Eyelid aging: the historical evolution of its management

Supraorbital Bone Shaving (S.O.S Procedure) in Restoration of Upper Lateral Convexity in Sunken Eyes

BACKGROUND

Sunken eyes have become a most important target of periorbital area aesthetics. Throughout history, the aesthetics of the periorbital region have been emphasized, and various surgical techniques related to this region have been described. Most of these techniques provide only soft tissue solutions; therefore, additional surgical interventions may be required. The aim of our study was to introduce an endoscopic supraorbital shaving (SOS) technique for the treatment of individuals with sunken eyes.

METHODS

Between 2020 and 2021, 34 patients (30 females, 4 males; mean age 36.2 years) with sunken eyes were treated with our described technique. All patients underwent an endoscopic SOS procedure under general anesthesia.

RESULTS

A total of 34 patients (30 women and four men), aged 23-59 years old (mean = 36.2 years), underwent the endoscopic SOS procedure. The mean follow-up period was 13 months (range: 12-16 months). Postoperatively, significant improvement in lateral convexity was achieved in all patients. Physical examinations performed at the control visits revealed no functional problems in any patients and no visible or palpable irregularities or contour deformities. No complications were encountered regarding the SOS procedure.

CONCLUSIONS

The technique described here provides significant improvement in lateral convexity compared to other techniques used in patients with sunken eyes. No additional eyelid intervention is needed. Unlike the techniques previously described in the literature, intervention is made in the bone structure, thereby providing more accurate results.

LEVEL OF EVIDENCE V

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Fat or fillers: The dilemma in eyelid surgery

The aging of the periocular region has always aroused great interest. A fresh, young, and attractive sight determined an ever-greater attention to surgical and non-surgical techniques to obtain this result. In particular, the change in the concept of a young look, considered then "full", led to the increasing use of surgical (fat grafting) or medical (hyaluronic acid) filling techniques. Eyelid rejuvenation became increasingly popular in the field of cosmetic treatments, with a focus on achieving a youthful and refreshed appearance. Among the various techniques available, the choice between using fat grafting or fillers presented a clinical dilemma. In particular, what surgery considered of fundamental importance was a long-lasting result over time. On the other hand, aesthetic medicine considered it fundamental not to have to resort to invasive treatments. But what was the reality? Was there one path better than the other, and above all, was there a better path for patients? The minireview aims to explore the physiopathology, diagnosis, treatment options, prognosis, and future studies regarding this dilemma. We analyzed the literature produced in the last 20 years comparing the two techniques. Current literature reveals advancements in biomaterials, stem cell research and tissue engineering held promise for further enhancing the field of eyelid rejuvenation. The choice between fat grafting and fillers in eyelid cosmetic treatments presented a clinical dilemma. Understanding physiopathology, accurately diagnosing eyelid aging, exploring treatment options, assessing prognosis, and conducting future studies were essential for providing optimal care to patients seeking eyelid rejuvenation.

Fat management in upper blepharoplasty: Addition or subtraction blepharoplasties, how and when

BACKGROUND

As one of the most common aesthetic surgical procedures carried out today, blepharoplasty should be in the repertoire of every plastic surgeon. The term blepharoplasty encompasses a wide range of techniques and options that must be tailored to the specific defect and patient one has to treat. A sound knowledge of the upper and lower eyelids' anatomy is essential for proper surgical execution. Trends have shifted towards more conservative methods (especially of the fat compartment) and sometimes in combination with augmentation techniques, helping to reach a rejuvenated appearance.

AIM

To present an overview of the surgical techniques considered for upper lid blepharoplasty and fat pad management, in addition to information on how a surgeon may approach the best treatment for his patient based on current publications in literature.

METHODS

We searched the literature published between 2013, to 2023 using Medline and Reference Citation Analysis. The database was searched using the keywords "upper blepharoplasty" AND "fat". Papers without full text/abstracts and reviews were excluded. The search strategy followed the PRISMA. The American Society of Plastic Surgeons guidelines for Therapeutic Studies checklist was used to assess all articles. Two authors individually reviewed each article and rated them for importance and relevance to the topic. A consensus was sought and the most relevant studies.

RESULTS

After the application of the selection criteria used in our review, 13 publications were found to address upper lid blepharoplasty specifically. Three of these studies were reviews and three were retrospective studies. Five publications were comparative studies and a further two were clinical trials.

CONCLUSION

The tendency of modern surgery is to be conservative, by removing adipose tissue only if strictly necessary and restoring the volume of the upper eyelid in a concept of beauty that espouses a "full" sight. There is no gold standard technique to achieve younger and enhanced eyelids. Long-term prospective comparative studies are fundamental in understanding which path is the best to follow.

Upper eyelid morphology and age-related changes in Japanese and Chinese females

BACKGROUND

Many consumers use cosmetic eye products to counteract age-related changes in appearance. Measurements of eyelid shape in Asian women have been reported in the frontal view or 45-degree profile only. The aim of this study was to describe morphological characteristics of the upper eyelid in Japanese and Chinese females from the frontal and profile aspects and examine morphological changes with age.

MATERIALS AND METHODS

Standardized digital photographs of 772 Japanese and 346 Chinese women (15-79 years of age) were acquired in frontal and 90-degree profile aspects. Eleven upper eyelid parameters (e.g., width, length, depth, aperture, and curvature) were measured using image analysis to determine age-related changes and compare by ethnicity.

RESULTS

Eyelid width, area between eyebrow and eyelid, and eyelid curvature were comparable for both ethnicities under age 40, but the aging effect was more pronounced in Chinese subjects. Eyelid height, depth, and upper eyelid aperture angle were also comparable for both ethnicities under age 40, but the aging effect was more evident in Japanese subjects. Upper eyelid incline angle, eye orientation, and upper eyelid protrusion angle changed comparably with age for both ethnicities. No prominent age-related changes were evident for eyelid length or area between eyebrow and eye with the eye closed.

CONCLUSION

Upper eyelid morphology changes with age in Japanese and Chinese females, starting around 40 years of age. Ethnic differences are limited in younger age groups but become more prominent with age. The findings suggest that aging affects some upper eyelid features earlier than others.

Evaluation of Fat Excision versus Sparing in Lower Blepharoplasty Using Orbital Gray Scale Analysis

Orbital septum plication provides various benefits, including eliminating the necessity for a septal incision and the ability to relocate infraorbital fat in a more anatomically suitable manner. This study aimed to compare the results of traditional lower blepharoplasty with fat excision and the orbital septal plication method using orbital grey scale analysis as a new objective method for assessment.

Autologous Fine Particles Fat Filling Under Direct Vision in the Repair of Sunken Upper Eyelid After Double Eyelid Surgery

BACKGROUND

To explore the clinical effect of filling the preaponeurotic fat with autologous fine particles fat under direct vision to correct the sunken upper eyelid after double eyelid surgery.

METHODS

From June 2017 to May 2020, 134 cases of sunken upper eyelid after double eyelid surgery were treated by sharp needle injection of autologous fine particles fat under direct vision, and the surgical effect of each case was analyzed and evaluated.

RESULTS

The sunken upper eyelid was corrected, the appearance was satisfactory, the shape was in good state, and there was no lump and obvious displacement of the transplanted fat. And in the sunken upper eyelid group after double eyelid surgery, 5 patients had severe upper eyelid adhesions and lost plenty of preaponeurotic fat; among them, 4 patients underwent secondary repair surgery, and one did not.

CONCLUSION

The sharp needle injection method of filling autologous fat in the preaponeurotic fat under direct vision can accurately correct the sunken upper eyelid and replenish the preaponeurotic fat. The positioning is accurate, the filling amount is easy to control, and the transplanted fat particles survive well.

LEVEL OF EVIDENCE IV

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 .

Effects of Fat Repositioning for Tear Trough Deformity on Eye Movement

ABSTRACT

Fat repositioning is a common surgical technique for treating tear trough deformity. As this technique is mainly performed for cosmetic purposes, its functional outcomes have rarely been evaluated. The purpose of this study was to evaluate the changes in eye movements that occur after fat repositioning for tear trough deformity. The authors performed fat repositioning on 18 eyelids of 9 patients and evaluated their eye movements and binocular vision before surgery and at 1, 3, and 6 months after surgery. Hess screen and Binocular single vision tests were performed during each follow-up examination and the scores were recorded. The authors observed that fat repositioning did not affect binocular vision; however, vertical and horizontal eye movements worsened at 3 months after surgery. Nevertheless, there was no significant difference between the eye movements recorded before surgery and those recorded 6 months after surgery. Regardless of this finding, it should be noted that vertical or horizontal strabismus might occur after fat repositioning for tear trough deformity.

Eponym of Naso-Jugal Fold and Tear Trough

The aim of this study is to find out the eponym of the naso-jugal fold and tear trough and to make a suggestion to standardize the terminology.In a PubMed search, the search terms (naso-jugal) and (fold OR groove); (tear trough) and (anatomy) were used, which resulted in 48 and 37 titles, respectively. Eliminating duplicated titles, 80 abstracts were reviewed. Among them, 18 full papers were reviewed. Two papers were excluded and 3 mined papers were added. Finally, 19 papers were reviewed.In a paper published by an ophthalmologist Dr David Miller, "tear trough" was first used for designating the circular trough carved into a scleral contact in 1969. In the remaining 18 papers including 1 conference presentation, 6 terms were used for the same structure; naso-jugal fold (4), naso-jugal groove (4), naso-jugal ditch (1), tear trough (5), tear trough deformity (6), and tear trough depression (1). Whitnall first used "naso-jugal" and 10 other papers stated "naso-jugal." Eight papers cited Whitnall (2), Duke-Elder (2), and Loeb (4) in the origin of the term "naso-jugal." Flowers adapted "tear trough" for the cheek groove and 12 other papers wrote "tear trough." Eleven papers cited Flowers (9), Le Louarn (1), Mendelson (1) when referring to the origin of the term "tear trough."The name of the structure should contain "naso-jugal" rather than "tear trough" because "naso-jugal" was coined earlier and expresses the location of the structure. The recommended term should be "the deepened naso-jugal groove" since it deepens with age.

The Use of P45 Plastination Technique to Study the Distribution of Preseptal and Preaponeurotic Fat Tissues in Asian Eyelids

This study evaluated the anatomical features of preseptal and preaponeurotic fat tissues in the upper eyelids of individuals of Asian heritage. Specifically, we attempted to elucidate the role of these tissues in the formation of sunken upper eyelids and devise an easy and feasible approach to rectify this. Sixteen heads (32 facial halves) from fresh adult cadavers were processed using the P45 plastination techniques. The polymer resulted in transparent plastination, and the sagittal median section of the eyeballs was dissected. Gross anatomy results of 12 adult cadaveric heads (24 facial halves) were included as supplementary data. The orbital septum was observed on sagittal section slides prepared with P45 sheet plastination. Based on the amount of fat distribution, the upper eyelid was classified into three groups: preseptal fat predominant type, preaponeurotic fat predominant type, and orbital septum equilibrium type (relative distribution of 31.3, 12.5, and 56.3 % in plastinated slices, and 29.2, 16.7, and 54.2 % in gross anatomical studies). Major tissues on P45 sheet plastination slices in the supraorbital region were preseptal fat, preaponeurotic fat, frontalis muscle and frontalis muscle aponeurosis, and partial orbicularis oculi muscle. The muscle fibers of the frontalis muscle and orbicularis oculi were interconnected and extended backward to connect with the orbital septum through preseptal fat. In conclusion, the morphology and external appearance of the upper eyelids depend on the relative relationship between preseptal and preaponeurotic fat tissues. Mildly or moderately sunken upper eyelids can be corrected by modifying the soft tissue in the supraorbital margin.

Patients With Lower Eyelid Orbital Fat Hyperplasia

PURPOSE

Lower eyelid orbital fat hyperplasia has not been described in young age patients.

METHODS

A fourteen-year-old girl, a 29-year-old man, and 42-year-old man had visited our hospital complaining of a lower eyelid bulge. In orbital computed tomography examination, there was excess fat tissue compared with the opposite side, but no mass lesion matched with the area of lower eyelid bulge in our patients. The authors planned surgery for the removal of excess fat through the conjunctival incision. Intraoperatively, there was no real fat herniation through the septum. Septum continuity was maintained and thinning or distention of the orbital septum was not observed in our patients. The authors opened the orbital septum and removed the excess fat to make symmetry bilaterally. In the pathologic examination, removed fat tissue is not different with normal fat tissue.

CONCLUSIONS

The authors reported these findings at the first time. So they proposed the patient's condition as "lower eyelid orbital fat hyperplasia."

Involutional entropion and ectropion of the lower eyelid: prevalence and associated risk factors in the elderly population

PURPOSE

To determine the prevalence of involutional entropion and ectropion of the lower eyelid in the elderly population; to examine how these disorders are related to gender, age, skin color, and axial ocular globe projection; and to define the incidence of associated ocular surface and pathologic eyelid findings.

METHODS

An ophthalmic survey was conducted in 24,565 elderly people. All participants underwent ophthalmic examination by general ophthalmologists to identify entropion and ectropion. Information about associated ocular surface and pathologic eyelid findings were collected from all patients with involutional eyelid malposition. Patients with involutional entropion and ectropion underwent measurements of the axial ocular globe projection. The Pearson chi-square test and the Mann-Whitney U test were performed.

RESULTS

The prevalence of involutional entropion was 2.1%; 1.9% in men and 2.4% in women. The prevalence of involutional ectropion was 2.9%; 5.1% in men and 1.5% in women. Dry eye syndrome, lower retractor laxity, and superficial punctate keratopathy were seen significantly more often in patients with involutional entropion than in those with involutional ectropion (p < 0.001). Chronic conjunctivitis was significantly more common in patients with involutional ectropion than in those with involutional entropion (p < 0.001). The axial ocular globe projection was significantly smaller in patients with involutional entropion than in those with involutional ectropion (p < 0.001).

CONCLUSIONS

The prevalence of involutional entropion and ectropion in the elderly population is 2.1% and 2.9%, respectively. The axial ocular globe position plays a pathogenic role in involutional lower eyelid malposition.

The volumetric change of orbital fat with age in Asians

Lower eyelid prominence occurs as an aging process. Several causes of age-related lower eyelid prominence including herniated excessive intraorbital fat or fat atrophy, weakening of supporting components, and globe descent have been proposed. However, actual occurrence of excessive intraorbital fat herniation is still controversial. We measured volume of total orbital fat (OF) and fat anterior to the inferior orbital rim (IORF) using computed tomography (CT) to evaluate volumetric change of orbital fat with age in Asians. A total of 130 patients (65 men and 65 women) were evaluated, and volumes of OF and IORF were measured. OF and IORF volumes increased until the 60 years of age, and then decreased in both male and female groups. IORF/OF ratio increased with age, and, unlike fat volume, there was no decline after 70 years of age. Increase of orbital fat volume contributed to lower eyelid prominence. Reduction of anterior orbital fat volume could improve age-related lower eyelid prominence, and conservative fat excision in lower blepharoplasty can be useful in management of lower eyelid prominence.

Correction of superior sulcus deformity with orbital fat anatomic repositioning and fat graft applied to retro-orbicularis oculi fat for Asian eyelids

BACKGROUND

"Sunken eyelid" is a term used to describe a deeply sunken area between the upper eyelid and upper edge of the orbital bone. The condition frequently is accompanied by blepharoptosis. Correction of a "sunken eyelid" generally is performed with a fat graft. However, surgical limitations such as a movement dysfunction of the upper eyelid or irregular skin surface often are encountered using the grafting method previously reported. An open technique is believed to be more precise than a closed procedure, and satisfactory results may be achieved by repositioning the upper eyelid fat and applying a fat graft to the retro-orbicularis orbital fat (ROOF).

METHODS

Fat was harvested from the medial thigh area using a 10-ml syringe with minimal pressure. During the upper eyelid surgery, the orbital fat was relocated between the conjoined tendon of the levator aponeurosis and the lower orbicularis oculi muscle and skin flap. The ROOF was verified, and fat grafting then was performed from the upper medial side to the lower lateral side and from the medial aspect to the lateral direction using an 18-gauge Coleman needle. The sunken eyelids were classified into grades 1 to 4 according to the sunken depth (i.e., the distance between the most inferior orbital rim and the site of the most sunken area). The amount of fat graft and the technique of incorporating the fat were different according to sunken depth.

RESULTS

From January 2006 to June 2008, 50 Korean and Chinese patients (48 women and 2 men) underwent fat repositioning and ROOF fat grafting using an open technique. The patients ranged in age from 24 to 67 years. The mean observation period was 4.7 months. The amount of fat graft for each palpebra was 0.3 to 3.3 ml, and the mean graft amount was 1.4 ml. Satisfactory results were obtained for most of the patients, but four patients required additional surgery. The reasons for the secondary surgery were a translocation of the fat graft to a lower position forming a lump (2 patients) and undercorrection (2 patients). The rate of fat absorption was relatively low and the complications very few compared with surgical cases involving a noninvasive method.

CONCLUSIONS

More precise treatment is possible by dividing the depressed area of the upper eyelid according to the stage. Satisfactory results were achieved by relocating the orbital fat using an open method and adjusting the ROOF fat graft according to the stage.

Vertical plication of attenuated orbital septum: a modification for reduction of lower lid bulge

Aesthetic surgery for correction of the lower lid bulge can be classified into 3 groups of subtractive surgery, redraping, and repositioning. The authors present a new repositioning technique with vertical plication of the orbital septum for correction of lower lid bulge. This procedure was performed on 30 individuals during a 3-year period between March 2003 and March 2006. The length of follow-up varied from 3 months to 1 year, with an average of 6 months. There was no lower lid retraction or ectropion. Contour was smooth without any visible deformation or palpable suture line along the vertical plication. In the follow-up visits of minimum of 3 months, no recurrence of bulge was present and the scar was inconspicuous. Vertical plication of the orbital septum is an effective way to reposition the orbital fat inside the orbit. It anatomically corrects lower lid bulge, preserves the orbital fat pad and the vertical dimension of the lower lid, and provides a smooth contour in the periorbital area without the need to penetrate the orbital septum or manipulate the fat pad. Morbidity is minimal and transient, and the results are satisfactory. We suggest this technique for correction of lower lid bulge when there is excess lower lid skin and a subciliary approach is selected.

Aesthetic blepharoplasty

Blepharoplasty is one of the most demanding aesthetic procedures, and relevant anatomical knowledge of the eyelid and surrounding area is essential. The pathophysiology of ageing in these sites results in varied clinical features. In upper blepharoplasty, lateral brow lift is a necessary adjunctive procedure. Access through the upper blepharoplasty incision is used to adjust retro-orbicularis oculi fat, for glabellar myotomy, and lateral canthopexy. In lower blepharoplasty, the traditional approach is to use a skin and muscle flap, but skin-only flaps are being reported increasingly. Septal reset and plication of the orbicularis oculi is recommended instead of excision of fat. The aim is improvement of cosmesis with no signs of the procedure.

The tear trough and lid/cheek junction: anatomy and implications for surgical correction

BACKGROUND

The tear trough and the lid/cheek junction become more visible with age. These landmarks are adjacent, forming in some patients a continuous indentation or groove below the infraorbital rim. Numerous, often conflicting procedures have been described to improve the appearance of the region. The purpose of this study was to evaluate the anatomy underlying the tear trough and the lid/cheek junction and to evaluate the procedures designed to correct them.

METHODS

Twelve fresh cadaver lower lid and midface dissections were performed (six heads). The orbital regions were dissected in layers, and medical photography was performed.

RESULTS

In the subcutaneous plane, the tear trough and lid/cheek junction overlie the junction of the palpebral and orbital portions of the orbicularis oculi muscle and the cephalic border of the malar fat pad. In the submuscular plane, these landmarks differ. Along the tear trough, the orbicularis muscle is attached directly to the bone. Along the lid/cheek junction, the attachment is ligamentous by means of the orbicularis retaining ligament.

CONCLUSIONS

The tear trough and lid/cheek junction are primarily explained by superficial (subcutaneous) anatomical features. Atrophy of skin and fat is the most likely explanation for age-related visibility of these landmarks. "Descent" of this region with age is unlikely (the structures are fixed to bone). Bulging orbital fat accentuates these landmarks. Interventions must extend significantly below the infraorbital rim. Fat or synthetic filler may be best placed in the intraorbicularis plane (tear trough) and in the suborbicularis plane (lid/cheek junction).

Definition of the tear trough and the tear trough rating scale

BACKGROUND

Nasojugal groove and tear trough are interchangeably used terms by many authors in the literature despite the fact that they describe distinct and different anatomic entities. In the same vein, there are multiple descriptions of treatments and techniques for the cosmetic improvement of these anatomic areas without specifically addressing the anatomic difference between them.

OBJECTIVE

This study aims to define the anatomic characteristics of the tear trough and describe a novel classification scale for the evaluation of the tear trough deformity.

METHODS

The tear trough rating scale (TTRS) was applied to a representative sample of our patient population. Five of the authors evaluated each patient using the TTRS, and the numeric results were tabulated and compared. Results The TTRS provided an effective, reproducible method for evaluating tear trough deformities, and there was very little interobserver variability.

CONCLUSION

The tear trough should be defined as the depression of the medial lower eyelid just lateral to the anterior lacrimal crest and limited in its inferior aspect by the inferior orbital rim. The TTRS is a reliable tool for the classification of the tear trough and evaluation of therapeutic and cosmetic interventions.

Transconjunctival Septal Suture Repair for Lower Lid Blepharoplasty

BACKGROUND

The need for a safer lower-lid blepharoplasty procedure than the classic subciliary approach has long been recognized. In 1996, de la Plaza and de la Cruz first theorized septal suturing via a transconjunctival approach that preserves both muscle and infraorbital fat. This is the first report of a series of patients treated with this technique. The transconjunctival approach can avoid the complications of "scleral show" and changes in the shape of the aperture that are associated with the subciliary/muscle cutting approach to the fat pads.

METHODS

Transconjunctival septal suturing of the middle and medial fat bags was used to treat 78 consecutive patients (72 women and six men) with visible bulging fat of the lower eyelids. Some patients underwent simultaneous resection of fat from the lateral pad.

RESULTS

Bulging fat in the middle and medial compartments was eliminated without overtreatment or undertreatment. Substantial but not total improvement in tear trough deformity was often observed. Aperture shape and lid level were preserved.

CONCLUSIONS

The results achieved with this series of patients indicate that transconjunctival suture repair of the orbital septum is a safe, predictable, and effective treatment for bulging fat of the medial and middle fat pads of the lower eyelid. Changes in aperture shape and lid level can be avoided without the need for simultaneous lid-tightening procedures.

Analysis of the orbital floor morphology

INTRODUCTION

For the repair of large orbital floor defects due to blow-out fractures or those involved by tumours, it is necessary to understand the detailed morphology. The purpose of the present study was to elucidate how age and gender affect its three-dimensional morphology.

METHODS

The 3-D computer tomography data of 305 orbits of 182 patients were included in the study. Using the CT data, the orbital floor angle (the angle between the orbital floor and the horizontal plane) and the location of the most inferior point of the orbital floor were measured. Patients were classified into subgroups according to their gender and age. Data were compared among the subgroups.

RESULTS

The orbital floor angle was greater in males than in females, and in children than in adults. The location of the lowest point of the orbital floor moves postero-inferiorly with increasing age.

CONCLUSION

The present study demonstrated that gender and age affects morphology of the orbital floor. These findings should be useful for reconstruction of the orbital floor.