Yao Wang, MD, Raymond S Douglas, MD, Amy Patel, MD, John Holds, MD, Guy G Massry, MD
Various procedures to efface age-related lower eyelid/cheek interface depressions, or primary periorbital hollows (POHs), have been reported in the literature. Postsurgical, or secondary, POHs are a distinct contour irregularity that have received little such attention. Dermal onlay grafts (DOGs), a site-specific term for autologous dermis fat grafts, have been used to treat secondary POHs for which less invasive measures have proved unsuccessful.
The aim of this study was to describe the surgical technique and outcomes of DOGs for secondary POHs.
A retrospective analysis of patients who underwent DOGs for secondary POHs over a 27-month period was performed. The surgical technique and outcomes are reviewed.
Thirteen patients (10 women and 3 men; average age, 52 years; average follow-up, 9 months) were included in the study. Nine patients had bilateral surgery, and all had received previous filler or fat injection, or both, with poor outcomes. Generally, surgical complications were minor, required minimal intervention, or were self-limiting. One patient had persistent infraorbital dysesthesia which improved with oral tricyclic antidepressant treatment. Eleven of 13 patients stated satisfaction with hollow effacement and outcome, a finding verified by subjective assessment by a surgeon.
DOGs yielded good results in this initial description of their utility as a rescue procedure to surgically address secondary POHs. Further quantitative volumetric studies to validate outcome would of value.
Oren Tepper, MD
I congratulate the authors on their manuscript titled “Dermal Onlay Grafts: A Rescue Procedure for Secondary Inferior Periorbital Hollows,” 1 which sheds light on an important yet challenging area of aesthetic surgery. The eyelid-cheek junction has long been an area of interest and controversy in facial surgery, with various techniques having been described ranging from excision of fat, to additional of fat/filler, to transposition of fat, or some combination of the above. Despite the vast clinical experience and data that have accumulated in our field related to this region, peri-orbital hollows remain a frustrating and difficult treatment area for both patients and physicians.
In the following manuscript, the authors introduce a novel approach to the lower eyelid-cheek junction using dermal…
Hans Olav Ueland, Roy M. Nilsen, Eyvind Rødahl, Svein Arthur Jensen
To compare injections of hyaluronic acid (HA) and autologous fat (AF) for the treatment of unsightly temporal hollowing after lateral orbital wall decompression in thyroid eye disease.
In this nonblinded prospective comparative interventional study, patients received injections of HA in the right temple and AF in the left temple. Additional injections were given when needed at follow-up after 6, 12, 18, and 24 months. Follow-up included an interview; clinical examination with an evaluation of symmetry, contour, and skin surface; and ultrasound measurements. From photographs, the temporal hollowing was graded 1–3. The main endpoints were grading of temporal hollowing and temporal soft tissue thickness.
Seventeen patients were treated bilaterally and 12 unilaterally (five received HA and seven AF). Injection(s) of HA and AF administered at each site were a median (range) of 1 (1–4) and 2 (1–5), respectively. The total combined volume of HA injected per site was 0.9 (0.2–2.0) ml and that of AF was 3.1 (0.5–9.6) ml. At the final examination, a statistically significant difference in mean (SD) grading scores of temporal hollowing due to HA (1.18 (0.26)) compared to those of AF (1.85 (0.44)) was observed (p < 0.001). Six months after administering an injection of HA, the temporal soft tissue thickness was 2.35 (0.24) cm compared to 2.19 (0.28) cm obtained with an injection of AF (p < 0.001). By using a linear mixed-effect model and adjusting for baseline values, age, sex, and refill, the difference in favor of HA persisted at all later follow-ups. Increased fibrosis of the subcutaneous tissue developed at 5/24 sites that received AF.
Injection of HA is superior to that of AF for treating temporal hollowing after lateral orbital wall decompression.
Steven R. Cohen, MD, FACS Sierra Hewett Lauren Ross Flore Delaunay, MD Ashley Goodacre, PA Char Ramos, ORT Tracy Leong, MD Ahmad Saad, MD
Zuk et al in 2001 identified stem and regenerative cells within the stromal vascular fraction of fat. In preclinical studies, these cells appeared to stimulate angiogenesis and reduce inflammation, and soon thereafter, clinical use of stromal vascular fraction (SVF) evolved as researchers such as Rigotti, Coleman, Mojallal, our group, and others demonstrated that fat can be used for both therapeutic and aesthetic indications. The regenerative effects of fat and its contents on facial aesthetics have been shown at the histologic and cellular level. Regeneration of elastin and collagen fibers as well as improvement in capillary density and reduction of inflammation have been reported. We review our current approach to the use of regenerative cells and different types of fat grafts in facial surgery. The fat graft is classified, both from a regenerative point of view as well as a tissue product that can be modified into different tissue characteristics, depending on the area and condition treated. Clinical use of SVF enriched fat, millifat, microfat, and nanofat grafts as well as composite fat grafts are reviewed. Based on clinical experience and evidence to date, it appears that the regenerative effects seen with the use of SVF in aesthetic surgery are modest, but there appear to be definite histologic findings of regeneration. These improvements may not be clinically apparent to a patient when cell enriched fat grafts are compared to fat grafts alone. However, the subtle changes seen in histology may be cumulative over time. Three types of fat grafts are defined: millifat (parcel size 2.4<), microfat (1.2<), and nanofat (400-600 μm). Each are characterized by their injectability ratings and emulsification parcel size as well as amount of sSVF cells. Newer concepts of periosteal fat grafting, buccal fat pad grafting, pyriform aperture fat grafting, intraorbital fat grafting, and nanofat grafting are discussed. Composite fat grafts are presented as a new concept as is biofilling and biocontouring. The use of regenerative cells in facial surgery is evolving rapidly. Our understanding of the anatomic changes that occur with aging has become more precise and our ability to target histologic changes seen with aging has become more effective. Deep fat compartment grafting, superficial fat grafting, nanofat, and SVF are becoming important components of contemporary facial rejuvenation. The use of regenerative approaches in facial rejuvenation is a logical step in changing the paradigm from surgical treatment of aging to a more proactive prevention and maintenance approach that keeps up with changes in the tissues as they age.
Siah, We Fong; Litwin, Andre S.; Nduka, Charles; Malhotra, Raman
Purpose: To report outcomes and complications of periorbital autologous fat grafting (AFG) in improving volume loss-related symmetry and function in facial nerve palsy patients and to assess patient satisfaction.
Methods: A retrospective, noncomparative review of all facial nerve palsy patients who underwent periorbital AFG at single center over a 4-year period. Two independent graders objectively assessed standard photographs for any change in volume loss and symmetry: pre- and postoperative periods (early, 0–2 months; intermediate, 3–9 months; and late, >10 months). Any adverse outcomes were recorded. Patient satisfaction was assessed by questionnaire survey.
Results: A total of 18 facial nerve palsy patients (13 females) underwent periorbital AFG between February 2011 and 2015. Mean age was 51.9 ± 15.3 years (range, 26–76). Mean follow up was 6.8 ± 4.6 (range, 0.5–15) months. Photographs of 14 patients were eligible for evaluation. Tear trough visibility (p < 0.01), infraorbital rim visibility (p = 0.03), and lower eyelid-cheek junction symmetry (p < 0.01) improved in the early postoperative period with persistence of improvement in the latter parameter at intermediate postoperative period (p < 0.01). Lagophthalmos significantly improved (p = 0.03) in the early postoperative period. Two patients developed cheek cellulitis and 4 had persistent malar edema (3 had existing edema). Questionnaire survey showed a reduction in daytime ocular lubricants and an improvement in nocturnal-lagophthalmos symptoms.
Conclusion: Periorbital AFG is a useful adjunct in improving symmetry and lagophthalmos in facial nerve palsy patients where volume loss is a contributory factor but effects were not long lasting. Patient satisfaction is high. Those with preexisting malar bags are at higher risk of developing persistent malar edema following periorbital AFG.