Aesth Plast Surg DOI 10.1007/s00266-014-0275-9
I N N OV A T I V E T E C H N I QU E S
AESTHETIC
Subciliary Augmentation of the Lower Eyelid in Asians Using a Deep Temporal Fascia Graft: A Preliminary Report Tsutomu Mizuno
Received: 10 August 2013 / Accepted: 3 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background Pretarsal fullness of the lower eyelid has recently gained popularity in the Asian population. Hyaluronic acid injection is a simple, nonsurgical method for creating pretarsal fullness of the lower eyelid, but the effects last only 6–12 months. A need exists for a surgical procedure with long-term effects. We describe the use of a deep temporal fascia graft for subciliary augmentation of the lower eyelid. Methods Between September 2009 and October 2011, seven Japanese patients underwent subciliary augmentation of the lower eyelid. This retrospective study was conducted on four of the seven patients who were followed for more than 1 year. A skin incision of approximately 1 cm was made at the lateral canthus along the subciliary crease of the lower eyelid and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made 2 mm below the ciliary margin near the level of the lower lacrimal punctum. The orbicularis oculi muscle was incised under the skin incision at the lateral canthus, and the stump of the incised muscle was suspended to the periosteum of the lateral orbital rim. A deep temporal fascia graft was placed in the undermined subcutaneous plane of the lower eyelid. Results Lower-eyelid pretarsal fullness was maintained at more than 1 year after surgery. The eyelids regained a natural appearance, and the patients were highly satisfied. Morphometric measurements demonstrated increased projection and width of the lower-eyelid pretarsal fullness. Conclusions Deep temporal fascia grafting is safe and reliable for subciliary augmentation of the lower eyelid.
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www. springer.com/00266. Keywords Lower-eyelid blepharoplasty Asian blepharoplasty Temporal fascia graft Pretarsal fullness Introduction Double-eyelid blepharoplasty, levator aponeurosis surgery, and epicanthoplasty are frequently performed in Asian countries, and additional surgical options have been developed in response to patient desires [1]. Pretarsal fullness of the lower eyelid, known as namidabukuro (in Japanese) [2], has recently gained popularity because it is believed to be associated with good luck in Asian physiognomy and it is also perceived as more attractive and youthful [3]. Hyaluronic acid injections are a simple, nonsurgical method to create pretarsal fullness of the lower eyelid. However, because hyaluronic acid is gradually absorbed, the effect of the injection is temporary, lasting 6–12 months, creating the need for a surgical procedure with long-term effects. However, the literature provides few examples of surgically created pretarsal fullness of the lower eyelid. Here I describe a deep temporal fascia graft for subciliary augmentation of the lower eyelid. Materials and Methods
T. Mizuno (&) Anesis Biyou Clinic, Meipuru Bldg. 9F, 3-20-17 Nishiki, Naka-ku, Nagoya 460-0003, Aichi Prefecture, Japan e-mail: [email protected]
Patients Between September 2009 and October 2011, seven Japanese patients underwent subciliary augmentation of the
123
Aesth Plast Surg Table 1 Patient demographic and morphometric data of pretarsal fullness Case
Age (years)
Sex
Follow-up (months)
Size of hDTF (mm)
Projection (mm) Pre
Width (mm) Post
Pre
Post
Right
Left
Right
Left
Right
Left
Right
Left
1
41
F
35
40 9 20
0.4
0.2
1.6
1.4
5.0
5.2
6.8
7.0
2
38
F
19
30 9 15
0.2
0.2
1.6
1.4
4.8
5.2
6.8
6.4
3 4
36 24
F F
34 24
23 9 20 32 9 25
0.2 0.6
0.2 0.2
1.6 1.6
1.6 1.4
5.8 5.2
5.2 5.2
6.8 6.8
7.4 7.2
Mean
34.8
28
31.3 9 20.0
0.4
1.5
4.9
7.0
F female, hDTF harvested deep temporal fascia, Pre preoperatively, Post postoperatively, Right right lower eyelid, Left left lower eyelid
lower eyelid using a deep temporal fascia graft. A retrospective clinical study was conducted on four patients who were followed up for more than 1 year (range 19–35 months; mean 28 months). All patients were female and the average age was 34.8 years (range 24–41 years) (Table 1). Patients were asked to quantify their subjective satisfaction at the last follow-up visit. The details of the study and technique were explained to all patients and written informed consent was obtained. This research conformed to the tenets of the Declaration of Helsinki. All preoperative and postoperative photographs were analyzed and postoperative histories were reviewed to assess complications, including postoperative infection, graft absorption, graft extrusion, ectropion, epiphora, and donor site morbidity. Surgical Technique The technique can be performed with the patient under local anesthesia, intravenous sedation, or general anesthesia. To harvest a temporal fascia graft, lidocaine (1 %) with epinephrine was injected to anesthetize the temporal area. A vertical skin incision was made in the unilateral hairbearing temporal area. After wide dissection, a deep temporal fascia segment, measuring approximately 3 9 2 cm, was harvested; the segment was then divided into two equal parts. The skin of the donor site was closed with staples, which were removed after 1 week. An approximately 1-cm skin incision was made at the lateral canthus along the subciliary crease of the lower eyelid and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made 2 mm below the ciliary margin near the level of the lower lacrimal punctum (Fig. 1a). The orbicularis oculi muscle was incised under the skin incision at the lateral canthus, and the stump of the incised muscle was suspended to the periosteum of the lateral orbital rim using 4-0 Vicryl suture (Fig. 1b). The deep temporal fascia graft was rolled into a
123
tube shape without sutures, introduced at the lateral canthus skin incision using mosquito forceps (Fig. 1c), and placed in the undermined subcutaneous plane of the lower eyelid (Fig. 1d). The skin incision was closed with 7-0 nylon sutures, which were removed after 1 week. Morphometric Measurements The clinical evaluation of surgical outcomes was performed by comparing morphometric parameters that were measured on facial photographs. Each patient held a ruler in front of the face while the photograph was taken. The projection and width of pretarsal fullness of the lower eyelid were measured from the photographic profile view (Fig. 2). The pretarsal fullness projection was defined as the distance in millimeters between the top of the pretarsal fullness and a line drawn from the upper edge of the lower eyelid to the lower edge of the pretarsal fullness. The width of the pretarsal fullness of the lower eyelid was defined as the distance in millimeters between the upper edge of the lower eyelid and the lower edge of the pretarsal fullness. Two measurements were obtained and the average value for each case was calculated.
Results Pretarsal fullness of the lower eyelid was maintained for more than 1 year postoperatively. The surgery provided a natural appearance, and all patients were highly satisfied with the aesthetic results. Revision surgery was not required for any patient. No prospective complications such as postoperative infection, graft absorption, graft extrusion, ectropion, epiphora, or donor site morbidity were observed in any patient during the follow-up period. Three representative clinical cases are shown in Figs. 3, 4, and 5 and morphometric outcomes are listed in Table 1. The pretarsal fullness projection and width of the lower
Aesth Plast Surg Fig. 1 Surgical technique for subciliary augmentation of the lower eyelid using a temporal fascia graft. a A skin incision of approximately 1 cm was made at the lateral canthus along the subciliary crease of the lower eyelid, and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made at the medial canthus. b The orbicularis oculi muscle was suspended to the periosteum of the lateral orbital rim using 4-0 Vicryl suture. c A deep temporal fascia graft was introduced at the lateral canthus skin incision using mosquito forceps. d This graft was placed in the undermined subcutaneous plane of the lower eyelid
Fig. 2 Measured parameters. The width of the pretarsal fullness of the lower eyelid was defined as the distance between the upper edge of the lower eyelid and the lower edge of the pretarsal fullness (in mm). The projection of the pretarsal fullness was defined as the distance between the top of the pretarsal fullness and a line drawn from the upper edge of the lower eyelid to the lower edge of the pretarsal fullness (in mm)
eyelid increased after surgery from 0.4 to 1.5 mm and from 4.9 to 7.0 mm, respectively.
Discussion Pretarsal fullness of the lower eyelid should be differentiated from baggy eyelids caused by fat protrusion [4, 5]. While baggy eyelids give an appearance of aging, pretarsal
fullness of the lower eyelid provides a youthful appearance, especially among Asians. Recently, hyaluronic acid injection to create pretarsal fullness of the lower eyelid has become a popular aesthetic procedure in Japan. Hyaluronic acid injection is advantageous because it is readily available in any desired volume and does not involve donor site morbidity. However, the effect is temporary. In our patients, other disadvantages include a pale transparent appearance because of the liquid nature of hyaluronic acid, and the gradual widening of pretarsal fullness over time. Therefore, there is a need for a surgical procedure with a long-term effect that also creates a natural appearance. However, there are few reports on the surgical creation of lower-eyelid pretarsal fullness. We found that temporal fascia grafting was a safe and reliable method for subciliary augmentation of the lower eyelid. Until recently, there had been few reports on surgically created pretarsal fullness of the lower eyelid [2, 3, 6–8]. However, in 2013, Chen et al. [9] described the detailed anthropometry of pretarsal fullness of the lower eyelid in the Chinese population. Pretarsal fullness of the lower eyelid is associated with a muscle roll, which attenuates when smiling. Chen et al. [9] divided pretarsal fullness of the lower eyelid into static and dynamic types. When a person smiles, the contraction of the orbicularis oculi muscle changes static pretarsal fullness to dynamic. Chen et al. [9] also reported that the prevalence of static pretarsal fullness was 19.2 %, and the width of static pretarsal fullness was 6.1–7.5 mm, with a reported mean width of the surgically created static pretarsal fullness of 7.0 mm. Orbicularis oculi muscle hypertrophy and/or the preseptal orbicularis oculi muscle overriding the pretarsal orbicularis
123
Aesth Plast Surg Fig. 3 Case 1: a 41-year-old woman requested pretarsal fullness of the lower eyelid. a, c, e Preoperative view. b, d, f Postoperative view at 2 years 11 months after subciliary augmentation of the lower eyelid using a deep temporal fascia graft measuring 40 mm 9 20 mm. Surgically created pretarsal fullness of the lower eyelid was maintained after surgery and postoperative patient satisfaction was high
Fig. 4 Case 2: a 38-year-old woman requested pretarsal fullness of the lower eyelid. a, c, e Preoperative view. b, d, f Postoperative view observed at 1 year 7 months after subciliary augmentation of the lower eyelid using a deep temporal fascia graft measuring 30 mm 9 15 mm. Surgically created pretarsal fullness of the lower eyelid was maintained after surgery and postoperative patient satisfaction was high
oculi muscle are the generally accepted causes of static pretarsal fullness. In contrast, Tsurukiri and Iwanami [2] reported that pretarsal fullness of the lower eyelid was
123
caused by a difference in subcutaneous fat volume. Therefore, the cause of static pretarsal fullness of the lower eyelid remains unclear.
Aesth Plast Surg Fig. 5 Case 3: a 36-year-old woman requested pretarsal fullness of the lower eyelid. a, c, e, g Preoperative view. b, d, f, h Postoperative view observed 2 years 10 months after subciliary augmentation of the lower eyelid using a deep temporal fascia graft measuring 23 mm 9 20 mm. Surgically created pretarsal fullness of the lower eyelid was maintained after surgery. Dynamic pretarsal fullness was slightly visible when she smiled after the surgery and the postoperative patient satisfaction was high
Subciliary augmentation of the lower eyelid using a deep temporal fascia graft provided satisfactory patient outcomes in our study. Before developing this surgical procedure, I performed the orbicularis oculi muscle overlapping procedure [7–9]. However, that procedure resulted in subtle changes that were less satisfactory to patients. To create a greater volume, a deep temporal fascia graft was used, which is a useful autologous graft for various facial plastic surgery procedures such as augmentation rhinoplasty [10–12], lip augmentation [13, 14], and the repair of upper-eyelid retraction [15]. An excellent effect was obtained by applying a deep temporal fascia graft for subciliary augmentation of the lower eyelid. Placement of a deep temporal fascia graft in the subcutaneous plane is thought to produce a greater bulging effect for pretarsal
fullness than placement in the submuscular plane of the lower eyelid. Despite the superficial placement of this graft, unnatural graft visibility was not observed in any patient. This surgical procedure is similar to that of the autogenous fascial sling procedure [16]. However, the shape of the graft in the autogenous fascial sling technique is a narrow strip and its purpose is to support the lower eyelid. In contrast, the purpose of our surgical procedure is to create a filling or bulging effect of the lower eyelid. Suspension of the orbicularis oculi muscle [17] was combined with deep temporal fascia grafting to create pretarsal fullness of the lower eyelid. The purpose of the muscle suspension was to make the lower border of the pretarsal fullness more distinct. Although some volume of the lower-eyelid pretarsal fullness was increased by the
123
Aesth Plast Surg
muscle suspension immediately after surgery, this may decrease over time because of muscle detachment from the periosteum or muscle atrophy. The surgical technique as described in this report is an excellent option for creating pretarsal fullness of the lower eyelid. However, a potential limitation is the limited amount of graft material available, which allows for only relatively small pretarsal fullness. If patients desire more prominent pretarsal lower-eyelid fullness, a greater volume of temporal fascia graft may be required. Some potential risk associated with this procedure must be considered. First, the surgical procedure itself is quite straightforward, but the lachrymal canaliculi are nearby. Therefore, this technique has a learning curve and should be performed by surgeons with experience working in the periocular region to prevent epiphora due to lachrymal injury. Also, late postoperative epiphora might occur because of tissue scarring around the graft that impairs lower-lid muscular function as a lachrymal pump. However, we place the graft subcutaneously, not submuscularly, so this risk is considered to be lower. Second, the grafts might be visible when the patient’s lower-eyelid skin and the soft tissue surrounding the graft undergo natural senescence later in life. The grafts might also predispose the lower eyelids to early ectropion due to their added bulk and weight. These aesthetic and functional uncertainties may affect long-lasting aesthetic outcomes.
Conclusion Subciliary augmentation of the lower eyelid using a deep temporal fascia graft is a new and effective option that provides satisfactory results for patients desiring an increase in pretarsal fullness. The use of a deep temporal fascia graft was proven to be safe, reliable, and consistent in our series of four patients who were followed retrospectively. To further corroborate these preliminary results, a study with a larger sample size and longer follow-up period is required. Adjusting the size of the lower-eyelid pretarsal fullness is a future challenge for clinicians. Conflict of interest The author has no conflicts of interest to disclose and declares that no financial support was received for this study.
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References 1. Hirohi T, Yoshimura K (2011) Vertical enlargement of the palpebral aperture by static shortening of the anterior and posterior lamellae of the lower eyelid: a cosmetic option for Asian eyelids. Plast Reconstr Surg 127:396–408 2. Tsurukiri K, Iwanami M (2005) The anatomy and clinical applications of ‘‘namidaburuko’’. J Jpn Aesthet Plast Surg 27: 165–172 3. McCurdy JA (2005) Asian blepharoplasty. In: McCurdy JA, Lam SM (eds) Cosmetic surgery of the Asian face, 2nd edn. Thieme, New York, pp 8–41 4. Momosawa A, Kurita M, Ozaki M, Miyamoto S, Kurachi I, Watanabe R, Harii K (2008) Transconjunctival orbital fat repositioning for tear trough deformity in young Asians. Aesthet Surg J 28:265–271 5. Guo L, Bi H, Xue C, Xue C, Li J, Yan C, Song J, Zhang M, Xing X (2010) Comprehensive considerations in blepharoplasty in an Asian population: a 10-year experience. Aesthetic Plast Surg 34: 466–474 6. Sheen JH (1978) Tarsal fixation in lower blepharoplasty. Plast Reconstr Surg 62:24–31 7. Lewis JM (1988) Augmentation blepharoplasty. Ann Plast Surg 21:434–438 8. Fodor PB (1989) Lower lid ‘‘tarsal fixation’’ blepharoplasty: a personal technique. Aesthetic Plast Surg 13:273–277 9. Chen MC, Ma H, Liao WC (2013) Anthropometry of pretarsal fullness and eyelids in Oriental women. Aesthetic Plast Surg 37: 617–624 10. Miller TA (1988) Temporalis fascia grafts for facial and nasal contour augmentation. Plast Reconstr Surg 81:524–533 11. Baker TM, Courtiss EH (1994) Temporalis fascia grafts in open secondary rhinoplasty. Plast Reconstr Surg 93:802–810 12. Besharatizadeh R, Ozkan BT, Tabrizi R (2011) Complete or a partial sheet of deep temporal fascial graft as a radix graft for radix augmentation. Eur Arch Otorhinolaryngol 268:1449–1453 13. Dickinson BP, Roy I, Lesavoy MA (2011) Temporal fascia for lip augmentation. Ann Plast Surg 66:114–117 14. Bohluli B, Amirzargar R, Moharamnejad N (2013) Augmentation of the upper lip with temporal fascia: a quantitative analysis. Aesthet Surg J 33:102–108 15. Schwarz GS, Spinelli HM (2008) Correction of upper eyelid retraction using deep temporal fascia spacer grafts. Plast Reconstr Surg 122:765–774 16. de la Torre J, Simpson RL, Tenenhaus M, Bourhill I (2001) Using lower eyelid fascial slings for recalcitrant burn ectropion. Ann Plast Surg 46:621–624 17. Mladick RA (1979) The muscle-suspension lower blepharoplasty. Plast Reconstr Surg 64:171–175
I N N OV A T I V E T E C H N I QU E S
AESTHETIC
Subciliary Augmentation of the Lower Eyelid in Asians Using a Deep Temporal Fascia Graft: A Preliminary Report Tsutomu Mizuno
Received: 10 August 2013 / Accepted: 3 January 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background Pretarsal fullness of the lower eyelid has recently gained popularity in the Asian population. Hyaluronic acid injection is a simple, nonsurgical method for creating pretarsal fullness of the lower eyelid, but the effects last only 6–12 months. A need exists for a surgical procedure with long-term effects. We describe the use of a deep temporal fascia graft for subciliary augmentation of the lower eyelid. Methods Between September 2009 and October 2011, seven Japanese patients underwent subciliary augmentation of the lower eyelid. This retrospective study was conducted on four of the seven patients who were followed for more than 1 year. A skin incision of approximately 1 cm was made at the lateral canthus along the subciliary crease of the lower eyelid and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made 2 mm below the ciliary margin near the level of the lower lacrimal punctum. The orbicularis oculi muscle was incised under the skin incision at the lateral canthus, and the stump of the incised muscle was suspended to the periosteum of the lateral orbital rim. A deep temporal fascia graft was placed in the undermined subcutaneous plane of the lower eyelid. Results Lower-eyelid pretarsal fullness was maintained at more than 1 year after surgery. The eyelids regained a natural appearance, and the patients were highly satisfied. Morphometric measurements demonstrated increased projection and width of the lower-eyelid pretarsal fullness. Conclusions Deep temporal fascia grafting is safe and reliable for subciliary augmentation of the lower eyelid.
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www. springer.com/00266. Keywords Lower-eyelid blepharoplasty Asian blepharoplasty Temporal fascia graft Pretarsal fullness Introduction Double-eyelid blepharoplasty, levator aponeurosis surgery, and epicanthoplasty are frequently performed in Asian countries, and additional surgical options have been developed in response to patient desires [1]. Pretarsal fullness of the lower eyelid, known as namidabukuro (in Japanese) [2], has recently gained popularity because it is believed to be associated with good luck in Asian physiognomy and it is also perceived as more attractive and youthful [3]. Hyaluronic acid injections are a simple, nonsurgical method to create pretarsal fullness of the lower eyelid. However, because hyaluronic acid is gradually absorbed, the effect of the injection is temporary, lasting 6–12 months, creating the need for a surgical procedure with long-term effects. However, the literature provides few examples of surgically created pretarsal fullness of the lower eyelid. Here I describe a deep temporal fascia graft for subciliary augmentation of the lower eyelid. Materials and Methods
T. Mizuno (&) Anesis Biyou Clinic, Meipuru Bldg. 9F, 3-20-17 Nishiki, Naka-ku, Nagoya 460-0003, Aichi Prefecture, Japan e-mail: [email protected]
Patients Between September 2009 and October 2011, seven Japanese patients underwent subciliary augmentation of the
123
Aesth Plast Surg Table 1 Patient demographic and morphometric data of pretarsal fullness Case
Age (years)
Sex
Follow-up (months)
Size of hDTF (mm)
Projection (mm) Pre
Width (mm) Post
Pre
Post
Right
Left
Right
Left
Right
Left
Right
Left
1
41
F
35
40 9 20
0.4
0.2
1.6
1.4
5.0
5.2
6.8
7.0
2
38
F
19
30 9 15
0.2
0.2
1.6
1.4
4.8
5.2
6.8
6.4
3 4
36 24
F F
34 24
23 9 20 32 9 25
0.2 0.6
0.2 0.2
1.6 1.6
1.6 1.4
5.8 5.2
5.2 5.2
6.8 6.8
7.4 7.2
Mean
34.8
28
31.3 9 20.0
0.4
1.5
4.9
7.0
F female, hDTF harvested deep temporal fascia, Pre preoperatively, Post postoperatively, Right right lower eyelid, Left left lower eyelid
lower eyelid using a deep temporal fascia graft. A retrospective clinical study was conducted on four patients who were followed up for more than 1 year (range 19–35 months; mean 28 months). All patients were female and the average age was 34.8 years (range 24–41 years) (Table 1). Patients were asked to quantify their subjective satisfaction at the last follow-up visit. The details of the study and technique were explained to all patients and written informed consent was obtained. This research conformed to the tenets of the Declaration of Helsinki. All preoperative and postoperative photographs were analyzed and postoperative histories were reviewed to assess complications, including postoperative infection, graft absorption, graft extrusion, ectropion, epiphora, and donor site morbidity. Surgical Technique The technique can be performed with the patient under local anesthesia, intravenous sedation, or general anesthesia. To harvest a temporal fascia graft, lidocaine (1 %) with epinephrine was injected to anesthetize the temporal area. A vertical skin incision was made in the unilateral hairbearing temporal area. After wide dissection, a deep temporal fascia segment, measuring approximately 3 9 2 cm, was harvested; the segment was then divided into two equal parts. The skin of the donor site was closed with staples, which were removed after 1 week. An approximately 1-cm skin incision was made at the lateral canthus along the subciliary crease of the lower eyelid and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made 2 mm below the ciliary margin near the level of the lower lacrimal punctum (Fig. 1a). The orbicularis oculi muscle was incised under the skin incision at the lateral canthus, and the stump of the incised muscle was suspended to the periosteum of the lateral orbital rim using 4-0 Vicryl suture (Fig. 1b). The deep temporal fascia graft was rolled into a
123
tube shape without sutures, introduced at the lateral canthus skin incision using mosquito forceps (Fig. 1c), and placed in the undermined subcutaneous plane of the lower eyelid (Fig. 1d). The skin incision was closed with 7-0 nylon sutures, which were removed after 1 week. Morphometric Measurements The clinical evaluation of surgical outcomes was performed by comparing morphometric parameters that were measured on facial photographs. Each patient held a ruler in front of the face while the photograph was taken. The projection and width of pretarsal fullness of the lower eyelid were measured from the photographic profile view (Fig. 2). The pretarsal fullness projection was defined as the distance in millimeters between the top of the pretarsal fullness and a line drawn from the upper edge of the lower eyelid to the lower edge of the pretarsal fullness. The width of the pretarsal fullness of the lower eyelid was defined as the distance in millimeters between the upper edge of the lower eyelid and the lower edge of the pretarsal fullness. Two measurements were obtained and the average value for each case was calculated.
Results Pretarsal fullness of the lower eyelid was maintained for more than 1 year postoperatively. The surgery provided a natural appearance, and all patients were highly satisfied with the aesthetic results. Revision surgery was not required for any patient. No prospective complications such as postoperative infection, graft absorption, graft extrusion, ectropion, epiphora, or donor site morbidity were observed in any patient during the follow-up period. Three representative clinical cases are shown in Figs. 3, 4, and 5 and morphometric outcomes are listed in Table 1. The pretarsal fullness projection and width of the lower
Aesth Plast Surg Fig. 1 Surgical technique for subciliary augmentation of the lower eyelid using a temporal fascia graft. a A skin incision of approximately 1 cm was made at the lateral canthus along the subciliary crease of the lower eyelid, and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made at the medial canthus. b The orbicularis oculi muscle was suspended to the periosteum of the lateral orbital rim using 4-0 Vicryl suture. c A deep temporal fascia graft was introduced at the lateral canthus skin incision using mosquito forceps. d This graft was placed in the undermined subcutaneous plane of the lower eyelid
Fig. 2 Measured parameters. The width of the pretarsal fullness of the lower eyelid was defined as the distance between the upper edge of the lower eyelid and the lower edge of the pretarsal fullness (in mm). The projection of the pretarsal fullness was defined as the distance between the top of the pretarsal fullness and a line drawn from the upper edge of the lower eyelid to the lower edge of the pretarsal fullness (in mm)
eyelid increased after surgery from 0.4 to 1.5 mm and from 4.9 to 7.0 mm, respectively.
Discussion Pretarsal fullness of the lower eyelid should be differentiated from baggy eyelids caused by fat protrusion [4, 5]. While baggy eyelids give an appearance of aging, pretarsal
fullness of the lower eyelid provides a youthful appearance, especially among Asians. Recently, hyaluronic acid injection to create pretarsal fullness of the lower eyelid has become a popular aesthetic procedure in Japan. Hyaluronic acid injection is advantageous because it is readily available in any desired volume and does not involve donor site morbidity. However, the effect is temporary. In our patients, other disadvantages include a pale transparent appearance because of the liquid nature of hyaluronic acid, and the gradual widening of pretarsal fullness over time. Therefore, there is a need for a surgical procedure with a long-term effect that also creates a natural appearance. However, there are few reports on the surgical creation of lower-eyelid pretarsal fullness. We found that temporal fascia grafting was a safe and reliable method for subciliary augmentation of the lower eyelid. Until recently, there had been few reports on surgically created pretarsal fullness of the lower eyelid [2, 3, 6–8]. However, in 2013, Chen et al. [9] described the detailed anthropometry of pretarsal fullness of the lower eyelid in the Chinese population. Pretarsal fullness of the lower eyelid is associated with a muscle roll, which attenuates when smiling. Chen et al. [9] divided pretarsal fullness of the lower eyelid into static and dynamic types. When a person smiles, the contraction of the orbicularis oculi muscle changes static pretarsal fullness to dynamic. Chen et al. [9] also reported that the prevalence of static pretarsal fullness was 19.2 %, and the width of static pretarsal fullness was 6.1–7.5 mm, with a reported mean width of the surgically created static pretarsal fullness of 7.0 mm. Orbicularis oculi muscle hypertrophy and/or the preseptal orbicularis oculi muscle overriding the pretarsal orbicularis
123
Aesth Plast Surg Fig. 3 Case 1: a 41-year-old woman requested pretarsal fullness of the lower eyelid. a, c, e Preoperative view. b, d, f Postoperative view at 2 years 11 months after subciliary augmentation of the lower eyelid using a deep temporal fascia graft measuring 40 mm 9 20 mm. Surgically created pretarsal fullness of the lower eyelid was maintained after surgery and postoperative patient satisfaction was high
Fig. 4 Case 2: a 38-year-old woman requested pretarsal fullness of the lower eyelid. a, c, e Preoperative view. b, d, f Postoperative view observed at 1 year 7 months after subciliary augmentation of the lower eyelid using a deep temporal fascia graft measuring 30 mm 9 15 mm. Surgically created pretarsal fullness of the lower eyelid was maintained after surgery and postoperative patient satisfaction was high
oculi muscle are the generally accepted causes of static pretarsal fullness. In contrast, Tsurukiri and Iwanami [2] reported that pretarsal fullness of the lower eyelid was
123
caused by a difference in subcutaneous fat volume. Therefore, the cause of static pretarsal fullness of the lower eyelid remains unclear.
Aesth Plast Surg Fig. 5 Case 3: a 36-year-old woman requested pretarsal fullness of the lower eyelid. a, c, e, g Preoperative view. b, d, f, h Postoperative view observed 2 years 10 months after subciliary augmentation of the lower eyelid using a deep temporal fascia graft measuring 23 mm 9 20 mm. Surgically created pretarsal fullness of the lower eyelid was maintained after surgery. Dynamic pretarsal fullness was slightly visible when she smiled after the surgery and the postoperative patient satisfaction was high
Subciliary augmentation of the lower eyelid using a deep temporal fascia graft provided satisfactory patient outcomes in our study. Before developing this surgical procedure, I performed the orbicularis oculi muscle overlapping procedure [7–9]. However, that procedure resulted in subtle changes that were less satisfactory to patients. To create a greater volume, a deep temporal fascia graft was used, which is a useful autologous graft for various facial plastic surgery procedures such as augmentation rhinoplasty [10–12], lip augmentation [13, 14], and the repair of upper-eyelid retraction [15]. An excellent effect was obtained by applying a deep temporal fascia graft for subciliary augmentation of the lower eyelid. Placement of a deep temporal fascia graft in the subcutaneous plane is thought to produce a greater bulging effect for pretarsal
fullness than placement in the submuscular plane of the lower eyelid. Despite the superficial placement of this graft, unnatural graft visibility was not observed in any patient. This surgical procedure is similar to that of the autogenous fascial sling procedure [16]. However, the shape of the graft in the autogenous fascial sling technique is a narrow strip and its purpose is to support the lower eyelid. In contrast, the purpose of our surgical procedure is to create a filling or bulging effect of the lower eyelid. Suspension of the orbicularis oculi muscle [17] was combined with deep temporal fascia grafting to create pretarsal fullness of the lower eyelid. The purpose of the muscle suspension was to make the lower border of the pretarsal fullness more distinct. Although some volume of the lower-eyelid pretarsal fullness was increased by the
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Aesth Plast Surg
muscle suspension immediately after surgery, this may decrease over time because of muscle detachment from the periosteum or muscle atrophy. The surgical technique as described in this report is an excellent option for creating pretarsal fullness of the lower eyelid. However, a potential limitation is the limited amount of graft material available, which allows for only relatively small pretarsal fullness. If patients desire more prominent pretarsal lower-eyelid fullness, a greater volume of temporal fascia graft may be required. Some potential risk associated with this procedure must be considered. First, the surgical procedure itself is quite straightforward, but the lachrymal canaliculi are nearby. Therefore, this technique has a learning curve and should be performed by surgeons with experience working in the periocular region to prevent epiphora due to lachrymal injury. Also, late postoperative epiphora might occur because of tissue scarring around the graft that impairs lower-lid muscular function as a lachrymal pump. However, we place the graft subcutaneously, not submuscularly, so this risk is considered to be lower. Second, the grafts might be visible when the patient’s lower-eyelid skin and the soft tissue surrounding the graft undergo natural senescence later in life. The grafts might also predispose the lower eyelids to early ectropion due to their added bulk and weight. These aesthetic and functional uncertainties may affect long-lasting aesthetic outcomes.
Conclusion Subciliary augmentation of the lower eyelid using a deep temporal fascia graft is a new and effective option that provides satisfactory results for patients desiring an increase in pretarsal fullness. The use of a deep temporal fascia graft was proven to be safe, reliable, and consistent in our series of four patients who were followed retrospectively. To further corroborate these preliminary results, a study with a larger sample size and longer follow-up period is required. Adjusting the size of the lower-eyelid pretarsal fullness is a future challenge for clinicians. Conflict of interest The author has no conflicts of interest to disclose and declares that no financial support was received for this study.
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