Fat Repositioning Blepharoplasty

This video will review fat repositioning blepharoplasty. A standard transconjunctival incision is made about four millimeters inferior to the inferior tarsal border across the entire horizontal extent of the lower eyelid. This is a very important part and demonstrates blunt dissection to the acus Ali. This is typically done with cotton tipped elevators, and this is performed through the fatty tissues in order to expose the acus Ali. An incision is then made with the monopolar cautery instrument about one to two millimeters inferior to the acus Ali across the entire horizontal extent of the orbital rim. Then the pockets are created. This can be performed with a periosteal elevator, but here I use a cautery instrument in order to create subperiosteal pockets deep underneath the entire hollows, across the entire eyelid. This shows the extent of the subperiosteal dissection well beneath the hollows. Here we expose the inferior oblique muscle and then create the medial pedicle. The medial pedicle is created by basically making circles around the pedicle, and that will create a longer and longer pedicle. Here you can see the inferior oblique muscle, which is avoided but not actually dissected. I then make a T-shaped medial pedicle, and this is the lateral extent of that T-shaped pedicle, and here is the medial component of that pedicle. And ultimately this pedicle will be in the shape of the letter T in order to fill the entire medial aspect of the hollow. Here you can see the pedicle. It still has a little bit of tension, so we will do some final trimming in order to create the pedicle so that it has no tension whatsoever once it is displayed into the pocket, and here you can see it is under no tension at all. Then I create the central and lateral pedicles in a similar fashion. Again, the pedicle is corded out by in sizing along its edges in order to create more length. The central pedicle is also created into a Ts shape in order to fill the central hollows. When we create a LA royal pedicle, it is also created into a similar shape. And here you can see when the pedicles are displayed, they're under no tension whatsoever, and in this way, they can fill the volume of the hollows without any suture fixation. And here I'm using a 0.5 millimeter forcep in order to place the fat into the proper locations. And sometimes I even use the backside, which is smoother in order to properly place the fat. This requires no suture fixation as long as there is a very deep pocket with long pedicles. The lid retractors are then reset, and this completes fat repositioning blepharoplasty. Thank you.