Periorbital Fat Grafting

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Periorbital Fat Grafting Guy G. Massry, MD1,2

Babak Azizzadeh, MD, FACS3,4

1 Beverly Hills Ophthalmic Plastic and Reconstructive Surgery, Beverly

Hills, California 2 Department of Surgery, Division of Opthalmology, Cedars-Sinai Medical Center, Los Angeles, California 3 Department of Facial Plastic & Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles, California 4 Division of Head & Neck Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Beverly Hills, California

Address for correspondence and reprint requests Guy G. Massry, MD, Beverly Hills Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills, CA, 90211 (e-mail: [email protected]).

Abstract

Keywords

► ► ► ► ►

eyelid fat grafting nasojugal groove tear trough orbitomalar groove eyelid–cheek interface ► eyelid–cheek junction ► fat repositioning

Periorbital aging is a multifactorial process involving volume loss (bone and soft tissue), tissue decent, and cutaneous degenerative changes. Traditional approaches to surgery on this area of the face have been subtractive in nature, focusing on excision of skin, muscle, and fat. This has frequently led to a gaunt or hollowed postoperative appearance. Contemporary aesthetic eyelid and periorbital rejuvenation has undergone a paradigm shift from an excisionally based surgical approach to one that prioritizes volume preservation and/or augmentation. The development of fat grafting to the eyelids and periorbita has given the eyelid surgeon a viable surgical alternative to prevent postoperative volume depletion, maintain the smooth transition of the lower eyelid to the cheek, and aid in restoring the youthful appearance desired after surgery. This article will focus of periorbital fat grafting and touch upon fat preservation techniques as primary restorative procedures or as surgical adjuncts

Aesthetic eyelid rejuvenation is a constantly evolving and challenging component of facial plastic surgery. Historically, upper blepharoplasty has consisted of the excision of fat, muscle, and as much skin as possible to still allow adequate eyelid closure.1 The traditional transcutaneous lower blepharoplasty surgery allowed an open view of the surgical field and simultaneous fat and skin excision through an infraciliary incision.2,3 Unacceptably high rates of lower lid malposition (ectropion and/or retraction) led to the development of various forms of canthal suspension techniques.4–11 Transconjunctival surgery, first described in 1924 and reintroduced 50 years later, has further enhanced outcomes and prevented lid malposition.12–14 A separate skin incision could be added easily to allow the addition of skin excision as needed (as with transcutaneous surgery) without violating the orbicularis muscle and orbital septum, surgical steps that can promote the development of lid retraction and ectropion.15 Although a more complex procedure, transconjunctival blepharoplasty has gained wide acceptance among all specialists performing cosmetic lower blepharo-

Issue Theme Aesthetic Treatment of the Eyelids and Midface; Guest Editors, Michael M. Kim, MD, and Tom D. Wang, MD, FACS

plasty. This history of eyelid surgery is important, as its lessons have led us to a different way of approaching restorative procedures of this area of the face. The goal of any aesthetic surgery is to improve appearance and re-create youth. We are now aware that youthful eyelids are full and devoid of skin laxity and excessive rhytids and transition (contour) well into adjacent structures, the brows above and the lower lids and midface below. Traditional excisional or subtractive blepharoplasty has often created the reverse. In these cases, areas of prominence and “pseudoexcess” of tissue (oftentimes fat) are excised, unmasking the underlying bony architecture with a resultant gaunt appearance. Over the last decade, it has been established that volume loss is a normal part of the periorbital aging process.16–21 Preventing volume depletion after surgery is important to promote a youthful outcome and to prevent potentially enhancing the aging process with the development of periorbital skeletonization. As such, an emphasis has been placed on procedures that preserve and/or augment periorbital volume. This shift in focus from an excisional

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DOI http://dx.doi.org/ 10.1055/s-0033-1333842. ISSN 0736-6825.

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Facial Plast Surg 2013;29:46–57.

approach to one of tissue addition is now a contemporary focus of blepharoplasty surgery. Addressing the cutaneous changes of eyelid and periorbital aging, although paramount to attaining an appropriate outcome, is beyond the scope of this discussion. This article will focus on the use of autologous fat to efface the depressions and improve the contour of the eyelids and their adjacent structures. There are two primary ways to do this: (1) the harvesting and transfer (grafting) of fat from a secondary site on the body and (2) the transposition of native eyelid fat. In addition to the review of the author’s techniques of fat augmentation/preservation, the authors will review the important anatomy, aging and topographic changes inherent to involutional changes of the eyebrows and upper lids, and lower eyelids and their transition to the cheek. The technique of harvesting and transferring autologous fat to the periorbita will be outlined in detail. Techniques to transpose (preserve) native eyelid fat will also be touched upon, because, especially in the lower lids, they can be combined with fat grafting to efface the lid–cheek interface. Specific pearls and techniques to avoid adverse outcomes will be discussed and complications and their management reviewed.

Anatomy Externally, the upper and lower eyelids span the superior and inferior orbital rims to the eyelid margin, respectively. Their most anterior layer is composed of thin skin with underlying orbicularis muscle. The orbicularis muscle is the primary protractor of the eyelid, aids in maintaining eyelid strength and tone (primarily in the lower lids), and is subdivided into a palpebral (pretarsal and preseptal) and orbital segment. The names of each division of the muscle are given based on the structures they overly. The orbicularis muscle and skin form the anterior lamella of the upper and lower lids. The posterior lamella of the eyelids changes in structure depending on location. In the upper lid it consists of the tarsus and palpebral conjunctiva inferiorly, and the conjunctiva and Müller’s muscle above the tarsus. In the lower lid the posterior lamella is composed of the tarsus and conjunctiva superiorly and continues as the lower lid retractors (capsulopalpebral fascia and inferior tarsal muscle) and conjunctiva below. A significant difference between upper and lower eyelid anatomy is that a primary function of the upper lid is to elevate the eyelid to allow a clear and full field of vision. As the lower lid lies below the visual axis, it inherently does not need or have this function. As such, there are two retractor muscles of the upper lid: the powerful levator muscle–aponeurosis complex and the sympathetically driven Müller’s muscle that acts as an accessory eyelid elevator. The previously mentioned inferior tarsal muscle in the lower lid is the analogue of Mueller’s muscle of the upper lid. The orbital septum is a connective tissue structure arising from the arcus marginalis periosteum at the orbital rim and fusing with the levator aponeurosis approximately at the level of the superior tarsus in the upper lid and with the lower eyelid retractors 5 mm below the tarsus in the lower lids. In the lower lid, the combined orbital septum–lower eyelid retractors

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continues to insert onto the inferior tarsus. In both the upper and lower lids, the eyelid fat lies posterior to the septum. In the upper lid there are two fat compartments: medial (nasal) and central. The nasal fat pocket is denser, whiter, and contiguous with the deeper extra and intraconal fat compartments. Thus it is orbital fat in structure and composition.1 The central eyelid fat pad is less dense, yellower in color, and separated from orbital fat by the levator aponeuorsis.1 This is true eyelid fat. These differences are important and will be discussed further in the section of eyelid aging. There is no third fat pad in the upper lid. The lacrimal gland, which normally sits in a fossa situated on the posterior surface of the superolateral rim, can prolapse and clinically appear as eyelid fullness. This should not be mistaken for a fat pad. As opposed to the upper lid, there are three fat compartments in the lower lid: nasal, central, and temporal. All three pads are in continuity and orbital in nature. The nasal and central fat pads are separated by the inferior oblique muscle, and the central and lateral pads by the arcuate ligament. The lower lid is suspended to the medial and lateral orbital rims by canthal tendons, with the lateral attachment 2 mm higher than the medial one, giving rise to the normal lateral canthal slant. ►Fig. 1 details relevant anatomical structures of the upper and lower lids. The midface (cheek) spans the lower lids to the oral commissure. Topographically it is a convex and full facial structure in youth that demonstrates maximal projection at the “zygomaxillary apex.”22 This is an anthropometric soft tissue point that can be located by the intersection of two lines: one traced vertically from the lateral external orbital rim and another horizontally oriented extending from the upper lateral cartilage of the nose to the tragus (►Fig. 2). It is the goal of midface surgery to recreate the aesthetics of this youthful cheek mound. The midface is comprised of skin, muscle, and various different compartments of fat. Although not completely understood, the aging process of the midface likely involves differential atrophy of these midface compartments that can further lead to a poor lid–cheek transition. The muscles in the midface are comprised of inner and outer lip elevators that span the infraorbital rim to the upper lip. The midface is suspended to the facial skeleton by two important connective tissue bands: the orbitomalar ligament (orbicularis retaining ligament) and the zygomaticocutaneous ligament. Laterally the masseteric–cutaneous ligament also aids in supporting the midface (►Fig. 3).

Eyelid/Periorbital Changes with Age Periorbital aging involves a complex interconnection of tissue descent, cutaneous degeneration (wrinkles, dyschromia, etc), and volume depletion (both fat and bone).To properly evaluate the patient presenting for eyelid surgery, the upper and lower lids must be viewed as aesthetic units with their adjacent structures. For this reason, when planning rejuvenation of the upper lids the position of the brow and its impact on the upper lids must be addressed. Similarly, the lower lids and midface must be evaluated together. Facial Plastic Surgery

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Periorbital Fat Grafting


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Fig. 1 Artist’s drawing of upper and lower eyelids with associated anatomic structures of importance. ROOF, retro-orbicularis oculi fat; SOOF, suborbicularis oculi fat. (Reprinted with permission from Springer Science þ Business Media B.V. From Massry GG, Murphy M, Azizzadeh BA. Master Techniques in Blepharoplasty and Periorbital Rejuvenation. Chapter 2. “Surgical Anatomy of the Forehead, Eyelids, and Midface for the Aesthetic Surgeon”: 11–24.

Fig. 2 Three-quarter oblique view of the face demonstrating the “zygomaxillary point,” (asterisk) or the highest point of the youthful cheek convexity. It is delineated by the intersection of two lines: one traced vertically on the lateral external orbital rim, and another horizontally from the upper lateral cartilage of the nose to the tragus. (Reprinted with permission from Springer Science þ Business Media B.V. From Massry GG, Murphy M, Azizzadeh BA. Master Techniques in Blepharoplasty and Periorbital Rejuvenation. Chapter 20. “Midface and Lower Eyelid Rejuvenation”: 225–241.) Facial Plastic Surgery

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Although the eyebrows tend to descend with age, the tail of the brow is most significantly affected. This temporal brow ptosis has a tendency to accentuate the classic involutional lateral lid fullness. Associated with this are equally typical deficits in central and medial eyelid appearance. This includes dermatochalasis and areas of fullness and hollows. It has recently been established that the nasal eyelid/orbital fat is rich in stem cells and tends to clinically appear more prominent with age, and the central preaponeurotic eyelid fat is stem cell poor and involutes with age.23,24 These changes manifest as a central lid hollow (A-frame deformity) and nasal prominence. As with the brows and upper lids, to properly rejuvenate the lower lid and midface a contemporary understanding of the aging changes that affect these combined areas is essential. In the lower eyelid, septal attenuation and eyelid laxity lead to fat pseudoherniation and the appearance of eyelid “bags.” Skin thinning, wrinkling, and redundancy can exacerbate this appearance. Volume deficit over the inferior orbital rim leads to a classic hollowing (periorbital hollows) over this area, which have been named the nasojugal groove nasally


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Fig. 3 (A) Coronal view of the orbitomalar and zygomaticocutaneous ligaments. (B) Sagittal view of the three retaining ligaments of the midface: the orbitomalar ligament (OL), zygomaticocutaneous ligament (ZL), and masseteric cutaneous ligament (MCL). (Reprinted with permission from Springer Science þ Business Media B.V. From Hartstein MH, Wulc AE, Hulc DE. Midfacial Rejuvenation. Chapter 1. “Anatomy of the Midface”: 1–14.)

and the orbitomalar groove laterally. Often a V-shaped depression intersects the two grooves, which has been called a V deformity (►Fig. 4). The fat prominence of the eyelid above the lid–cheek interface depressions topographically accentuates the hollows, worsening both contour and appearance.

The aging process of the midface, whether a primary issue of descent, volume loss, or both, also causes the thick cheek skin to descend, resulting in thinner eyelid skin overlying the orbital rim. This unmasks the orbital rim and further accentuates the depressions of the lid–cheek junction. These cumulative changes convert the lid–cheek transition from the youthful concavity/convexity to the double convexity of age (►Fig. 5). Finally, the differential atrophy of the midface fat compartments combined with cutaneous changes results in predictable cheek hollows and depressions that produce shadows rather than highlights.

Patient Assessment

Fig. 4 Frontal view of a man with typical lid–cheek interface depressions. Abbreviations: NJG, nasojugal groove, V deformity; OMG, orbitomalar groove.

Creating a customized approach to volume augmentation in the periorbital region is critical to attaining an appropriate result and satisfied patient. As discussed on the section on periorbital aging, brow position plays an important role in upper eyelid appearance. Typically the temporal brow tends toward ptosis and would benefit from a mild lift. If not Facial Plastic Surgery

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Massry, Azizzadeh largely been abandoned (except in selected cases) in our practices over the past 5 years.

Fat Harvesting

Fig. 5 Oblique facial view of a woman demonstrating typical double convexity of eyelid and periorbital aging: (A) eyelid fat (pseudo) herniation; (B) lid–cheek interface depression with unmasked orbital rim; (C) midface convexity (resulting from tissue descent and/or deflation).

planned surgically, this can be accomplished with neuromodulation (botulinum toxin A), fillers, fat grafting, or a combination thereof. The authors have employed fat grafting successfully even in those undergoing surgical browlifting (endoscopic procedures) by injecting preperiosteally outside the surgical plane. Glassgold and colleagues have characterized upper eyelids as type 1 and type 2 based on topographic appearance (type 1 full/convex, type 2 more hollow/concave).21 These are useful distinctions as the goal is to recreate the individual’s particular eyelid appearance of youth. For this reason reviewing old patient photographs is beneficial for surgical planning. Lower lid fat grafting has been much more common than its upper lid counterpart. The lid–cheek interface hollows and often adjacent midface are the primary targets. Identifying which depressions are most significant (nasojugal groove, V deformity, orbitomalar groove) is imperative to create a tailored approach. The youthful appearance of the lower lid–cheek junction also requires the anterior midface to be augmented in regions far from the lower lid such as the canine fossa and inferior malar fat pad. Reinflation of an involuted midface can have a profound impact in the overall outcome of the procedure. Additionally, the lateral zygomatic arch needs to also be considered to create a youthful fullness and overall smooth transition of all contours of the midface. Finally, before proceeding with fat transfer, additional procedures needed to attain the desired outcome are determined. This may include various forms of browlifting, blepharoplasty, fat translocation procedures, and chemical peels or laser resurfacing. Due to our philosophical evolution of lower lid and midface rejuvenation, endoscopic midface-lifting has Facial Plastic Surgery

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The goal of fat transfer to the eyelids and adjacent structures is to recreate the youthful fullness and contours inherent to these areas of the aging face. With all procedures there are risks and benefits. The authors have significant experience with facial fat grafting, and although they feel it is an excellent stand-alone and adjunctive procedure in the appropriate patients, it also carries risks of potentially difficult to manage and/or permanent adverse sequelae. This is especially true around the eyelids as the skin is thin, there is little subcutaneous fat, and every irregularity can become apparent. As such, periorbital fat grafting should be employed with caution and with full disclosure to patients of potential temporary and permanent complications. It should be stressed that hyaluronic acid fillers are a viable, effective, albeit nonpermanent option for periorbital volume augmentation for both the upper and lower lids.25–28 This treatment option is less invasive and risky and should be presented as a treatment alternative to all patients presenting for fat transfer. In the authors’ daily practice, hyaluronic acid fillers are commonly used as first-line treatment when patients are not seeking surgical blepharoplasty. Fat can he harvested from any site on the body. However, the authors typically perform the procedure in association with other periorbital and facial surgeries. As patients are supine for these procedures, it is easiest and safest to use the periumbilical area or inner thigh (in women) as the fat donor site. In awake patients where body repositioning is not an issue, other sites, such as the outer thigh, buttocks, or hip, are easily accessible and contain good fat stores. Very thin patients or those with little subcutaneous fat are not good candidates for fat transfer surgery. Although fat can be harvested in this setting, it is often not good-quality fat, and the harvesting step can lead to contour irregularities at the donor sites. Hyaluronic acid fillers are a better option in these patients. Finally, it is also important to look for previous surgical scars in potential donor sites as this can complicate or limit the harvesting step. For the sake of brevity only the periumbilical harvesting technique will be described in this article. Please refer to other references for information on the harvesting maneuver in other areas.18 After the surgical field is prepped and draped, local anesthetic is injected in a pseudotumescent fashion. The authors prefer 40 mL of 0.25% xylocaine with 1:400:000 epinephrine. This is prepared by mixing 10 mL of 1% xylocaine with 1:100:000 epinephrine with 30 mL of saline. Typically the 40 mL of solution prepared is an adequate injection for hemostasis and pain control (in the awake patient). A 22-guage spinal needle is used to infiltrate the anesthesia in both the superficial and deep fat planes if possible. A bleb of 1% xylocaine with 1:100:000 epinephrine is given to both lateral aspects of the umbilicus in a generally concealed location. A no. 11 blade is used to perforate the skin. A 2.1-mm multiport cannula is used to harvest fat (Tulip Medical Inc., San Diego, CA). The harvesting cannula is


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connected to a 10-mm syringe, and manual suction is applied on the plunger of the syringe with a constant back-and-forth motion of the cannula during harvesting. Wall suction is easier and can be used, but the negative pressure created is greater and may damage the harvested adipocytes. Similarly larger syringes can be used, but again pressure control is limited. Typically no more that 2 mL of applied negative pressure is needed to harvest fat. As each syringe is filled it is passed off the assistant for preparation. On average each 10-mL syringe will yield 5 mL of injectable fat. There are a variety of ways to process fat. It is not the authors’ practice to centrifuge fat. References on this can be found elsewhere.21 The assistant removes the plunger from the syringe and empties the fat onto standard Telfa™ (Covidien, Mansfield, MA) dressing and lets it sit for 10 minutes to drain. The fat is then collected with a sterile tongue depressor and placed back into a 10-mL syringe. From this syringe the fat is transferred to the posterior opening (plunger off) of a tuberculin syringe (1 mL) by direct injection. An appropriate number of tuberculin syringes are prepared for fat injection (►Fig. 6).

in more superficial locations (suborbicularis) to address subtle contour issues and for fine-tuning. These injections should be given in even smaller amounts as there is little room for error.

The Brow and Upper Lid ►Fig. 7 demonstrates the entry port sites for grafting to the periorbital area. The author’s preference for brow injections is to place an entry site 15 to 20 mm above the central brow. From this point fat is injected into the brow fat pad and just above the periosteum perpendicular or in an angled manner

Fat Injection Harvested fat is injected through 0.9-mm blunt-tipped cannulas (Tulip Medical Inc.). The entry sites for fat injections are infiltrated with 0.25 mL of 1% xylocaine with 1:100:000 epinephrine. An 18-gauge or Nokor needle (Delasco Dermatologic Laboratory & Supply, Inc., Council Bluffs, IA) is used to create an entry path for the cannula. The cannula is passed to and fro to the specific areas of fat deposition. With each pass a small aliquot of fat is injected. On average a full syringe of fat (1 mL) will be injected with 10 to 20 passes of the cannula. The initial goal of injections is to build a foundation and elevate discrete topographic depressions. This is performed by deep injections to the level of the periosteum. This is especially critical in the periorbital region as the skin is thin with little buffer overlying tissue. The deeper the injections of fat in this area, the less there is a chance of developing postinjection lumps. With experience subsequent injections can be placed

Fig. 7 Entry points for fat injections. Facial Plastic Surgery

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Fig. 6 (Left to right) Fat harvesting/grafting instrumentation, periumbilical entry for fat harvesting, fat left to drain over Telfa™ (Covidien, Mansfield, MA) with associated tongue depressor used to fill syringes, fat loaded into 1-mL syringes for injection.


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to the brow. The central and lateral brow is emphasized. Typically 2 to 3 mL of fat is injected. When endoscopic browlifting precedes fat injections, the fat is placed above the dissection plane of surgery (supraperiosteal). The lateral entry site is placed 10 to 15 mm lateral to the canthus. From this point fat can also be grafted to the infrabrow area, especially when there is a hollow sulcus and the inferior brow can be volume-augmented to camouflage the sulcus depression. This site is also used for augmentation of upper lid volume. The authors inject fat deep, attempting to fill the retroseptal space. In addition the fat is placed at the junction of the thin lid skin and thick brow skin. Superficial injections are avoided to prevent postprocedural contour irregularities. Injections through the lateral entry port are the only periorbital injection site that fat is injected parallel to the orbital rim. The authors have found that parallel injections in general, but primarily at the lower lid–cheek transition, can lead to “sausaging” with topographic deficits. As fat is injected deep into the brow fat pad or below the thicker skin of the brow from this site, these contour issues tend not to occur in this location (►Fig. 8).

The Lid–Cheek Interface and Midface When injecting the eyelid–cheek interface, it must be stressed that the skin in this area is very thin with only

minimal subcutaneous fat. A conservative approach with meticulous technique is critical to prevent “lumps and bumps.” A central entry point just below the junction of the nasojugal and orbitomalar groove is marked and anesthetized. The skin over the nasojugal groove (tear trough) is exceedingly thin and the area most susceptible to unsightly contour problems. No more than 1 to 1.5 mL should be grafted to this area. Multiple passes are placed as deep as possible. Superficial injections here are an advanced maneuver and should be avoided until experience and comfort with periorbital fat grafting are attained. The central lid depression (V deformity) and orbitomalar groove are then filled. These areas are more forgiving to contour issues. In the authors’ experience a total of 3.5 mL given to the lid–cheek interface in total typically does not lead to postoperative contour complications (►Figs. 9 to 11). The midface is grafted through one or two entry sites. Here injections can be given in both deep and superficial planes with low risk. A 5-mL injection per side is usually an adequate amount with first time fat grafting.

Postoperative Care The typical postoperative course is explained to the patient prior to surgery as to reduce potential anxiety. No dressings

Fig. 8 (Top) Results of sub-brow and upper eyelid fat grafting. (Bottom) Same woman after midface fat grafting. Facial Plastic Surgery

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Fig. 9 (Left) Entry port for fat injection. (Right) Fat injection with small cannula.

are applied to the face, and a small adhesive cover of Telfa™ (Covidien) with overlying Tegaderm™ (3M, St. Paul, MN) is placed over the fat harvesting entry site. Strenuous physical activity is avoided for 21 days. Bruising and swelling vary, depending on whether excisional surgery was also performed. As a general rule, patients return to normal activity in 1 to 3 weeks. Fat grafting does have a level of unpredictability with its durability and resorption. Patients are told that fat “take” is variable and may require staged augmentation at a later date. This is very important and must be

discussed prior to surgery rather than after the procedure. The authors wait 12 months before considering reinjection. Patients are also made aware that fillers may be utilized in 6 months if the patient does not desire to have additional surgical procedures or if the area of augmentation is limited.

Complications As with all surgical procedures an array of potential postoperative complications can occur. Some are mild and mostly a

Fig. 10 Frontal and oblique views of eyelids and periorbita in a patient who underwent revisional fat grafting after previous lower blepharoplasty, which left the patient with a gaunt appearance. Facial Plastic Surgery

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Fig. 11 Improved lower lid and lid–cheek interface after fat transfer.

nuisance and others are a source of significant patient frustration. Sound judgment, appropriate surgical experience, and meticulous procedural technique are the best way to avoid such issues. However, even in the best of hands they do occur. The following paragraphs will outline some of the more common problems and discuss management options. Scars and pigment disturbances (hyperpigmentation, persistent erythema) can develop at the harvesting cannula entry points. Although infrequent, these can be disturbing, especially to women. Masking the placement of incisions discretely (i.e., within the umbilicus) is the best way to avoid these problems. Bleaching creams such as hydroquinone may be of benefit for hyperpigmentation. This rarely requires revision surgery. Erythema tends to resolve over time. Depressions, linear tracks, and contour irregularities of the donor site can develop if fat is harvested too superficially. Again the proper technique of deeper harvesting will avoid this complication. If this problem occurs and does not improve over time, fat injections can be attempted, although this can be a troublesome problem to address. Although depressions or irregularities at the entry points for fat injections have been reported in the literature, the authors have rarely encountered this in clinical practice. Techniques such as local subcision or direct excision can be employed if the patient is sufficiently bothered.21 Contour irregularities to the eyelids/periorbita are more commonly encountered.29 When conservative amounts of fat are grafted (especially at the nasojugal groove where skin is thinnest), the incidence of this complication is reduced. The authors have found two distinct types of contour issues (lumps and bumps) to occur. Some patients develop “bulges.” The authors define bulges as larger areas of prominence that tend to be soft and diffuse. These are typically related to an overcorrection. They are usually seen in the lower lids and are addressed with surgical debulking. The authors prefer a transconjunctival approach to the lower lid with direct excision. Note that the grafted fat is often more superficial than the native retroseptal eyelid fat. As such, a preseptal dissection with excision may be needed. In these cases of diffuse overcorrection, the authors have also excised retroseptal fat to allow the grafted fat to recess and reduce eyelid prominence. Microliposuction has also been reported for overcorrections. The authors have used this technique in a few patients who have had uneven postrevision contours. Facial Plastic Surgery

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The other potential contour issue seen postoperatively is a discrete nodule. These are smaller and harder and related to a local granulomatous inflammatory response. Granulomas are more common and more challenging than overcorrections (bulges). Local injections of steroids or 5-fluorouracil can be attempted to treat these lesions. If this proves unsuccessful, direct excision is useful.30 These often occur over the thin skin of the nasojugal groove. Incisions in these areas usually heal well with imperceptible scars. Finally, intravascular injection of fat is a potentially devastating complication of this procedure.21 This should be rare when proper technique (blunt cannulas, small aliquot injections under low pressure) is used.

Adjunctive Local Fat Translocation As fat grafting the periorbita can be unpredictable and can lead to potential surface irregularities, one of the authors (G.M.) often combines fat grafting with native eyelid fat preservation techniques to reduce the amount of grafted fat delivered. In the upper lids when grafting of the brows is combined with blepharoplasty, the nasal fat pad (typically prominent) can be translocated as a pedicle to the central eyelid space as a filler or to prevent iatrogenic volume depletion (►Fig. 12).1,24 As previously reviewed, the nasal fat pad is denser, becomes more prominent with age, is an extension of deeper orbital fat, and is relatively rich in stem cells. This is in sharp contrast to the central (preaponeurotic) fat, which is separated from orbital fat by the levator aponeurosis. This fat is less dense, tends to involute with age, and is relatively stem cell deficient.23,24 A variant of this technique is now being studied by one of the authors (G.M.). In this instance, the nasal fat pedicle is repositioned over the superior orbital rim to fill the superonasal orbital rim hollow, which the author has called the “orbitoglabellar groove,” similar to the nasojugal groove of the lower lid–cheek interface. A dissection pocket is created pre-periosteally and the fat secured to this space with full-thickness bolster sutures. This technique has yielded superior results over the initial 15 cases at an average of 5 months’ follow-up (unpublished data, author’s personal experience). In the lower lid, local fat translocation (fat repositioning; ►Fig. 13) is a more established procedure; it was first described in 1981 and has been elaborated on by many


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Fig. 12 Surgical series of upper nasal fat repositioning. (A) Nasal (lighter) and central (yellower) fat exposed. (B) Nasal fat pedicle fashioned and (C) transposed to central eyelid. (D) Transposed pedicle lifted to ensure no undue pressure on levator aponeurosis muscle. (Reprinted with permission from Wolters Kluwer/Lippincott Williams & Wilkins. From Ophthalmic Plastic and Reconstructive Surgery. Massry, GG. Nasal fat preservation in upper blepharoplasty. Ophthal Plast Reconstr Surg. 2011; 27(5):352–355.1)

Fig. 13 Lower fat repositioning procedure. (Left top and bottom) Surgical photographs. (Center) Accompanying artist’s drawing of periosteal exposure and fat pedicle suture fixation in preparation for translocation into a subperiosteal pocket. (Right) Artist’s drawing of sagittal view of eyelid and midface demonstrating repositioned fat pedicle. (Reprinted with permission from Springer Science þ Business Media B.V. From Massry GG, Murphy M, Azizzadeh BA. Master Techniques in Blepharoplasty and Periorbital Rejuvenation. Chapter 16. “Transconjunctival Lower Blepharoplasty: Fat Excision and Repositioning”: 173–184.) Facial Plastic Surgery

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Fig. 14 (Top) Frontal view and (bottom) oblique view of lower lids and transition to midface demonstrating filling of depressions with repositioned fat to the nasojugal groove and fat grafted to the V deformity and orbitomalar groove.

Fig. 15 Oblique view of a woman with same findings and procedure as patient in ►Fig. 14.

since.31–34 Fat can be transposed transcutaneously, transconjunctivally, and in a sub- or supraperiosteal plane. With all approaches excellent results with few complications have been reported. As the nasojugal groove is more susceptible to fat grafting-related contour issues, the authors often reposition fat to this area and graft fat to the central and lateral depressions (►Figs. 14, 15).

Conclusion Periorbital aging is a complex and multifactorial process involving degenerative changes in skin, loss of volume, tissue descent, and environmental and genetic factors. Aesthetic rejuvenation of this area of the face is challenging and requires a tailored approach for each patient. Techniques to augment and preserve autologous fat have allowed aesthetic facial surgeons a means of maintaining the natural fullness, curves, and contours of youth while avoiding the typical stigmata of and surgical look inherent to iatrogenic volume depletion found in traditional excisional surgical approaches in this area of the face. Facial Plastic Surgery

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The authors have found that the fat grafting technique described in this article has proven to be effective means of augmenting eyelid, periorbital, and midface volume in a consistent and reliable way. An emphasis must be placed on a conservative approach to avoid potentially permanent postoperative contour issues. In addition, detailed understanding of the management of potential postoperative complications is essential, as these can lead to significant patient and surgeon frustration.

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