Original Investigation
Volumetric Rejuvenation of the Tear Trough With Repo and Ristow Adi Einan-Lifshitz, M.D.*, John B. Holds, M.D.†, Allan E. Wulc, M.D.‡, and Morris E. Hartstein, M.D.* *Department of Ophthalmology, Assaf Harofeh Medical Center, Tel Aviv University, Tel Aviv, Israel; †Department of Ophthalmology and Otolaryngology, Saint Louis University, Saint Louis, Missouri; and ‡Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania, Departments of Ophthalmology and Otolaryngology, Drexel University, Philadelphia, Pennsylvania, U.S.A.
I
fat repositioning may be limited by the amount of fat available to transpose, the ultimate viability of the transposed fat, and a steep learning curve. Rohrich et al.8 have elegantly described the multiple fat compartments of the face. By recognizing these various facial fat compartments and by using autologous fat transfer to the individual compartments on an anatomical basis, the effects of deflation that occur with aging may be reduced or corrected. Seminal to the treatment of the tear trough is addressing the deep medial fat compartment. Ristow described a space (Ristow’s space) that exists between the periosteum of the maxilla and the deep medial fat compartment, as a potential site for rejuvenation of the tear trough.8,9 In their study on cadavers, Rohrich et al.8 demonstrated that direct augmentation of the deep medial fat compartment with saline effaced the tear trough and enhanced cheek projection. After observing this same correction of the tear trough and improved appearance of the cheek with saline injection into Ristow’s space in their own independent cadaver study (Fig. 1), the authors began to inject autologous fat into this space during fat repositioning lower blepharoplasty as a way of supplementing the volume added by the repositioned fat. In this way, they could more fully treat the tear trough depression than with fat repositioning alone with improved esthetic results. It was believed that there is a synergistic effect between these 2 procedures, which enables successful rejuvenation of the tear trough and the eyelid–cheek junction.
Accepted for publication June 18, 2013. The authors have no financial or conflicts of interest to disclose. Presented at the annual American Society of Ophthalmic Plastic and Reconstructive Surgery Symposium, Chicago, 2012. Address correspondence and reprint requests to Adi Einan-Lifshitz, M.D., Department of Ophthalmology, Assaf Harofeh Medical Center, Zerifin 70300, Israel. E-mail: [email protected] DOI: 10.1097/IOP.0b013e3182a23270
FIG. 1. The deep medial fat compartment lies beneath the superficial subcutaneous fat compartment, medial to the zygomaticus major and buccal fat, and is bound superiorly by the orbitomalar ligament. Ristow’s space exists beneath the deep medial fat pad and the periosteum of the maxilla.
Purpose: The authors report the results of their approach for the treatment of the tear trough deformity, by lower eyelid blepharoplasty with fat repositioning and fat transfer to Ristow’s space and the deep medial fat compartment. Methods: One hundred fourteen eyes of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat transfer between 2010 and 2012. Results: No major complications were observed in any of the patients in this series. In all cases, there was significant improvement in the lower eyelid contour, tear trough, and blending of the transition at the eyelid–cheek junction noted by both patients and physicians. Conclusions: Despite the availability of multiple procedures, effacement of the tear trough region remains a challenge. The addition of fat transfer to Ristow’s space and the deep medial fat compartment to traditional fat repositioning lower blepharoplasty are effective methods for volumizing the tear trough and may synergistically improve outcomes. (Ophthal Plast Reconstr Surg 2013;29:481–485)
n recent years, there has been an appreciation that a youthful periocular appearance consists of a smooth transition between the lower eyelid and the cheek, and a goal of lower eyelid blepharoplasty should be to blend the eyelid–cheek junction. To achieve this goal, the area of depression known as the tear trough must be addressed. The anatomy of this depression or hollow between the eyelid and the cheek has been well studied and its relationship to the orbital retaining or orbital malar ligament. Many procedures have been described in an attempt to correct the tear trough deformity and to blend the eyelid–cheek junction, including filling procedures with implants, synthetic fillers, or fat.1–3 Surgical procedures such as midface lifting, orbicularis suspension, and canthoplasty techniques have all been described for the treatment of this region.4,5 Among the surgical treatment options, lower blepharoplasty with fat repositioning has evolved as an accepted technique for correction of the tear trough,6,7 to create a smooth transition from the eyelid to the cheek. However, optimal effacement of the tear trough with
Ophthal Plast Reconstr Surg, Vol. 29, No. 6, 2013
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Ophthal Plast Reconstr Surg, Vol. 29, No. 6, 2013
Adi Einan-Lifshitz et al.
METHODS Between 2010 and 2012, 114 eyes of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat transfer to Ristow’s space (J.B.H., M.E.H.). Patients often underwent other eyelid procedures as well, including upper blepharoplasty, brow lift, laser skin resurfacing, lower eyelid tightening, and fat transfer to other regions of the face. The study followed the tenets of the Declaration of Helsinki. None of the patients in this study came from an institution with an institutional review board (IRB) nor were operated on or were seen at an institution with an IRB, so an IRB waiver was not obtained. Operative Technique. All patients underwent transconjunctival lower blepharoplasty with fat repositioning in the preperiosteal plane as describe previously.6 Briefly, a transconjunctival incision was made using monopolar cautery or CO2 laser. Dissection was carried out until the fat pads and inferior oblique muscle were identified. The temporal fat pocket was usually excised and the central and medial pockets sculpted (Fig. 2). Dissection was carried out medially and inferiorly over the inferior orbital rim in the preperiosteal plane for a distance of about 10 mm. A 6-0 prolene suture was passed externally in the preperiosteal plane, weaved through the fat pedicle, and then brought out through the skin again and tied with or without a bolster. Prior to securing the suture, the fat was inspected to ensure that there was no traction on the inferior oblique muscle. Fat was harvested with a 10-cm3 syringe under low suction pressure from the thigh and umbilical area (Fig. 3). Fat was filtered through a telfa pad to remove the supranatant and infranatant (Fig. 4). Fat was then transferred back into the 10-cm3 syringe, transferred via a connector (Tulip Medical, San Diego, CA, U.S.A.) to 1-cm3 luer lock syringes (Fig. 5), and attached to a 0.9-mm cannula (Tulip Medical; Fig. 6). An 18-gauge or Nokor needle (Becton, Dickinson, Franklin Lakes, NJ, U.S.A.) was used to make stab incisions in the skin for introduction of the injection cannula. For injection into Ristow’s space, a stab incision was made within the nasolabial fold. With 1 finger on the medial inferior orbital rim just superior to the fat compartment, the injection cannula was introduced and 1 to 3 cm3 of fat was injected slowly into Ristow’s space and into the deep medial fat pad (Fig. 7). Other areas of the face were also injected with fat in standard fashion.
FIG. 3. Fat is harvested from the outer thigh with a 10-cm3 syringe.
FIG. 4. Fat is filtered over telfa to remove supranatant and infranatant.
RESULTS One hundred fourteen eyelids of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat injection to Ristow’s space. Ten patients were men and 47 were women, with an age range of 43 to 77 years. Follow up ranged from 4 to 40 months (average 8
FIG. 5. Fat is transferred from 10-cm3 syringe to 1-cm3 luer lock syringes.
FIG. 2. Using a transconjunctival approach, the medial fat pad is isolated and prepared for transposition.
482
months). No major complications were observed in any of the patients in this series. Two patients needed additional fat grafting and 2 patients received additional injection of synthetic filler material in the face, though not in the area of the tear trough. Four patients underwent simultaneous unrelated eyelid procedures. In all cases, there was significant improvement in the lower eyelid contour, tear trough, and blending of the transition at the eyelid–cheek junction noted by both patients and physicians (Figs. 8 and 9). In addition, the patients were satisfied with the surgical outcome especially in the area of the tear trough.
© 2013 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 29, No. 6, 2013
FIG. 6. Fat is injected into the periocular region using the 0.9 mm or 1.2 mm cannulas (Tulip Medical).
FIG. 7. Injection of fat into Ristow’s space through the nasolabial fold. A total of 1 to 3 cm3 is injected.
DISCUSSION The tear trough is a concave deformity caudal to the orbital fat that is noticeable as a result of inherited anatomical differences and aging.10–12 The nasojugal fold was initially defined by Duke-Elder and Wybar in 1961.13 In 1969, Flowers10 renamed this fold as the “tear trough deformity” given the observation that tears will track along this groove. Patients will often note this area as a dark circle under the eye.12 Loeb14 further hypothesized 3 potential factors that produce the tear trough deformity, which include fixation of the septum orbitale
Volumetric Rejuvenation of the Tear Trough
to the inferomedial arcus marginalis, the existence of a triangular gap between the angular muscle and the orbicularis muscle, and the absence of fat tissue from the central and medial fat pads subjacent to the orbicularis oculi muscle inferior to the nasojugal fold. Muzaffar et al.15 described the tear trough as a weakening of the central portion of the orbicularis retaining ligament exposing the central fat pad, with the laxity of the eyelid–cheek junction over time augmenting the tear trough deformity by accentuating the herniation of orbital fat. This area of depression has also been referred to as the orbitomalar sulcus, with the tear trough referring to the medial one third of this sulcus.16 Herniated orbital fat above the sulcus accentuates the hollow further. The “V” shape deformity that is sometimes observed in the sulcus results from the pattern of insertion of the orbicularis retaining ligament.16 To summarize, the tear trough is a natural anatomical surface landmark that is accentuated with aging by prolapsing fat from above, by atrophy or ptosis of the malar fat below, and by soft tissue tethering in the area of the ligamentous attachments of the orbicularis retaining ligament.16 Although many well-documented techniques for rejuvenating the lower eyelid region have been described, the treatment of the tear trough has remained a challenge. Fat repositioning lower blepharoplasty has evolved since its initial description by Loeb.11 Goldberg et al.7 described fat repositioning of the medial and central lower eyelid fat pads through a transconjunctival approach. Mohadjer and Holds6 have further refined the technique to reposition the fat in the preperiosteal plane. However, there may be limitations to the amount of “fill” that can be obtained with this technique due to the amount of fat available to transpose and the variability of fat that survives after transposition. Autogenous fat grafting or liposculpture directly to the tear trough area can potentially help to correct the tear trough deformity. However, the skin and soft tissue overlying the tear trough area are very thin and may result in palpable and visible contour abnormalities if the fat is not precisely placed. Imprecise placement of the fat, especially when injected in isolation into the tear trough region, can also lead to a sausage-shaped deformity. These same challenges are true when placing synthetic filler in this region. Still, it is possible to obtain similar results as ours with fat repositioning lower blepharoplasty combined with nonautologous injectables. Transcutaneous injections of tissue fillers like hyaluronic acid can yield satisfying results1,2; however, the effect of hyaluronic acid fillers is temporary.12 Long-lasting fillers are available; however, there is a risk of creating a deformity, which is much more difficult to correct than with HA fillers (lumps from HA fillers can be dissolved with hyaluronidase), and therefore in general is discouraged.3,17–20 Rohrich et al.8 have identified various fat compartments of the face, divided by a series of ligaments. Among them is the deep medial fat compartment. Anatomically, the deep medial fat compartment lies beneath the superficial subcutaneous fat compartment, medial to the zygomaticus major and buccal fat, and is bound superiorly by the orbitomalar ligament. In contrast to the sub-orbicularis oculi fat, which is adherent to the underlying periosteum, Ristow’s space exists beneath the deep medial fat pad and extends to the area of the nasolabial fold. Rohrich et al.8 have shown that the fat compartments are anatomically distinct in cadaver studies. It has been shown that the deeper fat compartments support the more superficial ones.6 As shown in the study by Rohrich et al.,8 the injection of fluid into Ristow’s space can restore the eyelid–cheek junction and improve midface projection without the need for lifting.
© 2013 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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FIG. 8. Before lower blepharoplasty with fat repositioning and fat injection into Ristow’s space with excellent effacement of the tear trough.
FIG. 9. After lower blepharoplasty with fat repositioning and fat injection into Ristow’s space with excellent effacement of the tear trough.
In this technique, the fat was injected into the deep plane (Ristow’s space and the deep medial fat compartment) combined with fat repositioning lower blepharoplasty allowing for correction of the tear trough and improving midface projection. An advantage of this technique is that the injection is deep, which lessens the risk of a noticeable contour deformity in an area where the tissues are thin. In addition, if the fat injection is performed properly, effacement of the tear trough and enhancement of the cheek can be observed as more volume is added. A rare but devastating side effect of fat injection is ophthalmic artery obstruction; however, in this study there was no patient with that serious side effect.21–23 It should be emphasized that the outcomes are based on the patients’ and authors’ assessment, as opposed to a masked and graded comparison. However, in this initial study, the safety and efficacy of this procedure are described.
CONCLUSIONS Despite the availability of multiple procedures, the tear trough region remains challenging to treat. The potential limits of fat repositioning lower blepharoplasty led us to search for adjunctive procedures to assist in lower eyelid rejuvenation. Injection of fat into Ristow’s space and the deep medial fat compartment is an effective method for volumizing the tear trough and blending the eyelid–cheek junction. It was believed that there is a synergistic effect between these 2 procedures. This experience suggests that the combination of lower blepharoplasty with fat repositioning and deep medial fat compartment injection is a reliable and safe treatment option for the tear trough, with a high rate of patient and surgeon satisfaction.
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REFERENCES 1. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg 2005;29:363–7. 2. Airan LE, Born TM. Nonsurgical lower eyelid lift. Plast Reconstr Surg 2005;116:1785–92. 3. Cook T, Nakra T, Shorr N, et al. Facial recontouring with autogenous fat. Facial Plast Surg 2004;20:145–7. 4. Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty. Facial Plast Surg 2001;17:37–48. 5. Correa BJ, Eisemann B, Eisemann M. Transconjunctival midface lift: a “hole” different fixation. J Craniofac Surg 2013;24:987–91. 6. 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;22:409–13. 7. Goldberg RA, Edelstein C, Balch K, et al. Fat repositioning in lower eyelid blepharoplasty. Semin Ophthalmol 1998;13:103–6. 8. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and deep medial fat compartment. Plast Reconstr Surg 2008;121:2107–12. 9. Ristow B. Personal communication, September 2001. 10. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993;20:403–15. 11. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 1981;8:757–76. 12. Espinoza GM, Holds JB. Evaluation and treatment of the tear trough deformity in lower blepharoplasty. Semin Plast Surg 2007;21:57–64. 13. Duke-Elder S, Wybar KC. The eyelids. In: Duke-Elder S, ed. System of Ophthalmology: The Anatomy of the Visual System, Vol. 2. Saint Louis, MO: C.V. Mosby Company, 1961:499–539. 14. Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast Surg 1993;20:393–400; discussion 401. 15. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002;110:873–84; discussion 897–911.
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1 6. Schiller JD. Lysis of the orbicularis retaining ligament and orbicularis oculi insertion: a powerful modality for lower eyelid and cheek rejuvenation. Plast Reconstr Surg 2012;129:692e–700e. 17. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with artecoll: 10-year history, indications, techniques, and complications. Dermatol Surg 2003;29:573–87; discussion 587. 18. Vleggaar D. Facial volumetric correction with injectable ply-Llactic acid. Dermatol Surg 2005;31:1511–8. 19. Humble G, Mest D. Soft tissue augmentation using sculptra. Facial Plast Surg 2004;20:157–63.
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20. Douglas RS, Donsoff I, Cook T, et al. Collagen fillers in facial aesthetic surgery. Facial Plast Surg 2004;20:117–23. 21. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and small case series: ocular and cerebral ischemia following facial injection of autologous fat. Arch Ophthalmol 2001;119:777–8. 22. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol 1989;107:85–7. 23. Lee CM, Hong IH, Park SP. Ophthalmic artery obstruction and cerebral infarction following periocular injection of autologous fat. Korean J Ophthalmol 2011;25:358–61.
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Volumetric Rejuvenation of the Tear Trough With Repo and Ristow Adi Einan-Lifshitz, M.D.*, John B. Holds, M.D.†, Allan E. Wulc, M.D.‡, and Morris E. Hartstein, M.D.* *Department of Ophthalmology, Assaf Harofeh Medical Center, Tel Aviv University, Tel Aviv, Israel; †Department of Ophthalmology and Otolaryngology, Saint Louis University, Saint Louis, Missouri; and ‡Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania, Departments of Ophthalmology and Otolaryngology, Drexel University, Philadelphia, Pennsylvania, U.S.A.
I
fat repositioning may be limited by the amount of fat available to transpose, the ultimate viability of the transposed fat, and a steep learning curve. Rohrich et al.8 have elegantly described the multiple fat compartments of the face. By recognizing these various facial fat compartments and by using autologous fat transfer to the individual compartments on an anatomical basis, the effects of deflation that occur with aging may be reduced or corrected. Seminal to the treatment of the tear trough is addressing the deep medial fat compartment. Ristow described a space (Ristow’s space) that exists between the periosteum of the maxilla and the deep medial fat compartment, as a potential site for rejuvenation of the tear trough.8,9 In their study on cadavers, Rohrich et al.8 demonstrated that direct augmentation of the deep medial fat compartment with saline effaced the tear trough and enhanced cheek projection. After observing this same correction of the tear trough and improved appearance of the cheek with saline injection into Ristow’s space in their own independent cadaver study (Fig. 1), the authors began to inject autologous fat into this space during fat repositioning lower blepharoplasty as a way of supplementing the volume added by the repositioned fat. In this way, they could more fully treat the tear trough depression than with fat repositioning alone with improved esthetic results. It was believed that there is a synergistic effect between these 2 procedures, which enables successful rejuvenation of the tear trough and the eyelid–cheek junction.
Accepted for publication June 18, 2013. The authors have no financial or conflicts of interest to disclose. Presented at the annual American Society of Ophthalmic Plastic and Reconstructive Surgery Symposium, Chicago, 2012. Address correspondence and reprint requests to Adi Einan-Lifshitz, M.D., Department of Ophthalmology, Assaf Harofeh Medical Center, Zerifin 70300, Israel. E-mail: [email protected] DOI: 10.1097/IOP.0b013e3182a23270
FIG. 1. The deep medial fat compartment lies beneath the superficial subcutaneous fat compartment, medial to the zygomaticus major and buccal fat, and is bound superiorly by the orbitomalar ligament. Ristow’s space exists beneath the deep medial fat pad and the periosteum of the maxilla.
Purpose: The authors report the results of their approach for the treatment of the tear trough deformity, by lower eyelid blepharoplasty with fat repositioning and fat transfer to Ristow’s space and the deep medial fat compartment. Methods: One hundred fourteen eyes of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat transfer between 2010 and 2012. Results: No major complications were observed in any of the patients in this series. In all cases, there was significant improvement in the lower eyelid contour, tear trough, and blending of the transition at the eyelid–cheek junction noted by both patients and physicians. Conclusions: Despite the availability of multiple procedures, effacement of the tear trough region remains a challenge. The addition of fat transfer to Ristow’s space and the deep medial fat compartment to traditional fat repositioning lower blepharoplasty are effective methods for volumizing the tear trough and may synergistically improve outcomes. (Ophthal Plast Reconstr Surg 2013;29:481–485)
n recent years, there has been an appreciation that a youthful periocular appearance consists of a smooth transition between the lower eyelid and the cheek, and a goal of lower eyelid blepharoplasty should be to blend the eyelid–cheek junction. To achieve this goal, the area of depression known as the tear trough must be addressed. The anatomy of this depression or hollow between the eyelid and the cheek has been well studied and its relationship to the orbital retaining or orbital malar ligament. Many procedures have been described in an attempt to correct the tear trough deformity and to blend the eyelid–cheek junction, including filling procedures with implants, synthetic fillers, or fat.1–3 Surgical procedures such as midface lifting, orbicularis suspension, and canthoplasty techniques have all been described for the treatment of this region.4,5 Among the surgical treatment options, lower blepharoplasty with fat repositioning has evolved as an accepted technique for correction of the tear trough,6,7 to create a smooth transition from the eyelid to the cheek. However, optimal effacement of the tear trough with
Ophthal Plast Reconstr Surg, Vol. 29, No. 6, 2013
481
Ophthal Plast Reconstr Surg, Vol. 29, No. 6, 2013
Adi Einan-Lifshitz et al.
METHODS Between 2010 and 2012, 114 eyes of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat transfer to Ristow’s space (J.B.H., M.E.H.). Patients often underwent other eyelid procedures as well, including upper blepharoplasty, brow lift, laser skin resurfacing, lower eyelid tightening, and fat transfer to other regions of the face. The study followed the tenets of the Declaration of Helsinki. None of the patients in this study came from an institution with an institutional review board (IRB) nor were operated on or were seen at an institution with an IRB, so an IRB waiver was not obtained. Operative Technique. All patients underwent transconjunctival lower blepharoplasty with fat repositioning in the preperiosteal plane as describe previously.6 Briefly, a transconjunctival incision was made using monopolar cautery or CO2 laser. Dissection was carried out until the fat pads and inferior oblique muscle were identified. The temporal fat pocket was usually excised and the central and medial pockets sculpted (Fig. 2). Dissection was carried out medially and inferiorly over the inferior orbital rim in the preperiosteal plane for a distance of about 10 mm. A 6-0 prolene suture was passed externally in the preperiosteal plane, weaved through the fat pedicle, and then brought out through the skin again and tied with or without a bolster. Prior to securing the suture, the fat was inspected to ensure that there was no traction on the inferior oblique muscle. Fat was harvested with a 10-cm3 syringe under low suction pressure from the thigh and umbilical area (Fig. 3). Fat was filtered through a telfa pad to remove the supranatant and infranatant (Fig. 4). Fat was then transferred back into the 10-cm3 syringe, transferred via a connector (Tulip Medical, San Diego, CA, U.S.A.) to 1-cm3 luer lock syringes (Fig. 5), and attached to a 0.9-mm cannula (Tulip Medical; Fig. 6). An 18-gauge or Nokor needle (Becton, Dickinson, Franklin Lakes, NJ, U.S.A.) was used to make stab incisions in the skin for introduction of the injection cannula. For injection into Ristow’s space, a stab incision was made within the nasolabial fold. With 1 finger on the medial inferior orbital rim just superior to the fat compartment, the injection cannula was introduced and 1 to 3 cm3 of fat was injected slowly into Ristow’s space and into the deep medial fat pad (Fig. 7). Other areas of the face were also injected with fat in standard fashion.
FIG. 3. Fat is harvested from the outer thigh with a 10-cm3 syringe.
FIG. 4. Fat is filtered over telfa to remove supranatant and infranatant.
RESULTS One hundred fourteen eyelids of 57 patients underwent lower eyelid blepharoplasty, fat repositioning, and fat injection to Ristow’s space. Ten patients were men and 47 were women, with an age range of 43 to 77 years. Follow up ranged from 4 to 40 months (average 8
FIG. 5. Fat is transferred from 10-cm3 syringe to 1-cm3 luer lock syringes.
FIG. 2. Using a transconjunctival approach, the medial fat pad is isolated and prepared for transposition.
482
months). No major complications were observed in any of the patients in this series. Two patients needed additional fat grafting and 2 patients received additional injection of synthetic filler material in the face, though not in the area of the tear trough. Four patients underwent simultaneous unrelated eyelid procedures. In all cases, there was significant improvement in the lower eyelid contour, tear trough, and blending of the transition at the eyelid–cheek junction noted by both patients and physicians (Figs. 8 and 9). In addition, the patients were satisfied with the surgical outcome especially in the area of the tear trough.
© 2013 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 29, No. 6, 2013
FIG. 6. Fat is injected into the periocular region using the 0.9 mm or 1.2 mm cannulas (Tulip Medical).
FIG. 7. Injection of fat into Ristow’s space through the nasolabial fold. A total of 1 to 3 cm3 is injected.
DISCUSSION The tear trough is a concave deformity caudal to the orbital fat that is noticeable as a result of inherited anatomical differences and aging.10–12 The nasojugal fold was initially defined by Duke-Elder and Wybar in 1961.13 In 1969, Flowers10 renamed this fold as the “tear trough deformity” given the observation that tears will track along this groove. Patients will often note this area as a dark circle under the eye.12 Loeb14 further hypothesized 3 potential factors that produce the tear trough deformity, which include fixation of the septum orbitale
Volumetric Rejuvenation of the Tear Trough
to the inferomedial arcus marginalis, the existence of a triangular gap between the angular muscle and the orbicularis muscle, and the absence of fat tissue from the central and medial fat pads subjacent to the orbicularis oculi muscle inferior to the nasojugal fold. Muzaffar et al.15 described the tear trough as a weakening of the central portion of the orbicularis retaining ligament exposing the central fat pad, with the laxity of the eyelid–cheek junction over time augmenting the tear trough deformity by accentuating the herniation of orbital fat. This area of depression has also been referred to as the orbitomalar sulcus, with the tear trough referring to the medial one third of this sulcus.16 Herniated orbital fat above the sulcus accentuates the hollow further. The “V” shape deformity that is sometimes observed in the sulcus results from the pattern of insertion of the orbicularis retaining ligament.16 To summarize, the tear trough is a natural anatomical surface landmark that is accentuated with aging by prolapsing fat from above, by atrophy or ptosis of the malar fat below, and by soft tissue tethering in the area of the ligamentous attachments of the orbicularis retaining ligament.16 Although many well-documented techniques for rejuvenating the lower eyelid region have been described, the treatment of the tear trough has remained a challenge. Fat repositioning lower blepharoplasty has evolved since its initial description by Loeb.11 Goldberg et al.7 described fat repositioning of the medial and central lower eyelid fat pads through a transconjunctival approach. Mohadjer and Holds6 have further refined the technique to reposition the fat in the preperiosteal plane. However, there may be limitations to the amount of “fill” that can be obtained with this technique due to the amount of fat available to transpose and the variability of fat that survives after transposition. Autogenous fat grafting or liposculpture directly to the tear trough area can potentially help to correct the tear trough deformity. However, the skin and soft tissue overlying the tear trough area are very thin and may result in palpable and visible contour abnormalities if the fat is not precisely placed. Imprecise placement of the fat, especially when injected in isolation into the tear trough region, can also lead to a sausage-shaped deformity. These same challenges are true when placing synthetic filler in this region. Still, it is possible to obtain similar results as ours with fat repositioning lower blepharoplasty combined with nonautologous injectables. Transcutaneous injections of tissue fillers like hyaluronic acid can yield satisfying results1,2; however, the effect of hyaluronic acid fillers is temporary.12 Long-lasting fillers are available; however, there is a risk of creating a deformity, which is much more difficult to correct than with HA fillers (lumps from HA fillers can be dissolved with hyaluronidase), and therefore in general is discouraged.3,17–20 Rohrich et al.8 have identified various fat compartments of the face, divided by a series of ligaments. Among them is the deep medial fat compartment. Anatomically, the deep medial fat compartment lies beneath the superficial subcutaneous fat compartment, medial to the zygomaticus major and buccal fat, and is bound superiorly by the orbitomalar ligament. In contrast to the sub-orbicularis oculi fat, which is adherent to the underlying periosteum, Ristow’s space exists beneath the deep medial fat pad and extends to the area of the nasolabial fold. Rohrich et al.8 have shown that the fat compartments are anatomically distinct in cadaver studies. It has been shown that the deeper fat compartments support the more superficial ones.6 As shown in the study by Rohrich et al.,8 the injection of fluid into Ristow’s space can restore the eyelid–cheek junction and improve midface projection without the need for lifting.
© 2013 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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FIG. 8. Before lower blepharoplasty with fat repositioning and fat injection into Ristow’s space with excellent effacement of the tear trough.
FIG. 9. After lower blepharoplasty with fat repositioning and fat injection into Ristow’s space with excellent effacement of the tear trough.
In this technique, the fat was injected into the deep plane (Ristow’s space and the deep medial fat compartment) combined with fat repositioning lower blepharoplasty allowing for correction of the tear trough and improving midface projection. An advantage of this technique is that the injection is deep, which lessens the risk of a noticeable contour deformity in an area where the tissues are thin. In addition, if the fat injection is performed properly, effacement of the tear trough and enhancement of the cheek can be observed as more volume is added. A rare but devastating side effect of fat injection is ophthalmic artery obstruction; however, in this study there was no patient with that serious side effect.21–23 It should be emphasized that the outcomes are based on the patients’ and authors’ assessment, as opposed to a masked and graded comparison. However, in this initial study, the safety and efficacy of this procedure are described.
CONCLUSIONS Despite the availability of multiple procedures, the tear trough region remains challenging to treat. The potential limits of fat repositioning lower blepharoplasty led us to search for adjunctive procedures to assist in lower eyelid rejuvenation. Injection of fat into Ristow’s space and the deep medial fat compartment is an effective method for volumizing the tear trough and blending the eyelid–cheek junction. It was believed that there is a synergistic effect between these 2 procedures. This experience suggests that the combination of lower blepharoplasty with fat repositioning and deep medial fat compartment injection is a reliable and safe treatment option for the tear trough, with a high rate of patient and surgeon satisfaction.
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