excision of Skin, Orbicularis, and Fat pads Technique
The combined blepharoplasty technique involves:
Skin excision along the upper-lid crease.
Orbicularis oculi muscle removal, typically a central strip, while preserving lateral continuity.
Resection of preaponeurotic and/or nasal fat pads, performed conservatively to avoid overcorrection.
The procedure is performed under local anesthesia, and wounds are closed with absorbable or non-absorbable sutures. The extent of tissue removal is determined by the surgeon based on preoperative assessment of lid bulk and fat prolapse.
Comparison with Skin-Only Blepharoplasty
Skin-only blepharoplasty removes redundant skin while preserving the orbicularis oculi muscle and fat pads. This approach minimizes dissection, reduces immediate postoperative bruising, and shortens recovery time.
Combined orbicularis and fat resection differs in three key ways:
Deeper tissue removal: Excises the orbicularis oculi muscle and herniated preaponeurotic or nasal fat, addressing heavy lids and lateral hooding.
Mechanical debulking: Direct removal of fat reduces anterior lamellar bulk and enhances tarsal platform exposure, improving crease definition and upper-lid contour.
Functional modification: Partial orbicularis resection can decrease muscular weight and tone, producing mild upper-brow elevation by weakening the depressor effect. Careful preservation is essential, as excessive muscle removal may compromise tear pumping and exacerbate dry-eye symptoms.
Mechanism of benefit: By addressing both skin redundancy and subcutaneous bulk (muscle and fat), combined excision provides a more durable and aesthetically refined contour. This dual approach likely explains the higher patient satisfaction observed in the study.
The study reports that combined excision does not increase major complication rates compared to skin-only blepharoplasty, though it is associated with modestly longer operative times and recovery periods. Patients consistently reported higher satisfaction with outcomes following combined excision.
Step-by-Step Procedure
Preoperative planning
Assess MRD-1, brow position, lateral hooding, fat herniation and lacrimal gland position.
Document dry-eye symptoms and tear film tests if indicated. Counsel re: ecchymosis, downtime and small increased risk of transient dry eye.
Marking
Mark the upper-lid skin crease and the redundant skin to be excised with patient upright; allow for expected postoperative swelling and avoid over-resection.
Plan central orbicularis strip length (limited to central 1/3–2/3 depending on need).
Anesthesia
Local infiltration with lidocaine ± epinephrine. Consider sedation as required.
Incision and skin excision
Full-thickness skin incision along marked line; remove the predetermined skin strip.
Orbicularis handling
Elevate skin-muscle flap to expose orbicularis. Resect a conservative strip of orbicularis (typically central segment) tailored to avoid lateral continuity loss. Hemostasis with bipolar cautery—gentle to minimize thermal injury.
Fat pad evaluation and selective resection
Identify preaponeurotic and nasal fat compartments. Excise only prolapsed fat in a conservative, minimal fashion — preserve volume where ageing hollowing is a risk.
Assess lacrimal gland and adjacent structures
If lacrimal gland prolapse or significant fat herniation is present, address appropriately (reposition or partial excision per surgeon preference).
Closure
Reapproximate subcutaneous tissues as needed; skin closure with fine interrupted or running sutures. Choice of absorbable vs non-absorbable per surgeon’s routine (study used both).
Postoperative care
Cold compresses first 48 hours, head elevation, avoid heavy exertion for 7–14 days. Monitor for ecchymosis and wound issues. Screen for dry-eye symptoms; lubricants if indicated.
Technical pearls
Be conservative with orbicularis resection to preserve blink/tear pump function.
Maintain meticulous hemostasis — the study associated more extensive procedures with higher ecchymosis rates.
Symmetry checks before final closure are crucial.
Image: Preoperative view of a 55-year-old female patient (A, B), and 2 months after skin, orbicularis oculi muscle and preaponeurotic, or nasal fat pad removal blepharoplasty (C, D)
Outcomes Reported in the Study
Sample: 51 combined-resection cases vs. 335 skin-only cases
The study reports that combined excision is safe, with no increase in serious complications compared to skin-only excision. Ecchymosis was more frequent in the combined group, reflecting the deeper dissection, but remained a minor complication. Patient satisfaction was significantly higher following combined excision.
Key Takeaways:
Combined excision provides superior patient satisfaction and improved lid contour.
Longer operative time and increased ecchymosis are predictable but manageable.
Careful patient selection is essential, particularly for those with thin lids or dry-eye risk.
Both techniques demonstrate very low risk of major complications, confirming safety in trained hands.
Indications and Contraindications
Recommended for:
Patients with visible preaponeurotic or nasal fat prolapse
Those with heavy or thick upper lids seeking sharper crease definition
Individuals with normal tear film and no pre-existing ocular surface disease
Revision cases where persistent heaviness or fat herniation remains after prior surgery
Avoid or modify in:
Elderly or volume-deficient patients (risk of hollowing)
Patients with moderate to severe dry eye or incomplete blink
Individuals requiring minimal downtime
Cases without fat prolapse, where skin-only excision provides adequate correction
The authors note that patient selection is critical to optimizing outcomes, particularly when deeper tissue resection is considered.
Conclusion
This study demonstrates that upper blepharoplasty with combined skin, orbicularis, and fat pad excision is a safe and effective procedure in a reconstructive setting. Although it requires slightly longer operative time and recovery, it results in higher patient satisfaction and superior upper-lid contouring compared to skin-only excision.
Both techniques show low complication rates, and careful preoperative assessment is essential to determine which method best addresses functional and aesthetic goals. These findings provide evidence to guide surgeons in selecting the appropriate blepharoplasty approach based on eyelid anatomy and patient expectations.
Reference:
Viscardi, J.A., Giordano, S. Upper Blepharoplasty for Dermatochalasis With or Without Resection of the Orbicularis Oculi Muscle, Preaponeurotic and Nasal Fat Pads: A Comparative Study. Aesth Plast Surg 49, 1689–1696 (2025). https://doi.org/10.1007/s00266-025-04657-7
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