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Deep and Superficial Eyelid Fascia

Balik, Ozan M.D.

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Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 723e
doi: 10.1097/PRS.0b013e318245ea50
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“The anatomy of the orbital septum and its surgical applications are at times questionable,” as Dr. Putterman also stated. Ultrastructural studies may report tissues from various anatomical origins; however, two separate tissue dissections are not always surgically possible, especially fresh tissue dissection, such as the orbital septum and suborbital fascia.

Dr. Putterman has reported a powerful and intact orbital septum but only the presence of detachment of the aponeurotic linkage in the dissection on the cadaver. Within the framework of his finding, according to Dr. Putterman, the cause of baggy eye is not the orbital septum but the suborbital fascia.

In my opinion, this result is insufficient and should be particularized. A great number of authors have associated baggy lower eyelids with orbital septum weakening and planned their treatment in accordance with this framework before Dr. Putterman's study.15 I also detected weakening and reduction in the orbital section in many cases and planned my treatment within this framework. Dr. Putterman's study is very valuable and suggests for us a new terminology; however, I do not understand why some articles, included in the surgical literature, that associated baggy eyelids with weakening of the orbital septum were not included in this discussion of baggy eye.15

Dissection should be performed without contacting muscle. If the thin fascial tissue of the eyebrow located in the inferior surface is examined, we usually detach the orbital septum with sharp dissection. Therefore, I consider that we directly see the orbital septum in front of the fat pad and surgically repair it. The aim of my study6 was to create a dynamic wall that can be neurotized by the frontalis muscle rather than performing a similar neo–septum orbitale. In the future, I will mention the present study as a treatment of baggy eye by means of eyebrow graft.

Ozan Balik, M.D.

Plastic Reconstructive and Aesthetic Surgery Department, Doğalife Beauty Clinic, Pendik, Istanbul, Turkey 34893,


1. Mendelson BC. Herniated fat and the orbital septum of the lower eyelid. Clin Plast Surg. 1993;20:323–330.
2. Cook TA, Derebery J, Harrah ER. Reconsideration of fat pad management in lower eyelid blepharoplasty surgery. Arch Otolaryngol. 1984;110:521–524.
3. Bisaccia E, Scarborough DA, Swensen RD. A technique for blepharoplasty without incising or “puncturing” orbital septum. J Dermatol Surg Oncol. 1990;16:360–363.
4. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg. 1988;81:677–687.
5. Beare R. Proceedings of the Second International Symposium on Plastic and Reconstructive Surgery of the Eye and Adnexa. St. Louis: Mosby; 1967:362.
6. Balik O. Lower blepharoplasty with orbital septum reconstruction using upper blepharoplasty excision material. Plast Reconstr Surg. 2011;127:137e–139e.


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