American Academy of Ophthalmology
Orbital septal tightening has not gained wide acceptance for lower eyelid fat herniation because of the theoretical risk of inducing eyelid retraction, which can occur when eyelid reconstruction involves inadvertent suturing of the orbital septum. Richard C. Sadove, MD, presents a technique of orbital septal plication to tighten the orbital septum, which in his hands produced good outcomes and no cases of retraction or eyelid malposition.1 Though this technique defies a common eyelid surgical teaching point of not suturing the septum to avoid potential complication of an immobile, retracted eyelid, the author reports 78 consecutive patients, with only one early case of entropion related to poor conjunctival incision placement and four cases of persistent lateral orbital fat pads after surgery. Six patients had temporary lower eyelid laxity, which improved without intervention over four weeks. Finally, three patients felt the Prolene suture.
The article presents five photo vignettes that showed excellent postoperative results. This technique may have a lower complication rate compared with other septum-tightening techniques, because the “weak” septum is over-sewn instead of being contracted by thermal energy. Given these results, it may be a worthwhile technique for addressing lower eyelid fat herniation.
The procedure begins with a transconjunctival incision, through which a preseptal dissection plane is carried down to the orbital rim. The surgeon should notice initially robust septum superiorly and then a thinner area in which the orbital fat is herniating. Using 5-0 Prolene suture, the inferior margin of the robust septum (the superior margin of the herniated fat) is sutured to the orbital rim periosteum in a running fashion, medially to laterally. This closes the thin septum over the herniating fat pad, reducing it to a more youthful position. The conjunctival incision is then closed with an absorbable suture.
Sadove notes that no lateral canthal suspension was needed in any patient, not even in those with moderate lid laxity. Skin excision or tightening can be performed as needed.