The shade procedure: for lower lid deformities

Early procedures designed to address fat herniation deformities in the lower lid relied on resection of herniated orbital fat. In some cases, this approach results in an abnormal depression of the periorbital soft-tissue profile and reduced globe prominence. The shade procedure was developed to address these concerns.

Sixty-five patients underwent lower lid blepharoplasty either alone, in combination with upper lid blepharoplasty, or with face lift using the shade technique over the past 11 years. The shade procedure treats the fat herniation contour change by repositioning the fat as an apron over the orbital rim and elevating depressed midface fat and muscle. Essential components for both efficacy and safety relate to developing a symmetric apron of herniated fat and orbital septum; limited dissection (5 to 10 mm) of an intramuscular pocket at the inferior orbital rim; translocation and fixation of the fat apron over the orbital rim; elevation and secure fixation of the superior quadratus and zygomaticus muscle flap to the medial and lateral orbital periosteum and the normal thickness orbital septum; release of the septum and capsulopalpebral fascia from the tarsus; and lateral canthopexy.

Two patients developed ectropion postoperatively requiring reoperation. No hematomas, facial nerve palsy, or skin slough occurred. An independent lay rater group judged the operative results to be improved in all cases (average, 4.3 on a five-point Likert scale).

The shade procedure should be considered for patients with lower lid fat herniation, particularly when depression at the inferior orbital rim accompanies convex prominence of the lower lid profile.