Superior Sulcus Volumetric Rejuvenation Utilizing Dermis Fat Grafting

The Preaponeurotic Fat Advancement Pedicle for Correction of Upper Eyelid Volume Asymmetry: A Case Series

Preoperative volume asymmetry in the upper eyelid sulci can pose a challenge in achieving symmetry after upper eyelid blepharoplasty. Reported methods to improve volume asymmetry include the use of soft tissue filler and various surgical techniques. The authors present 6 cases where a central preaponeurotic fat advancement pedicle was utilized during upper eyelid blepharoplasty for improved upper eyelid symmetry (Fig. 1A-L). No complications or need for postoperative filler or other interventions were noted in all cases, and all patients reported satisfaction with the preaponeurotic fat advancement pedicle procedure. The technique is technically easy, cost-effective, adds minimal operative time to standard upper blepharoplasty, and is associated with high patient satisfaction in this small case series.

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.

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 .

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.

Penis Girth Augmentation Using SEPA Flap and Dermofat Grafts

Background

Men of various ages feel that an increase in penile size would give them and their sexual partners an increased confidence. There are a variety of methods for increasing penile girth, such as injection therapies and surgery. All of these methods have a high complication rate which must be emphasized to the patients. In this article, the techniques used for increasing penile girth using dermofat grafts and SEPA (superior external pudendal artery) flaps are highlighted along with their complications and their management thereof.

Patients and Methods

Ten patients were operated for penile girth augmentation between June 2016 and March 2022. Of these, six patients had augmentation using dermofat grafts and four patients had SEPA flaps. Patients were chosen as per the Augmentation Phalloplasty Patient Selection and Satisfaction Inventory (APPSSI) score which was between 2 and 6 in the pre-operative period. The age range of the patients were between 25 and 57 years. The mid-penile girth in the flaccid state ranged from 8.8 to 12.3 cm.

Results

Post-operatively, after 6 months, the final girth increase varied from 1.9 to 2.6 cm. The complication rate was 50% and included skin loss, urinary obstruction, fat necrosis, and so on. The post-operative APPSSI score ranged from 2 to 12. Complications were more in uncircumcised patients and in those who desired excessive augmentation.

Conclusion

Penis girth augmentation using SEPA flaps and dermofat grafts is indicated in patients who fulfill the criteria and give appreciable girth increase, but patients need to be aware of the potential complications of these surgeries.

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.

A Sandwich-Like Oral Mucosa Graft-Conjunctiva In Situ-Dermis-Fat Graft for Reconstruction of the Anophthalmic Socket with Ocular Infection History

INTRODUCTION

A novel technique of using a sandwich-like structure, namely, an oral mucosa graft (OMG)-conjunctiva in situ-dermis-fat graft (DFG) (OMG-C-DFG), to reconstruct a contracted and low-capacity anophthalmic socket for a patient with ocular infection history was evaluated.

METHODS

This was retrospective case study of four patients (cases) who underwent anophthalmic socket reconstruction surgery in which the OMG-C-DFG technique was applied. The procedures were performed in the Department of Ophthalmology at the Ninth People's Hospital, Shanghai JiaoTong University School of Medicine (Shanghai, China). Postoperative cosmetic appearance, graft outcome, the ability to wear an ocular prosthesis, and postoperative complications were evaluated.

RESULTS

The median (± standard deviation) age of patients was 41.5 ± 22.1 (range 10-60) years. All patients suffered from contracted and low-capacity anophthalmic sockets. Three patients had a history of orbital implant infection and one patient had a history of enucleation due to exogenous endophthalmitis after globe rupture. The DFG and OMG were harvested from the abdominal region and lower lip, respectively. All four patients achieved a good postoperative appearance, with dermal surfaces appearing pink and smooth, the orbital areas showing good fullness, the ocular prosthesis showing good wearability, and no narrowing of the sockets. There was no lipid secretion, fat lysate outflow, or infection in the graft bed. There were only small amounts of scars and no infection of the donor site.

CONCLUSION

The sandwich-like structure can be effectively used to reconstruct the contracted and low-capacity anophthalmic socket with a history of orbital infection in one stage.

Combination of Dermal fat Grafting and Frontalis Suspension Using Polytetrafluoroethylene Sheet for Blepharoptosis With a Deep Sulcus

ABSTRACT

The frontalis suspension procedure is a common surgical method for patients with severe blepharoptosis. While frontalis suspension is a very effective method, the transplant material may be visualized after surgery in patients with a deep sulcus and severe blepharoptosis. To prevent this complication, we performed a combination of dermal fat grafting and frontalis suspension using a polytetrafluoroethylene sheet in 5 patients (6 eyelids). We followed-up the patients for at least 6 months postoperatively (mean: 6.8 months) and observed no transplant material visualization or occurrence of infection. The mean pre- and postoperative margin reflex distance-1 was -3.75 (-5 to -2) and 2.10 (1-3), respectively. Bulky upper eyelids were observed 6 months postoperatively in 1 patient (2 eyelids). None of the patients underwent reoperation. In conclusion, the combination of frontalis suspension using a polytetrafluoroethylene sheet and dermal fat grafting for severe blepharoptosis and a deep upper eyelid sulcus was effective in preventing visualization of the transplant material.

Dermal Onlay Grafts: A Rescue Procedure for Secondary Inferior Periorbital Hollows

BACKGROUND

Various procedures to efface age-related lower eyelid/cheek interface depressions, or primary periorbital hollows (POHs), have been reported in the literature. Postsurgical, or secondary, POHs are a distinct contour irregularity that have received little such attention. Dermal onlay grafts (DOGs), a site-specific term for autologous dermis fat grafts, have been used to treat secondary POHs for which less invasive measures have proved unsuccessful.

OBJECTIVES

The aim of this study was to describe the surgical technique and outcomes of DOGs for secondary POHs.

METHODS

A retrospective analysis of patients who underwent DOGs for secondary POHs over a 27-month period was performed. The surgical technique and outcomes are reviewed.

RESULTS

Thirteen patients (10 women and 3 men; average age, 52 years; average follow-up, 9 months) were included in the study. Nine patients had bilateral surgery, and all had received previous filler or fat injection, or both, with poor outcomes. Generally, surgical complications were minor, required minimal intervention, or were self-limiting. One patient had persistent infraorbital dysesthesia which improved with oral tricyclic antidepressant treatment. Eleven of 13 patients stated satisfaction with hollow effacement and outcome, a finding verified by subjective assessment by a surgeon.

CONCLUSIONS

DOGs yielded good results in this initial description of their utility as a rescue procedure to surgically address secondary POHs. Further quantitative volumetric studies to validate outcome would of value.

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.

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.

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 .

Bipedicle Dermis Fat Graft for Orbital Volume Augmentation and Repair of Lower Eyelid Retraction in an Anophthalmic Socket With Prior Orbital Implant Placement

Buphthalmos can create treatment challenges for socket rehabilitation following enucleation due to compression atrophy and mechanical stretching of adnexal tissues. The authors report a case demonstrating a surgical technique for simultaneous volume augmentation of the anophthalmic socket, expansion of the conjunctival fornix, and repair of lower eyelid retraction in a patient with history of buphthalmos and a previously placed 22 mm orbital implant at the time of enucleation. The authors utilized a single-stage, bipedicle dermis fat graft. Postoperatively, the patient demonstrated improvement in lower eyelid position, lower eyelid volume, improved prosthesis fit, improved three-dimensional projection of the ocular prosthesis, and an improvement in the superior sulcus deformity. Bipedicle dermis fat grafts are an option for surgical rehabilitation of the anophthalmic socket when orbital volume deficiency, conjunctival fornix contracture, and eyelid retraction are present and an adequately sized orbital implant has previously been placed.