Addition of “Septal Window” to Lower Blepharoplasty for the Management of Fat of the Lower Eyelids

The most common reason for dissatisfaction and reoperation in lower blepharoplasty patients is persistent bulging of the lateral fat pad. This compartment contributes the most to fat herniation and yet is the most commonly overlooked. The addition of a septal window, a small opening of the septum on the most prominent part of the lateral fat compartment, helps with precise removal of lateral fat and allows for additional fat excision after septal reset without disrupting the arcuate expansion. Our lower blepharoplasty approach includes 1) a subcilliary incision; 2) aggressive lateral fat excision through a septal window; 3) central and medial fat excision, transposition, and septal reset; 4) canthopexy; 5) orbicularis oculi muscle suspension; and 6) no dissection of orbicularis oculi medially and no skin resected medially to avoid lid retraction. We performed a retrospective review of all lower blepharoplasty cases by a single surgeon over 10 years. Demographics and operative outcomes were queried. There were 224 cases, 90% were women with a mean age of 58.2 years. The most common postoperative occurrences were eyelid edema, malar edema, and chemosis, all of which were self-limiting. Two patients needed additional removal of lateral fat of their lower eyelids.Two patients had lid retraction, one of which had a previous facial nerve palsy and the other did not have a canthopexy and developed transient unilateral lid retraction that resolved with conservative treatment. Resumption of full activities and exercises at 6 weeks was typical. The septal window facilitates aggressive resection of the lateral fat pad and additional fat excision after septal reset to create a smooth lid-cheek junction. In our practice, it is a critical component of a successful lower blepharoplasty.