Type 2 upper lids, characterized by skeletonization of the entire SOR, need larger volume augmentation. Fat is placed across the entire SOR, with greater attention placed on filling inferior to the bony orbital rim and not deep to the brow (Fig. 22.19). In these eyes, the brow is already isolated by the surrounding volume loss and brow position is usually felt to be relatively good. In order to lessen the apparent depth and hollowing of these upper lids, the lid is essentially unfolded from the depth of the sulcus. This leads to a greater span of visible upper lid skin below the brow and a reduction of the upper lid concavity (Fig. 22.20). The goal is not to create a Type 1 lid, which is neither realistic nor representative of the

Fig. 22.19 The highlighted area (in red) demonstrates the focal point of volume augmentation in the Type 2 upper lid. Volume is added inferior to the superior orbital rim to unfold the upper lid skin and reduce the degree of visible shadowing. A greater amount is usually required medially to correct the A-frame deformity

Type 2 patients’ youthful upper lid. Rather the aim is to appropriately reinflate the lid back to its prior appearance.

After completing upper and lower lid fat augmentation, there is usually an apparent volume deficit at the lateral canthal region of the orbital rim. Through the entry point at the lateral canthus, a very small amount of fat (0.5 mL) is placed subcutaneously to soften the transition.

22.5Postoperative Considerations

No dressings are applied at the harvest or injection site. All entry sites made with a needle are small enough that they need not be closed with sutures. We recommend applying ice to the transfer sites intermittently for the first 48–72 hours. Patients are also instructed to keep their head elevated to reduce swelling during this time. If just fat transfer is performed, strenuous physical activity is discouraged until 1 week after surgery, at which time patients may gradually begin to return to normal activities. If other surgical procedures are performed at the same time, the patients are encouraged to wait 3 weeks to resume strenuous activity.

It is very important that the postoperative recovery phase is reviewed carefully prior to the operation in order to better manage patient expectations. Patients are instructed that they will have significant swelling and bruising in the immediate postoperative period, more than if they had a traditional upper or lower lid blepharoplasty alone. After 2 weeks, most patients feel as if they can return to work or daily activities. But at this point, they should expect to feel their face is fuller than what they hoped for. Over the subsequent 2 weeks, patients will begin to attain what they wanted. The end result is really not known for up to 12 months. Patients are cautioned that, on average, 30% of the fat injected is retained [8].

Fig. 22.20 Pre- (a) and postoperative (b) results of fat transfer to the superior orbital rim for a Type 2 upper lid. This result demonstrates how the upper lid skin is unfolded and brought inferiorly so that there is a greater degree of visibility of the upper lid, particularly medially.

The harsh shadows are lessened, creating a younger and rejuvenated appearance, and the parallel relationship of the superior orbital rim shadow and the lash line is reestablished

It is essential that patients understand that a secondary touchup procedure may be needed to obtain the ideal result. A touch-up procedure is generally not performed until at least 6 months, and frequently closer to 1 year, after the initial fat transfer.

22.6Complications

The primary complications of fat transfer are related to contour irregularities and unpredictable volume retention. Less common complications include entry site irregularity and surgical site infections. Neurovascular complications are exceedingly rare [9]. Most of these potential complications can be minimized with appropriate planning and technique.

Contour irregularities typically appear as an isolated lump, from fat deposited in an area where it is visible, or as an elevated roll of tissue [10]. Isolated lumps are generally the result of poor technique in the periorbital region. They can be prevented by carefully depositing small parcels of fat (no more than 0.03 mL per pass), placing fat only deep to the orbicularis oculi muscle, and an overall conservative approach to fat injection. Some surgeons recommend fat infiltration superficial to the orbicularis oculi muscle. This maneuver will significantly increase the risk of contour problems while providing little potential benefit. When a periorbital lump occurs, intralesional kenalog injection can be attempted but is typically not as effective or precise as a direct excision.

A thickened roll of tissue along the inferior orbital rim, and less likely along the SOR, is a complication we have only seen when injecting strands of fat parallel to the orbital rim from a lateral entry point. Fat should always be placed with the cannula passing perpendicular to the inferior orbital rim. Adoption of this technique has all but eliminated this complication. These rolls often respond to intralesional kenalog injection, starting with very dilute (0.05 mg/mL) amounts, with gradual increases in concentration and spacing injections at 4-week intervals. If kenalog fails, direct transcutaneous excision can be performed. The incision heals very well when placed in a natural lower lid skin crease, or in the tear trough, at the junction of the thin lower lid skin and the thick cheek skin.

Overcorrection is a complication avoided by grafting conservative amounts of fat. Surgical intervention can include microliposuction. However, in the periorbital region, direct excision is more like to be successful. When overcorrection is present, we recommend waiting at least 6 months, and preferably a year, to assess if intervention should proceed. This delay allows swelling to fully dissipate and a truer assessment of volume status. Undercorrection is not a complication, but an inherent aspect of fat transfer that must be explained to patients in advance. It is much better to be faced with having to augment fat than having to excise it.

Although uncommon, there have been reports of intravascular injection and associated complications with any type of facial injections [11]. This complication should not occur if blunt infiltration cannulas are used, small volumes are injected, and minimal force is applied when injecting. Furthermore, by not forcing the cannula through significant tissue resistance; one is less likely to cause damage to neurovascular structures. We have not seen sensory or motor nerve injury with the technique described.

The fat infiltration entry sites are made with a 20-gauge needle and typically heal well without closure. On two occasions have we seen an entry site divot formation. In each case the divot was successfully treated by subcision with a 20-gauge needle. Persistent erythema, or discoloration, at facial entry points are generally not an issue. In contrast, the entry points on the body, where a larger cannula is used for harvesting, more commonly demonstrate persistent erythema that resolves over months. Placement of the entry site into a well-concealed location will help prevent patient concern regarding prolonged erythema. Should discoloration present a significant issue, resolution can be accelerated with the use of a pulse dye laser or intense pulse light (IPL) treatment.

Infection following fat transfer is exceedingly rare, and appropriate sterile technique aids in preventing its occurrence [12]. We use one dose of ancef, or clindamycin if penicillin allergic, preoperatively. We have only seen postfat transfer infection in two cases. In both patients, the infection was delayed (weeks after surgery) and manifested erythema and mild discomfort. Both were diagnosed as atypical mycobacterial infection and successfully treated with clarithromycin.

22.7Conclusion

Over the last decade, our understanding that volume loss is a major component of facial/periorbital aging has become increasingly accepted. This paradigm shift, and the implementation of volume augmentation in periorbital region, has led to more natural results and less stigmata of plastic surgery. Fat grafting and fillers such as hyaluronic acids should be a key component to the treatment algorithm for any patient seeking periorbital rejuvenation. Overall, they provide a safe and effective approach to volume augmentation of the upper lid/brow and lower lid/midface regions.

References

1.Lam S, Glasgold M, Glasgold R. Complementary fat grafting. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

2.Coleman S. Structural fat grafting. St. Louis, MO: Quality Medical; 2004.

3.Lambros VS. The dynamics of facial aging. Paper presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, Las Vegas, NV, April 27–May 3, 2002.

4.Donath AS, Glasgold R, Glasgold M. Volume loss versus gravity: new concepts in facial aging. Curr Opin Otolaryngol Head Neck Surg. 2007;15(4):238–43.

5.Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, sclera show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479–88; discussion 489–90.

6.Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110(3): 885–96.

7.Donath A, Glasgold R, Meier J, Glasgold M. Quantitative evaluation of volume augmentation in the tear trough with a hyaluronic acid-based filler: a 3-dimensional analysis. Plast Reconstr Surg. 2010;125:1515–22.

8.Meier JD, Glasgold RA, Glasgold MJ. Autologous fat grafting: long term evidence of its efficacy in midfacial rejuvenation. Arch Facial Plast Surg. 2009;11(1):24–8.

9.Kranendonk S, Obagi S. Autologous fat transfer for periorbital

rejuvenation: indications, technique, and complications. Dermatol Surg. 2007;33:572–8.

10. Glasgold RA, Glasgold MJ, Lam SM. Complications following fat transfer. Oral Maxillofac Surg Clin North Am. 2009;21:53–8.

11. Murillo J, Torres J, Bofill L, et al. Skin and wound infection by rapidly growing mycobacteria. Arch Dermatol. 2000;136: 1347–52.

12. Feinendegen D, Baumgartner R, Vuadens P, et al. Autologous fat injection for soft tissue augmentation in the face: a safe procedure? Aesthet Plast Surg. 1998;22:163–7.

13. Carniol PJ, Sadick NS, editors. Clinical procedures in laser skin rejuvenation. London: Informa Healthcare; 2007.

14. Glasgold M et al. Volumetric rejuvenation of the periorbital region. Facial Plastic Surg. 2010;26:3.