Lower lid bulge is known as a part of the aging process. Lower lid bulge can be produced by one of the 2 major mechanisms or a combination of the mechanisms: herniated excessive intraorbital fat and weakening of supporting components of the lower eyelid, including skin, orbicularis oculi muscle, orbital septum, capsulopalpebral fascia, Lockwood ligament, and lateral canthus.1–4 Lee et al5 reported that total orbital fat (OF) volume and fat volume of anterior to the inferior orbital rim (IORF) increased significantly after 40s in both male and female groups compared with that of the 20s. The ratio of IORF to OF showed significant differences after 60s compared with that of 20s.
Lower eyelid bulge is a common finding in the elderly patients. We observed lower eyelid bulge in the young age patients. They, however, do not show the typical characteristics of the age-related lower eyelid bulge, such as flaccid and thinning of the orbital septum. So we reported these findings and named these findings as “lower eyelid orbital fat hyperplasia”.
MATERIALS AND METHODS
Because this was a retrospective medical record review, no institutional review board approval was necessary. Three young patients visited our hospital complaining of a lower eyelid bulge. Excess fat tissue was observed in orbital computed tomography (CT). There was no mass lesion matched with the area of lower eyelid bulge. These patients underwent removal of excess orbital fat in lower eyelid through the conjunctival incision.
We draw the margin of eyelid bulging area for determining the amount of fat removal with the gentian blue. After the local anesthesia by 2% lidocaine mixed with 1:100,000 epinephrine, we opened the conjunctiva and capsulopalpebral fascia along the horizontal length of the eyelid. We dissected between the orbital septum and orbicularis oculi muscle inferiorly. There was no real herniation of the fat pad through the septum. Continuity of the septum was present and thinning or distention of the orbital septum was not observed in our patients. We opened the orbital septum with Bovie cautery and removed the excess fat. We checked the similarity between bilateral lower eyelid contour and conjunctiva is sutured.
RESULTS (REPORT OF PATIENTS)
An otherwise healthy 14-year-old girl visited our hospital complaining of lower eyelid mass in the left side. The patient mentioned that left lower eyelid mass was formed since she was a schoolchild. She mentioned that there was no size change. The patient's best-corrected visual acuity was 20/20 in the right eye and finger count in the left eye because of anisometric amblyopia. Other ophthalmic examination, such as pupillary reflex, anterior segment, fundus examination, and extraocular muscle movement showed no significant abnormalities. On the physical examination, grossly lower eyelid bulging was observed, but there was no palpable mass in the left side. Infection sign such as tenderness or redness was not present (Fig. 1A). Orbital CT showed no mass-like lesion at the left lower eyelid area. The area matched with lower eyelid bulging were slightly more protruded than right lower eyelid, and the density of the area was similar to density of the fat (Fig. 1B). We planned surgery for the identification of lower eyelid bulge and removal of lower eyelid bulge. There, however, was no mass lesion and excess fat observed intraoperatively. We believed that septal plication suture is good rather than removing the excess fat to decrease the asymmetric lid contour, because of the young age. After operation, lower eyelid bulging slightly decreased but the difference between the both lower lid was existed (Fig. 1C). Three years later, we planned excess fat removal through the conjunctival incision. Removed lateral fat showed a more rigid contour and a more pale-yellowish color than normal orbital fat, so we sent it to a pathologist for pathologic examination (Fig. 1E). Biopsy result shows adipose tissue with some loose fibrous tissue. After operation, bulging of eyelid disappeared and bilateral lower eyelid contour showed symmetry. After 1month, bulging of eyelid was disappeared and bilateral eyelid contour showed symmetry (Fig. 1D).
A 29-year-old man with no significant medical history presented with right lower eyelid swelling from birth. He mentioned that the right lower eyelid swelling is caused by forceps delivery trauma. He has double eyelid surgery at middle school student. The patient's best-corrected visual acuity was 20/25 in right eye and 20/20 in left eye because of anisometropic amblyopia. Other ophthalmic examination, such as pupillary reflex, anterior segment, fundus examination, and extraocular muscle movement showed no significant abnormalities. Physical examination revealed right lower eyelid bulging, but there was no palpable mass lesion. Infection sign such as tenderness or redness was not present (Fig. 2A). Orbital CT showed prominency of the fat at the lower eyelid (Fig. 2B). We planned surgery for the fat removal through the conjunctival incision. After 1month, bulging of eyelid was disappeared and bilateral eyelid contour showed symmetry (Fig. 2C).
A 42-year-old man with no significant medical history presented with right lower eyelid swelling for 3 years. He mentioned that right lower eyelid swelling was increased for 2 years. The patient's best-corrected visual acuity was 20/20 in the both eyes. Other ophthalmic examination, such as pupillary reflex, anterior segment, fundus examination, and extraocular muscle movement showed no significant abnormalities. Physical examination revealed right lower eyelid bulging, but there was no palpable mass lesion. Infection sign such as tenderness or redness was not existed (Fig. 3A). Orbital CT showed prominency of the fat at the lower eyelid (Fig. 3B). We planned surgery for the fat removal through the conjunctival incision. After 1-month operation, bulging of eyelid was disappeared and bilateral eyelid contour showed symmetry (Fig. 3C).
We have presented 3 patients with lower eyelid bulge. They are characterized as having lower eyelid bulge that is commonly seen in patients with age-related lower eyelid bulge. Orbital CT examination showed excess fatty tissue, which matched the area of lower eyelid bulge, and no mass-like lesion.
There are several ways for management of lower eyelid bulge in patient with age-related lower eyelid bulge.
The standard technique is excision of the excess fat via transconjunctival approach or transcutaneous approach.6,7 Disadvantage of this technique is the difficulty of estimating the correct amount of the fat to remove. Undercorrection or overcorrection can occur. Undercorrection can result in recurrence and overcorrection can produce a sunken eyelid appearance, which may paradoxically exaggerate the aged look.8
Some authors have tried to reverse the mechanism of the aging by repositioning of the orbital fat into the orbital cavity by reinforcing supporting structures.9,10 Repositioning techniques aim at relocating the fat bag in its normal youthful position in the orbit through measures to increase support and reinforce supportive structures. Examples of these techniques are tightening and supraplacement of the inferior orbicularis muscle arc,11 repairing of dehiscent orbital septum to the capsulopalpebral fascia,12 suturing the upper septum with the fold of capsulopalpebral fascia down to the arcus marginalis,8 transverse placation of the attenuated orbital septa,9 and approximating capsulopalpebral fascia to the orbital rim periosteum with a suture.3,13,14
We plan the management of lower eyelid bulge like age-related lower eyelid bulge, because there is excess fat tissue without other abnormalities in the orbital CT examination. In the first case, patient's age is too young to remove the orbital fat, so we do the septal plication for the cosmetic reason at the first time. After 3 years, we decide to remove the excess fat through the conjunctival incision. Because there is no change of lower eyelid bulge, we consider that patient's growth is ended. In the second and third case, we remove the excess fat through conjunctival incision. Intraoperative findings of our patients, however, are different to age-related lower eyelid bulge. There is no real herniation of the fat pad through the orbital septum. Orbital septum continuity is present and thinning or distention of the orbital septum is not observed intraoperatively. Another different thing compared to age-related lower eyelid bulge is the patients’ age. Patients’ age is too young to consider that cause of lower eyelid bulge is aging changes. We send the obtained fat tissue to the pathologist for pathologic examination. The pathologist mentioned that there are no specific findings to fat tissue.
According to several studies reporting a lipoma, lipoma is defined as a distinctive mass on clinical, imaging, and histologic examination.15 Lipoma consists of circumscribed collection of mature fat behaving as an independent mass rather than infiltrate surrounding soft tissues. Histologically, lipoma is composed of mature adipose tissue, which is lobulated and surrounded by a fine capsule. In our patients, mass lesion is not observed in clinical, imaging study, and intraoperative finding. In patient I, intraoperatively observed fat tissue is differed to normal fat tissue, so we conduct pathologic examination. Result of pathologic examination, however, is normal fat tissue. In patient II and III, intraoperatively observed fat looks same to the normal fat, so we do not conduct the pathologic examination. Although the 2 patients do not conduct pathologic examination, mass or capsule is not founded intraoperatively and normal fat lobule is observed when opened the septum. So, we can exclude the lipoma by clinical, imaging, and intraoperative findings.
Taken together with the above things, findings of our patients are different from the age-related eyelid bulge. So we propose the concept of “lower eyelid orbital fat hyperplasia” and we define “lower eyelid orbital fat hyperplasia” as following. First, lower eyelid bulge is existed but not because of aging. Second, there are no abnormalities except excess fat in the orbital CT examination. Third, intraoperative findings are included such as no real fat herniation through the orbital septum, intact of orbital septum, and no thinning or distention of orbital septum. Fourth, pathology of the fat tissue has no differences with normal fat tissue pathology.
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