Orbit, 2014; 33(6): 406–411 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.949787
ORIGINAL ARTICLE
Fat transposition with a single subdermal stitch for the treatment of deep tear trough Ramo´n Medel, Vanessa Hristodulopulos, and LuzMarı´a Va´squez
Orbit Downloaded from informahealthcare.com by Kainan University on 04/09/15 For personal use only.
Institut de Microcirurgia Ocular, Josep Maria Llado 3, Barcelona, Spain
ABSTRACT Goal: To describe a fixation technique of the medial and central fat pads in the subperiosteal pocket for transconjunctival fat transposition, using a single subdermal, non-removable, non-absorbable stitch. Materials and methods: Retrospective study of 19 patients with bilateral deep tear through treated by means of transconjunctival fat transposition. Charts and photographic records were reviewed. Results: Photographical and clinical improvement of the deep tear through and fat prolapse was observed in all patients in variable degrees. There were no intraoperative complications. Significant periocular hematoma occurred in 1 patient and solved without complications. Two patients presented transitory fat pedicle hardening and one patient presented a conjunctival inferior fornix granuloma, surgically removed. All patients were satisfied. Conclusions: Transconjunctival subperiosteal fat transposition with single subdermal stitch to fix the medial and central fat pads, for the treatment of deep tear trough and fat prolapse demonstrated high patient satisfaction, good aesthetic results with no significant or permanent complications. Keywords: Deep tear trough, fat reposition, fat prolapse, transconjunctival blepharoplasty
cheek/malar mound convexity).5 The herniated fat distracts from the deficiency in the trough, which is an independent problem. Nonsurgical correction of the deep tear trough can be performed using fillers such as hyaluronic acid,6,7,8,9 calcium hydroxyapatite,10 polymethylmethacrylate (PMMA)11 among others. Surgical treatment options include autologous fat,12 midface lift,13,14 micro fat grafting15 suborbital malar (cheek) implants16 and transconjunctival lower lid blepharoplasty with fat transposition or transfer.17,18 A transconjunctival blepharoplasty alone may aggravate the appearance of excess skin and increase wrinkling,19,20 and fat removal may increase the concavity rather than restore the youthful lower eyelid leading to skeletonization of the orbital rim.21 Fat transposition is the subperiosteal or supraperiosteal repositioning of the medial and central lower lid herniated orbital fat pads. Advantages of fat
The tear trough is the depression of the medial lower eyelid just lateral to the anterior lacrimal crest, limited in its inferior aspect by the inferior orbital rim. Loeb1 called it a ‘‘nasojugal groove’’ in 1961 and Flowers2 named it the ‘‘tear trough’’ in 1969. Lambros defined it as the junction of the thin lower lid skin with the thicker cheek skin at the medial canthus to the midpupillary line.3 A deep tear trough is characterized by a sunken appearance of the globe that results in the casting of a dark shadow over the nasal lower eyelid, responsible for the fatigued appearance despite adequate rest and cosmetic concealment.4 It becomes more prominent with age and midface descent but it can also be hereditary. A deep tear trough is often associated with herniation of the lower lid fat pads, creating a double-convexity contour deformity (lower eyelid herniated orbital fat convexity followed by the
Received 7 March 2014; Revised 26 June 2014; Accepted 27 July 2014; Published online 5 September 2014 Correspondence: LuzMaria Vasquez, Institut de Microcirurgia Ocular, Josep Maria Llado 3, 08035, Barcelona, Spain. Tel: +34-93 253 15 00. E-mail: [email protected]
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Fat Transposition with a Single Subdermal Stitch repositioning include prevention or improvement of a tear-trough deformity and treatment of the herniated orbital fat. We describe our surgical technique of transconjunctival lower eyelid blepharoplasty with subperiosteal fat repositioning, using a single stitch to fixate the medial and central fat pads.
Orbit Downloaded from informahealthcare.com by Kainan University on 04/09/15 For personal use only.
Patients and Methods Retrospective study of patients treated by means of transconjunctival lower eyelid blepharoplasty with subperiosteal fat reposition, at the Institut de microcirurgia ocular (IMO) between January 2009 and February 2013. Approval for the study was obtained from the research ethics committee of IMO (CEIC-IMO). Examinations included assessment of the distribution and prolapse of the fat pads, deep tear trough, the presence of malar hypoplasia and skin changes. Pictures with and without flash were taken in primary position and upgaze. The primary end points were patient satisfaction as reported to the physician and evaluation of preoperative and postoperative photographs. Due to facial asymmetries, orbits of each patient were evaluated independently. The deep tear trough and fat prolapse was classified in absent, mild, moderate or severe, based in the pre- and postoperative photos and clinical notes.
Surgical Technique The procedure is performed under sedation with local infiltration of bupivacaine 0.5% with epinephrine 1:200,000 through the inferior fornix and infraorbital nerve block, having previously marked the fat pads and the deep tear trough. Through a standard transconjunctival blepharoplasty incision in the inferior fornix the individual fat pads are exposed. Blunt dissection is carried posterior to the orbital septum down to the orbital rim, exposing the periosteum at the inferomedial arcus marginalis where the periosteum is cut to reach the bony surface of the maxilla. With a periosteal elevator, the periosteum of the medial surface of the maxilla is dissected and extended onto the nasal bridge releasing part of the origin of the levator alae nasi muscle in order to create a pocket medial to the infraorbitary nerve. Under direct visualization, the fat pedicles, created from the medial and central fat pads, are gently freed from the inferior oblique muscle and orbital connective tissue, and then transposed over the orbital rim, into the subperiosteal pocket. A 21 g needle is used to perforate the skin at the bottom of the pocket, !
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medial to the marked tear trough close to the nasal bridge, and a double-armed 5-0 prolene suture is passed from the skin in to the subperiosteal space in a transfixing way. Traction is made in a cheese wire like manoeuvre to deepen the suture to a subdermal level. Both ends of the suture emerge from the bottom of the subperiosteal pocket. One end of the suture is passed into the medial fat pedicle engaging its substance, and the second needle is passed through the central fat pedicle. Then the suture is tied pulling the pedicles deep into the pocket through the tear-trough deformity. The lateral fat is removed as needed. The skin can be treated at the end of the procedure with TCA or Er:CO2 if necessary (Figures 1 and 2). Postoperative treatment included mild analgesics, topical and oral prophylactic antibiotics and cold compresses.
RESULTS Thirty-eight orbits of 19 patients were included, 17 females (89%) and 2 males (11%) with ages that ranged from 37 to 74 (mean = 55 years old). Preoperative pictures allowed us to classify 6 orbits as mild deep tear trough, 15 as moderate, and 17 as severe, and the fat prolapse as mild in 10, moderate in 14 and severe in 14. Two patients had photographically significant malar hypoplasia. Mean follow-up time was 14 months (3–45 months). The surgery was performed with a CO2 laser in 12 patients (63%) and with a Colorado needle in 7 patients (37%). Twenty-eight orbits (74%) required lateral fat pad lipectomy. No patient required lateral fat pad reposition to our opinion. Two patients, one with malar hypoplasia and mild fat prolapse and one with mild fat prolapse and severe deep tear trough, required extra fat pearls obtained from the superior eyelid or the periumbilical area. Combined procedures in the same surgical act included superior blepharoplasty (13), medial superior lipectomy (3), ptosis correction (3) and endoscopic brow lifting (1). Five patients received botulin toxin to treat crowfeet and frontal lines. As for inferior eyelid skin management, 15 (80%) patients had TCA peeling and 2 (10%) had Er:CO2 skin resurfacing. Two patients did not require treatment of the skin. There were no intraoperative complications. Mild or moderate postoperative oedema was presented in all patients as expected with any inferior blepharoplasties and/or fat transpositions. Complica tions in the postoperative period included: severe periorbital haematoma in one patient, a granuloma in the inferior fornix in one patient that was surgically removed and hardening of the transposed fat zone in 2 patients that resolved after one month. All patients were satisfied with the surgical outcome. One patient with malar festoons was satisfied
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FIGURE 1. Surgical scheme. Frontal (A) and lateral (B) view of the subperiosteal pocket created medial to the infraorbital nerve. The double-armed suture enters the pocket inferomedial to the deep tear trough, deepened with cheese wire traction, emerging from the bottom and engaging the medial and central fat pads. Frontal (C) and lateral (C) view of the dissected fat pedicles freed from the oblique muscle and intraorbital connective tissue, pulled in to the pocket with the suture. The stitch remains subdermal.
FIGURE 2. Surgical technique. After the creation of subperiosteal pocket (A) both needles of the double-armed suture are passed through the skin entering at the same point, medial to the deep tear trough and close to the nasal bridge (B). Both ends of the suture emerge from the bottom of the subperiosteal pocket (C). After the suture is deepened at a subdermal level, the fat pedicles are engaged (D) and fixed inside the pocket.
with the deep tear trough and fat prolapse improvement despite the partial improvement of the festoon0 s oedema. Postoperative examination and photographs showed improvement of tear trough and fat prolapse
in all patients in varying degrees (Figure 3). Thirty-six orbits (95%) had no residual fat and 2 had mild residual fat. As for the tear trough, 28 (74%) were completely resolved and ten (26%) remained mild. Orbit
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FIGURE 3. Clinical pictures. (A1) Preoperative mild (right) and moderate (left) deep tear trough with bilateral moderate fat prolapse. (A2) Postoperative (13 months) absent deep tear trough and fat prolapse. (B1) Preoperative right mild deep tear trough and fat prolapse, left moderate deep tear trough with mild fat prolapse. (B2) Postoperative (45 months) absent deep tear trough and fat prolapse (C1) Preoperative: severe deep tear trough and fat prolapse. (C2) Postoperative (10 months): absent deep tear trough and fat prolapse. (D1) Preoperative severe deep tear trough and fat prolapse. (D2) postoperative (7 months): right absent deep tear trough and fat prolapses, left absent deep tear trough and mild persistent fat prolapse.
Of those with severe deep tear trough and fat prolapse, 8/17 (47%) had absent postoperative deep tear trough and 12/14 (86%) absent fat prolapse. As for the moderate deep tear trough and fat prolapse, 14/15 (93%) had absent postoperative deep tear trough, and 14/14 (100%) absent fat prolapse. Mild preoperative deep tear trough and fat prolapse resulted absent in all cases.
DISCUSSION Subperiosteal fat transposition under the tear trough aims to lift the depression centred over the medial inferior orbital rim bounded superiorly by the inferior !
2014 Informa Healthcare USA, Inc.
orbital fat protuberance. Candidates for fat repositioning include patients with lower eyelid herniated fat, presence of a tear trough deformity, acceptance of the possible risks and complications and realistic expectations.22 Loss of osseous support and soft tissue, orbital fat herniation above the orbitomalar ligament and the overlying skin changes (skin hyperpigmentation, rhytidosis and sun damage) may contribute to the tear trough deformity. The association of fat repositioning with chemical peelings or laser resurfacing significantly improves the outcomes. All our patients were satisfied with the results including the patient with associated malar festoons. As we know, lower blepharoplasty is not enough to correct malar
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410 R. Medel et al. festoons, albeit the overall appearance improves with the skin treatment and the deep tear trough/fat prolapse improvement. Transconjunctival subperiosteal fat transposition has the advantage of producing a more regular contour due of the deeper position where the fat pedicles are transposed, although this fat flaps can develop some mild degree of reabsorption, fibrosis or liponecrosis.18,23 Transconjunctival approach also diminishes the risk of inferior eyelid retraction as the septum is avoided, although in this technique the inferior margin of the septum, where the arcus marginalis begins, is incised, so eyelid retraction should be monitored. None of our patients has developed retraction. We believe is important to fixate the fat pedicles to give stability in time to the procedure. Of the several fixation techniques described, the most common is transfixing sutures (from subperiosteal space to the skin) with an external knot4,18,23 that are wide and left in place for at least 1 week. A longer postoperative oedema is expected with fat reposition compared with standard blepharoplasty, due to the dissection of the arcus marginalis and the compartment created to introduce the repositioned fat18 Transfixing sutures may block the lymphatic drainage during the period the sutures remain tied delaying the resolution of the oedema above the suture. We believe there is less impairment of the lymphatic drainage with our fixation technique as the suture is more focally located in a subdermal plane. Badley et al. described an interesting supraperiosteal non-removable internal fixation of the medial and central fat pedicles separately.25 However, we prefer the subperiosteal plane that results in a more even external surface, and we only use one stitch to fixate both central and medial pedicles. It is crucial to make adequate traction of the suture and deepen it to completely to avoid the risk of leaving a dimple in the skin or a palpable sub-dermal knot. The traction must be strong enough to achieve cheese-wiring penetration in the tissues without the breaking suture. No patient complained nor was visible on the photographs. Complications of fat repositioning are diplopia due to injury of the inferior oblique muscle, fat granulomas, prolonged oedema, and soft-tissue irregularities. Careful dissection of the fat pedicles is imperative to avoid extraocular muscle traction. Diplopia is usually transient; fat granuloma may be treated with intralesional steroids or with local excision. Prolonged oedema (persisting for more than 6 weeks) may be treated with oral steroids and ultrasound, and soft tissue irregularities may need surgical retouch.22,24 None of our patients had any significant complication. Only 4 of our patients had
transitory minor complications, all completely solved as mentioned in the results. A proper prospective study, based on the clinical evaluation and measurements instead of the clinical pictures, is necessary to achieve a more standard classification. However, the analysis of the clinical charts and photographs allowed us to perceive improvement in all patients, as they all had postoperative absent or mild tear trough or fat prolapse. We believe the best candidates for this technique are patients with any degree of deep tear trough but keeping in mind that some fat prolapse must be present or other methods to obtain fat to fill the subperiosteal pocket under the deep tear trough must be found. Improving the appearance of the inferior eyelid is a complex goal that has to be approached in a multifactorial manner in many of the anatomical layers involved. The reported technique was demonstrated as being reproducible, achieved good aesthetic results and high patient satisfaction. The mentioned potential complications are minor, infrequent and easy to address.
ACKNOWLEDGMENTS Meeting presentation: This research was presented at SECPOO June 2013 and ESOPRS September 2013.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Loeb R. Fat pad sliding and fat grafting for levelling lid depressions. Clin Plast Surg 1981;8:757–776. 2. Flowers RF. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993;20:403–415. 3. Lambros V. Observation on periorbital and midface aging. Plast and Reconstr Surg 2007;120(3):1367–1376. 4. Espinoza G, Holds JB. Evaluation and treatment of the tear trough deformity in lower blepharoplasty. Semin Plast Surg 2007;21(1):57–64. 5. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg 2012;129(6):1392–1402. 6. Kane MC. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg 2005;29:363–367. 7. Hirmand H. Anatomy and non surgical correction of the tear trough deformity. Plast Reconstr Surg 2010;125(2): 699–708. 8. Montes JR. Volumetric considerations for lower eyelid and midface rejuvenation. Curr Opin Ophthalmol 2012; 23(5):443–449.
Orbit
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Fat Transposition with a Single Subdermal Stitch 9. Morley AM, Malhotra R. Use of hyaluronic acid filler for tear-trough. Rejuvenation as an alternative to lower eyelid surgery. Ophthal Plast Reconstr Surg 2011;27(2): 69–73. 10. Sklar JA, White SM. Radiance fn: a new soft tissue filler. Dermatol Surg 2004; 30(5):764–768; discussion 8. 11. Hilinski JM, Cohen SR. Soft tissue augmentation with artefill. Facial Plast Surg 2009;25(2):114–119. 12. Coleman S. Periorbital rejuvenation. Aesthet Surg J 2001;21: 337–343. 13. Persing JA, Knoll B, Shin J. The shade procedure: for lower lid deformities. Plast Reconstr Surg 2008; 121(4):1398–1404. 14. Attire BS, Hayek SN. Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation. Aesthetic Plast Surg 2004; 28(4):197–202. 15. Seiff SR. The fat pearl graft in ophthalmic plastic surgery: everyone wants to be a donor! Orbit 2002; 21(2):105–109. 16. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993;20(2):403–415. 17. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg 1999;15(3):225–229.
!
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18. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000;105(2):743–748; discussion 9–51. 19. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995;96:354–362. 20. Carter SR, Seiff SR, Choo PH, Vallabhanath P. Lower eyelid CO2 laser rejuvenation: A randomized, prospective clinical study. Ophthalmology 2001;108:437–441. 21. Baker SR. Orbital fat preservation in lower-lid blepharoplasty. Arch Facial Plast Surg 1999;1:33–39. 22. Nassif PS. Lower blepharoplasty: transconjunctival fat repositioning. Otolaryngol Clin North Am 2007;40(2): 381–390. 23. Stutman RI, Codner MA. Tear trough deformity: review of anatomy and treatment options. Aesthetic Surg J 2012; 32(4):426–440. 24. Mohadjer Y, Holds JB. Cosmetic lower eyelid blepharoplasty with fat repositioning via intra-SOOF dissection: surgical technique and initial outcomes. Ophthal Plast Reconstr Surg 2006;22(6):409–413. 25. Kawamoto H, Bradley J. The tear trough procedure: transconjunctival repositioning of orbital unipedicled fat. Plast Reconstr Surg 2003;112(7):1903–1907.
ORIGINAL ARTICLE
Fat transposition with a single subdermal stitch for the treatment of deep tear trough Ramo´n Medel, Vanessa Hristodulopulos, and LuzMarı´a Va´squez
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Institut de Microcirurgia Ocular, Josep Maria Llado 3, Barcelona, Spain
ABSTRACT Goal: To describe a fixation technique of the medial and central fat pads in the subperiosteal pocket for transconjunctival fat transposition, using a single subdermal, non-removable, non-absorbable stitch. Materials and methods: Retrospective study of 19 patients with bilateral deep tear through treated by means of transconjunctival fat transposition. Charts and photographic records were reviewed. Results: Photographical and clinical improvement of the deep tear through and fat prolapse was observed in all patients in variable degrees. There were no intraoperative complications. Significant periocular hematoma occurred in 1 patient and solved without complications. Two patients presented transitory fat pedicle hardening and one patient presented a conjunctival inferior fornix granuloma, surgically removed. All patients were satisfied. Conclusions: Transconjunctival subperiosteal fat transposition with single subdermal stitch to fix the medial and central fat pads, for the treatment of deep tear trough and fat prolapse demonstrated high patient satisfaction, good aesthetic results with no significant or permanent complications. Keywords: Deep tear trough, fat reposition, fat prolapse, transconjunctival blepharoplasty
cheek/malar mound convexity).5 The herniated fat distracts from the deficiency in the trough, which is an independent problem. Nonsurgical correction of the deep tear trough can be performed using fillers such as hyaluronic acid,6,7,8,9 calcium hydroxyapatite,10 polymethylmethacrylate (PMMA)11 among others. Surgical treatment options include autologous fat,12 midface lift,13,14 micro fat grafting15 suborbital malar (cheek) implants16 and transconjunctival lower lid blepharoplasty with fat transposition or transfer.17,18 A transconjunctival blepharoplasty alone may aggravate the appearance of excess skin and increase wrinkling,19,20 and fat removal may increase the concavity rather than restore the youthful lower eyelid leading to skeletonization of the orbital rim.21 Fat transposition is the subperiosteal or supraperiosteal repositioning of the medial and central lower lid herniated orbital fat pads. Advantages of fat
The tear trough is the depression of the medial lower eyelid just lateral to the anterior lacrimal crest, limited in its inferior aspect by the inferior orbital rim. Loeb1 called it a ‘‘nasojugal groove’’ in 1961 and Flowers2 named it the ‘‘tear trough’’ in 1969. Lambros defined it as the junction of the thin lower lid skin with the thicker cheek skin at the medial canthus to the midpupillary line.3 A deep tear trough is characterized by a sunken appearance of the globe that results in the casting of a dark shadow over the nasal lower eyelid, responsible for the fatigued appearance despite adequate rest and cosmetic concealment.4 It becomes more prominent with age and midface descent but it can also be hereditary. A deep tear trough is often associated with herniation of the lower lid fat pads, creating a double-convexity contour deformity (lower eyelid herniated orbital fat convexity followed by the
Received 7 March 2014; Revised 26 June 2014; Accepted 27 July 2014; Published online 5 September 2014 Correspondence: LuzMaria Vasquez, Institut de Microcirurgia Ocular, Josep Maria Llado 3, 08035, Barcelona, Spain. Tel: +34-93 253 15 00. E-mail: [email protected]
406
Fat Transposition with a Single Subdermal Stitch repositioning include prevention or improvement of a tear-trough deformity and treatment of the herniated orbital fat. We describe our surgical technique of transconjunctival lower eyelid blepharoplasty with subperiosteal fat repositioning, using a single stitch to fixate the medial and central fat pads.
Orbit Downloaded from informahealthcare.com by Kainan University on 04/09/15 For personal use only.
Patients and Methods Retrospective study of patients treated by means of transconjunctival lower eyelid blepharoplasty with subperiosteal fat reposition, at the Institut de microcirurgia ocular (IMO) between January 2009 and February 2013. Approval for the study was obtained from the research ethics committee of IMO (CEIC-IMO). Examinations included assessment of the distribution and prolapse of the fat pads, deep tear trough, the presence of malar hypoplasia and skin changes. Pictures with and without flash were taken in primary position and upgaze. The primary end points were patient satisfaction as reported to the physician and evaluation of preoperative and postoperative photographs. Due to facial asymmetries, orbits of each patient were evaluated independently. The deep tear trough and fat prolapse was classified in absent, mild, moderate or severe, based in the pre- and postoperative photos and clinical notes.
Surgical Technique The procedure is performed under sedation with local infiltration of bupivacaine 0.5% with epinephrine 1:200,000 through the inferior fornix and infraorbital nerve block, having previously marked the fat pads and the deep tear trough. Through a standard transconjunctival blepharoplasty incision in the inferior fornix the individual fat pads are exposed. Blunt dissection is carried posterior to the orbital septum down to the orbital rim, exposing the periosteum at the inferomedial arcus marginalis where the periosteum is cut to reach the bony surface of the maxilla. With a periosteal elevator, the periosteum of the medial surface of the maxilla is dissected and extended onto the nasal bridge releasing part of the origin of the levator alae nasi muscle in order to create a pocket medial to the infraorbitary nerve. Under direct visualization, the fat pedicles, created from the medial and central fat pads, are gently freed from the inferior oblique muscle and orbital connective tissue, and then transposed over the orbital rim, into the subperiosteal pocket. A 21 g needle is used to perforate the skin at the bottom of the pocket, !
2014 Informa Healthcare USA, Inc.
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medial to the marked tear trough close to the nasal bridge, and a double-armed 5-0 prolene suture is passed from the skin in to the subperiosteal space in a transfixing way. Traction is made in a cheese wire like manoeuvre to deepen the suture to a subdermal level. Both ends of the suture emerge from the bottom of the subperiosteal pocket. One end of the suture is passed into the medial fat pedicle engaging its substance, and the second needle is passed through the central fat pedicle. Then the suture is tied pulling the pedicles deep into the pocket through the tear-trough deformity. The lateral fat is removed as needed. The skin can be treated at the end of the procedure with TCA or Er:CO2 if necessary (Figures 1 and 2). Postoperative treatment included mild analgesics, topical and oral prophylactic antibiotics and cold compresses.
RESULTS Thirty-eight orbits of 19 patients were included, 17 females (89%) and 2 males (11%) with ages that ranged from 37 to 74 (mean = 55 years old). Preoperative pictures allowed us to classify 6 orbits as mild deep tear trough, 15 as moderate, and 17 as severe, and the fat prolapse as mild in 10, moderate in 14 and severe in 14. Two patients had photographically significant malar hypoplasia. Mean follow-up time was 14 months (3–45 months). The surgery was performed with a CO2 laser in 12 patients (63%) and with a Colorado needle in 7 patients (37%). Twenty-eight orbits (74%) required lateral fat pad lipectomy. No patient required lateral fat pad reposition to our opinion. Two patients, one with malar hypoplasia and mild fat prolapse and one with mild fat prolapse and severe deep tear trough, required extra fat pearls obtained from the superior eyelid or the periumbilical area. Combined procedures in the same surgical act included superior blepharoplasty (13), medial superior lipectomy (3), ptosis correction (3) and endoscopic brow lifting (1). Five patients received botulin toxin to treat crowfeet and frontal lines. As for inferior eyelid skin management, 15 (80%) patients had TCA peeling and 2 (10%) had Er:CO2 skin resurfacing. Two patients did not require treatment of the skin. There were no intraoperative complications. Mild or moderate postoperative oedema was presented in all patients as expected with any inferior blepharoplasties and/or fat transpositions. Complica tions in the postoperative period included: severe periorbital haematoma in one patient, a granuloma in the inferior fornix in one patient that was surgically removed and hardening of the transposed fat zone in 2 patients that resolved after one month. All patients were satisfied with the surgical outcome. One patient with malar festoons was satisfied
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FIGURE 1. Surgical scheme. Frontal (A) and lateral (B) view of the subperiosteal pocket created medial to the infraorbital nerve. The double-armed suture enters the pocket inferomedial to the deep tear trough, deepened with cheese wire traction, emerging from the bottom and engaging the medial and central fat pads. Frontal (C) and lateral (C) view of the dissected fat pedicles freed from the oblique muscle and intraorbital connective tissue, pulled in to the pocket with the suture. The stitch remains subdermal.
FIGURE 2. Surgical technique. After the creation of subperiosteal pocket (A) both needles of the double-armed suture are passed through the skin entering at the same point, medial to the deep tear trough and close to the nasal bridge (B). Both ends of the suture emerge from the bottom of the subperiosteal pocket (C). After the suture is deepened at a subdermal level, the fat pedicles are engaged (D) and fixed inside the pocket.
with the deep tear trough and fat prolapse improvement despite the partial improvement of the festoon0 s oedema. Postoperative examination and photographs showed improvement of tear trough and fat prolapse
in all patients in varying degrees (Figure 3). Thirty-six orbits (95%) had no residual fat and 2 had mild residual fat. As for the tear trough, 28 (74%) were completely resolved and ten (26%) remained mild. Orbit
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FIGURE 3. Clinical pictures. (A1) Preoperative mild (right) and moderate (left) deep tear trough with bilateral moderate fat prolapse. (A2) Postoperative (13 months) absent deep tear trough and fat prolapse. (B1) Preoperative right mild deep tear trough and fat prolapse, left moderate deep tear trough with mild fat prolapse. (B2) Postoperative (45 months) absent deep tear trough and fat prolapse (C1) Preoperative: severe deep tear trough and fat prolapse. (C2) Postoperative (10 months): absent deep tear trough and fat prolapse. (D1) Preoperative severe deep tear trough and fat prolapse. (D2) postoperative (7 months): right absent deep tear trough and fat prolapses, left absent deep tear trough and mild persistent fat prolapse.
Of those with severe deep tear trough and fat prolapse, 8/17 (47%) had absent postoperative deep tear trough and 12/14 (86%) absent fat prolapse. As for the moderate deep tear trough and fat prolapse, 14/15 (93%) had absent postoperative deep tear trough, and 14/14 (100%) absent fat prolapse. Mild preoperative deep tear trough and fat prolapse resulted absent in all cases.
DISCUSSION Subperiosteal fat transposition under the tear trough aims to lift the depression centred over the medial inferior orbital rim bounded superiorly by the inferior !
2014 Informa Healthcare USA, Inc.
orbital fat protuberance. Candidates for fat repositioning include patients with lower eyelid herniated fat, presence of a tear trough deformity, acceptance of the possible risks and complications and realistic expectations.22 Loss of osseous support and soft tissue, orbital fat herniation above the orbitomalar ligament and the overlying skin changes (skin hyperpigmentation, rhytidosis and sun damage) may contribute to the tear trough deformity. The association of fat repositioning with chemical peelings or laser resurfacing significantly improves the outcomes. All our patients were satisfied with the results including the patient with associated malar festoons. As we know, lower blepharoplasty is not enough to correct malar
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410 R. Medel et al. festoons, albeit the overall appearance improves with the skin treatment and the deep tear trough/fat prolapse improvement. Transconjunctival subperiosteal fat transposition has the advantage of producing a more regular contour due of the deeper position where the fat pedicles are transposed, although this fat flaps can develop some mild degree of reabsorption, fibrosis or liponecrosis.18,23 Transconjunctival approach also diminishes the risk of inferior eyelid retraction as the septum is avoided, although in this technique the inferior margin of the septum, where the arcus marginalis begins, is incised, so eyelid retraction should be monitored. None of our patients has developed retraction. We believe is important to fixate the fat pedicles to give stability in time to the procedure. Of the several fixation techniques described, the most common is transfixing sutures (from subperiosteal space to the skin) with an external knot4,18,23 that are wide and left in place for at least 1 week. A longer postoperative oedema is expected with fat reposition compared with standard blepharoplasty, due to the dissection of the arcus marginalis and the compartment created to introduce the repositioned fat18 Transfixing sutures may block the lymphatic drainage during the period the sutures remain tied delaying the resolution of the oedema above the suture. We believe there is less impairment of the lymphatic drainage with our fixation technique as the suture is more focally located in a subdermal plane. Badley et al. described an interesting supraperiosteal non-removable internal fixation of the medial and central fat pedicles separately.25 However, we prefer the subperiosteal plane that results in a more even external surface, and we only use one stitch to fixate both central and medial pedicles. It is crucial to make adequate traction of the suture and deepen it to completely to avoid the risk of leaving a dimple in the skin or a palpable sub-dermal knot. The traction must be strong enough to achieve cheese-wiring penetration in the tissues without the breaking suture. No patient complained nor was visible on the photographs. Complications of fat repositioning are diplopia due to injury of the inferior oblique muscle, fat granulomas, prolonged oedema, and soft-tissue irregularities. Careful dissection of the fat pedicles is imperative to avoid extraocular muscle traction. Diplopia is usually transient; fat granuloma may be treated with intralesional steroids or with local excision. Prolonged oedema (persisting for more than 6 weeks) may be treated with oral steroids and ultrasound, and soft tissue irregularities may need surgical retouch.22,24 None of our patients had any significant complication. Only 4 of our patients had
transitory minor complications, all completely solved as mentioned in the results. A proper prospective study, based on the clinical evaluation and measurements instead of the clinical pictures, is necessary to achieve a more standard classification. However, the analysis of the clinical charts and photographs allowed us to perceive improvement in all patients, as they all had postoperative absent or mild tear trough or fat prolapse. We believe the best candidates for this technique are patients with any degree of deep tear trough but keeping in mind that some fat prolapse must be present or other methods to obtain fat to fill the subperiosteal pocket under the deep tear trough must be found. Improving the appearance of the inferior eyelid is a complex goal that has to be approached in a multifactorial manner in many of the anatomical layers involved. The reported technique was demonstrated as being reproducible, achieved good aesthetic results and high patient satisfaction. The mentioned potential complications are minor, infrequent and easy to address.
ACKNOWLEDGMENTS Meeting presentation: This research was presented at SECPOO June 2013 and ESOPRS September 2013.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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