Monday, July 20, 2015

Doc, what are these swellings in my upper eyelids?

This 60 year-old woman is bothered by swellings in her upper eyelids near the nose. Examination shows these swellings were soft to the touch and can be pushed inwards (see figure 1). The features suggest these swellings were caused by prolapse of the medial fat pad. 

Figure 1. The patient is concerned by the swellings in her upper lids 
near the nose (areas circles in blue).

Anatomically, the upper eyelid contains two fat compartments: medial and central and the lower eyelids three: media, central and lateral (see figure 2). In young people, the fats are not visible but with age, the fat may become protruded due to weakness of the overlying structures such as muscles and septum (the fibrous tissue that separates fat from the muscles). 

Figure 2. Picture showing the right eye of a 70 year-old man with severe fat prolapse.
A = medial fat pad; B = central fat pad; 
1 = medial fat pad, 2 = central fat pad and 3 = lateral fat pad.

The swellings are easily removed through a limited incision along the skin creases (double eyelids). To get to the fat pad, the incision needs to go to through 3 layers namely: skin, orbicularis oculi muscle and the orbital septum. The fat needs to be handled with care to avoid bleeding into the back of the eye. After enough fat was taken the wounds are closed with sutures which are removed in one week.  
Figure 3. The patient shown in figure 1 undergoes fat incision under local anaesthesia.
a. marking along the skin crease (double eyelid); 
b. the fat is teased out from the medial fat compartment; 
c. the fat was clamped with a pair of artery forceps to prevent bleeding; 
d. the fat is excised and cauterized (burnt); 
e. at the end of the fat excision; 
f. the wound is sutured with 6/0 nylon. 

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