INTRODUCTION In steatoblepharon the orbital septum becomes weakened and redundant. This allows the extraconal orbital fat pockets to herniate forward into the eyelids. In younger individuals it may be seen as a familial condition, not associated with other signs of aging. However, in most cases steatoblepharon is seen as an involutional phenomenon associated with dermatocholasis, eyelid laxity, and ptosis.
CLINICAL PRESENTATION The eyelids appear full as the prolapsed orbital fat protrudes beneath the eyelid skin. In the upper eyelid the medial fat pocket is typically the most prominent. Bulging in the lateral upper eyelid is usually not fat, but almost always the result of a prolapsed lacrimal gland. In the lower eyelid there are three compartmentalized fat pockets in 70% of individuals. Other variations include two pockets or even one contiguous pocket. The lateral pocket is typically the most prominent, but fat prolaps often also involves the medial and central fat pockets with a bulging contour across the entire lower eyelid. Steatoblepharon is usually associated with dermatocholasis and in the upper lid may be obscured by extensive overhanging skin folds. Excessive steatoblepharon is typically associated with some systemic disease such as Graves' orbital disease where the fat can be edematous and also increased in volume.
TREATMENT Treatment is surgical, and often combined with a blepharoplasty. If skin is also to be excised the incision is anterior. For mild fat prolapse the orbital septum can be tightened with light cautery. For more significant degrees of fat prolapse the septum is opened and each fat pocket is isolated, cauterized, and excised. If the lacrimal gland is prolapsed into the lateral upper lid, it is reposi-tioned beneath the superior lateral orbital rim with a suture. In the lower lid when only steatoblepharon is present without dermatochalasis, as in younger patients, a transconjunctival incision can be used. Here the lower capsulopalpebral fascia is opened and the fat pockets excised without disturbing the orbital septum. Care should be taken not to put excessive traction on the fat to avoid possible orbital hemorrhage. When excess skin is also present in the lower lid, a transcutaneous incision is preferred, and the skin is tightened laterally. The modern trend is to reposition most of the fat into the tear trough and beneath the descended malar fat pad.
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