Upper lid hooding also tends to be much less significant in these patients. Rarely will it drape to the point of hitting the lash line. Volume rejuvenation generally takes on an even greater importance in the Type 2 patient.

22.3Volume Source: Fat Versus Filler

This chapter emphasizes the use of autologous fat transfer for volume restoration, but for many patients HA fillers provide an excellent alternative. In the periorbital region, HA fillers routinely give a result lasting from 1.5 to 2.5 years. Patients are informed that by 1.5 years they will often see some resorption [7]. For patients, the advantages of HA fillers over fat transfer include previewing the results of volume restoration before opting for a more permanent solution, avoiding prolonged recovery associated with fat transfer and providing a nonsurgical alternative. From the physician perspective, the HA fillers may also be preferable for patients with smaller volume requirements, where a very precise result is needed. The analogy used for educating patients on the difference between the two is that an HA filler provides the precision of a fine drawing pencil, whereas fat is more akin to the broad strokes of a paintbrush.

When counseling patients on the option of HA filler or autologous fat transfer, there are several factors to consider. In patients requiring larger volume rejuvenation, extending throughout the face (pan facial volume augmentation), we recommend using fat transfer. When surgical procedures such as blepharoplasty (with its associated need for anesthesia and recuperative period) are added to obtain the optimal result, we also recommend using fat for volume augmentation. In patients with small volume deficiencies in the inferior orbital rim, and little to no pseudoherniated fat, we feel HA fillers will provide a greater degree of satisfaction based on the precision of the result.

In Type 1 upper eyelids, we suggest HA fillers for two reasons. First, many patients are attuned to removing eyelid skin and are not focused on the importance of volume loss in the aging upper lids. Despite viewing photos of themselves and others to demonstrate the role of volume, they may only reluctantly buy into these concepts and feel more comfortable using a reversible material. Secondly, Type 1 upper lids generally require smaller volumes that require precise placement. The reversibility and precise filling provided of HA fillers make this a great option in these patients.

Restylane® (Medicis Pharmaceutical Corporation, Scottsdale, AZ) and Juvederm® (Allergan Inc., Irvine, CA) are the primary HA filler options for periorbtial rejuvenation. We strongly recommend the use of Restylane® for this area. We have experience using both products, and while both have an excellent track records for facial filling, we have seen a significant number of issues with Juvederm® in the

periorbital region. Often times, patients will note worsening of “bags” under the eyes or too much puffiness in the upper lids. In our experience, Juvederm® does not have the precise filling effect of Restylane®. We believe the source of the problem is that Juvederm® is more hydrophilic than Restylane® resulting in more edema and therefore less precise volumetric effect.

22.4Surgical Technique

22.4.1 General Considerations

Once the preoperative analysis has been completed and the surgical plan reviewed, patients are marked in an upright position to delineate the fat recipient sites. In most cases, we perform these procedures using intravenous conscious sedation combined with infiltration of the surgical sites with local anesthetic. If upper or lower lid blepharoplasty is being performed concurrently, we will generally begin with fat harvest, followed by upper and/or lower lid blepharoplasty and ending with fat injection.

22.4.2 Fat Harvest

The most commonly used donor sites are the lower abdomen, inner thigh, outer thigh, and hip. Determination of the donor site is generally based on where the patient has the most abundant fat stores. A secondary factor is the depth of anesthesia. Certain donor sites (outer thigh and hip) require repositioning the patient, which is more cumbersome with deeper levels of anesthesia. As such, these sites are preferred in the awake patients. Finally, patients are evaluated for the presence of prior surgical incisions and/or hernias (umbilical or incisional). If present, these are avoided.

The surgical field is sterilely prepped and draped prior to beginning the procedure. The area of fat harvest is infiltrated with a 20 mL solution of local anesthetic on a 22-gauge spinal needle. If intravenous sedation is used, the 20 mL mix injected into each donor site consists of 5 mL of 1% lidocaine with 1:100,000 epinephrine and 15 mL of normal saline. If only local anesthetic is used, then the 20 mL mix contains 10 mL of 1% lidocaine with 1:100,000 10 mL of normal saline. Local anesthetic is injected by concentrating 10 mL superficially in the immediate subdermal plane and 10 mL at the deeper aspect of the fat, just superficial to the muscle. The rationale for this is to minimize the potentially destructive effect of the local anesthetic solution on the target adipocytes.

Fat is harvested via a stab incision placed in a relatively concealed location. For example, the lower abdomen access incision is placed in the umbilicus and the inner thigh entry

incision is in the crease in the inguinal fold. These entry sites are anesthetized with a bleb of 1% lidocaine with 1:100,000 epinephrine. The incision is then made with a 16-gauge Nokor needle or a No. 11 blade. One of two fat harvesting cannulas are generally used: a 3.0 mm bullet-tip harvesting cannula or a 2.1 mm multiport harvesting cannula (Tulip Medical, Inc., San Diego, CA) (Fig. 22.13). The 2.1 mm multiport is a less-aggressive cannula and is useful for areas where there is greater concern of contour irregularity. In addition, when performed under local anesthetic, harvesting with the 2.1 mm multiport cannula is less painful and better tolerated.

Fig. 22.13 Fat transfer instruments (Tulip Medical, Inc., San Diego, CA), from top to down. The 0.9 mm (4 cm length) injecting cannula is used to infiltrate local anesthetic and is the primary cannula for all periorbital fat injections. The 2.1 mm multiport harvesting cannula. The 3.0 mm bullet-tip harvesting cannula. (Adapted from Lam et al. [1], used with permission)

Fig. 22.14 (a) Immediately following fat harvest (left) and upon completion of centrifugation (right). The supranatant is poured off into a gauze (b), the infranatant drained (c), leaving an isolated layer of fat. The fat is then wicked with a sterile guaze to remove residual supranatant. (d, Adapted from Lam et al. [1], used with permission)

A 10-mL syringe is used with the harvesting cannula, and fat is suctioned while placing only 1–2 mL of manually applied negative pressure on the plunger. The cannula is gently passed back and forth through the midlayer of fat, avoiding superficial (which will appear as tethering on the skin) or deeper (which will elicit significant pain from muscle irritation) manipulation. Fat harvest should be performed uniformly over the region so as to avoid contour irregularities.

As each 10-mL syringe is filled, it is passed off to an assistant for preparation under continued sterile conditions. In determining the amount of fat to harvest, each 10-mL syringe will, on average, yield 5–7 mL of usable fat.

22.4.3 Fat Processing

A plug is fastened onto the Luer-Lok end of each syringe and the plunger is removed. A cap is then placed on the plunger end of the syringe. A balanced number of syringes are placed in sterile sleeves that fit into a centrifuge. This maintains the sterility of the syringes for subsequent steps in preparation. The centrifuge is turned on for 1–2 min at 2,000–3,000 rpm (Fig. 22.14). Upon completion of centrifugation, the syringes are removed and placed back on the surgical field. The syringes now demonstrate three layers: a supranatant, made up of free fatty acids; an infranatant, consisting of blood and lidocaine; and a central core of viable fat. With the cap still on, the Luer-Lok

Fig. 22.16 Preoperative markings demonstrate the entry points (in red) for periorbital fat transfer. Moving from inferior to superior they include: (a) the midcheek entry site for inferior orbital rim augmentation; (b) the lateral canthal entry site for filling the lateral superior orbital rim and the depression in the region of the lateral canthus; and (c) the brow entry site for filling the superior orbital rim/upper eyelid

end is opened to allow the infranatant to drain out. The cap is then removed from the plunger end and the supranatant is poured off. The syringes are stood upright in a cup or test tube holder and the supranatant end is wicked using a cotton guaze. After several minutes, the individual 10-mL syringes are consolidated to facilitate the injection process. The plunger is removed from a 20-mL syringe and fat is poured from the plunger end of the 10-mL syringes into the 20-mL syringe (Fig. 22.15). The 20-mL syringes should not be filled with more than 15 mL of fat. A transfer hub is placed on the LuerLok end of the 20-mL syringe and the plunger is carefully placed back into the syringe. Fat is then transferred into individual 1-mL Luer-Lok syringes for injection.

22.4.4 Fat Injection

Local anesthetic consisting of 1% lidocaine with 1:100,000 epinephrine is administered at the planned entry site. An infraorbital and/or supraorbital nerve block (depending on the area addressed) is also given. Entry sites for the cannulas are created with a 20-gauge needle. Using a 0.9 mm injecting cannulas (Tulip Medical, Inc., San Diego, CA), local anesthetic is infiltrated into the recipient bed via the needle stick entry ports. Fat is then injected using blunt cannulas on 1-mL Luer-Lok syringes (see Fig. 22.12). The preferred cannula for fat infiltration in the periorbital region is a 0.9-mm injecting cannula, 4 cm in length (Tulip Medical, Inc., San Diego, CA). Small parcels, 0.03–0.05 mL, of fat are placed with each pass of the cannula.

The inferior orbital rim is approached through a midcheek entry point so that all fat is placed with the cannula passing perpendicular to the orbital rim (Fig. 22.16). The degree of volume loss will dictate the amount of fat to be placed. As a general rule, we recommend the total amount of fat injected in this area does not exceed 4 mL. We typically distribute the fat as follows. The initial injections of fat are placed in the immediate supraperiosteal plane. These are placed not with the intent of filling the visible defect, but following the bony landmarks by feel to build a foundation volume. The first milliliter is placed with the cannula passing back and forth across the medial half of the bony inferior orbital rim (Fig. 22.17). The fat is deposited in tiny parcels over the bone. The second milliliter placed at this depth is along the lateral half of the bony inferior orbital rim. The next set of injections is placed more superficially, just deep to the orbicularis oculi muscle. With the more superficial injections, the fat is injected focusing on filling the visible, marked out, volume deficit. We strongly recommend not placing fat superficial to the orbicularis oculi muscle, as this will significantly increase the risk of contour irregularities. The first of the superficial injections is directed at the medial half of the inferior orbital, or the “tear trough.” The second superficial

Fig.22.17 (a) The cannula is positioned to demonstrate the orientation of the cannula passing perpendicular to the inferior orbital rim from the midcheek entry point. (b) The initial deep injections placed just superficial to the periosteum of the inferior orbital rim. The index finger of the

Fig. 22.18 By adding volume below the left superior orbital rim in this patient with a Type 1 upper lid, the A-frame deformity is corrected; the lid fold is pushed inferiorly, reestablishing the parallel relationship

surgeon’s nondominant hand gives tactile feedback on the location of the bone and also serves to protect the globe. (c) The superior orbital rim is approached from an entry point just superior to the midportion of the brow. (b, Adapted from Lam et al. [1], used with permission)

of lid fold and lash line. Pre- (a) and post- (b) volume augmentation of the left medial superior orbital rim. (Adapted from Glasgold et al. [14])

injection is placed to fill the lateral half of the visible inferior orbital rim depression.

The technique for approaching the SOR is the same as its lower lid counterpart. The goals of adding volume will depend on the individual’s upper lid structure, Type 1 or 2, as delineated earlier. The medial half of the SOR is preferentially approached through an entry point superior to the brow. This allows very direct and precise placement of the fat. The fat is injected perpendicular to the orbital rim, as was done at the inferior rim. Filling of the lateral SOR is also performed from an entry point above the brow with the cannula passing perpendicular to the bony rim. Alternatively, the lateral SOR can be approached from a lateral canthal entry point (see Fig. 22.16). From this direction, the fat is placed with the cannula running parallel to the orbital rim. In the upper lid, this is an acceptable approach not associated with the contour problems inherent to inferior orbital rim grafting from a lateral entry point. As with the lower lid, fat is infiltrated in staged levels, supraperiosteal, and

just deep to the orbicularis oculi muscle. As is prudent anywhere in the periorbital region, a conservative approach is suggested. Patients are happier with a slight undercorrection of volume, versus the potential prominence and contour irregularities and prolonged recovery of an overcorrection.

Type 1 upper lids generally require less volume augmentation, as these individuals have a fuller upper lid at baseline. The tendency in Type 1 lids is to concentrate the most volume in the medial half of the SOR. The ultimate goal is to eliminate the concavity from the brow to lid fold and to correct the A-frame deformity. Across the entire SOR, fat can be placed at and below the orbital rim. This allows the deflated brow to be minimally elevated off the bone while also putting volume at the level of the concavity inferior to the brow. Filling below the rim is very important medially where correction of the A-frame deformity requires pushing the lid fold inferiorly to reestablish the parallel relationship of the lid fold and lash line (Fig. 22.18).