Correction of Adhesive Folded Upper Eyelid by Adhesiotomy and Restoration of Volume with Retro–Orbicularis Oculi Fat Flap and Fat Granule Injection

Sir: Incorrect double eyelid operation could result in complications, such as folds that are too high and sunken/adhesive eyelids.1–3 We applied adhesiotomy, relieved orbital fat, and restored the volume with the retro–orbicularis oculi fat flap to correct the deformation. For a severe condition, fat granules were injected. Good results were obtained. The incision of the upper eyelid was designed under the scar. If there was excessive skin on the upper eyelid, we could resect the skin between the former and the new double line, and the incision could be designed with the principle of attempting to cut the previous scar but avoiding excessive removal. Skin or scar was incised. Dissection was continued below the subcutaneous tissue. The orbicularis oculi muscle was debulked and pretarsal connective tissue and apertor oculi aponeurosis were exposed. Dissection was continued upward from the upper edges of the incision over the tarsal plates, below the orbital septum to completely relieve the adhesion until normal tissue was exposed. The orbital fat that protruded spontaneously should be released. Dissection should be continued laterally upward to expose the lateral extension of the retro–orbicularis oculi fat pad. The fat pad would form an upper pedicle fat flap after tissues are cut off along bilateral borders. The lateral portion of the pedicle should be appropriately and transversely cut to make it rotate medial downward with enough blood supply. Several 6-0 absorbable stitches were placed to fix the fat flap with released orbital fat and fix the lower edge of fat flat with the upper border of the supratarsal (Fig. 1). Damage of the levator aponeurosis should be avoided. Repair should be performed if there is damage. The fat flap should be descended as possible and fixed properly during the operation. Absorbable sutures are placed to fix the lower border of the incision and the outline of the double eyelid is determined. The skin is closed. Lipochondria (from any position of the body) is injected through spaces between stitches. Less than 1 ml for each side is generally suitable. Then, eyelids are flattened and redundant fat is crushed through the spaces between stitches. Gauze covering the eyelids should be taped with slight pressure to reduce errhysis, and removed in 12 to 24 hours. Immediately, normal eyelid movements should be started.Fig. 1.: Preoperatively, folds were located too high and the eyelids were sunken/adhesive.Forty-two cases were treated using this method over the past 2 years. In 10 of them, fat granule injection was added (Figs. 1 and 2). Results were satisfactory.Fig. 2.: Postoperatively, adhesive folded upper eyelids were corrected.For some patients, retro–orbicularis oculi fat was poor or had been removed during a previous operation, and fat granule injection should be performed. It is also different from other fat granule injections. Generally, more than 50 percent of injected fat granules will be absorbed gradually. However, with the existence of the retro–orbicularis oculi fat flap in the upper eyelids, the injected fat granules will not be absorbed within a period of time. Consequently, no matter how much will be absorbed eventually, the upper eyelid will not conglutinate as well. The goals of treatment will be achieved. With the application of fat granule injection, this method was suitable for different levels of deformity. In conclusion, this method is a simple and effective procedure for correction of sunken/adhesive upper eyelids. Jiaqi Wang, M.D. Yirong Wang Li Yu, M.D. Xin Guo Ling Zhang Plastic Surgical Hospital Chinese Academy of Medical Sciences Ba-Da-Chu Beijing, China

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