Tear trough deformity: review of anatomy and treatment options

Treatment Algorithm for Surgical Correction of Lower Eyelid Bags and Tear Trough Deformity Based on Barton Grading System

Facial rejuvenation procedures for lower eyelid bags and tear trough deformity have recently gained increasing attention. This study introduced a treatment algorithm tailored to the severity of tear trough deformity, categorized using the Barton grading system, to tackle this concern effectively. One hundred seventy-six patients with combined lower eyelid bags and tear trough deformity underwent lower lid blepharoplasty at our center between 2018 and 2023. Preoperative assessment utilized the Barton grading system to categorize the severity of tear trough deformity, guiding personalized surgical approaches for each patient. Postoperative outcomes, including satisfaction levels, complications, and tear trough deformity improvement, were evaluated. Following surgery, 175 out of 176 patients achieved a reduction to Barton grade level of 0. Postoperative satisfaction scores averaged 4.4, with a satisfaction rate of 96.6%. Complications were minimal, including mild postoperative ectropion in patients and single occurrences of postoperative hematoma, infection, insufficient improvement, and recurrence. Our treatment algorithm offers a straightforward and effective approach for addressing tear trough deformity and lower eyelid bags. Further research is warranted to validate these findings.

Lower Eyelid Dark Circles (Tear Trough and Lid-Cheek Junction): A Stepwise Assessment Framework

BACKGROUND

Despite increasing popularity, the use of hyaluronic acid (HA) fillers for the correction of dark under-eye shadows remains challenging. Specific guidance on patient assessment is limited.

OBJECTIVES

The aim of this study was to develop a stepwise assessment framework for lower eyelid dark shadows to help practitioners classify patients based on their underlying problems and facilitate a more strategic approach to treatment.

METHODS

Literature review and peer collaboration informed the current availability of educational material for use by experienced injectors when assessing patients presenting with dark circles. A practitioner survey provided insight into current practices. A focus group convened to review the survey results and discuss best practice approaches to patient assessment.

RESULTS

Surveyed practitioners (n = 39) reported patient concern about under-eye hollows (91%), dark eye circles (80%), and looking tired (60%). All (100%) agreed that midcheek volume was critical when treating tear-trough depression, and only 26% reported use of a tear-trough classification system. The focus group developed a framework for assessing tear-trough depression and the lid-cheek junction in patients presenting with dark circles. Key factors within this framework included the importance of appropriate lighting when conducting a visual inspection, regional inspection of the cheek and tear trough, palpation of the orbital rim and soft tissues, determination of the orbital vector, and assessment of lower eyelid pigmentation and skin quality.

CONCLUSIONS

Careful step-by-step assessment can reduce the challenges of treating dark circles by identifying patients in whom dark eye circles may be improved without the need to directly inject filler into the tear trough.

LEVEL OF EVIDENCE: 5

Surgical Removal of Fat Nodules Formed in the Tear Trough After Autologous Fat Grafting

BACKGROUND

Autologous fat grafting is a common treatment for tear trough deformities. This procedure involves a potential complication of fat nodule formation, leading to abnormal bulging of the lower eyelid. However, limited information exists about this complication, and an effective treatment is lacking. The present study aimed to present a novel surgical approach for the removal of fat nodules caused by autologous fat grafting in the tear trough.

METHODS

This retrospective study included 33 patients who underwent surgery for the removal of fat nodules formed after autologous fat grafting. The procedure was performed using a conjunctival approach, allowing exposure and removal of all fat nodules in the anterior septal space, with the method adapted according to the severity of the deformity.

RESULTS

A total of 66 eyelids were treated surgically, including 30 (45.45%) with mild nodular deformity, 23 (34.85%) with moderate nodular deformity, and 13 (10.70%) with severe nodular deformity. A second surgical procedure was required on 3 eyelids (4.56%). The main complications of the surgery were conjunctival congestion (21.21%), and localized depression (18.18%), bruising (12.12%). Among the patients, 29 (87.88%) were satisfied and 4 (12.12%) were dissatisfied with the treatment results.

CONCLUSION

Conjunctival approach surgery is an effective method of removing fat nodules formed after autologous fat grafting in the tear trough, with good results and high levels of patient satisfaction. This approach enables the effective management of a common complication of autologous fat grafting and may enable the wider application of autologous fat grafting in the periorbital region.

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 .

Orbital fat graft retroseptal transconjunctival blepharoplasty for treatment of groove in the infraorbital region

PURPOSE

To investigate the efficacy of the retroseptal transconjunctival blepharoplasty together with tear trough ligament (TTL) and Orbicularis retaining ligament (ORL) release with orbital fat graft in the management of groove in the infraorbital region (GIR).

METHODS

A prospective study of 80 eyes of 40 patients that underwent retroseptal transconjunctival lower blepharoplasty together with TTL and ORL release and resected orbital fat grafting. An ophthalmic examination includes lower eyelid evaluation and Barton's Tear trough deformity grading was done at baseline, 2 weeks, 3 months, and 6 months after the surgery. Patient satisfaction was evaluated using Global aesthetic improvement scale (GAIS) and Blepharoplasty outcomes evaluation (BOE).

RESULTS

Baseline tear trough defects were graded into grade 1, 2, and 3 in 12 (15%), 39 (48.75%) and 29 (36.25%) eyes, respectively. While at 6 months follow-up, grade 0 was recorded in 63 (78.75%) eyes, and grade 1 was recorded in 17 (21.25%) eyes. The amount of fat removed was 0.52 ± 0.04 mL per eye, whereas the amount of injected fat graft was 0.24 ± 0.04. The mean operative time was 33.2 ± 4.1 min per eye. GAIS showed degree 1, 2, and 3 in 8 (20%), 29 (72.5%), and 3 (7.5%) patients at 6 months follow-up, respectively. The mean baseline BOE increased significantly from 36.5 ± 5.9 to 86.9 ± 5.5 at 6 months follow-up.

CONCLUSIONS

Our cohort highlights the beneficial effects of TTD/ORL release with resected orbital fat grafting in the management of GIR and infraorbital hollow.

Transconjunctival Fat Repositioning Blepharoplasty: Is Excess Fat Herniation a Prerequisite?

BACKGROUND

The fat repositioning technique has been widely used for the treatment of tear trough deformity, and there is a strong belief that excess fat herniation is a prerequisite for the procedure. The purpose of this study was to evaluate its effect in patients with minimal or no excess fat herniation.

METHODS

A total of 232 patients underwent the procedure and met the inclusion criteria. Of them, 198 were primary cases, and 34 had a hisory of fat removal for blepharoplasty. The amount of infraorbital fat was evaluated preoperatively by palpation. Release of the tear trough ligament and fat redistribution were sequentially performed as described previously. Surgical outcome was assessed based on the Hirmand grading system and the FACE-Q scales.

RESULTS

Tear trough deformities were eliminated in more than 85% of cases. Aesthetic results were comparable between the primary and secondary surgery groups. The percentage of patients who complained of extremely or moderately severe tear trough deformities decreased from 86.3% preoperatively to 34.0% postoperatively. The scores of the lower eyelid FACE-Q decreased significantly ( P < 0.05). Patients were satisfied with their decision to undergo blepharoplasty (78.2 ± 18.7). Undercorrection of the tear trough occurred in 30 patients. Other complications included 12 cases of transient conjunctiva bleeding, two cases of eyelid numbness, and six cases of dry eye. These resolved spontaneously.

CONCLUSION

Fat repositioning is a feasible and effective technique for the treatment of tear trough deformities in patients with minimal or no excess orbital fat herniation, provided that a fat pad is palpable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Clinical Assessment, Diagnosis, and Management of Infraorbital Wrinkles and Pigmentation

Lower eyelid skin is unique and different from that of other areas. In addition to being an area of high exposure to the sun and elements, there are anatomic considerations and specific histologic characteristics that can cause the skin in this area to be more sensitive. These attributes can readily cause under-eye wrinkling and pigmentation. This review aims to present an updated overview of the current knowledge regarding the clinical characteristics, diagnosis, and management of wrinkles and pigmentation in this area. These disorders are usually caused by different factors, such as genetics, aging, sun exposure, lack of sleep, and stress.

Stromal Vascular Fraction Gel (SVF-Gel) Combined with Nanofat for Tear Trough Deformity

BACKGROUND

Tear trough deformity makes patients appear tired. Patients with less severe tear trough deformity prefer a less invasive method to correct the deformity. The infraorbital area is a multilayered tissue, and the aging of various components leads to tear trough deformity. To this end, we utilized the different characteristics of different fat derivatives to correct tear trough deformity.

METHODS

Thirty-two patients with Barton Grade I/II tear trough deformity were enrolled in this study between September 2020 and March 2021. We injected Stromal Vascular Fraction Gel (SVF-Gel) into the suborbicularis oculi fat layer and Nanofat into the subcutaneous. After 12 months of follow-up, we evaluated the changes using standardized clinical photogrammetric techniques, volume, global aesthetic improvement scale, and patient self-evaluation.

RESULTS

There were no major complications in any of the 32 patients. The measured data points demonstrated improvements in all aesthetic parameters. The width of the tear trough and the distance from the pupil to the tear trough improved. The Global Aesthetic Improvement Scale (GAIS) showed a high score (2.45±0.64 points), with patient self-assessment showing satisfactory results.

CONCLUSION

SVF-Gel combined with Nanofat injection can effectively correct tear trough deformities.

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 .

Analysis of the efficacy of blunt separation combined with uncrosslinked sodium hyaluronate composite solution for the treatment of tear trough deformity in Asians

BACKGROUND

Filling therapy is becoming increasingly popular for correcting tear trough deformities (TTD). However, its therapeutic effect and retention time are limited.

AIMS

To improve the clinical efficacy and safety of TTD treatment in Asians, we used a blunt separation technique to break the adhesion site of periorbital subcutaneous tissue, and while repairing skin dermis after injury, it was combined with uncrosslinked hyaluronic acid compound solution to promote collagen regeneration and treat TTDs.

PATIENTS/METHODS

Twenty-six Chinese patients (21 women and 5 men) with TTD, with a mean age of 34.54 ± 9.21 (range, 20-56) years, were enrolled. Symptom improvement, recurrence rates, treatment safety, and patient satisfaction were evaluated.

RESULTS

All patients' tear trough rating scale (TTRS) scores decreased significantly immediately after treatment. The TTRS scores at 1, 3, and 6 months, and 1 year after treatment demonstrated significant differences from those before treatment (all p < 0.05). All patients' experienced mild pain, erythema, and swelling during the treatment. Three patients developed postinjection bruising after treatment, which lasted for 6-7 days and subsequently disappeared. No other adverse reactions were observed during the follow-up. There were no recurrent cases, and patient satisfaction was very high.

CONCLUSIONS

Blunt separation combined with an uncrosslinked sodium hyaluronate composite solution is safe and effective for treating TTDs in Asians with few side effects and has good clinical application prospects.

A Quantitative Three-Dimensional Tear Trough Deformity Assessment and Its Application in Orbital Septum Fat Transposition

BACKGROUND

Existing evaluation tools of tear trough deformity are based on subjective impression of clinicians. More accurate quantitative assessment methods are needed. This study aimed to propose a quantitative three-dimensional assessment method for the tear trough deformity in comparison with the Barton's grading system and apply it to the efficacy evaluation of orbital septum fat transposition.

METHODS

117 healthy Chinese adults (234 eyes) were enrolled and divided into four groups according to the Barton's grading system. Three-dimensional facial images were captured using Vectra H1 handheld camera. 6 anthropometric landmarks were identified on each eye and 8 linear measurements were generated accordingly. Intra-observer reliability was determined and measurements were compared between groups. Pre- and post-operative three-dimensional measurements were compared in 19 patients who received lower blepharoplasty with orbital septum fat transposition.

RESULTS

The severity of tear trough was positively correlated with age (P < 0.001) but not BMI (P = 0.145) or gender (P = 0.280). Intra-rater reliability of the 8 linear measurements was excellent except for the vertical distance between the palpebrale inferioris margin and the tear trough below the pupillary center. Intergroup comparison showed that the horizontal distance between the lateral end of tear trough (P < 0.001) and medial canthus and the sagittal vector from tear trough point toward eyelid bag point (P = 0.009) increased with grade, while the vertical distance from mid-pupil to palpebrale inferioris margin decreased gradually (P = 0.001). Orbital septum fat transposition significantly improved the tear trough deformity as assessed by these three-dimensional measurements.

CONCLUSIONS

We demonstrated a novel quantitative evaluation method of the tear trough deformity using three-dimensional stereophotogrammetry and proved it to be valid and reliable. It showed good value of clinical application and might help with periorbital rejuvenation planning and outcome assessment.

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 .

Novel Treatment Protocol for Combined Tear Trough Ligament Stretching and Injection

BACKGROUND

Complex anatomical changes have been the main challenges for optimal treatment results of tear trough deformities through hyaluronic acid (HA) injections. The authors present a novel technique consisting of a preinjection tear trough ligament stretching (TTLS-I) leading to its release, and compared its efficacy, safety, and patient satisfaction to tear trough deformity injection (TTDI).

METHODS

This was a 4-year, retrospective, single-center cohort study of 83 TTLS-I patients, with a follow-up period of 1 year. One hundred thirty-five TTDI patients served as a comparison group. Outcome analyses included the analysis of possible risk factors for adverse outcome and comparative statistics between the complication and satisfaction rates of the two groups.

RESULTS

TTLS-I patients received significantly less HA (0.3 cc; range, 0.2 to 0.3 cc) than TTDI patients did (0.6 cc; range, 0.6 to 0.8 cc; P < 0.001). The injected HA amount was a significant predictive factor for complications ( P < 0.05). Complication rates assessed during the follow-up visit for hematomas, edema, and the need for corrective hyaluronidase injection were low in both groups, with no significant differences between the groups. TTDI patients had significantly higher rates (5.1%) of lump surface irregularities during follow-up, compared with 0% in the TTLS-I group ( P < 0.05). After 1 year of follow-up, 98.8% of TTLS-I patients were satisfied, whereas 95.6% of TTDI patients were satisfied, with no significant difference between groups.

CONCLUSIONS

TTLS-I is a novel, safe, and effective treatment method, necessitating significantly less HA compared with TTDI. Moreover, it leads to very high satisfaction rates and very low complication rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Three-Dimensional Analysis of Tear Trough Volume After Lower Blepharoplasty with Midface Lift

Background: This study aims to evaluate three-dimensional stereophotogrammetry measured volume changes in the tear trough area after lower blepharoplasty with midface lift with or without orbital fat manipulation. Objective: Among patients undergoing midface lift surgery, volume change by three-dimensional photography in the tear trough region was compared between those having no orbital fat manipulation, fat transposition, or fat resection. Methods: This is a prospective study of 260 eyelids of 130 patients who underwent cosmetic midface surgery. All patients had an external skin muscle flap midface lift. During the procedure, medial inferior orbital fat was resected, repositioned to a preperiosteal dissection pocket, or not manipulated. Forty-six patients (35.4%) had no fat manipulation, 42 patients (32.3%) had fat preservation with repositioning to the preperiosteal pockets on the medial inferior orbital rim, and 42 patients (32.3%) had fat resection without repositioning. Results: All patients had volume gain in tear trough volume. The amount was not statistically significantly different between fat treatment groups. Mean follow-up time was 12 months (range 6-20 months). Conclusions: Midface lifting improved tear trough volume irrespective of how fat was manipulated.

Creation and Validation of a Photonumeric Scale for Assessment of Infraorbital Hollows

BACKGROUND

Validated clinical scales are needed to assess aesthetic improvement of the infraorbital hollows (IOHs) after treatment with dermal fillers.

OBJECTIVE

To develop an IOHs scale and establish its reliability and sensitivity for grading subjects in clinical trials or routine practice.

METHODS AND MATERIALS

The Teoxane IOHs Scale (TIOHS), a 5-grade photonumeric scale, was developed based on real-subject photographs and validated through photographic and live subjects' evaluation.

RESULTS

Clinician intra- and inter-rater agreements during the TIOHS validation were excellent. The mean intrarater-weighted Kappa score between the 2 sessions of photographic validation was 0.92, while inter-rater interclass correlation coefficient (ICC) was 0.92 for the combined sessions. The average intrarater-weighted Kappa score and inter-rater ICC for the live validation reached 0.80 and 0.76, respectively. In addition, evaluators identified clinically significant differences between photographs of subjects presenting a 1-grade or 2-grade difference in 82% and 86% of cases, respectively.

CONCLUSION

The intrarater Kappa scores and inter-rater ICCs met their predetermined acceptance criteria of >0.70. The TIOHS is a repeatable and reproducible clinician-reported outcome for health care providers to classify IOHs in clinical trials and routine patient care. A 1-grade difference on the TIOHS can detect a clinically meaningful difference in infraorbital hollowing.

Application of infraorbital rim augmentation with pocket fat filling to correct tear trough deformity

Background

Tear trough deformity is one of the most common complaints in clinical settings. The correction of this groove is challenging in facial rejuvenation. The lower eyelid blepharoplasty varies with different conditions. A novel approach of using orbital fat in the lower eyelid to increase the volume of the infraorbital rim with granule fat injection has been applied in our institution for more than 5 years.

Objectives

This article aims to describe the detailed steps of our technique and verify its effectiveness by a cadaveric head dissection after surgical simulation.

Methods

In this study, a total of 172 patients with tear trough deformity underwent lower eyelid orbital rim augmentation with fat filling in the sub-periosteum pocket. According to Barton's grades, 152 patients underwent lower eyelid orbital rim augmentation with orbital fat filling, 12 patients had it combined with autologous granule fat from other body parts, and 8 patients received only transconjunctival fat removal to correct tear trough.

Results

The modified Goldberg score system was used to compare preoperative and postoperative photographs. Patients were satisfied with the cosmetic results. Excessive protruding fat was released, and the tear trough groove was flattened by using autologous orbital fat transplantation. The lower eyelid sulcus deformities were well-corrected. To further illustrate the anatomical structure of the lower eyelid area and injection layers, six cadaveric heads were used for surgical simulation and demonstrated the effectiveness of our technique.

Conclusions

This study indicated that the infraorbital rim could be increased by transplanting orbital fat to the pocket, which was dissected under the periosteum, and the procedure has been verified as reliable and effective.

Evidence-based medicine EBM level

Level II.

Surgical Correction of Tear Trough Deformity (TTD) with Orbicularis Retaining Ligament Release and Volume Augmentation for Periorbital Rejuvenation: Review of the Literature

BACKGROUND

Tear trough deformity is a hallmark of periorbital aging. It is not, however, an exclusive feature of old age. While protruding orbital fat results in lower lid bags that are traditionally corrected by excision, correction of TTD can constitute a real challenge requiring volume enhancement in addition to addressing prolapse of orbital fat and descent of cheek tissues. Described therapeutic options include minimally invasive soft tissue augmentation with fillers or structural autologous fat transfer as well as invasive surgical procedures concomitantly with lower lid blepharoplasty or other facial rejuvenation procedures.

MATERIAL AND METHODS

Six eponyms have been used in the literature to describe the condition: (1) naso-jugal fold, (2) naso-jugal groove, (3) naso-jugal ditch, (4) tear trough, (5) tear trough deformity, and (6) tear trough depression. A separate PubMed database search of each of the 6 terms was conducted in addition to an advanced literature and systematic PICO searches to identify all described clinical retrospective or prospective, comparative or simple cohort studies related to surgical correction of TTD. An additional screening of references of retrieved clinical studies was performed to identify any missed reports.

RESULTS

A total of 435 publications were identified with the initial search. After excluding all none relevant studies, 44 papers were selected for review. 6 additional studies were identified by screening relevant references.

CONCLUSION

Almost all authors agree on the necessity to release the tear trough retaining ligament together with volume enhancement. Transconjunctival and transcutaneous incisions are reported. Most recommend repositioning of the protruding orbital fat for volume enhancement to mostly subperiosteal, or pre-periosteal pockets. Other reported options include pedicled buccal fat pad transposition, segmental fat grafting, and minced micrografts. Internal as well as external fixation of repositioned fat flaps have been described. Despite lack of solid objective evidence, several of these techniques when properly executed for the proper indication in selected patients are reported to result in a rewarding and long-lasting outcome. Unfortunately, it is difficult to determine the most appropriate technique that would universally yield the most pleasant and harmonious facial contour without creating an unnatural puffy appearance. It remains for the surgeon to identify the safe surgical approach that does not compromise lower eyelid function and achieves the most pleasing aesthetic outcome with the least complications and downtime.

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 .

Tear trough ligament reset as a new method for tear trough deformity and dark circles correction

Tear trough deformities and dark circles are important parts of periorbital aging. In this study, the tear trough ligament was reset to correct the tear trough deformity, and its effect on dark circles was analysed. The medical records of 60 patients who underwent eye bag plastic surgery between January 2021 and February 2022 were analysed (30 had traditional eye bag plastic surgery and 30 had the tear trough ligament reset). The tear trough deformity score and the dark circle score showed that the corrective effect on the tear trough deformity in the reset group was better than in the traditional surgery group at six-month follow up (mean (SD) tear trough rating scale (TTRS) score = 4.82 (0.95) vs 5.92 (1.00), p < 0.0001; L* value 55.27 (2.90) vs 47.51 (3.00), p < 0.0001). The satisfaction of patients in the reset group was significantly higher than it was in the traditional surgery group (25/30 vs 18/30, p = 0.045). Tear trough ligament reset is a safe and effective surgical method of periorbital rejuvenation, especially for beauty seekers with obvious tear trough deformities.

Global Research Trends and Perspectives of Blepharoplasty: A 20-Year Bibliometric Analysis Based on Web of Science

BACKGROUND

The number of publications on blepharoplasty is increasing rapidly. Bibliometric analysis can help surgeons quickly and systematically understand the current state of development. To our knowledge, there are no bibliometric studies on blepharoplasty, and therefore, we conducted this study to reveal research trends and perspectives of blepharoplasty.

METHODS

Relevant publications from 2002 to 2021 were extracted from the Web of Science Core Collection database. After manual screening, VOSviewer software and CiteSpace software were used to collect and analyze the acquired data.

RESULTS

A total of 1125 publications were included and the publications per year increased annually. Contributions from the USA led both quantity and quality. The University of California System was one of the most influential academic institutions. Aesthetic Plastic Surgery had the most publications, and Plastic and Reconstructive Surgery was the most frequently cited or co-cited journal. Massry GG and Hamra ST were the most prolific and co-cited authors, respectively. Additionally, Rohrich RJ had the highest number of citations per publication. References co-cited analysis identified that lower eyelid research was a hotspot. Keywords were mainly divided into 6 clusters, namely "lower lid blepharoplasty," "complications," "facial rejuvenation," "blepharoptosis," "upper blepharoplasty," and "Asian blepharoplasty and epicanthoplasty."

CONCLUSIONS

Blepharoplasty research is flourishing, and three clusters may be the hotspots: "Lower blepharoplasty and mid-face rejuvenation," "overall facial outcome and quality-of-life," and "Asian blepharoplasty and epicanthoplasty."

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 .

Loss of Lower Eyelid Bulge after the Reconstruction of Zygomatic Complex Fractures

Background:

Surgery for zygomatic complex fractures primarily aims to obtain facial symmetry. We investigated facial symmetry specific to lower eyelid bulges following zygomatic complex fractures approached through the lower eyelid.

Methods:

Forty-one consecutive patients underwent treatment of zygomatic complex fractures by swinging eyelid approach or subciliary approach. In both approaches, the periosteum was incised 2 mm caudal to the inferior orbital rim and the orbicularis retaining ligament (ORL) was released. The orbital rim periosteum was interruptedly sutured and reconstruction of the orbital septum or ORL was not performed at the time of closure. In cases with a lower eyelid bulge on the nonfractured side, in a frontal photograph 6 months after the operation, the degree of loss of the lower eyelid bulge on the fractured side was classified as either “none,” “mild,” or “severe.”

Results:

Lower eyelid bulge was present on the nonfractured side in 19 of 41 patients, all of whom were over 50 years old. Loss of lower eyelid bulge was observed on the fractured side in all cases: 15 cases following the swinging eyelid approach (mild/severe; 6/9) and four cases following the subciliary approach (mild/severe; 2/2).

Conclusions:

In reconstruction after zygomatic complex fractures, lower eyelid bulges were lost in both the swinging eyelid and subciliary approaches in patients over 50 years old. The cause was thought to be an ORL release or an unintended septal reset-like effect.

Invited Comment on: "Hyaluronic Acid Gel Injection for the Treatment of Tear Trough Deformity: A Multicenter, Observational, Single-Blind Study." by Alberto Diaspro et al

From this article of Diaspro and colleagues, we can safely conclude that it proves that HA fillers are an effective treatment of tear troughs. A full analysis of the face in general, and the peri-orbital area in particular, is essential to select the right candidates for this treatment. A thorough knowledge of the anatomy is essential to do this selection and to avoid possibly serious complications.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 .

Anatomical Characterization of the Tear Trough and the Lid-Cheek Junction: An Iodine Staining Technique Based on High-Resolution Micro-Computed Tomography

BACKGROUND

The literature presents the tear trough and lid-cheek junction's controversial anatomical explanations. In this study, the authors explored the anatomical characterization of the tear trough deformity and lid-cheek junction.

METHODS

Twelve human cadaver specimens were obtained from the authors' anatomy department. Iodine staining and high-resolution micro-computed tomography was used to observe the suborbital area's anatomy. Anatomical studies and histologic evaluation were performed.

RESULTS

The orbicularis retaining ligament is composed of a main septum right on the rim and multiple fibrous septa in the retro-orbicularis plain. The septum arises from the deep fascia of the palpebral part of the orbicularis oculi at approximately the level of the medial corneoscleral limbus, anchors the muscle to the orbital rim, and continues laterally as the lateral orbital thickening at the lateral canthus. Along the lid-cheek junction, multiple fibrous septa emanating from the deep fascia of the orbital part of the orbicularis oculi converge to the above septum. Using three-dimensional simulation, the skin-insert junction between the pre-palpebral part of the orbicularis oculi and pre-orbicularis oculi fibers precisely corresponded with the tear trough and the lid-cheek groove. Anatomical studies and histologic evaluation confirmed these observations.

CONCLUSIONS

The orbicularis retaining ligament's subtle anatomical features are clearly seen using the approach described. The tear trough and the lid-cheek junction's anatomical characterization is defined by a suborbital ligament-fascia system whose description has implications in designing lower eyelid cosmetic surgery.

Tear Trough and Lid-Cheek Junction Anatomy: Current Understanding and Non-Surgical Treatment

The tear trough and lower eyelid are sentinel sites of facial aging and are increasingly the target of non-surgical aesthetic procedures. This article will review the advances that have led to our current understanding of tear trough anatomy. We propose a new functional classification of the lid-cheek junction for soft tissue filler treatment, and suggest simpler stratification of patients seeking lower eyelid treatment based on the etiology of their tear trough depression. We aim to describe a stepwise approach to management, with specific technical considerations targeting the underlying causes of lower eyelid pathology. The common complications and pitfalls of non-surgical tear trough management will be discussed.

A Prospective, Multicenter, Single-Blind, Randomized, Controlled Study of VYC-15L, a Hyaluronic Acid Filler, in Adults for Correction of Infraorbital Hollowing

BACKGROUND

Rejuvenation of the under-eye area is a popular facial aesthetic treatment option.

OBJECTIVES

This study evaluated the safety and effectiveness of VYC-15L for the correction of moderate or severe infraorbital hollowing.

METHODS

This was a randomized, controlled, single-blind study with a primary endpoint defined as the proportion of participants with ≥1-grade improvement at Month 3 assessed by an evaluating investigator employing the Allergan Infraorbital Hollow Scale. Three-dimensional imaging was conducted to assess infraorbital volume up to Month 12. Procedure pain and injection-site responses (ISRs) were documented, and safety was monitored throughout the study.

RESULTS

At Month 3, the difference between treatment (83.1%) and control (15.6%) was 67.5% (95% CI = 52.9 to 82.0, P < 0.0001). 3D imaging showed a mean volume increase from baseline of 0.733 mL (left) and 0.777 mL (right) at Month 12. Mean pain scores were ≤1.7 (scale of 0 to 10). Most ISRs with initial treatment were mild/moderate and resolved in ≤1 week, including tenderness (49.5%), bruising (42.7%), and swelling (41.7%). Thirty-four participants had treatment-emergent adverse events (TEAEs), of which 14 (10.3%) had treatment-related TEAEs, including bruising (3.8%) and swelling/edema (2.9%), which resolved in ≤2 weeks. Three participants had swelling/edema starting >30 days posttreatment; 2 resolved in ≤4 days, 1 by 45 days. No treatment-related serious AEs were reported.

CONCLUSIONS

VYC-15L was safe and effective for the correction of moderate or severe infraorbital hollowing and lasted through 1 year.

LEVEL OF EVIDENCE: 2

Lower Eyelid and Midface Rejuvenation: Suborbicularis Oculi Fat Lift

The lower eyelids and midface are considered to be a contiguous aesthetic unit although they are different anatomic structures. Through in-depth understanding of complex anatomy and aging theory and appropriate surgical strategies according to the type of aging, surgical outcome of aging lower eyelid/midface can be more and more predictable. This article discusses the characteristics and theories of aging and 5 types of lower eyelid/middle face aging based on 4 key factors, namely, protruding fat in the orbital, excess skin on the lower eyelid, sagging midface and soft tissue deflation. Various combinations of surgical strategies are adopted accordingly.

Innovative approach for tear trough deformity correction using higher G prime fillers for safe, efficacious, and long-lasting results: A prospective interventional study

BACKGROUND

One of the most challenging areas for facial rejuvenation is the lower eyelid. Apart from the protruding orbital fat causing lower lid bags, a discrete entity called the "tear trough deformity" is distinguishable in this area.

AIM

The objective of this study is to compare and evaluate the standard technique of tear trough deformity correction with the lateral injection technique using a high G prime filler to establish a guideline for the safe and effective correction of tear trough deformity.

METHODS

A prospective, double-blind, study was carried out from Dec 2017 to 2019 including 30 participants in the age range of 35-60 years. The participants were divided into two groups of 15 patients each. In group A patients, conventional technique with a low G Prime filler was used, whereas in group B, lateral injection technique with a high G Prime filler was used.

RESULTS

Marked improvement was seen in appearance and skin quality on both the sides in all the patients. As compared to our technique (lateral injections) where a mean of 0.5 ml of filler was used to lift the cheek and reduce the tear trough, the standard technique (Mauricio de Maio's 3-point tear trough reshape technique) required a mean of 1.2 ml of filler for the same. Post-procedure complications including bruising and Tyndall effect were much higher (statistically significant) using the standard medial technique for the correction tear trough.

CONCLUSION

Aesthetically satisfying results for the tear trough correction are possible, without actually injecting the tear trough directly, based on the knowledge of the underlying anatomy.

Fat Repositioning With a Combination of Internal Fixation and External Fixation in Transconjunctival Lower Blepharoplasty

BACKGROUND

Various methods on transconjunctival fat repositioning have been promoted to treat tear trough deformities in patients with eye bags.

OBJECTIVES

The authors present a modified approach based on the facial soft-tissue spaces with the combined fixation method.

METHODS

A total 226 patients underwent this procedure. Through a preseptal approach, the premaxillary and prezygomatic spaces were sequentially separated. Orbital fat was repositioned into the spaces together with the septum. The proximal part of the septum-fat flap was sutured to orbital rim with internal fixation, and their distal stumps were fixed to the end of the soft spaces with externalized percutaneous sutures. Surgical outcome was assessed by surgeons based on Hirmand's grading system. Patients' satisfaction and quality of life were measured using FACE-Q scales. Magnetic resonance imaging was employed to assess the long-term fate of the transposed fat.

RESULTS

Tear trough deformities were eliminated in 86.7% of cases. Scores of lower eyelid FACE-Q decreased significantly (P < 0.05). Patients demonstrated enhanced social confidence (P < 0.05) and high satisfaction (74.3 ± 17.2) and were satisfied with their decision to undergo blepharoplasty (78.2 ± 18.7). Undercorrection occurred in 1 patient. Additional complications included transient granulomas, dye eye, unexplained swelling, and numbness, which resolved in all patients. Magnetic resonance imaging confirmed viability of the transposed fat within 6 to 8 months follow-up.

CONCLUSIONS

Transconjunctival fat repositioning, utilizing a combination of internal fixation and external fixation, is an effective approach to treat eye bags and tear trough deformities with good patient and surgeon satisfaction.

LEVEL OF EVIDENCE: 4

Comparison of Fat Repositioning Versus Onlay Segmental Fat Grafting in Lower Blepharoplasty

BACKGROUND

Lower blepharoplasty is one of the most challenging procedures in aesthetic surgery. In particular, blending the lid-cheek junction and correction of the tear trough are prone to failure and unsatisfactory outcomes.

OBJECTIVES

The aim of this study was to combine lower eyelid blepharoplasty with a novel technique of autologous fat grafting, commonly called segmental fat grafting, and to analyze the safety and efficacy of this approach.

METHODS

A retrospective analysis of 339 lower blepharoplasties was performed to compare the novel technique of segmental fat grafting to traditional fat transposition during lower blepharoplasty. Outcomes were assessed objectively by several measurements as well as via online survey of 148 invited experts in plastic surgery. Statistical analysis included t test for unpaired and paired samples as well as 1-way analysis of variance for matched data.

RESULTS

There were no differences in baseline characteristics and comorbidities between study groups. After a mean follow-up of 12.9 months (range, 5-120 months), the group that underwent segmental fat grafting had a significant reduction in tear trough width compared compared with the group receiving lower blepharoplasty with fat transposition. Based on an expert (blinded) online survey, segmental fat grafting was superior or equal in 47% and 35% of cases, respectively. Complications (4%) and revision surgeries (9%) did not differ significantly between study groups.

CONCLUSIONS

The novel technique of transplantation of a segmental fat graft during lower blepharoplasty is a safe and effective way to overcome tear trough deformity and blend the lid-cheek junction.

LEVEL OF EVIDENCE: 4

Management of Tear Trough with Hyaluronic Acid Fillers: A Clinical-Practice Dual Approach

Introduction

Tear trough deformity (TTD) is currently a major concern for many individuals that seek periorbital rejuvenation. Among the different options currently available for treating TTD, hyaluronic acid (HA) filler injections have become increasingly popular.

Purpose

To provide a dual approach, direct and indirect strategies for treating TTD with HA fillers according to patient facial structure.

Methods

The current paper combined the authors’ experience with the currently available scientific evidence.

Results

The current study presents the authors clinical experience regarding TTD treatment and serves as a guide on the best therapeutic approach with HA fillers. For achieving good aesthetic outcomes, especially in TTD, it is crucial to have a detailed understanding of both facial anatomy and the individual characteristics of the HA fillers. Proper management of full-face facial rejuvenation should have into consideration three main pillars: structure, contour, and refinement.

Conclusion

Treatment of TTD should be addressed from a comprehensive perspective, including potential lack of structural support, as well as interventions on the dynamic processes involved in the problem. Additionally, HA fillers can be used to modulate mechanically muscle movement by either facilitating their action or decreasing contractility by reducing their movement. Clinicians can benefit from ongoing guidance on the use of these products in order to tailor and optimize treatments to patient’s requirements. Although HA filler injections have low rates of side effects, TTD was listed as the most challenging area to treat with HA. Therefore, TTD treatment should be performed only by well-trained and experienced specialists.

Complications of Periocular Dermal Fillers

Dermal fillers, in particular hyaluronic acid gel (HAG) fillers, are used in the treatment of aging changes in the periocular area. Filler treatment requires in-depth knowledge of specific issues relating to product performance and administration, safety protocols, and recognition and treatment of complications. There are different approaches to treatment of the tear trough. Prior filler treatment must be suspected in patients presenting for aesthetic evaluation, and the possibility of migration with a dysmorphic appearance and/or Tyndall effect appearance always is kept in mind. Treatment with hyaluronidase injection generally is effective in reducing overcorrection or migration of HAG in this area.

Transcutaneous Blepharoplasty with Volume Preservation: Indications, Advantages, Technique, Contraindications, and Alternatives

The aging appearance of the lower eyelids is multifactorial, involving changes in the skin, orbital fat, orbicularis muscle, soft tissue of the midface, and tear trough. The extent of these changes differs in each case and happens in a background of volume loss that occurs with facial aging. We present the indications, advantages, and technique for volumizing transcutaneous lower blepharoplasty with fat transposition. The absolute and relative contraindications to transcutaneous surgery are discussed, and surgical details of transconjunctival blepharoplasty with fat repositioning and autologous fat grafting as alternative approaches are included.

An Update on Subciliary Lower Eyelid Blepharoplasty

The subciliary lower eyelid blepharoplasty has evolved considerably to create a more harmonious natural appearance with a fuller and unoperated look and also to minimize the complications. While lower eyelid malposition was very common in the past, now this complication is significantly reduced by attention to preoperative evaluation, meticulous surgical planning, precise surgical technique, and postoperative care. Various prophylactic maneuvers maintaining/strengthening lower lid support can be utilized to prevent lower lid malposition including preservation of the pretarsal orbicularis oculi muscle, conservative resection of skin and muscle, and suspension of the orbicularis oculi muscle and/or tarsus to the periosteum of the lateral orbital rim. The release of the orbicularis retaining ligament and surgical transposition of orbital fat over the rim rather than excision allows for smoothing of the lid-cheek junction, filling the tear trough deformity, and reducing the appearance of bulging fat in the lower eyelid. In this article the reader will find a comprehensive approach for achieving a smooth contour with gradual blending at the lower eyelid-cheek junction while maintaining/restoring normal lower lid support. A descriptive outline of postoperative care is also provided to help in optimal healing for the patient.

Transconjunctival lower eyelid blepharoplasty with fat transposition above the orbicularis muscle for improvement of the tear trough deformity

BACKGROUND

The tear trough is the hollow concavity of the medial lower eyelid. Surgery can address tear trough deformities and reverse visible signs of periorbital aging. The previous methods of transconjunctival blepharoplasty with fat transposition were first described with subperiosteal placement of fat (Plast Reconstr Surg, 125, 2010,699, Aesthetic Surg J, 32, 2012, 426). This was followed by techniques with submuscular transposition of fat, which overcame certain difficulties associated with the subperiosteal methods (Clin Plast Surg, 20, 1993, 393, Arch Facial Plast Surg, 2, 2000, 16).

OBJECTIVES

We present a detailed description, evaluate the efficacy, safety, and advantages of transconjunctival blepharoplasty with fat pedicle transposition above the orbicularis muscle for lower eyelid rejuvenation and improvement of the tear trough deformity.

METHODS

Forty-one patients underwent lower eyelid blepharoplasty with fat transposition above the orbicularis muscle. Clinical and photographic documentation along with patient satisfaction ratings were evaluated for a minimum of 44 months postoperatively.

RESULTS

Significant improvements of lower eyelid aesthetics and correction of tear trough abnormalities were observed in most patients. At 44 months postoperatively, surgical correction was maintained in all patients with a high satisfaction and long-term survival. No contour irregularities or significant long-term complications were detected in any of the patients.

CONCLUSION

Transconjunctival blepharoplasty with the fat pedicle transposition placed above the orbicularis muscle is a safe and effective technique for lower eyelid rejuvenation. Compared to previously described techniques of repositioning fat into the subperiosteal or submuscular plane, this technique of transposing fat above the orbicularis muscle is an alternative technique resulting in long-term improvement of tear trough abnormalities with no major complications.

Novel technique of non-surgical rejuvenation of infraorbital dark circles

BACKGROUND

Infraorbital dark circles are a common esthetic concern which can be challenging to treat given their multifactorial nature. Under-eye dark circles are seen in all skin types, with a strong familial component in darker skin types. Other major contributing factors include soft tissue and bony changes, skin changes, lifestyle contributions, and allergies. Involutional periorbital volumetric changes cause volume loss in the tear trough, naso-jugal and palpebro-malar grove, skin and subcutaneous tissues with tethering of the eyelid skin to the tear trough ligament, giving a sunken and hollow appearance to the lower lid. Associated prolapse of the orbital fat and thin skin can worsen the appearance of a dark circle. Hyaluronic acid fillers placed in the pre-periosteal plane in the tear trough, palpebro-malar and naso-jugal grooves, give good results in patients with thick eyelid skin and negligible fat prolapse. However, in patients with thin skin and moderate fat prolapse, authors have reported worsening outcomes with risk of Tyndall (blue-gray discoloration) and contour irregularities from visible lumps.

AIMS

To describe a novel technique to improve dark circles caused by a diffuse valley-type pre-septal tear trough deformity in patients with thin eyelid skin.

METHODS

Retrospective case note review of 330 eyelids treated with microdroplet subdermal placement of filler in the preseptal tear trough area by a single surgeon.

CONCLUSION

This novel technique shows good esthetic outcomes in patients with dark circles, with good longevity and a low risk of complications.

Platelet-poor plasma gel vs platelet-rich plasma for infraorbital rejuvenation: A clinical and dermoscopic comparative study

Infraorbital dark circles and tear trough deformity are considered common aesthetic problems. Numerous therapeutic modalities have been suggested with variable outcomes. The aim of this study was to compare the efficacy of platelet-poor plasma (PPP) gel vs platelet-rich plasma (PRP) in infraorbital rejuvenation. A total of 68 females presented with dark circles and/or tear trough deformity were recruited and treated by PPP gel injection in the right infraorbital region (Group A) and PRP injection in the left infraorbital region (Group B). They received three treatment sessions at 2-week interval, and followed up monthly for 3 months. They were evaluated clinically and dermoscopically before treatment and at the end of follow-up period. Both groups showed significant clinical improvements proved by significant reduction of degree of hyperpigmentation and tear trough rating scale. Obviously, more significant clinical and dermoscopic improvements were observed in Group A than Group B. Therefore, it could be concluded that both PPP gel and PRP were clinically effective procedures for aesthetic improvement of infraorbital region. Moreover, PPP gel seems to be significantly more effective than PRP as a therapeutic modality.

Internal Fixation Method Using EZ-Tcon for Transconjunctival Fat Repositioning: Clinical Outcomes and Efficacy

Background

Transconjunctival fat repositioning is the gold standard for the correction of tear trough deformity. For fixation of fat pedicle, the internal fixation (IF) and externalized percutaneous suture (EPS) techniques are used, which have their own advantages and disadvantages. The present study aimed to introduce a new IF technique using a devised needle (EZ-Tcon) and to compare its outcomes with those of the conventional EPS technique.

Methods

Patients with primary tear trough deformity who underwent transconjunctival fat repositioning were reviewed and categorized into two cohorts according to the fixation technique: cohort 1 consisted of patients treated using the conventional EPS technique and cohort 2 consisted of those in whom the new IF technique using EZ-Tcon was adopted. Post-operative complications and aesthetic outcomes were assessed using a four-scale grading system.

Results

A total of 545 patients, 211 from cohort 1 and 344 from cohort 2 were evaluated with a median follow-up of 70 days. Compared to cohort 1, cohort 2 showed significantly lower rates of long-standing conspicuous scars on lower eyelid, re-operation and overall complications. In the analysis of aesthetic outcomes, 88.9 percent of cohort 2 showed grade 0 (no deformity) or I (mild deformity) post-operatively. The rate of excellent outcomes (improvements of ≥ two grades) was significantly higher in cohort 2 than in cohort 1 (p-value < 0.001).

Conclusion

Our technique using EZ-Tcon could possess advantages of the conventional IF and EPS techniques, showing lower complication rates and aesthetically satisfactory outcomes, and could be a safe and reliable method of transconjunctival fat repositioning.

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.

Electronic supplementary material

The online version of this article (10.1007/s00266-020-01873-1) contains supplementary material, which is available to authorized users.

Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler

Background

Recent years have seen a growing interest in the appearance of the eyes among the concerns expressed by patients in cosmetic clinics. This has led to an increase in the frequency of diagnosis of tear trough deformity, and, as a result, the number of treatments performed by specialized professionals has also risen. Hyaluronic acid filler injection is a rapid, nonsurgical technique that gives good long‐lasting, but not permanent, results. However, to achieve optimal results, the attending physician must have good anatomical knowledge of the area and involvement of the structures in the tear trough, carry out proper clinical assessment of the patient, and use an appropriate injection technique with the right product.

Aims

To support good practice among the professionals who carry out these procedures, this interdisciplinary consensus document describes the relevant issues and recommendations, in order to improve safety standards and to help successfully resolve this aesthetic problem.

A Method to Reproduce Symmetry in Midfacial Reconstruction: A Report of 19 Cases

BACKGROUND

Reconstruction of facial skin defects remains a clinical challenge. With aging, ptosis of tissue over fixed structures creates an important facial feature known as the tear trough. This study aimed to evaluate the efficacy and aesthetic outcome of a novel surgical technique that reproduced this facial feature while avoiding ectropion during midfacial skin defect repair.

METHODS

Nineteen patients with midfacial skin defects received local flap reconstruction combined with an anchoring suture. The flap was designed in a unilateral pedicled V-Y pattern. When the flap was advanced to cover the defect, one or two sutures that connected the dermis of the flap with the infraorbital periosteum were made to reproduce the tear trough line.

RESULTS

Midfacial defects were successfully repaired with the V-Y flap in all 19 patients. No lower eyelid ectropion or conspicuous scars were noted in any of the patients. Further, the tear trough was successfully reconstructed in each patient. Facial symmetry was maintained with static positioning and animation.

CONCLUSIONS

The combination of local V-Y flap reconstruction with anchoring sutures to reproduce facial feature lines is an effective technique in midfacial skin defect repair.

An Alternative Periorbital Treatment Option Using Calcium Hydroxyapatite for Hyperpigmentation Associated with the Tear Trough Deformity

Background

The nasojugal groove or tear trough (TT) area deformity produces visible, pigmented, difficult-to-treat hollows. Hyaluronic acid (HA) filler-based correction yields variable results and complications. We developed an alternative, minimally invasive treatment for this area.

Methods

Patients with significant, visible TT area pigmentation, and/or those requiring corrections for TT filler removal, were given lignocaine-diluted calcium hydroxyapatite (CaHA) fillers. CaHA boluses were placed deep on the bone, under the origin of the orbicularis retaining ligament, and under the sub-orbicularis oculi fat. Diluted CaHA was used as a subcutaneous biostimulatory wash. Efficacy and complications were assessed using the Global Aesthetic Improvement Scale and a modified Tear Trough Rating Scale, at 4 and 18 months.

Results

Twelve patients, between 25 and 52 years of age, were treated and showed immediate improvements in hyperpigmentation due to light reflection and some visibility of the filler through skin. Lower eyelid swelling and redness occurred a few days postinjection but resolved spontaneously. Over 4 to 6 months, hyperpigmentation and skin tone, thickness, and color improved noticeably. Global Aesthetic Improvement Scale and modified Tear Trough Rating Scale scores indicated that all patients experienced satisfactory improvements. Three prior HA patients required a second CaHA treatment at 4-6 months for a satisfactory correction, one of whom required a third CaHA "wash" at 10 months. Some mild redness was observed for up to 12 weeks in a few patients; however, no differences in the degree of redness were observed between those treated for dark circles or post-HA correction. One patient experienced a persistent, dull erythema for 8 months; another had overt erythema and swelling following a chest infection which resolved with antibiotics and hydrocortisone cream. No nodules developed in any patient.

Conclusions

We developed an alternative TT deformity treatment that leverages CaHA unique rheology and neocollagenesis-stimulating ability, which lifted and supported the prolapsing orbicularis retaining ligament, improved skin quality, and rejuvenated the periocular area without direct injections into the TT.

Facelift Part I: History, Anatomy, and Clinical Assessment

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Treating Excess Lower Eyelid Skin Without Incisions

INTRODUCTION

Periocular rhytids and dermatochalasis are common and striking signs of facial aging. The CO₂ laser technique described herein addresses Hester classification type I, aging at the level of the lower eyelid, focus on the treatment of the dermatochalasis.

MATERIALS AND METHODS

In this retrospective study of patients undergoing treatment at our clinic between 2000 and 2018, 263 were classified as Hester I and CO₂ laser therapy was the treatment to improve the local rhytids.

RESULTS

Improvement in dermatochalasis was found in all patients, resulting in better rejuvenation of the target area while eliminating visible scarring from a suture through the skin.

DISCUSSION

In our experience, CO₂ laser functions as a substitute for transcutaneous lower blepharoplasty, due to the fact that the contracture of the skin renders resection of that skin unnecessarily, thus avoiding the tell-tale scalpel incisions under the lashes.

CONCLUSION

The quality of the results of this retrospective study allows us to offer this laser therapy to treat lower eyelids classified as Hester I.

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 .

Treating Tear Trough Deformity: Transconjunctival Blepharoplasty with Fat Pad Repositioning and Fixation in the Intranasal Mucosa-18 Years' Experience

INTRODUCTION

With aging, progressive changes occur in the eyelid region. The novel technique for repositioning of the fat pads described herein addresses Hester classification type II, lower eyelid aging with minimal decrease in the eyelid/cheek juncture.

MATERIALS AND METHODS

In this retrospective study of patients undergoing surgery at our clinic between 2000 and 2018, 92 were classified as Hester II and a transconjunctival surgical procedure was performed with repositioning of the fat pads and intranasal fixation assisted by the Casagrande needle.

RESULTS

Erasure of the nasojugal fold was observed in all patients, offering a greater uniformity in the convexity of the middle third and resulting in better rejuvenation of the target area while eliminating visible scarring from a suture through the skin.

DISCUSSION

The repositioning of fat pads using intranasal fixation offers the necessary anchoring qualities without worrying about unsightly scars or the need to remove stitches early, which can decrease the proper scarring and adhesion of the pads in their new pockets.

CONCLUSION

The quality and longevity of the results of this retrospective study allow us to offer this novel fat pad fixation method in transconjunctival blepharoplasty.

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 .

Management of tear trough deformity with and without tear trough-orbicularis retaining ligament complex release in transconjunctival blepharoplasty: a comparative study

AIM

To evaluate the effect of releasing the orbicularis retaining ligament (ORL) complex of the tear trough combined with the transconjunctival blepharoplasty in the surgical management of tear trough deformity compared with the effect of blepharoplasty alone.

METHODS

A prospective, randomized (by closed envelope technique), controlled surgical trial which included 50 patients (100 eyes) with bilateral visible tear trough deformity and lower eyelid fat bulging, was divided into two groups where 25 patients (50 eyes) had tear trough-ORL release with blepharoplasty and 25 patients (50 eyes) didn't. Qualitative and quantitative assessments of tear trough deformity were done at 6mo postoperatively, achieving grade 0 or 1 of Barton's classification was considered a success. Standardized photographic documentation of each patient was done pre and postoperatively, also assessment of the patients' satisfaction postoperatively was done and ranked as excellent, very good, good or fair.

RESULTS

There was statistically significant difference between the two groups in the overall aesthetic results postoperatively regarding the qualitative and quantitative analysis of the tear trough deformity, where patients who had tear trough-ORL complex release had more successful outcomes than those of the second group.

CONCLUSION

ORL release should be done in patients with tear trough deformity in order to release the tethering effect of this ligament which causes the prominence of the naso jugal groove.

Blepharoplasty: Anatomy, Planning, Techniques, and Safety

Blepharoplasty is one of the most commonly performed cosmetic surgical procedures. To date it remains the most powerful method of periorbital rejuvenation when compared to other nonsurgical modalities, especially in the aging face. Despite that, the procedure has its shortcomings that include a steep learning curve, prolonged recovery, and potential for appearance and life-changing complications. Attaining successful outcomes relies on a solid understanding of facial topography, patient and technique selection, and, when appropriate, following a conservative approach. Modern blepharoplasty relies on tissue conservation and volume enhancement rather than aggressive removal. This concept was conceived after the realization that older techniques resulted in a hollowed appearance, which accentuated the aging process. It was further reinforced by advances in knowledge of periorbital anatomy and aging changes. This Continuing Medical Education article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient's anatomy.

Percutaneous Autologous Fat Injection Following 2-Layer Flap Lower Blepharoplasty for the Correction of Tear Trough Deformity

Tear trough deformity has been an area that has received much attention in terms of esthetic improvements. Fat transposition has been commonly used for the treatment of tear trough deformity. As some patients have had minimal improvement by that method, we propose the use of fat grafting combined with open blepharoplasty to complement the sunken area, including some of anterior maxilla region, and evaluate and precisely remove the excessive tissue.Lower blepharoplasty was performed by separating the skin and muscle flap. The excessive or laxed tissue was evaluated during the procedure and resected in each flap. Fat grafting was performed after completing a lower blepharoplasty, to ensure accurate placement on the spot where the surgeon originally intended. Overcorrection is not recommended.No serious complications were reported during a period of 10 years. Only 4 patients required a secondary fat injection.Patients who require structural correction of the lower eyelid area (eg, aggressive herniated fat, excessive skin laxity, or bulky orbicularis oculi muscle) and who need complementary material to fill the lower lid area (eg, deep, wide sunken area or relative exophthalmos) are good candidates for blepharoplasty with a fat grafting procedure.

The Application of the Acellular Dermal Matrix in the Correction of the Tear Trough Deformity

OBJECTIVE

The acellular dermal matrix (ADM) used in correcting the tear trough deformity has been reported, but there were only a few cases. The long-term effectiveness of ADM was not clear. We aim to discuss the technique and the effect of using ADM to correct the tear trough deformity through more cases.

METHODS

A retrospective study was conducted from January 2012 to January 2017. Twenty-six patients who showed obvious tear trough deformity with moderate or severe orbital fat bulging and excess of lower eyelid skin were treated with ADM to improve the appearance of the midface. Follow-up was performed for 2-12 months in 26 cases. The level of postoperative satisfaction was assessed by interview during the follow-up and rated as very satisfied, satisfied, acceptable, or unacceptable.

RESULT

Twenty patients were very satisfied for having achieved complete correction. Three patients were satisfied for having achieved obvious improvement. Three patients felt the results were just acceptable and were refilled because of the insufficiency of the filler. No one was unacceptable. There were no complications such as rapid resorption, rejection, or inflammation.

CONCLUSION

The method of using ADM for the correction of tear trough deformity has the advantages of low absorption rate, good appearance, and high security. It provides a new choice for the treatment of tear trough deformity.

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 .