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

A Simple Procedure of Fascia-Fat Grafting and Blepharoplasty as a Single-Stage Procedure for the Correction of Sunken Eyelids in Vietnamese Population

PURPOSES

Upper sunken eyelids, which are characterized by the hollowness of the upper eyelids, often cause a poor aesthetic appearance. Herein, we present a simplified technique using fascia-fat grafts for volume augmentation combined with blepharoplasty as a single-stage procedure.

METHODS

From January 2021 to December 2021, 30 patients with sunken eyelids visiting our clinic for hollow eyelid treatment underwent a fascia-fat grafting derived from the inguinal crease combined with simultaneous eyelid reconstruction. A modified classification of sunken eyelids that was more suitable for the Asian population was proposed.

RESULTS

Postoperatively, edema and ptosis were transient and addressed thanks to proper massage and compresses. Two cases had scar fibers leading to a slight tension of upper eyelids at 6-month follow-up. This event was addressed by triamcinolone acetonide injections at 4-6-week intervals with satisfactory results. The orbital volume of all patients was satisfying and stable up to 12 months after the surgery. The satisfaction rate was 100% and 88.8% in group 1 and group 2, respectively, at 12-month follow-up.

CONCLUSIONS

Fascia-fat grafting combined with blepharoplasty as a single-stage procedure was a simplified method that did not require varied types of surgical tools but brought satisfactory results. This method facilitated the routine procedure and eased surgeons in the clinical practices.

Selection of Optimal Double-Lid Blepharoplasty Based on Asian Upper Eyelid Tissue Structure

OBJECTIVE

To investigate the postoperative effect of double-lid blepharoplasty based on the histological difference in the upper eyelid of Asian patients.

MATERIAL AND METHODS

A total of 76 patients with poor bilateral upper eyelid morphology or a single eyelid were included in this study. Different techniques of double-eyelid blepharoplasty were performed based on the thickness of the palpebral tissue. The improved PARK method (group A: 15 participants) was employed for patients with orbicularis oculi muscle being thinner, and the fat bulge of orbital septum was less. The improved traditional method (group B: 52 participants) was employed for patients with hypertrophy of the eyelid skin, orbicularis oculi muscle, and fat bulge in the orbital septum.

RESULTS

All 76 patients achieved satisfactory outcomes in a single surgical procedure. Postoperative follow-up ranged from 3 to 6 months. In group A, there was no obvious swelling of flap near the palpebral margin and the double blepharon line becomes shallow. Although some patients in group B experienced varying degrees of bruising in the early postoperative period, all patients returned to a more natural shape 1-3 months after surgery. Furthermore, after 3-6 months postoperatively, there were no obvious scar adhesion and ladder sensation in the both sides of the incision.

CONCLUSION

Preoperative analysis of the thickness of the upper eyelid tissue is essential to determine the appropriate surgical technique for double-eyelid blepharoplasty. The improved traditional method is recommended for patients with hypertrophy of the upper eyelid tissue (group A), as it minimizes scar adhesion and reduces the stair-step sensation in the lower eyelid tissue during long-term follow-up. For patients with thin upper eyelid tissue, the improved PARK method should be employed to avoid issues such as tissue accumulation, double eyelid crease became shallower, or disappearance. In order to obtain natural and long-term surgical results, different surgical methods should be provided according to the patient's eye tissue condition.

LEVEL OF EVIDENCE II

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 .

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.

Cause Analysis and Surgical Treatment of Aponeurotic Ptosis With Upper Eyelid Depression

BACKGROUND

Ptosis and upper eyelid depression were previously diagnosed as 2 separate diseases. The authors found that in patients with aponeurotic ptosis accompanied by upper eyelid depression, the main cause of upper eyelid depression was impaired dynamic transmission of the levator aponeurosis.

OBJECTIVE

To analyze the causes of upper eyelid depression in patients with aponeurotic ptosis accompanied by upper eyelid depression and to introduce the best treatment methods.

METHODS

The authors enrolled 15 eyes (11 patients) with aponeurotic ptosis accompanied by upper eyelid depression from October 2021 to August 2022. The authors analyzed the causes of upper eyelid depression in those patients and performed aponeurotic ptosis correction surgery and orbital septum fat release surgery. After 6 to 12 months of follow-up, the authors reviewed the patient's medical records and photographs to evaluate the treatment outcomes.

RESULTS

After surgery, ptosis was corrected and upper eyelid depression significantly improved in all the patients. One patient had poor eyelid morphology and upper eyelid depression due to habitual brow lifting, which was relieved after an injection of botulinum toxin into the frontalis muscle. One patient had overcorrection of the upper eyelid depression on the affected side and no other complications.

CONCLUSION

The main cause of upper eyelid depression in patients with aponeurotic ptosis is impaired dynamic transmission of the levator aponeurosis. Aponeurotic ptosis repair surgery and orbital septum fat release surgery are simple surgical procedures that restore the normal anatomy and physiology of the upper eyelid and maintain the normal structure of the eyelid, with good post-operative outcomes.

A Prospective Randomized Study of Lateral Brow-Eyelid Complex Volume after Internal Browpexy Using Three-Dimensional Stereophotogrammetry

Background: A full lateral brow-eyelid complex may help rejuvenate and feminize the face. Objectives: To compare periorbital volume change of patients as measured by three-dimensional (3D) stereophotogrammetry before and after blepharoplasty with or without internal browpexy sutures. Methods: This is a prospective randomized controlled study of 124 eyelids of 62 adult female patients who underwent cosmetic upper eyelid blepharoplasty by a single surgeon. Subjects were randomized to blepharoplasty alone (control) or blepharoplasty with an adjunctive "brassiere suture" internal browpexy (intervention). An observer masked to the intervention measured the brow-eyelid volume using standardized images obtained with a 3D camera, before and after surgery. The minimum follow-up was 6 months postoperatively. Results: Sixty eyelids (30 patients) were treated with upper blepharoplasty alone and 64 eyelids (32 patients) had blepharoplasty plus internal browpexy. The mean volume gain was 0.85 mL in the internal browpexy intervention group and 0.19 mL in the control group. The volume increased in all patients receiving browpexy and this change was greater than after blepharoplasty alone (p < 0.05). The mean follow-up time was 16.8 months (range 6-24 months). Conclusions: Adjunctive internal browpexy during blepharoplasty was associated with increased volume of the lateral brow-eyelid complex.

Correction of severe upper-eyelid sunken deformity in Asians by double-eyelid procedure and combination of orbital fat pad repositioning and autologous fat transplantation: a one-year follow-up study of 79 cases

Background

Nowadays, people's pace of life continues to rapid up, and many bad habits will accelerate the aging of the eye periphery, and patients with sunken upper eyelids are to be found in younger people. In young Asians, single eyelids are often accompanied by upper eyelid depression, so correcting the upper eyelid depression during blepharoplasty becomes a higher challenge for plastic surgeons. Current surgical methods for upper eyelid depression include three major categories: tissue repositioning, injection and filling, and combined use. According to grades 1 and 2 are mild or moderate upper eyelid sunken. The sunken can be well corrected only by repositioning the orbital fat pad, while the correction effect for severe upper eyelid sunken in grades 3 and 4 is Poor, need to be used in combination to achieve the desired effect.

Purpose

The authors sought to determine whether, for patients with single eyelids and severe upper eyelid depression of grades 3 and 4, combined with orbital fat pad repositioning and autologous fat transplantation during blepharoplasty, an aesthetic and youthful blepharoplasty can be achieved.

Methods

This study included 79 patients with single eyelids and severe upper eyelid depression of grades 3 and 4 who received treatment between June 2020 and July 2022. All patients underwent double eyelid surgery plus orbital fat repositioning and autologous fat grafting.

Results

After a minimum follow-up period of 1 year, overall patient satisfaction was 92%. The recurrence rate within the first year was 6% and the complication rate was 5%.

Conclusion

This combined surgery may be an option for young Asians with single eyelids and severe upper eyelid depression. In this study, the surgery resulted in natural-looking double eyelids and younger-looking eye sockets in most patients. A combination of different surgical methods based on the patient's preoperative condition is critical to achieving long-term correction.

Surgical correction of sunken upper eyelid with upper arcus marginalis release and precision fat distribution technique

BACKGROUND

Sunken upper eyelids, characterized by hollowing in the upper orbital region, can contribute to an aged or fatigued appearance. We aim to report on the surgical technique and its effects, involving the release of the arcus marginalis of the upper eyelid and the precise distribution of orbital fat.

METHODS

From December 2021 to March 2023, a total of 84 eyelids from 42 patients who underwent surgical correction for sunken upper eyelids, utilizing the upper arcus marginalis release and precision fat distribution technique, were included in this study. Preoperative and postoperative sunken depths were measured and statistically analyzed. Aesthetic satisfaction was assessed through patient questionnaires.

RESULTS

Preoperative and postoperative sunken depths measured 9.2 ± 2.2 mm and 5.9 ± 2.3 mm, respectively. The mean improvement was 3.3 mm, a change of statistical significance. Aesthetic outcomes and patient satisfaction yielded favorable results. No major complications were observed during the follow-up period.

CONCLUSION

The upper arcus marginalis release and orbital fat distribution technique demonstrated favorable outcomes in correcting sunken upper eyelids. This procedure ensures stable placement of orbital fat at the deepest sunken point, resulting in aesthetically pleasing and enduring results. This technique serves as a valuable alternative for patients with moderate to severe sunken eyelids.

The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat: A New Strategy for Correction of Sunken Eyelid Deformity in Revision Upper Blepharoplasty for Asian Patients

BACKGROUND

With an increasing number of East Asians undergoing blepharoplasty, the number of patients with secondary upper eyelid deformities is increasing. The sunken eyelid deformity is a common deformity after upper blepharoplasty in Asians due to over-resection, retraction, or atrophy of the nasal and central orbital fat pads. Herein, we present a novel procedure, the pendulum movement of orbital fat and retro-orbicularis oculi fat ("POR" technique), for correction of sunken eyelid deformity in secondary Asian blepharoplasty.

METHODS

Patients who underwent secondary upper blepharoplasty with the POR technique by the senior author between January 2020 and October 2021 were identified retrospectively. Those with fewer than 6 months of follow-up were excluded. Patient charts and images were reviewed for demographic data, comorbidities, concomitant eyelid deformities, and postoperative complications. Pre- and postoperative aesthetics, including degree of sunken eyelid deformity, were assessed by two independent raters and by self-reported patient satisfaction.

RESULTS

Forty-nine consecutive patients were identified, all of whom were female and had grade I or II sunken eyelid deformity. Median follow-up was 8 months. Concomitant deformities included high tarsal crease (N = 31 patients, 63.3%), ptosis (N = 13, 26.5%), and upper eyelid retraction (N = 5, 10.2%). Almost patients had improvement in their eyelid volume, and 95.9% had improvement in their aesthetic rating. Approximately 93.9% of patients were satisfied with the outcome.

CONCLUSIONS

The POR technique is an effective technique for correction of sunken eyelid deformity and can be utilized in conjunction with other techniques during secondary blepharoplasty.

LEVEL OF EVIDENCE III

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 .

Correction of Sunken Upper Eyelid in Asian Blepharoplasty Based on Anatomical and Histological Study of Orbital Fat Fascia Flap

OBJECTIVES

To explore the clinical application of orbital fat fascia flap in the correction of sunken upper eyelid in Asian blepharoplasty based on anatomical and histological research.

METHODS

Observe the histological structure of the orbital fat and its fascia vascularity through cadaver anatomy and histological sections of 10 cadavers. Based on the anatomical and histological characteristics of orbital fat, 36 patients with mild to moderate sunken upper eyelids were corrected by transposition of orbital fat fascia flap with preservation of fascia vascular pedicle. During the operation, the lateral part of the central cellulite of orbital fat was separated longitudinally and transferred to the sunken place to correct the sunken upper eyelid.

RESULTS

Anatomy and histology show that the orbital fat was located between the anterior layer of the levator aponeurosis and the posterior layer of the orbital septum and was separated into fat lobules by many fibrous septa. The blood vessels move forward from back to front along the orbital fat interlobular septum, and the blood vessels in the capsule below the orbital fat are abundant. Clinical results showed that the shape of the sunken upper eyelid was significantly improved in 35 cases after correction with this method during the postoperative follow-up from 9 months to 18 months. The mean sunken depth improved from 6.2mm (±1.0 mm) preoperatively to 2.2mm (±0.9 mm) at the last follow-up with a statistical significance. And only 1 case had partial depression in the unilateral eyelid and received autologous granular fat transplantation with satisfactory postoperative results.

CONCLUSION

The transposition of orbital fat fascia flap with longitudinal separation and preservation of fascia vascular pedicle can better correct the sunken upper eyelid during blepharoplasty, and the long-term effect is stable, which is worthy of clinical promotion.

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 .

Individualized High Double Eyelid Fold Correction in Secondary Blepharoplasty: A Free-Style Design

BACKGROUND

High crease correction is difficult to achieve in secondary blepharoplasty. Currently, patients tend to have more precise requirements for crease-lowering procedures, such as low in-fold or low out-fold creases. For the out-fold crease, the height of the central crease is similar with the height of the medial crease, whereas for the in-fold crease, the height of the medial crease is lower than the height of the central crease.

OBJECTIVES

In this study, the authors developed a strategy to create low in-fold or out-fold creases to satisfy patients' individualized requirements.

METHODS

The medical records of patients who received crease-lowering secondary blepharoplasty from January 2015 to January 2021 were reviewed. The results were grouped by preoperative condition (high in-fold/out-fold) and patients' expectations for postoperative outcome (low in-fold/out-fold). Preoperative and postoperative images were collected, and patient satisfaction, complications and revisions were evaluated.

RESULTS

In total, 297 consecutive patients were included in this study with an average follow-up duration of 12.3 months. Eighteen patients had high in-fold creases, and 279 patients had high out-fold creases. Regarding patients with high out-folds, 233 patients wanted to have low out-folds, and 46 patients wanted to have low in-folds. Two hundred and sixty-six (89.6%) patients were satisfied with their results. Complications included complete crease loss (n = 3, 1.0%), partial crease loss (n = 5, 1.7%), multiple creases (n = 6, 2.0%), asymmetric creases (n = 7, 2.4%), and upper eyelid skin laxity (n = 10, 3.4%).

CONCLUSIONS

This flexible, novel technique for customizing low out-fold or in-fold creases is reliable in high double-eyelid crease correction based on preoperative upper eyelid skin tightness, scar positions, and the patient's expected double-eyelid crease shape.

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 .

Buccal Fat Pad Transplantation for Correction of Asian Upper Eyelid Depression: A Clinical Study

OBJECTIVES

To investigate the effect of buccal fat pad transplantation in front of the aponeurosis to correct Asian upper eyelid depression.

METHODS

Eighty-five individuals who were treated with buccal fat pad transplantation were recruited for this study. The upper eyelid depression data were collected before and after treatment, and the aesthetic outcomes were assessed using the Global Aesthetic Improvement Scale (GAIS) and the Likert scale.

RESULTS

All patients obtained natural-looking eyelids, and the sunken contour deformity improved. The mean preoperative sunken depth was 6.7±1.0 mm (4-12 mm), and the mean sunken depth at the last follow-up was 4.2±0.9 mm (2-6 mm) (P <0.05). The visual analogue scale score was 2.12±1.75 (1-4) in the immediate postoperative period. The GAIS scores were satisfactory (very much improved, 89.4%; much improved, 7.1%; and improved, 3.5%). According to the Likert scale scores, all patients were satisfied with the clinical outcomes (excellent, 87.1%; very good, 9.4%; and good, 3.5%). A 'fair' or 'poor' result was not reported by any patient.

CONCLUSION

Buccal fat pad transplantation corrects upper eyelid depression in a simple, safe, and effective manner and can efficiently fill the depressed portion and restore a beautiful double 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 .

Comprehensive management for complex complications after periumbilical fat implantation into the upper eyelid

BACKGROUND

Recently, periumbilical fat (PF) mass, an autologous material with a high survival rate, has been transplanted to treat sunken or dissatisfactory double eyelids. However, the intricate complications of PF grafts and associated reconstructive strategies are infrequently discussed.

METHODS

During 3 years, 20 patients (33 eyes) with eyelid malformations caused by PF grafts into the orbital septum or on the surface of the levator aponeurosis underwent corrective blepharoplasty. We recorded patients' subjective feelings and identified deformities from crease abnormalities, bloated appearance, and problems with the eyelid's height. Then, we categorize them into three types based on their complexity: type I, swollen appearance; type II, obvious adhesion; type III, severe comprehensive damage. The relevant management included removing fat implants, releasing the adhesion, and rebuilding the physical structure according to the anatomic damage mechanism. The improvement effect was assessed with a satisfaction survey from patients and doctors at 6 months of follow-up.

RESULTS

The swollen appearance was observed in 26 eyes (78.8%), an unsmooth double-eyelid line was in 23 eyes (69.7%), and the incidence of adhesion was in 22 eyes (66.7%). Following a comprehensive evaluation, 15 eyes (45.5%) and 13 (39.4%) were classified as type I and type II respectively. After the 6-month follow-up, 22 eyes (66.7%) showed exceptional aesthetic results, whereas only 2 eyes as type III had a poor outcome.

CONCLUSIONS

The deformities emerging from periumbilical fat into the upper eyelid are associated with the shape of the fat and the adhesion in tissues. Graft removal, adhesion release, and restoration of the natural anatomic structure can have positive outcomes.

Anatomic and Magnetic Resonance Imaging-Based Correction of Upper-Eyelid Depression and Blepharoptosis in Senile Patients

In senile patients with sunken superior sulcus, involutional ptosis, and higher eyelid crease, a single operation to correct depression or ptosis cannot achieve good results. We demonstrated the anatomy of periorbital septum fibers, which may contribute to the levator muscle's volume depletion and dynamic power transmission disorder, and described a procedure for correcting upper-eyelid depression and blepharoptosis in senile patients. The fibrous webs in these patients connected the posterior aspect of the orbicularis and the orbital septum and extended to the orbital fat and levator aponeurosis. These fibers were dissected to release the periorbital septal fibers, and the orbital septal fat flap was transferred to the depressed region. Advancement or plication of the levator aponeurosis was performed in patients with uncorrected blepharoptosis after the procedures described above. The technique was applied to 13 Chinese patients (25 eyes) between May 2021 and April 2022. Postoperative magnetic resonance imaging revealed that the preaponeurotic fat was displaced forward and down to the upper margin of the tarsus, and the curvature of the upper-eyelid depression was significantly improved. Moreover, the superior sulcus deformity improved, the ptosis was corrected, and the uppermost crease decreased in all patients. No recurrence of ptosis or abnormal adhesion was observed. We believe this is the first study using magnetic resonance imaging to evaluate eyelid anatomy and the effects of surgery in this patient group. Releasing periorbital septum fibers is crucial for correcting a portion of the sunken eyelid and ptosis in Asians.

Sunken Upper Eyelid Deformity Correction by Orbital Fat Pad Repositioning and Orbicularis Oculi Muscle Folding in Blepharoplasty

BACKGROUND

Sunken upper eyelid deformity results in an aged and unnatural appearance and is common among Asians along with the single eyelid. The upper eyelid volume restoration is as important as the creation of a supratarsal fold for patients with sunken eyelids. In the present study, the combination of orbital fat pad repositioning and orbicularis oculi muscle flap folding was established to correct the upper eyelid depression during blepharoplasty.

METHODS

A retrospective study was conducted on patients who underwent the orbital fat pad repositioning and orbicularis oculi muscle flap folding to correct the upper eyelid depression between July 2020 and October 2021. The preoperative and postoperative sunken depths were calculated and compared, and overall patient satisfaction was performed to evaluate the operation efficiency.

RESULTS

There were 40 patients, including 39 females and 1 male, who underwent surgery with an average age of 25.4 years. During the mean follow-up period of 12.7 months, the sunken depth improved from 3.2 mm preoperatively to 1.5 mm postoperatively with a statistical significance. Satisfactory results were achieved without major complication.

CONCLUSIONS

For patients with mild to moderate sunken upper eyelids, the combination of orbital fat pad repositioning and orbicularis oculi muscle folding has been proved efficient and consistent to restore the upper eyelid volume and helpful to build esthetic double eyelids.

Comprehensive Treatment of Lower Eyelid Plasty Based on Intraoral Fixation and Redistribution of Lower Eyelid Fat

BACKGROUND

Eye bags especially give an impression of aging and mental exhaustion. At present, the surgical methods of bags mainly include conjunctival approach and lower eyelid skin approach. With the continuous upgrading of the concept of facial esthetics, the lower eyelid pouch surgery for middle-aged and elderly patients pays more attention to reducing surgical trauma, improving tear trough deformity along with the effacement of lid‑cheek junction.

OBJECTIVE

This paper discusses the clinical effect of the lower lid blepharoplasty involved orbital septum fat repositioning based on oral fixation via conjunctival approach combined with relaxation skin resection in the treatment of eye bags in elderly patient.

METHODS

Fifty elderly patients underwent blepharoplasty between January of 2021 and June of 2021 at our hospital. The lower eyelid orbital septum fat was released along with the prezygomatic space and the premaxillary space were stripped through the conjunctival approach. The released cellulite was redistributed in the prezygomatic space/premaxillary space and fixed in the oral vestibular with 5-0 Polysorb through the middle facial tunnel. Finally, the appropriate skin was finally removed.

RESULTS

After operation, 48 patients were satisfied with the operation results, with tight lower eyelid skin and natural lid‑cheek junction. One patient with conjunctival infection was cured after 7 days of antibiotic eye drops. One patient felt foreign body when chewing, and the symptoms disappeared naturally after 5 days without treatment.

CONCLUSION

For middle-aged and elderly patients with bags, the surgical method in this study not only has good postoperative effect, but also has small damage to the lower eyelid orbicularis muscle. The appearance is natural and the lower eyelid skin is tight. The effacement of lid‑cheek junction and recreating a smooth transition of lower lid cheek interface, which can correct lacrimal groove deformity. The patients have high acceptance and satisfaction, which can be widely used in clinical practice.

The Safety of Fat Grafting: An Institutional Retrospective Review

BACKGROUND

Autologous fat grafting is a popular technique for volume replacement in the breast and face. The efficacy, safety, and complication rate of this technique at the division of plastic surgery at the University of Alabama at Birmingham will be described in this review.

METHODS

An institutional review board-approved retrospective review of patients undergoing fat grafting procedures from January 2015 to July 2018 was performed. Records were reviewed for fat graft recipient site, donor site, amount grafted, and complications. Continuous variables were compared using either a t test or one-way analysis of variance test. Categorical data were compared using χ2 test. A P value of 0.05 or less was considered statistically significant for all comparisons.

RESULTS

A total of 396 patients who underwent fat grafting procedures of the face and body from January 2015 through July 2018 met inclusion criteria. Average amount of fat grafted for all grafts was 124.4 +/- 6.74 grams. Two hundred fifty of the grafts (62.7%) involved the bilateral breasts with an average of 140.6 +/- 93.97 g used, 70 per side. Of the 396 patients, 110 (27.8%) experienced complications. Forty three of the complications (10.9%) were considered to be major, which included hematomas/seromas, fat necrosis, dermatitis/cellulitis, and infection. No statistical differences were seen among recipient site complication rate. Types of minor complications were statistically significant per recipient sites with bilateral breasts more likely to experience asymmetry than the other recipient sites (20% for bilateral breasts vs 16% overall, P < 0.05). Fifty nine of the 110 patients (53.6%) had the complications reported to be resolved.

CONCLUSIONS

Fat grafting is a reliable method for volumization of the breasts and face. Minor complications were not infrequent in this case series; however, no life-threatening complications were observed. Continued work needs to be done to use fat grafting beyond traditional measures.

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 .

Porcine Acellular Dermal Matrix Increases Fat Survival Rate after Fat Grafting in Nude Mice

Background

Autologous fat grafts have been widely in use for reconstruction, contour abnormalities, and cosmetic surgeries. However, the grafted fat one-year survival rate is unpredictable and always low (20%–80%). Standardizing the existing transplantation technology is difficult due to the limiting conditions. Scaffold materials or drugs are unsuitable to employ because of legal restrictions, complex production, and undetermined hazards. Therefore, a simpler and more effective approach to improve grafted fat survival rate is using commercial products as additives. Earlier studies proved that porcine acellular dermal matrix (PADM), a biomaterial clinically used for wound repair, could work as a scaffold for lipo-implantation. This study aimed at investigating the hitherto unclear effect of PADM on transplanted fat survival.

Methods

Thirty-two 8-week-old female nude mice were divided into two groups. Control mice received a 300 μl fat injection, while the PADM group mice were injected with a 300 μl PADM-fat mixture. After a 4-week treatment, fat weight and liquefaction ratio were assessed. Histological changes were quantified via hematoxylin & eosin (H&E) staining. Macrophage infiltration and vascular regeneration were revealed using an anti-CD34 antibody. Mouse and human mRNA expression levels were gauged via RNA-sequencing. On the third day post implantation, the mRNA expression levels of inflammatory genes Mcp-1 and Tnf-α were measured by qRT-PCR.

Results

The weight of surviving grafted fat did not differ between the control and the PADM group. However, adding PADM significantly decreased fat liquefaction. H&E-stained sections showed that PADM decreased fat necrosis, increased fat tissue regeneration, and raised CD34 levels in the regenerated tissue. RNA-sequencing showed that, compared to controls, fats from PADM-added group expressed more mouse-related mRNA but less human-related mRNA. The following GO and KEGG analysis showed that added PADM increased extracellular matrix (ECM) genes expression levels. The qRT-PCR showed that adding PADM increased Mcp-1 and Tnf-α mRNA expression levels.

Conclusions

In summary, PADM addition increased fat survival rate by reducing fat liquefaction through an increased macrophage infiltration, ECM regeneration, and revascularization. Therefore, PADM addition is a workable application in autologous fat grafting.

No Level Assigned

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.

Orbital Septum Fat Flap Transfer for Upper Eyelid Depression

BACKGROUND

Sunken upper eyelid makes people's eyes look gaunt and aging. At present, more and more people are paying attention to eye rejuvenation, and more and more people are asking for correction of sunken upper eyelid. Orbital septum fat plays an important role in the display of eye contour. Therefore, the position of orbital septum fat can be adjusted surgically to improve the upper eyelid depression.

OBJECTIVE

This article discusses the clinical effect of orbital septum fat flap transfer in the upper eyelid depression of mild to moderate.

METHODS

Thirty patients with single eyelid depression in our hospital from April to September 2020 were selected. After blepharoplasty, the orbital septum fat was fully released and the lateral orbital fat transfer was fixed to the mid-medial upper eyelid depression.

RESULTS

After the operation, 29 patients were satisfied with the results, with good incision healing, bilateral basic symmetry no obvious scar, and negative effect of non-convex and concave eyelid inequality. One patient did not achieve the expected results and was treated with a second autologous fat filling.

CONCLUSIONS

For patients with mild to moderate sunken upper eyelid, orbital septal fat flap metastasis during blepharoplasty has not only good effect, natural appearance, and smooth upper eyelid skin, but also only 1 incision for upper eyelid formation, which has high acceptance and satisfaction of patients and can be widely used in clinical practice.

A Comprehensive Approach to Upper Eyelid Rejuvenation Surgery

BACKGROUND

Upper eyelid aging results from comprehensive changes, and studies have failed to comprehensively address these changes.

OBJECTIVES

This study proposes a comprehensive approach to the surgical treatment of aging upper eyelids.

METHODS

Data of 116 patients with aging upper eyelids were analyzed. Each eye was scored on upper eyelid laxity, degree of blepharoptosis, and upper eyelid socket depression at preoperation and 6 months after surgery. Based on average scores of both eyes, three degrees of aging were considered: mild, moderate, and severe. All patients underwent comprehensive surgical treatments. Depending on its condition, loose skin was appropriately removed, and the levator palpebrae superioris (LPS) was corrected in patients with degenerative ptosis. Meanwhile orbital septum fat was released or periumbilical fat mass was used as a filler to correct upper eyelid socket depression. All cases were summarized based on a classification and grading system. Scores were reassessed, and satisfaction survey was conducted after 6 months follow-up.

RESULTS

The preoperative and postoperative scores of the three groups were significantly different (p < 0.05), and the difference in preoperative and postoperative scores between the three groups was also statistically significant (p < 0.05). The severe aging group had the greatest difference in score. Aside from 8 patients requiring reoperation, patients reported satisfied results after the 6 month follow-up.

CONCLUSIONS

Comprehensive surgical treatment for patients with different grades of upper eyelid aging can achieve a satisfactory effect of upper eyelid rejuvenation.

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.

Efficacy, safety and complications of autologous fat grafting to the eyelids and periorbital area: A systematic review and meta-analysis

Background

In recent years, autologous fat grafting (AFG), also known as fat transfer or lipofilling, has been widely performed for periorbital rejuvenation and defect correction, although the evidence regarding its efficacy and safety is still lacking. Besides, with respect to the periorbital region, it is invariably the earliest appearance area of the facial aging phenomenon. Therefore, a systematic review and meta-analysis is needed to evaluate the efficacy and safety of this technique.

Methods

A literature search was performed in PubMed, Embase, and the Cochrane library databases on November 20, 2020, adhering to the PRISMA guidelines, to identify all relevant articles. Then, a data extraction and standardization process was performed to assess all outcome data. Ultimately, the data were assessed using a random effects regression model with comprehensive meta-analysis software.

Results

Thirty-nine studies consisting of 3 cohorts and 36 case series with a total of 4046 cases were included. Meta-analysis revealed a relatively high satisfaction rate of 90.9% (95% CI, 86.4%–94.0%). Frequent complications in 4046 patients receiving AFG were edema, chemosis, and contour irregularity, with an overall complication rate of 7.9% (95% CI, 4.8%–12.8%).

Conclusion

This systematic review and meta-analysis showed that AFG for rejuvenation of eyelids and periorbital area provided a high satisfaction rate and did not result in severe complications. Therefore, AFG might be performed safely for periorbital rejuvenation and reconstruction.

A Retrospective Study of Double Eyelid Surgery for Sunken Upper Eyelid in Chinese

OBJECTIVE

The aim of this study was to explore the effective technique of double eyelid surgery for mild, moderate, and severe sunken upper eyelid in Chinese.

METHODS

According to the degree of the sunken upper eyelid, different procedures were performed. For mild sunken upper eyelid, the key technique was named eyelid volume redistribution (EVR)-1 technique, which was advancing or folding the pretarsal orbicularis oculi muscle flap toward up to the upper margin of the incision. For moderate sunken upper eyelid, the EVR-2 technique included EVR-1 technique and releasing orbital fat toward the upper margin of the tarsus. The other surgical steps were the same as conventional double eyelid surgery. For severe sunken upper eyelid, 2 steps were needed. The first step was eyelid volume augmentation (EVA). This technique injected fat into the retroorbicularis oculi fat layer. The second step was conventional double eyelid surgery which was performed 3 to 6 months later.

RESULTS

One hundred sixty-seven patients with sunken upper eyelid underwent double eyelid surgery. In addition to the ameliorative recontouring of the sunken deformity, natural double eyelid was created. All patients had no complication, such as infection, skin irregularities, and lumps. The edema, bruising, and temporary ptosis recovered in 2 weeks. The edema resulted from double eyelid surgery, which last about 2 to 3 months.

CONCLUSIONS

Our study showed that EVR-1, EVR-2, and EVA techniques have stable surgical results for mild, moderate, and severe sunken upper eyelids in Chinese. The procedures are simple, safe, and have less complications and preferable clinical reference value.

Correction of Upper-Eyelid Depression Through Retro-Orbicularis Oculi Fat (ROOF) Augmentation Using Periumbilical Adipose Graft

OBJECTIVE

The authors sought to determine the efficacy of periumbilical fat block grafting to the orbital retro-orbicularis oculi fat (ROOF) layer to correct sunken-upper eyelids in Asians.

METHODS

All patients complained about upper-eyelid hollowness and a variety of deformities. Invasive double-eyelid procedures were performed, and periumbilical fat blocks were grafted for these patients. The core procedure of this approach was to make a separation between the orbicularis oculi muscle and septum to expose the retro-orbicularis oculi fat (ROOF) and fixate the fat grafts to the desired region of ROOF.

RESULTS

From February 2018 to October 2019, the novel technique was performed on 38 Chinese patients (76 eyes) in our department. After follow-up of 6-15 months, 35 patients (92%) showed satisfactory aesthetic results with approximately 20-40% fat absorption rate. No cases required a second procedure. Periumbilical scars remained hidden within the umbilicus area.

CONCLUSIONS

Periumbilical fat grafting in the ROOF of the sunken upper eyelid can both fill the depression and help correct over-wide double eyelid.

EBM LEVEL 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 .

A Novel Way for Upper Eyelid Rejuvenation by Combination of Local Fat-Fascia-Muscle Flap Repositioning for Middle-Aged Asian Women

BACKGROUND

Upper eyelid aging is common among middle-aged Asians. Apart from skin aging, there has been an increasing recognition for the role of sunken eyelid playing in upper eyelid aging. Various methods have been developed to deal with the upper eyelid volume deflation. However, autologous fat tissue could not achieve stable and satisfying rejuvenation results, especially for middle-aged patients who have established extremely low adipose tissue survival rates. Therefore, efficient rejuvenation methods with consistent long-term improvement are needed, especially for middle-aged patients.

METHODS

A retrospective study was conducted of 248 middle-aged patients who underwent the upper eyelid tightening and local fat-fascia-muscle flap reposition for upper eyelid rejuvenation in our department between 2015 and 2017. A precise sunken upper eyelid calculation method was used to evaluate the patients' upper eyelid sunken volume prior to the operation for the guidance of sunken correction. The same method was also used to calculate the post-operation upper eyelid sunken volume to evaluate the operation efficiency.

RESULTS

The average age of the patients who underwent the surgery was 49.5±7 years-old. The fat-fascia-muscle flap was repositioned according to each patient's pre-operation sunken upper eyelid evaluation result, and precise and satisfying immediate sunken correction was observed after the surgery. Long-term consistent improvement was achieved. Compared to the pre-operation evaluation, the upper eyelid sunken correction ratio was nearly 90% in one year's follow-up, and no major complication occurred.

CONCLUSIONS

The fat-fascia-muscle flap reposition combined with sunken upper eyelid calculation has been proved efficient and consistent for middle-aged Asians upper eyelid rejuvenation.

The Anatomy and Clinical Application of Preorbital Septum Fiber

BACKGROUND

In patients with mild superior sulcus deformity, pseudoptosis, or multiple eyelid folds, several bulky fibers can be found anterior to the orbital septum. These fibers, called preorbital septum fibers, may constrict protrusion of the fat pad and movement of the levator palpebrae muscle.

OBJECTIVES

In this study, the authors illustrated the anatomy of these fibers and described the double-eyelid procedure to correct pseudoptosis, mild superior sulcus deformity, and multiple eyelid folds, which may be caused by these fibers.

METHODS

The bulky preorbital septum fibers were dissected and severed during upper blepharoplasty to release the orbital septum fat pad and levator palpebrae muscle. This procedure was performed between January 2016 and January 2018 in 56 patients with distinct preorbital septum fibers.

RESULTS

Of the 56 patients, 38 displayed mild to moderate upper eyelid depression and multiple eyelids, and 18 displayed pseudoptosis. Bulky fibers that existed in the superficial layer of the orbital septum were all dissected and removed. After 6 months' recovery, the superior sulcus deformity improved in all patients. No recurrence of multiple eyelids was observed. Patients with pseudoptosis showed a notable release of their upper eyelids.

CONCLUSIONS

This is the first time to our knowledge that the preorbital septum fibers are described as a distinct anatomical structure. They are clinically important in upper eyelid anatomy and the improvement of sunken upper eyelids or pseudoptosis. The combination of blepharoplasty with release of these fibers is easy to perform and promote.

LEVEL OF EVIDENCE: 4

Orbicularis Oculi Muscle Flap Rotation for Correction of Sunken Eyelid in Cosmetic Blepharoplasty

BACKGROUND

Attempting traditional cosmetic blepharoplasty in a sunken eyelid may cause complications such as multiple folds, irregular or high placement of fold. Additional surgical procedures, such as orbital fat repositioning or free fat grafting, are introduced to correct the sunken appearance. The study sought to introduce a novel orbicularis oculi muscle flap (OOMF) rotation procedure for the correction of the sunken eyelid during blepharoplasty.

METHODS

Retrospective chart review was performed on patients who presented with sunken eyelid(s) and underwent cosmetic blepharoplasty. All patients underwent OOMF rotation to fill the sunken area during blepharoplasty. Postoperative follow-up ranged from 12 to 15 months - the esthetic outcome and complication rates were recorded at each visit.

RESULTS

The sunken appearances of eyelids were improved, and smooth double eyelid folds were achieved in all 62 patients (62 females, mean age 24.1±5.2 years, range: 19-34 years). The mean sunken depths were measured as 6.5 ± 1.0 mm (range: 5-9 mm) preoperatively, and were improved to 4.2 ± 0.9 mm (range: 3-6 mm) at the last follow-up visit (P<0.05). At the last follow-up visit, patients rated the surgical result as good in 88.7% (satisfied with the appearance improvement, n=55), fair in 11.3% (mild complaints about the surgical outcome, n=7), and poor in 0 of cases (unsatisfied with the surgical outcome, n=0).

CONCLUSIONS

In selected patients with sunken eyelid who seek cosmetic blepharoplasty, the OOMF rotation offers a simple and effective way to fill the sunken area and help to form beautiful double eyelids.

Periorbital Injection of Hyaluronic Acid Gel in Patients With Deep Superior Sulcus

PURPOSE

Hyaluronic acid gel (HAG) fillers provide a versatile and safe correction method for a sunken superior sulcus (SS) resulting from soft tissue volume loss occurring with aging, previous surgery, or enophthalmos related to trauma or phthisis bulbi. The purpose of this study was to report the long-term clinical outcomes of filler injection for soft-tissue augmentation in patients with a deep SS.

DESIGN

Retrospective, interventional case series METHODS:: The medical records of 27 patients (32 eyes) with deep superior sulci were reviewed. Twenty injections of hyaluronic acid fillers (Restylane; Q-med AB, Uppsala, Sweden) were performed in the retrobulbar (RB) area, and 15 injections were performed in the SS. Pre- and post-treatment photographs were taken.

MAIN OUTCOMES MEASURES

Visual acuity for seeing eyes, intraocular pressure, exophthalmos measurement, marginal reflex distance 1, interpalpebral fissure, tarsal platform show, and SS hollowing depth grade RESULTS:: Enophthalmos corrections were 1.3 ± 0.8 mm (P < 0.001) and the SS hollowing grade decrease was 1.2 ± 0.9 (P < 0.01) after 1 month of RB injection. Enophthalmos corrections were 0.1 ± 0.4 mm (P = 0.317) and the SS sunkeness grade decrease was 1.7 ± 0.8 (P < 0.001) after 1 month of SS injection. The amount of filler to correct enophthalmos of 1 mm was 0.83 ± 0.53 mL using the RB injection. Using Kaplan-Meier survival analysis, the mean period of maintenance for deep SS correction was 9.1 months for RB injections and 8.5 months for SS injections.

CONCLUSION

Retrobulbar (RB) hyaluronic acid gel (HAG) injections corrected enophthalmos and a deep SS, while SS injections corrected only a deep SS. These 2 techniques of RB and direct sulcus injection are safe and effective methods for the correction of a deep SS.

Free Orbital Fat Grafting During Upper Blepharoplasty in Asians to Prevent Multiple Upper Eyelid Folds and Sunken Upper Eyelids

BACKGROUND

Nowadays, a sharp, well-defined supratarsal fold and appropriate fullness of the upper eyelid tissue are considered important features of beautiful and youthful eyes. Individuals with thin upper eyelid tissue are at high risk of developing multiple upper eyelid folds and/or sunken appearance after upper blepharoplasty. Innovatively, the authors propose the application of free orbital fat grafting to the postorbicularis oculi space during upper blepharoplasty in order to achieve better aesthetic results.

METHODS

Fifty Chinese patients with congenital single eyelids combined with mildly sunken upper eyelid tissue were operated on between June 2017 and October 2018. During blepharoplasty, the lateral portion of the orbital septum was dissected, and appropriate lateral orbital fat was harvested. When the double-eyelid fold was formed and skin was interruptedly sutured, the harvested fat was divided into several pieces each side according to the sunken depth, and they were used to replace a layer on two-thirds of the central region of the supraseptal skin-muscle flap through the zipping gaps.

RESULTS

Forty-five patients underwent the follow-up interview for 6 to 18 months with a mean period of 10 months. The satisfaction rate was 82%. No significant asymmetry, irregularities, and sunken upper eyelid and multiple upper eyelid folds occurred.

CONCLUSION

The lateral orbital fat grafting to the central region of the supraseptal skin-muscle flap during upper blepharoplasty is an effective and simple method to correct or prevent multiple upper eyelid folds and/or sunken upper eyelid in Asians.

Integrating Fat Graft with Blepharoplasty to Rejuvenate the Asian Periorbita

BACKGROUND

Contemporary periorbital rejuvenation is undergoing a paradigm shift to an approach that prioritizes volume preservation and/or augmentation. However, the technical difficulties of using traditional fat grafting techniques in this area and the distinct ethnic features make periorbital rejuvenation in Asians especially challenging. Here, the authors present their approach to enhance the periorbita and outcomes.

METHODS

A retrospective chart review was performed for 33 consecutive patients who underwent microautologous fat transplantation (MAFT) to the periorbita using the MAFT gun device combined with excisional blepharoplasty. Additionally, preoperative and postoperative photographs were analyzed by external evaluators to grade the aesthetic outcomes and fat resorption rates.

RESULTS

Three months after surgery, patients looked on average 5.4 ± 3.4 years younger, and the aesthetic result was graded 7.4 ± 2 in a one-to-ten scale. The fat resorption rate was 19.6% ± 3.5% at 3 months and 32.2% ± 3.9% after 12 months (range: 12-24 months; P = 0.007). The overall morbidity rate was 12% (4 patients), including 1 visible lump (3%), an overcorrection case (3%) in the lower eyelid, and 2 palpable lumps in the upper eyelid (6%) which were not visible. One case of lower eyelid hollowness required secondary fat grafting.

CONCLUSIONS

Traditional blepharoplasty procedures can be combined with fat grafting techniques to address volume loss and tissue descend while keeping ethnic identity. A fat injection device like the MAFT gun is safe and effective and provides long-term predictable outcomes for fat grafting around the periorbital thin skin.

Upper Eyelid Filling Approach [U.E.F.A.] Technique: State of the Art After 500 Consecutive Patients

BACKGROUND

Lately, it has become evident that eye physical aging is mainly due to depletion of the upper eyelid fat causing laxity and wrinkles of the eyelid skin, and new therapeutic strategies aimed at solving the volume loss have appeared in the literature. The aim of this study is to provide a clear classification of upper eyelid aging after 500 consecutive cases and to present a standardization of the therapeutic approach to be adopted when using hyaluronic acid (HA) as fillers or a surgical approach.

METHODS

The upper eyelid aging process of a total of 500 patients was classified based on the measurement of the pre-tarsal skin show m and the pre-septal skin show N. A total of 382 patients were treated exclusively with HA injections in the upper eyelid, 45 patients both with blepharoplasty surgery and HA filling, whereas only 73 patients underwent blepharoplasty only.

RESULTS

Patient satisfaction and at least 1-year clinical follow-up were used to evaluate the results. Pre-treatment and post-treatment photographic assessment was considered as well. A total of 447 patients were women, whereas 53 were men. The correct ratio between m and N was restored in all cases.

CONCLUSIONS

HA filling can be used as either the only volumization procedure or together with blepharoplasty to restore upper eyelid volume loss. The correct strategy has to be selected on the basis of a clear classification. The upper eyelid filling approach is a safe, manageable, lasting and low-cost technique providing excellent results when the correct procedure is followed.

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 .

Repair Techniques for Failed Double-Eyelids Involving Restoration of Eyelid Anatomical Structure and Function

BACKGROUND

This study aimed to evaluate techniques for repairing previously failed double-eyelid surgeries based on different anatomical structure injuries.

METHODS

A total of 120 patients with failed double-eyelids in our hospital were enrolled and classified into four types according to their anatomical structure damage: type I, unsmooth radians of the double-eyelid line; type II, upper socket depression; type III, iatrogenic ptosis; and type IV, comprehensive damage. Accordingly, methods of restoration included orbital septum fat supplement, repair of levator palpebrae superioris, and treatment of scar. Postoperative follow-up time points were 1 week, 1 month, and 6 months. Outcome observations were binocular symmetry, fluency of double-eyelid, scar recovery, height and contour profile of the upper eyelid margin, and plumpness of the upper eyelid. The eyelid morphological score was evaluated using photographs of preoperative and 6-month postoperative data, and the effect of eyelid repair was evaluated objectively by statistical analysis.

RESULTS

At 1 month after surgery, the height of the upper palpebral margin was maintained in most patients and located at 1-2 mm below the superior limbus. At 6 months after surgery, most patients had better restorative effects. Comparison of mean eyelid morphological scores showed a statistically significant improvement following surgery (P < 0.001).

CONCLUSIONS

The technique of restoring eyelid anatomical structure in failed double-eyelids not only recovered the normal function of injured eyelids but also produced satisfactory aesthetic effects.

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 .

Corrective Strategies for a Complex Deformity Caused by "European-Style Double Eyelid" Blepharoplasty in Asians

BACKGROUND

"European-style double eyelid" blepharoplasty often leads to a complex deformity, which includes one or more of the following features: a high fold, upper eyelid depression, multiple folds, an obvious scar, blepharoptosis, and lower flap tumidness. However, there is still a lack of comprehensive research on evaluation and treatment strategies for this complex deformity.

METHODS

During a 6-year period, 65 patients (106 eyes) with a high fold and upper eyelid depression underwent corrective blepharoplasty. The authors classified this complex deformity as mild, moderate, or severe based on the extent of adhesion and tissue insufficiency, and we performed preaponeurotic fat flap transfer in 47 eyes (44.3%), free fat graft in 35 eyes (33%), and free dermis-fat graft in 24 eyes (22.6%), respectively.

RESULTS

The outcomes in 87 eyelids were judged as excellent; and the grading was excellent in 41 eyes (87.2%) that underwent preaponeurotic fat flap transfer, 30 eyes (85.7%) that received a free fat graft, and 16 eyes (66.7%) that received a free dermis-fat graft. The outcomes in only 3 eyes (2.8%) were evaluated as unsatisfactory.

CONCLUSIONS

The fundamental reasons behind this deformity were adhesion and tissue insufficiency above the supratarsal crease. The purpose of correction was to reconstruct the gliding system and restore the volume. The authors performed preaponeurotic fat flap transfer, free fat graft, and free dermis-fat graft and achieved satisfactory results. Great improvement in ptosis was achieved by releasing the adhesion and lowering the fold in patients with normal levator muscle function.

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 .

Changes in Sunken Eyes Combined with Blepharoptosis after Levator Resection

Background:

This study aims to report the changes in sunken eyes combined with blepharoptosis after levator resection.

Methods:

Analysis involved 60 eyes from 32 patients with sunken eyes combined with blepharoptosis. Advancement of the levator aponeurosis and the Müller’s muscle complex (levator resection) was performed in these patients. Area of upper eyelid sulcus (AES) was defined as the area of the upper eyelid shadow. The digital images were converted to black and white using image-processing software (Adobe Photoshop), and the AES was calculated using ImageJ software. In addition, margin reflex distance, eyebrow height (EBH), and AES were measured before and 3 months after surgery to assess the changes in the eyelids.

Results:

Preoperative AES was significantly correlated to age (P < 0.0001; r = 0.8062). Sunken eyes were remarkably improved after levator resection in all patients. Mean margin reflex distance significantly increased, whereas mean EBH and mean AES significantly decreased at 3 months after surgery (P < 0.0001). The AES change was significantly correlated to the EBH change (P < 0.0001; r = 0.5184).

Conclusions:

The principal aim of levator resection is to improve upper eyelid height and visual fields; however, this technique can alter the location of the eyebrow and upper orbital fat. The effects fill the hollowness of the upper eyelid and can remarkably improve sunken eyes.

Is Centrifugation Necessary for Processing Lipoaspirate Harvested via Water-Jet Force Assisted Technique before Grafting? Evidence of Lipoaspirate Concentration With Enhanced Fat Graft Survival

BACKGROUND

Although water-jet force-assisted liposuction technique (WAL) was demonstrated to have favorable effects on fat grafting, controversy continues concerning the application of centrifugation for lipoaspirate harvested via WAL. As a controversial technique, plastic surgeons often get perplexed to the necessity of using centrifugation during fat grafting procedure. In the present study, we adopted the recommended centrifugal intensity (1200g, 3 minutes) to process lipoaspirate and focused on the influence of centrifugation on the fate of lipoaspirate harvested with WAL technique.

METHODS

Lipoaspirate was obtained from 10 healthy Chinese female patients who underwent cosmetic liposuction. The harvested lipoaspirate was either not centrifuged (group A) or centrifuged at 1200g for 3 minutes (group B). Lipoaspirate from each group was compared in the in vitro and in vivo experiments. The influence of centrifugation on lipoaspirate viability and lipoaspirate survival after grafting were evaluated.

RESULTS

The viability of the lipoaspirates was similar between equally volumetric uncentrifugal and centrifugal lipoaspirate. However, centrifugation at 1200g for 3 minutes concentrated stromal vascular fraction cells and adipose-derived stem cells in lipoaspirate; greater angiogenesis and weight retention rates were observed in centrifugal lipoaspirate after grafting than those uncentrifugal lipoaspirate.

CONCLUSIONS

Centrifugation at 1200g for 3 minutes enhanced the survival of lipoaspirate harvested via WAL technique after grafting. Centrifugation at 1200g for 3 minutes was recommended to process lipoaspirate harvested with water-jet force assistance before grafting.

Literature Review to Optimize the Autologous Fat Transplantation Procedure and Recent Technologies to Improve Graft Viability and Overall Outcome: A Systematic and Retrospective Analytic Approach

OBJECTIVE

Investigation and evaluation of the current methods and steps of autologous fat transplantation to optimize the viability of fat grafts and procedure outcome in quest of a more standardized protocol.

METHODS

A thorough literature search was performed across the CNKI, Wan Fang, PubMed, Ovid and EMBASE databases from the year 1970 to December 2014, collecting and classifying all of the autologous fat transplantation-related reports and articles, and after screening, a critical retrospective analysis was performed on the included data.

RESULTS

A total of 65 articles were included in the study. However, there were limited numbers of cases dealing with procedure-related steps such as the selection of donor sites, fat acquisition, graft treatment and methodology of transplant, resulting in a significant lack of evidence support, furthermore urging the need for more standardized protocol for the steps of autologous fat transplant to improve graft viability and overall outcome while decreasing procedure-related morbidity.

CONCLUSION

No good evidence was obtained to optimize the donor site, acquisition, processing and transplantation steps of the whole process of autologous fat transplantation. Tissue engineering and stem cell research have the potential to revolutionize the future of reconstructive surgery by replacing tissue, obviating the need for donor site morbidity. However, the use of stem cell therapies to expand and grow tissue for reconstruction must occur in the context of risk management. Balancing ease of harvest with yield and efficacy has been a delicate and often difficult trade-off which has prompted the scientific community to investigate alternative sources. However, there is much hope in the evaluation and implementation of multimodality approaches for autologous fat transplant, including thriving technologies such as ultrasound-assisted, water jet-assisted, nanotechnology-assisted liposuction in combination with revolutionary fat treatment technologies such as the VASER system.

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 .

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.

Upper Eyelid Filling With or Without Surgical Treatment

BACKGROUND

The upper eyelid of young people is characterized by a proper fullness and projection. Aging eyes show upper eyelid volume loss, symmetric or asymmetric hollowing with too much upper lid showing, dermatochalasis with skin excess. While in the past blepharoplasty surgery was the only approach used to improve eye appearance in the last years, hyaluronic acid (HA) filling of the upper eyelid area has been found very effective in reaching good eye rejuvenation and use of traditional surgical techniques can be limited.

METHODS

A total of 154 patients were enrolled in this study to improve eye appearance. One hundred twenty-eight patients were treated with HA injections in the upper eyelid only, 21 patients underwent surgical treatment followed by HA injections to ensure full correction, and 5 patients underwent blepharoplasty surgery only. The correct approach has been evaluated on the basis of standardized criterion.

RESULTS

Twelve-month clinical follow-up was used to evaluate the results and the degree of patient satisfaction was high. The results are very lasting and no modifications after 2 years are common.

CONCLUSIONS

HA filling is an effective means to rejuvenate the upper eyelid and in several cases it is the only approach able to restore the proper fullness of the upper eyelids. Surgical techniques should be used in the presence of dermatochalasis with excess skin. HA injections in the upper eyelid are easy to perform but it is important to use the correct technique and follow proper indications. This method is a manageable, lasting, and low-cost treatment.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Correction of Sunken Upper Eyelids by Anchoring the Central Fat Pad to the Medial Fat Pad during Upper Blepharoplasty

Background

Many methods have been proposed for the correction of sunken upper eyelids. These methods include surgical treatments, such as micro-fat, dermofat, or fascia-fat grafts, or the use of alloplastic materials. Here, we present our experience of sunken upper eyelid correction involving the simple addition of anchoring the central fat pad to the medial fat pad during upper blepharoplasty.

Methods

We performed 74 cases of upper blepharoplasty with sunken upper eyelid correction between October 2013 and September 2014. The lateral portion of the central fat pad was partially dissected to facilitate anchoring. The medial fat pad was gently exposed and then pulled out to facilitate anchoring. After the rotation of the dissected lateral portion of the central fat pad by 180° to the medial side, it was anchored spreading to the medial fat pad. Photographs taken at 6 months postoperatively were presented to three physicians for objective assessment. Of the 74 patients, 54 patients followed at 6 months postoperatively were included in this retrospective, objective assessment.

Results

Sunken eyelids were effectively corrected in 51 of the 54 patients, but 3 had minimal effect because preaponeurotic fat pads had been removed during previous upper blepharoplasty. In addition to correcting sunken eyelids, lateral bulging was corrected and a better definition of the lateral portion of upper lid creases was obtained.

Conclusions

Anchoring the central fat pad to the medial fat pad provides an effective means of correcting sunken upper eyelids during upper blepharoplasty.

Effect of autologous fat injection on lower eyelid position

PURPOSE

To evaluate the effect of autologous periorbital fat injections on lower eyelid position.

METHODS

Retrospective review of patients treated with autologous periorbital (malar/eyelid tear trough) fat injections for aesthetic purposes by a single surgeon (S.N.) between March 2007 and June 2011. The primary outcome, lower eyelid position as defined by marginal reflex distance 2 and inferior scleral show, was measured by standardizing and comparing pretreatment and posttreatment follow-up digital photos. Photographs were randomized and measured by 2 masked investigators.

RESULTS

Seventy patients (5 male; mean age, 53; range, 33 to 77 years) were treated with autologous fat injections to the malar and lower eyelid tear trough for aesthetic purposes. A mean decrease in marginal reflex distance 2 of 0.5 mm in both OS and OD was found when pre- and posttreatment measurements were compared. Primary and secondary mean follow-up period was at 117 and 316 days, respectively. The effect of the autologous periorbital fat injection was not diminished (n=21) between follow-up periods. A mean change in scleral show of 0.5 mm was found when pre- and posttreatment measurements were compared. The overall mean follow-up period for scleral show was 125 days. Minor complications occurred in 7% (n=5) of patients who had postinjection subcutaneous induration.

CONCLUSION

Autologous fat injections are well tolerated and have potential to be an effective adjuvant or primary treatment for mild lower eyelid retraction.

Correction of Sunken Upper-Eyelid Deformity in Young Asians by Minimally-Invasive Double-Eyelid Procedure and Simultaneous Orbital Fat Pad Repositioning: A One-Year Follow-up Study of 250 Cases

BACKGROUND

Double-eyelid procedure to construct a supratarsal fold is the most common aesthetic surgery in young Asian adults. More complex surgical procedures, such as fat grafting or filler injection, are often indicated during traditional, long-incision, double-eyelid procedures to achieve better aesthetic results for patients with hollowness of the upper eyelids.

OBJECTIVES

The authors sought to determine the efficacy of minimally-invasive double-eyelid procedures with concurrent repositioning of the orbital fat pads to correct sunken upper eyelids in young Asian adults.

METHODS

The study included 250 patients treated between June 2008 and July 2103. Preoperatively, all patients complained of upper-eyelid hollowness and had positive findings on a lower-eyelid compression test. All patients underwent a minimally-invasive double-eyelid procedure plus repositioning of orbital fat.

RESULTS

After the minimum follow-up period of 1 year, the overall patient satisfaction rate was 76%. The relapse rate was 10% within the first year, and the complication rate was 8%.

CONCLUSIONS

This minimally-invasive combination procedure may be an option for young Asian adults who have single upper eyelids and sunken eyes. The surgery resulted in a natural double eyelid and more youthful orbital appearance in the majority of patients in this study. Proper patient selection and evaluation, including lower eyelid compression testing, are essential to achieve long-term correction.

Application of microautologous fat transplantation in the correction of sunken upper eyelid

Supplemental Digital Content is available in the text.

Background:

Although fat grafting has been clinically applied by surgeons in esthetic and reconstructive surgery, it has widely evolved in processes such as harvesting, processing, and placement of fat, using the fat-grafting procedure, which dates back over 100 years. Surgeons frequently use fat grafting to recontour, augment, or fill soft-tissue defects, facial wrinkles, or skin problems such as depressions or scars. However, fat grafting has not been thoroughly understood and has not been conclusively standardized to ensure superior clinical results.

Methods:

This study was intended to determine the role of microautologous fat transplantation (MAFT) under evidence-based medicine, particularly in accurate delivery of small fat parcels. The research method involved the conceptualization of MAFT and the development of an innovative surgical instrument for fat placement. Clinically, 168 patients with sunken upper eyelids with multiple folds underwent this procedure.

Results:

The major findings suggested that MAFT exhibits promising clinical results and offers a superior guideline for fat placement. Details of the technique and theoretical implications are also discussed.

Conclusions:

The therapeutic effects of MAFT and the long-term clinical results of patients with sunken upper eyelids with multiple folds indicated satisfactory outcomes. Based on the results, MAFT offers an alternative option to surgeons for performing fat grafting and provides a more favorable option for the benefit and welfare of patients by reducing the potential complications.