Treatment of Steatoblepharon
Surgical blepharoplasty is the definitive treatment for steatoblepharon (prolapsed orbital fat causing eyelid bulging), with the choice between transcutaneous and transconjunctival approaches determined by the presence or absence of excess skin.
Surgical Approach Selection
The treatment algorithm depends on patient age and anatomical findings:
Transconjunctival Approach
- Indicated for younger patients with prominent fat herniation but minimal to no excess skin 1
- Avoids external incisions and associated complications like scleral show or lid malposition 2
- Can be performed for both upper and lower eyelids 2
- Particularly effective in preventing changes in aperture shape and eyelid level that occur with transcutaneous approaches 3
Transcutaneous Approach
- Required when significant skin excess (dermatochalasis) accompanies the fat prolapse 1
- Allows simultaneous treatment of redundant skin and steatoblepharon 1
- May require horizontal lower eyelid tightening in approximately two-thirds of cases 4
Specific Surgical Techniques
Fat Management Options
Three primary methods exist for managing prolapsed orbital fat:
- Fat excision: Traditional removal of herniated fat pads 2
- Fat repositioning: Relocation of intraorbital fat to correct inferior orbital hollowing and tear trough deformity 1
- Septal tightening/suturing: Transconjunctival septal suture repair that preserves fat while eliminating bulging 3
Orbital Septal Techniques
Septal manipulation provides effective alternatives to fat excision:
- Orbital septal excision with the "hanging curtain of fat" technique demonstrated good cosmetic outcomes in 274 consecutive surgeries with only 3% requiring surgical enhancement for retained fat 4
- Electrocautery grid application to the orbital septum is safe and effective, with no cases of postoperative eyelid retraction in 1,492 patients followed for 3 months to 20 years 5
- Transconjunctival septal suturing eliminates bulging in middle and medial compartments while preserving aperture shape and lid level without requiring simultaneous lid-tightening procedures 3
Critical Considerations
Patient Selection
- Younger patients with isolated fat herniation are ideal candidates for transconjunctival approaches 1, 2
- Patients with negative vector anatomy and inferior orbital hollowing benefit from fat repositioning rather than excision 1
- Assessment for lid laxity is essential, as two-thirds may require concurrent horizontal tightening 4
Avoiding Complications
- The transconjunctival approach specifically avoids "scleral show" and aperture shape changes associated with subciliary/muscle-cutting approaches 3
- Electrocautery to the septum does not cause late eyelid retraction when properly applied 5
- Minimum follow-up should be 6 months to assess for retained fat requiring enhancement 4