The Suborbicularis Oculi Fat Pads: An Anatomic and Clinical Study Adrien E. Aiache, M.D., and Oscar H. Ramirez, M.D. Beverly Hills, Calif, and Baltimore, Ma After the concept of retro-orbicularis oculi fathad been developed, the authors focused in particular on the ana- tomic entity named suborbiculars ocul fat, consisting of the supraperiosteal submuscular fat excess situated over the zygoma. Its correction is demonstrated as well as its anatomic description and the fact that itcontributes to the aesthetic deformity of the lower lids, just as the retro-orbicularis cul fat contributes to the aesthetic deformity of the upper lids. ‘The purpose of this paper is to study the upper and lower orbital areas, where a new approach is advocated for their correction in solo or in combination with a blepha- roplasty. (Plast. Reconstr. Surg. 95: 37, 1995.) The surgical treatment of the aging face has gradually evolved from simple skin undermin- ing and tightening to a combination of skin excision and release of “retaining ligaments” to the skeleton, SMAS repositioning, and fat sculp- turing“! The liposuction techniques have alerted surgeons to the variety of fat deposits that contribute to deform the aging face. Among the most notorious fatty bulges are the malar bags, the jowls, the melolabial mounds, and Bichat’s fat pads. Each of these areas rep- resents its own particular anatomic and surgical problems. There are diverse opinions concern- ing the aesthetic deformity presented by these fat deposits; some think that the fat pads en- large in size, while others believe that they only represent a “doubling” effect due to the plica tion of redundant skin over two layers of fat becoming opposed to each other. A similar phe- nomenon exists over the skin of the body where a combination of skin relaxation is associated with a cascading effect of the fatty skin such as seen in the “love handles,” the back and the torso, the abdomen, the lower thighs, and to a Received for publication March 18, 1993; revised January 13, 1994, a7 different degree and shape the “old age cellu- lite.” The surgical correction of these areas con- sists of fat suction with or without skin excision. ‘The anatomy of the orbital area is well-doc- umented, but it does not describe the perior- bital fat pads and, especially for our concern, the inferior orbital fat pads or suborbicularis oculi fat. We now feel that they are worth de- scribing because of their aesthetic signifi. cance? A New Anatomic Concer In the malar bag area, where an excess of fat develops at a deeper plane under the skin— orbicularis muscle complex and just over the periosteum, creating the “jowls of the eyes,” the problem is significant. A blepharoplasty cor- rects the orbicularis redundancy and the skin redundancy, in addition to removing or tight- ening the intraorbital fat compartments. How- ever, the area situated below the eyelid skin, called malar bags, is not corrected and often ‘becomes more apparent in sharp contrast to the lower lid concavity sometimes created by fat pad extirpation. Liposuction has been moderately successful in our hands, but we prefer a direct excision, this latter being more precise, exten- sive, and controlled. In other cases, the fat pads will simply be raised and pulled sideways. ‘The fatty deposits are different from the cres- cent type of muscle excess mentioned by Hamra"® and are not really corrected by his technique of orbicularis muscle crescent exci- sion and suspension, which treats only the su- perficial level of the skin-fat-muscle excess and neglects the deep fat situated below the orbic- ularis muscle and above the periosteum.38 Alternatively to the excision, these malar fat pads can be repositioned to a higher level on the malar projection by the subperiosteal ap- proach."™? The malar bags (clinical term) in our opinion are the result of ptosis of the malar fat pads (anatomic term) that we would prefer to call suborbicularis oculi fat. The suborbicularis oculi fat represents the position of the fat pad in relation to the orbic- ularis oculi muscle and is analogous to the retro- orbicularis oculi fat designated to the fat pad located in the brow area.!® Both may be the same type of anatomic aesthetic deformity and just located in different areas of the periorbita. The infrabrow fat or retro-orbicularis oculi fat bulge represents a similar problem. It con- sists of a combination of supraorbital fat depos- its associated with a doubling effect of the brow secondary to forehead skin relaxation and pto- sis, It has been described by Charpy,"* Lemke and Stasior,” McCord and Doxanas,'® and Ow- sley,!” who treated it as an integral part of the upper lid blepharoplasty. The malar bags are definitely a complex phe- nomenon. We must include in their cause mul- tiple factors that are often difficult to differen- tiate. Inferior palpebral edema, subcutaneous fat excess, skin relaxation such as the festoons, attenuation of the orbicularis muscle with her- PLASTIC AND RECONSTRUCTIVE SURGERY, January 1995 niation of the suborbicularis oculi fat at the malar level can all cause malar bags. The diagnosis of the causative factors is in order. Patients with chronic edema have skin thickening that does not change with head po- sition, as opposed to the inferior herniation of the suborbicularis oculi fat, which gets worse with forward tilting of the head. In other cases, the difference between the suborbicularis oculi fat and the superficial sub- cutaneous fat can be discerned when the pa- tient closes the eyes forcefully, since this ma- neuver would tighten the skin and remove the fat pad protrusion, while it would really not correct the actual suborbicularis oculi fat. SURGICAL TECHNIQUE Upper Lid Blepharoplasty and Retro-Orbicularis Oculi Fat Excision We approach the correction of the subor- bicularis oculi fat as well as the retro-orbicularis oculi fat at the time of the fourlid blepharo- plasty with or without facial rhytidectomy. Oc- casionally, we might treat them individually. Af ter a strip of skin and orbicularis muscle are excised, the superior orbital fat pads are ex- truded and excised as needed. This is done after the septum orbitale is opened from side to side. A double hook elevates the skin-muscle flap Ric, 1, Anatomic dissection of a human head showing the presence of intraorbital fat below the rim of the orbit and under the orbicularis muscle.Vol. 95, No. 1 / SUBORBICULARIS OCULI FAT PADS Zygomaticus Yemajor 39 ‘rep arrows Posing the dntceocbitel middle fat pat Shoving the SOF, bear the rin ypmatiou major muscle is looped wy & nylon stitch Elevated orbital septum ‘ocult retracted Fic. 2. Schematic drawing of Figure 1, showing the location and extension of the intraorbital fat pads, Ric. 3. Surgical dissection of the intraorbital fat pads; dis- section from the orbicularis skin flap above and the perios teum below. The fat pad is grasped and dissected, from the orbital ridge. The skin-muscle flap is elevated and then dissected free from the fat pads (retro-orbicularis oculi fat) until the hor- izontally running supraorbital vein is visualized. The fat pad is excised with the periosteum be- low it, sparing the exit of the supraorbital nerve. After hemostasis, the skin is simply closed over the defect with or without “anchoring” sutures to the septum orbitale. Lower Lid Blepharoplasty and Suborbicularis Oculi Fat Excision Askin incision is made 1 to 2 mm below the lower lid ciliary border; the incision curves lat- erally downward, following the line of a crow's foot. The skin-muscle flap is developed and el- evated from the septum orbitale down to the infraorbital rim. After skin retraction, the cen- tral, medial, and lateral orbital fat pads are ex- truded and excised. The septum orbitale can be then neglected or plicated and reinforced as described by De La Plaza.* A blunt dissection progresses inferiorly below the obicularis mus- cle and over the fat pad situated below the or- bital rim border. The fat pad is then exposed in its entirety, taking into account the actual area that has been marked to be excised. It is then grasped and dissected from the periosteum be- low it, sparing the infraorbital nerve. The bulk of the suborbicularis oculi fat is located below the lateral half of the infraorbital rim. The fat pad is excised in the precise area marked before surgery, which has been checked in the stand- ing position, evaluating aesthetically the area toPLASTIC AND RECONSTRUCTIVE SURGERY, January 1995 Ric. 4. (Above, lft) A 66-year-old woman with blepharochalasis and suborbicularis fat deposits. (Above, right) Postoperative result after upper and lower blepharoplasty with suborbicularis oculi fat excision. (Below, lef) Profile view. (Belew, right) Postoperative profile view. be improved on. The skin is then draped, and the wound is closed. To avoid ectropion, an absorbable suture can be used to suspend the orbicularis muscle to the periosteum at a higher level below the orbital rim, The skin-muscle flap from the lower lid is resected in standard fash- ion. The usual skin closure is performed, and no bandages are necessary. Discussion The excesses or lack of fatiin the diverse areas of the aging face have been the subject of pre- vious studies. If one recognizes the locations of “skin-retaining ligaments”? and their action in holding the drooping facial skin in specific ar- eas, one understands that the lower lid and upper cheek skin excess associated with under- lying fat contributes to creating the presence of malar bags or “jowls of the eyes.” In addition, there is often some fat excess that needs to be addressed. It is known in severe cases of “fes- toons,” which represent the same phenomenon without fat excess, that direct excision of that skin will suffice. If fat is present to some extent, ithas then to be excised with the skin. However, the resulting scar is not very desirable except in the very old individual. It is easier to excise the fat by elevating the skin-muscle flap during blepharoplasty, especially if that fat is really ex- cessive In contrast, in the technique of subperiosteal face lifting, there is repositioning of the malar fat pads without resection. Some plicate the orbicularis muscle, thus covering and draping the malar bags and improving the appearance of the bulge by an actual camouflaging technique. Although in principle it seems preferable to conserve fat in older faces where it is often missing, giving a gaunt appearance, it is, nev- ertheless, necessary to “sculpt” itwhere the dou- bling effect of the skin makes this fat unaes- thetic. The jowls are treated nowadays by suction in addition to face lifting. The melola- bial mounds are improved similarly by a tech- nique described by Millard et al.,!* Ellenbogen et al,,!? and Mendelson.” Judicious fat removal will only improve the suirface appearance of the skin if it is done in association with other procedures such as skinVol. 95, No. 1 / SUBORBICULARIS OCULI FAT PADS Ri. 5. (Above, left) A55-year-old woman after a blepharoplasty and intraorbital fat deposits. The blepharoplasty has apparently accentuated the earance of the suborbicularis oculi fat deposits situated below. (Above, right) Postoperative result after suborbicularis oculi fat excision. (Below, lef) Profile view. (Beoa, righ) Postoperative profile view Fe. 6. (L¢ft) A 43year-old man with blepharochalasis and suborbicularis oculi fat. (Right) Postoperative oblique view of the same patient, Note that in this case the suborbicularis oculi fat was not resected but rather was elevated superiorly and laterally. tightening and retaining ligament releasing. In our experience, no radical suborbicularis oculi fat excision is performed, and no postoperative depressions have been observed. To the con- trary, it has been at times too conservative, with only a moderate improvement. In some cases, no excision is performed if it is felt that the lateral and superior elevation of the retro-or- bicularis oculi fat will be aesthetically more ad- vantageous than its excision, In conclusion, we describe an anatomic entity present in the upper and lower orbital areas that is intimately associated with the upper and lower lids and their treatment during upper42 and lower lid blepharoplasty. Particularly, we emphasize the presence of the suborbicularis oculi fat and its surgical correction. Adrien E. Aiache, M.D. 9884 Little Santa Monica Boulevard Suite 102 Beverly Hills, Calif. 90212 REFERENCES 1, Castanares,S. Blepharoplasty for herniated intraorbital fat: Anatomical basis for a new approach. Plast. Recon str, Surg. 8: 46, 1951, 2 Gonzalez-Ulloa, M., and Stevens, E, The treatment of palpebral bags. Plas. Reconstr. Surg. 27: 881, 1961. 8. Stephenson, K. L. The history of blepharoplasty to cor- rectblepharochalasis, Aesthetic Plast. 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