Fat Repositioning With a Combination of Internal Fixation and External Fixation in Transconjunctival Lower Blepharoplasty

12 Aug 2021

Jianwu Chen, MD, Tao Zhang, MM, Xuanru Zhu, MM, Wenhua Huang, MD, PhD

Background

Various methods on transconjunctival fat repositioning have been promoted to treat tear trough deformities in patients with eye bags.

Objectives

The authors present a modified approach based on the facial soft-tissue spaces with the combined fixation method.

Methods

A total 226 patients underwent this procedure. Through a preseptal approach, the premaxillary and prezygomatic spaces were sequentially separated. Orbital fat was repositioned into the spaces together with the septum. The proximal part of the septum-fat flap was sutured to orbital rim with internal fixation, and their distal stumps were fixed to the end of the soft spaces with externalized percutaneous sutures. Surgical outcome was assessed by surgeons based on Hirmand’s grading system. Patients’ satisfaction and quality of life were measured using FACE-Q scales. Magnetic resonance imaging was employed to assess the long-term fate of the transposed fat.

Results

Tear trough deformities were eliminated in 86.7% of cases. Scores of lower eyelid FACE-Q decreased significantly (P < 0.05). Patients demonstrated enhanced social confidence (P < 0.05) and high satisfaction (74.3 ± 17.2) and were satisfied with their decision to undergo blepharoplasty (78.2 ± 18.7). Undercorrection occurred in 1 patient. Additional complications included transient granulomas, dye eye, unexplained swelling, and numbness, which resolved in all patients. Magnetic resonance imaging confirmed viability of the transposed fat within 6 to 8 months follow-up.

Conclusions

Transconjunctival fat repositioning, utilizing a combination of internal fixation and external fixation, is an effective approach to treat eye bags and tear trough deformities with good patient and surgeon satisfaction.

https://academic.oup.com/asj/article/41/8/893/6127292

COMMENTARY:

Guy Massry, MD

This is a well-written report on a novel technique of fat flap fixation during transconjunctival lower blepharoplasty with fat repositioning (TCBFR).1 As a specialty surgeon (oculoplastic surgery) I have had the opportunity to perform high volumes of TCBFR for the last 20 years. I have attempted every permutation of the procedure and have settled on what in my hands is the safest, most consistent, and most reproducible variant: a retroseptal approach involving subperiosteal fat redraping with external suture fixation.2 Given this, I appreciate all efforts at advancing and improving outcomes to this common procedure which has shown such great utility in effacing lower eyelid-cheek interface depressions.3 In this vein, I congratulate the authors on their work, and,…

https://academic.oup.com/asj/article-abstract/41/8/903/6127273?redirectedFrom=fulltext

Journal : Aesthetic Surgery Journal

Ref : Facial Aesthetics Fat repositioning Lower lid blepharoplasty

Current Upper Blepharoplasty and Ptosis Management Practice Patterns Among The Aesthetic Society Members

11 May 2021

Elbert E Vaca, MD, Jonathan T Bricker, BS, Mohammed S Alghoul, MD, FACS

Background

Patients presenting for upper blepharoplasty can exhibit different aging patterns and we have anecdotally observed wide variability in upper blepharoplasty approaches among surgeons. However, upper blepharoplasty practice patterns have not been systematically analyzed among members of The Aesthetic Society.

Objectives

The aim of this study was to report upper blepharoplasty practice patterns, the recognition of different patient presenting features, and to assess the incidence and management of ptosis as reported by members of The Aesthetic Society.

Methods

A 29-item electronic questionnaire was distributed to 1729 Aesthetic Society members with available email addresses.

Results

In total, 214 Aesthetic Society members submitted the questionnaire, for a response rate of 12.4%. There was a significantly increased rate of volume preservation among surgeons with greater experience (≥10 years in practice) and a high-volume (≥100 cases in past 12 months) of upper blepharoplasty cases. Furthermore, high-volume upper blepharoplasty surgeons were significantly more likely to perform concomitant upper lid fat grafting (P = 0.03), browlift (P = 0.02), and ptosis repair (P = 0.01). Ninety-five percent of respondents reported a mild/moderate ptosis (MRD1 2 to <4mm) incidence of <25%. Among surgeons who perform ptosis repair, 97.4% utilize levator advancement or plication as their most commonly used technique.

Conclusions

High-volume upper blepharoplasty surgeons are more likely to preserve upper lid volume and perform concomitant browlift and ptosis repair. Our data suggest that different upper eyelid aging patterns and mild/moderate ptosis are underrecognized.

https://academic.oup.com/asj/article/41/5/NP198/6042587

COMMENTARY:

Victoria S North, MD, Ann Q Tran, MD, Richard D Lisman, MD, FACS

We read “Current Upper Blepharoplasty and Ptosis Management Practice Patterns Among The Aesthetic Society Members” 1 with interest and commend Drs Vaca et al on their important contribution to the literature. This represents the first and largest collation of the standards of our peers for ptosis management amongst board-certified plastic surgeons. Their article raises many important considerations in approaching the patient with upper eyelid aging, notably the importance of identifying and appropriately managing involutional ptosis. In our opinion, an understanding of the complex mechanisms that underlie the clinical appearance of ptosis is vital to achieve the desired aesthetic result…..

https://academic.oup.com/asj/article/41/5/NP210/6145988

Journal : Aesthetic Surgery Journal

Ref : Acquired ptosis Facial Aesthetics Oculoplastics Upper blepharoplasty

Secondary Upper Blepharoplasty: Converting Static Folds Into Dynamic Folds

11 May 2021

Jiuzuo Huang, MD, Shouyun Feng, MD, Ruijia Dong, BS, Hefei Wang, MD, Sam T Hamra, MD, Zhigang Liu, MD, Xiao Long, MD

Background

For the patients seeking secondary upper blepharoplasty, a static double-eyelid fold featuring an immobile lower flap and depression of the fold is common.

Objectives

In this study, the authors propose a novel technique of reconstructing pretarsal tissue defects (PTDs) to converting static folds to dynamic folds.

Methods

A total of 203 patients with static folds underwent revision surgery. After complete adhesion release of the lower flap, a PTD was identified, which was defined as an area deficient of orbicularis oculi muscle in front of the tarsal plate. If the width of the PTD was over 2 mm, tissue transfer was performed to reconstruct the PTD, usually with a free retro-orbicularis oculus fat graft or a pretarsal orbicularis oculi flap.

Results

Among the 105 patients with severe static folds, 67 received retro-orbicularis oculus fat grafts and 38 received orbicularis oculi muscle flaps. This technique converted a static fold into a dynamic fold. The surgery satisfaction rate was 86.7%. Complications included partial fold loss (n = 7, 3.4%), complete fold loss (n = 3, 1.5%), sunken upper eyelids (n = 5, 2.5%), multiple folds (n = 3, 1.5%), an unnatural curve of the double fold (n = 5, 2.5%), and asymmetric folds (n = 4, 2.0%).

Conclusions

To convert a static fold to a dynamic fold, we devised a technique that releases adhesion of the lower flap and reconstructs the PTD with retro-orbicularis oculus fat graft or an orbicularis oculi muscle flap. Our study achieved a high patient satisfaction rate, and the resulting fold mimicked the dynamics of the congenital double-eyelid fold.

https://academic.oup.com/asj/article-abstract/41/5/NP188/6012403?redirectedFrom=fulltext

COMMENTARY:

Edmund Kwan, MD

The double eyelid fold is the most widely performed surgery among Asians around the world.1 The creation of a fold will yield a brighter, more youthful, and refreshed appearance of the upper orbital region. However, an upper eyelid fold can result in an unnatural and operated look. The surgery is fraught with many hidden postoperative complications, some of which are difficult to revise. The authors have presented one of the most common undesired outcomes of this surgery.2 This subtle issue may go unnoticed to the untrained eye, but it is a frequent cause of dissatisfaction.

I applaud the authors for identifying the pretarsal tissue defect and scar adherence to the levator as the main culprit. The double eyelid…

https://academic.oup.com/asj/article-abstract/41/5/NP196/6132280?redirectedFrom=fulltext

Journal : Aesthetic Surgery Journal

Ref : Blepharoplasty Facial Aesthetics Upper lid blepharoplasty

Dermal Onlay Grafts: A Rescue Procedure for Secondary Inferior Periorbital Hollows

2 Apr 2021

Yao Wang, MD, Raymond S Douglas, MD, Amy Patel, MD, John Holds, MD, Guy G Massry, MD

Background

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.

Objectives

The aim of this study was to describe the surgical technique and outcomes of DOGs for secondary POHs.

Methods

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.

Results

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.

Conclusions

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.

https://academic.oup.com/asj/article-abstract/41/4/418/5875040?redirectedFrom=fulltext

COMMENTARY:

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…

https://academic.oup.com/asj/article-abstract/41/4/426/6134574?redirectedFrom=fulltext

Journal : Aesthetic Surgery Journal

Ref : Autologous fat grafting Dermal filler Dermal graft Facial Aesthetics Periorbital hollows