Ultra‐minimal pinhole blepharoplasty: A minimally invasive technique for the correction of eyelid bags

The aim of the study was to investigate the efficacy and complications of ultra‐minimal pinhole blepharoplasty in the treatment of eyelid bags.

trans-eyelid conjunctival incision-blepharoplasty through an ultraminimal pinhole and observed the clinical effect of this procedure.

| Patients
Between May 2018 and June 2021, 460 patients with eyelid bags underwent blepharoplasty through an ultra-minimal pinhole. This retrospective study of consecutive patients was conducted by reviewing medical records. Informed consent was obtained from each patient prior to the procedure.
Patients aged 20-60 years with eyelid bags were enrolled in the study. All the patients signed a preoperative informed consent form and agreed for their data to be used for clinical studies. Inclusion criteria were as follows: (1) 20-to 60-year-old men and women; (2) patients with herniated orbital fat in the lower eyelid; (3) patients who wanted to correct their eyelid bags using minimally invasive surgery; (4) patients who understood and followed the instructions and took part in the entire study procedure; (5) patients who underwent no treatment for eyelid bags; (6) patients who were mentally healthy; and (7) patients who had no bleeding tendency.

| Treatment procedures
Instruments used for the ultra-minimal pinhole blepharoplasty are shown in Figure 1. Lidocaine 1% with 1:100 000 epinephrine was injected into the medial, central, and lateral intraorbital fat. The total volume of lidocaine administered on each side was approximately 1 ml. After the patients were under conscious sedation, an assistant helped to retract the lower eyelid to expose the conjunctiva.
An incision (0.5 mm) was made using a plasma electric needle on the conjunctiva 5 mm below the lower eyelid margin (Figure 2A). Plastic and microsurgical forceps were used to locate the capsulopalpebral fascia. A further incision was made in the capsulopalpebral fascia.
Next, the plastic and microsurgical forceps and plasma electric needle were collectively used to cut through the capsulopalpebral fascia, orbital septum, and orbital fat pads sequentially ( Figure 2B-D). The eye globe was gently pressed to herniate the fat through the incision and to evaluate the optimal volume of the excised fat ( Figure 2E). Excess fat was removed using microsurgical forceps and excised using a plasma electric needle ( Figure 2F). Usually, the central, medial, and lateral excess fats are sequentially excised. Special attention should be paid to protect the inferior muscle and prevent bleeding. The patient was asked to sit up and look forward, and the flatness and symmetry of the bilateral lower eyelids were evaluated until total satisfaction. The operation procedure was recorded in the Appendix S1.
After the surgery, the lower eyelids were pressurized with gauze rolls and frozen for 20 min each time, 3-5 times a day. It was done for 2 days. The incision on the conjunctiva was avoided by contact with water for 7 days.

| Efficacy assessment
Medical records were collected, and the patient's sex and age, dura-

| RE SULTS
Of the 460 patients, 136 were males and 324 were females. The age of the 460 patients ranged between 20 and 60 years, with a mean age of 42.12 ± 9.76 years. The operation lasted 15-30 min, and during the procedure, the volume of bleeding was not more than 1 ml. The mean score of patient satisfaction with improvement in fat prolapse was 2.037 ± 0.675. A total of 440 (95.65%) patients were satisfied with the improvement in the fat prolapse ( Figure 3). In particular, 95 patients experienced marked satisfaction, 307 were moderately satisfied, 39 were mildly satisfied, and 19 were dissatisfied. The mean satisfaction score for the improvement in tear trough deformity was 1.985 ± 0.709. A total of 434 (94.78%) patients were satisfied with the improvement in the tear trough deformity (Figure 3). Eighty-nine patients were markedly satisfied, 297 were moderately satisfied, 50 were mildly satisfied, and 24 were dissatisfied.
After the operation was completed, slight postoperative swelling was the most common complication, which persisted for more It is commonly accepted that for eyelid bags with skin rhytides or orbicularis oculi muscle laxity, removal is the right choice.
However, patients' willingness to choose minimally invasive surgery must be considered. Additionally, cutting the lower eyelid skin and orbicularis oculi muscle often leads to scars, scleral show, premature aging of the lower lid, and even ectropion. 15 Moreover, our findings showed that although elderly patients had mildly flabby skin and orbicularis oculi muscle, fat removal did not aggravate the skin and orbicularis oculi muscle relaxation, and the F I G U R E 3 Photographs showing the results of the ultra-minimal pinhole blepharoplasty. A 31-year-old man with mild skin laxity (A), a 44-year-old woman with moderate skin laxity (B), and a 50-year-old man with severe skin laxity (C), before and after the ultra-minimal pinhole blepharoplasty patients were satisfied with the aesthetic results. Certainly, if the patients also aim to obtain younger skin, it is a better choice to combine ultra-minimal pinhole blepharoplasty by peeling the skin and excising the excess skin.
By contrast, tear trough deformity is another common feature of eyelid bags. The tear trough deformity is a distinct skin groove between the palpebral and orbital parts of the orbicularis oculi. 16 The cause of tear trough deformity mainly includes the tear trough ligament, orbital fat prolapse, and midcheek tissue descent. 10,17,18 For the correction of eye bags with tear trough deformity, the mainstream methods include transconjunctival lower blepharoplasty using orbital fat transposition. [19][20][21] In these surgical procedures, it is essential to cut off the tear trough ligament and orbicularis retaining ligament, and then to reposition the orbital fat into the supraperiosteal or subperiosteal plane. 22 However, the potential complications of dissection of the middle lamellae include varying degrees of bleeding, trauma, and prolonged edema. 23 Although Yunbo et al. found that there was no obvious skin laxity, the nasolabial folds became mildly deeper 3 months after surgery, 4 indicating that the cause of deeper nasolabial folds is prolapse of the zygomatic and cheek fat pad. This suggests that these two ligaments play important roles in maintaining the homeostasis of midcheek. In our study, the satisfaction rate for the improvement in tear trough deformity was 94.78%. Ultra-minimal pinhole blepharoplasty can improve tear trough deformity without dissection of the middle lamellae. There was a limitation in that the ultra-minimal pinhole blepharoplasty did not reuse the excess orbital fat to improve the inferior orbital margin. Previous studies have reported that transplantation of resected orbital fat is effective for correcting mild tear trough deformities. 23 Together, it may be a more minimally invasive and effective treatment of eye bags and mild tear trough deformities by transconjunctival fat removal through ultra-minimal pinhole in combination with resected orbital fat grafting. Therefore, our findings suggest that ultra-minimal pinhole blepharoplasty using a plasma electric needle is an effective, safe, and minimally invasive technique for treating lower eyelid fat prolapse, thereby achieving and maintaining high patient satisfaction.
Moreover, this technique can improve tear trough deformities without disturbing the middle lamellae.

AUTH O R CO NTR I B UTI O N S
Haicheng Yu and Weiming Qiu modified the surgical method.
Haicheng Yu, Liming Ren, Kai Xu, and Weiming Qiu performed the operation. Ying Guo charged the review of medical cases. Liming Ren, Haijun Zhu, and Yi Zou analyzed the data. Weiming Qiu and Kai Xu wrote the paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

E TH I C A L A PPROVA L
The study was performed in accordance with the principles of the Declaration of Helsinki. Ethics Committee approval was obtained from the Institutional Ethics Committee of Gerneral Hospital of Central Theater Command.