Periorbital Fat Grafting

Key Points

•Traditional blepharoplasty techniques have focused on excision of skin/muscle and fat.

•While tissue excision has an important role in blepharoplasty surgery, it alone can lead to a hollowed, aged, and unnatural appearance.

•A detailed understanding of periorbital esthetics and how aging affects this esthetic is an essential component of blepharoplasty surgery.

•We now understand that volume loss is an important part of the periorbital aging process.

•Volume preservation/augmentation is equally important in esthetic rejuvenation of the periorbital region.

•Fat grafting allows periorbital volume augmentation with autologous tissue.

•Autologous fat grafting is an excellent stand-alone or adjunctive procedure to cosmetic blepahroplasty to recreate youthful appearing eyelids and adjacent structures (eyebrows/midface).

•In experienced hands, fat grafting yields excellent results with few complications.

22.1Introduction

Implementation of fat transfer for periorbital rejuvenation relies foremost on understanding patterns of soft and hard tissue (i.e., fat and bone) volume loss. Focusing volume rejuvenation on these areas of tissue deflation is a crucial step in achieving a natural and esthetically pleasing result.

R.A. Glasgold(*)

Clinical Assistant Professor of Surgery, Department of Surgery, UMDNJ-Robert Wood Johnson Medical School,

Highland Park, NJ, USA

e-mail: drrobert@glasgoldgroup.com

Most patients seeking facial rejuvenation emphasize a desire for a natural and younger appearance; a goal which should be shared by the esthetic surgeon. Many traditional approaches to periorbital rejuvenation have fallen short of attaining this objective. The downfall has been in the lack of understanding of what defines the naturally youthful periorbita. Traditionally, there has been a reflex action of excising skin, muscle, and fat in response to upper lid hooding or lower lid bags. These procedures were not driven by the esthetic goal of recreating a youthful eye, but rather, by a procedure-oriented mentality founded on tissue subtraction. The results of these procedures did not lead to a natural or youthful appearance. To the contrary, patients often appeared altered, skeletonized (deflated), and “done” (Fig. 22.1). Both patients and surgeons are to blame for this cycle by staying focused on hooding and bags, and not on the natural and youthful result that everyone aims for.

Over the last decade, our understanding that volume loss is a major component of facial and periorbital aging has become increasingly accepted, particularly in the region of the lower lid and midface [1–4]. This paradigm shift, and the implementation of volume augmentation in these areas, has led to more natural results and less stigmata of plastic surgery. Critical evaluation of upper lid surgery in regard to volume replacement has been lagging behind despite increasing use of volume augmentation to the lower lid and midface region.

To appropriately rejuvenate the periorbital area, we must have patients look away from the mirror and focus on photos of themselves at a younger age, as well as photos of other youthful faces. This will help patients appreciate what defines a youthful periorbital region and what the goals of facial and eyelid rejuvenation surgery should be (Fig. 22.2).

In this chapter, we will discuss the concepts of age-related volume loss and review autologous fat grafting techniques to the periorbital region. Off-the-shelf fillers such as hyaluronic acids (HA) provide an alternative means of periorbital volume replacement and will also be addressed.