replacement tissue graft is needed after an overzealous resection eventuating in ectropion. It is far better to prevent such complications by performing a conservative resection.

After fat removal from the second eyelid, simple interrupted 6–0 fast-absorbing gut sutures are placed to close the incision on the initial eyelid. Attention can then be redirected back to redraping, trimming, and suturing the second eyelid. Next, sterile strips are placed to aid in temporal support, and an antibiotic ointment is lightly applied to the sutured incision after irrigating the eyes with sodium chloride (Balanced Salt Solution).

Postoperative Care

Postoperative care after the skin–muscle approach is essentially identical to the aftercare used in the transconjunctival approach. Bacitracin ophthalmic ointment is given to the patient for the subciliary incision. Iced saline compresses, head elevation, and limited activity are stressed to all patients.

50.6Complementary Treatments with Restoration of Infraorbital Volume

Filling of the tear trough deformity and related lateral infraorbital hollows can be preformed in the office setting with topical and/or local anesthesia. Following nerve blocks a small amount of local anesthesia containing 1:100,000 or weaker of epinephrine can be injected directly into the treatment areas for vasoconstriction. Alternatively, ice packs may be applied before and after injection to decrease bruising. The borders of the tear troughs are marked and the filler is injected in a retrograde linear threading fashion in the submuscular plane.

The material should be injected only during retraction of the needle to prevent vessel embolization. Layered injections are suggested, beginning along the infraorbital rim, over the periosteum, and following with gentle layered “feathering” of the injectable material in multiple layers deep to the orbicularis muscle. Injection superficial to the orbicularis muscle can also be preformed, but it is suggested to attempt this only after mastery of the deeper injection technique. Gentle massage should be preformed after every few injections to disperse small isolated collections of material that may become palpable or visible as edema subsides. Risks specific to this treatment include bruising, palpable subcutaneous bumps, fluid collection in the injected area, and very remote risk of retinal embolus (Fig. 50.6).

Restoration of volume in the infraorbital area must be addressed in the appropriate candidate. Several approaches have been described, including the use of injectable fillers, fat transfer, midface elevation, orbital fat repositioning, and SOOF elevation. Orbital fat repositioning and SOOF elevation may be performed in conjunction with lower eyelid blepharoplasty without the need for additional incisions or approaches.

50.6.1 Injectable Fillers

Recent trends in nonsurgical treatment of facial aging have resulted in the creative application of the widely available injectable fillers in the periorbital area. Specifically, the use of nonanimal, stabilized, hyaluronic acid (NASHA) fillers have enabled the treatment of early signs of aging in the infraorbital complex [21, 22].

50.6.2 Orbital Fat Repositioning

Orbital fat repositioning has also been referred to as fat preservation blepharoplasty. This procedure employs the fat of the medial and middle inferior orbital compartments to restore volume over the inferior orbital rim, and efface the tear trough deformity and associated lateral infraorbital hollows [22]. This can be approached through any lower eyelid approach that addresses the postseptal fat compartments. In the increasingly popular transconjunctival approach, the fat of the medial and middle fat compartments are dissected through a septal incision, and left attached as a pedicled flap transposed over the orbital rim and beneath the depression of the tear trough deformity. Fixation can be performed using transcutaneous permanent sutures which are removed in 3–5 days, or absorbable sutures securing the fat to the periosteum of the infraorbital rim. This procedure may also be performed in conjunction with the skin–muscle flap