125
Pearls for Periorbital Fat Transfer
Lisa M. Donofrio
Aging in the periorbital area leads to demarcation of the bony landmark of the orbital rim, unmasking of the orbital fat pads, flattening of the frontal projection of the subcutaneous soft tissue with resultant downward displacement of skin.
Two suborbital aging patterns can be appreciated. The “atrophic” pattern leads to a sunken, hollow orbit. Blepharoplasty in these patients can further accentuate the suborbital shadowing. Most patients with suborbital hollowing complain of dark circles due to the shadow cast by the globe onto the skin of the orbital bowl and relative translucency of the skin itself to the underlying vasculature. The second pattern is a “hypertrophic” change where the orbital fat appears to protrude past the margin of the orbital rim. This is always seen in conjunction with an atrophic upper cheek (except in the case where it was present in youth). As the superior portion of the malar fat pad involutes with aging, the relationship of the upper cheek to the suborbital area changes. Restoring cheek volume in these patients resets the orbital fat posteriorly in relation to the cheek.
The upper lid and brow complex undergoes similar changes with hollowing and flattening of this area and the temple, causing an inferior displacement of skin into the lid crease with concomitant lateral brow ptosis. The goal of rejuvenation of the periorbital area with fat should be to restore normal (youthful) contour. This in and of itself will often result in adequate skin redraping (Figure 125.1)
Pearls of periorbital fat transfer are as follows:
1.Use only blunt cannulas to place fat in the periorbital area. 18gauge or smaller cannulas are suggested for smooth results with less tissue trauma.
2.Use only 1 cc syringes to inject.
3.Avoid entry at the lateral orbital rim. Avoid horizontal placement with parallel linear “threading” of fat in both the suborbital and brow
areas
4. Enter the suborbital area either through the mid-cheek (Figure 125.2), the base of the nasolabial fold, or from a tangential site on the
381
382 L.M. Donofrio
upper lateral cheek (Figure 125.3). Place fat in “droplets” along and perpendicular to the orbital rim. Pull the “tail” of the droplet through the tissue to blend. Enter the brow from either the hairline or the eyebrow (Figure 125.4). Avoid treatment of the eyelid skin.
5.Enter the temple from the temporal fusion line and dive deep to the temporalis muscle.
6.Stay posterior to the orbicularis occuli muscle.
7.Fat droplets should be no more than 0.05 cc total in volume per
pass
8.Place no more than 2 cc in the suborbital or brow area in one sitting.
9.Treat the neighboring areas to blend transitions and improve overall results.
10.Treat the cheek as the same “cosmetic unit” as the suborbit. Recreate the cheek–eye continuum.
11.Undercorrect. Build up the tissue in the periorbital area slowly with staged injection sessions.
A,B 
C
Figure 125.1. (A) 47-year-old female with typical age-related atrophic changes. (B) After lipoaugmentation to the suborbital, brow, temple, and cheek. (C) 2-year follow-up.
Figure 125.2. Suborbital augmentation from an |
Figure |
125.3. Suborbital filling from a tangential |
|
inferior approach. |
|||
approach. |
|||
|
|||
Chapter 125 Pearls for Periorbital Fat Transfer 383
Figure 125.4. Augmentation of the brow.
126
Complementary Fat Grafting in
the Periorbital Region
Samuel M. Lam, Mark J. Glasgold, and Robert A. Glasgold
Traditional blepharoplasty entails tissue excision: removing a combination of skin, muscle, and/or fat. Often tissue removal only makes an already hollow eye even more so, which accentuates the appearance of aging rather than achievihng the desired rejuvenation.
Autologous fat transfer is an integral part of our strategy toward periocular rejuvenation. We contend that volumetric depletion is a prime mechanism of the aging process. We call our approach “complementary fat grafting” to emphasize the role that blepharoplasty plays when combined with fat grafting to achieve the optimal aesthetic result.
The technique described in this chapter relies on blunt manual harvesting of fat with minimal negative pressure on the syringe and blunt cannulas to infiltrate. Blunt cannulas for fat infiltration permit unparalleled safety and minimize tissue trauma. The majority of local anesthetic is infiltrated into the recipient sites with the same blunt infiltrating cannula used for fat grafting. The fat is processed with centrifugation for 3 minutes at 3000 rpm and decanted. Atraumatic, purified fat that is bluntly injected in micro-droplets across multiple tissue planes helps optimize fat cell viability and thereby potential longevity of the result.
The primary goal in fat grafting is to frame the eye. Although fat grafting truly provides wonderful rejuvenation across the lower half of the face, especially in the prejowl region, the anatomic territory that achieves the most remarkable aesthetic impact with fat grafting is the periorbital region, which includes the cheek. With the aging process, the luster and beauty of the eye is detracted by the loss of volume that surrounds and supports the eye. Use of fat grafting facilitates rejuvenation by restoring the lost frame around the eye. Cheek enhancement with fat grafting is an extended frame for the eye. A youthful face exhibits a con uence between the lower eyelid and the cheek in which the two areas are united; one of the objectives of fat grafting is to restore this union between the lower eyelid and cheek.
To truly efface a prominent eyebag, or steatoblepharon, a higher volume of fat may be required. When approaching the orbital rim, the use of a conservative amount of fat reduces periocular complications. In fact, almost all complications that arise from autologous fat transfer in
384
Chapter 126 Complementary Fat Grafting in the Periorbital Region 385
the face arise in the unforgiving periocular region. Approximately 2 ml of fat transplanted to the inferior orbital rim is a safe starting point. A higher volume risks the development of overcorrection that is difficult to correct. We nd that a conservative transconjunctival blepharoplasty works well in reduction of excessive prolapsed fat. The surrounding tissue bed is undisturbed so that concurrent fat grafting can be easily undertaken. With only mild steatoblepharon, autologous fat transfer or a transconjunctival blepharoplasty alone may suffice to attain the desired rejuvenation. A conservative skin-only upper blepharoplasty combined with fat grafting along the hollowed superior orbital rim can create the best outcome with minimal morbidity.
Very small amounts of fat should be infiltrated per pass with the standard 1 cc Luer-Lock cannula, approximately .02–.03 of an ml per pass.
The plane of injection is relatively deep in the immediate supraperiosteal plane. Superficial injection with larger boluses of fat per pass is associated with visible contour irregularities. The injection of fat along the inferior orbital rim is best carried out from an inferior mid-cheek location rather than from a laterally oriented site. The nondominant hand is used to palpate the orbital rim to ensure that the cannula tip passes gently across the rim and protect the globe from injury.
A systematic approach to periocular injection with symmetric volumes allows ideal rejuvenation and minimal problems. We begin by dividing the inferior orbital rim into medial and lateral halves, injecting each half with 1 ml of fat, as described. An additional 0.5 ml is added per half of the rim for more visibly sunken orbital rims. The nasojugal trough can is then filled with an additional 1 ml of fat. It is more aggressively augmented with 1/10 ml per pass along the planes of least resistance.
The lateral canthus and lateral superior orbital rim are augmented from a lateral port 2–3 cm lateral to the lateral canthus. At times it is difficult to pass the cannula tip through fibrous adhesions near the lateral canthus. Gentle pressure overcomes these ligamentous restrictions without avulsing vessels. 0.5 ml of fat is sufficient to fill the depression near the lateral canthus. The lateral superior orbital rim can be enhanced easily by following a plane of least resistance. With 1 ml of fat, the appearance of a cigar roll along the borders of the injected superior orbital rim should not cause alarm, as it is temporary.
A sunken upper eyelid sulcus may be a product of prior overzealous blepharoplasty, aging, or the patient’s anatomy. The surgeon should approach this deficiency with great caution. Correction of this deficiency is associated with a relatively long recovery time, on the order of several weeks to months. Also, it can alter a patient’s look so that the patient feels that his or her identity is changed.
Fat grafting and volume restoration have assumed a greater role in periorbital rejuvenation. Viewed in a complementary fashion, fat grafting is effectively combined with standard blepharoplasty and tailored to individual anatomy, aesthetic deficits, and concerns.
127
Autogenous Orbicularis and Fat
as a Filler
John R. Burroughs, Michael T. Yen, and Richard L. Anderson
In patients who would like a longer-lasting effect and are undergoing a blepharoplasty surgery, we have used the removed fat and orbicularis as an autogenous graft to the nasolabial folds, lips, and glabellar folds.
We routinely place orbicularis grafts into the superolateral portion of the tissue removal in our myectomy patients.And we elevate and suspend the SOOF pads in the lower portion of the tissue removal. This not only helps with incision closure, but helps avoid postoperative hollowing routinely seen in the lateral eyelids of postmyectomy patients. Overcorrection can occur, so the orbicularis grafts need to be thinned and trimmed to just the area requiring volume augmentation. Over time, the orbicularis grafts shrink to approximately 50% of the original size as partial resorption and fibrosis occurs.1
In the lips, the orbicularis needs to be finely chopped by placing it in a specimen container and using a 15 blade or scissors to finely chop it into small particles. It can then be injected into the lips from the lateral oral commisure with a large-bore needle along the length of the lips or into the nasolabial folds. Great care must be taken in the glabellar region to avoid injecting into large vessels, which may cause necrosis of tissue or even potential vision loss. Many patients already undergoing eyelid surgery prefer the use of their own readily available autologous tissues over synthetic or animal-based products for filling these types of defects.
Reference
1.Yen MT, Anderson RL. Orbicularis oculi muscle graft augmentation after protractor myectomy in blepharospasm. Ophthal Plast Reconstr Surg 2003;19(4):287–296.
386
Part IX
Skin Rejuvenation
128
Skin Care 101: The Basics
Diane S. Berson
Patients undergoing rejuvenation procedures should be counseled regarding fundamental skin care to enhance the cosmetic outcome. Basic cleansing, moisturizing, and sun protection can be combined with prescription and cosmeceutical agents that address discoloration, wrinkling, and irregular tone and texture. Appropriate postsurgical wound care will also ensure faster healing and a better cosmetic result.
Basic Skin Care
Cleansing is an essential component of skin care that removes dirt, oil, environmental pollutants, and bacteria from the skin. Mild products such as liquid cleansers, foaming washes, and syndet bars containing mild synthetic surfactants (Neutrogena, Cetaphil, Dove, Olay) are recommended. Abrasive cleansers should be avoided so that the skin remains intact for surgery. Patients should gently rub with their fingers or a soft washcloth and avoid vigorous scrubbing. They should gently pat dry, rather than rub, and then apply a moisturizer to seal in the dampness. Moisturizers hydrate the skin and restore the epidermal barrier, thereby decreasing transepidermal water loss (TEWL). This is essential for keeping skin smooth and supple and will ensure optimal healing by protecting from dryness, irritation, and infection. Patients with dry skin should use moisturizers with emollients such as glycerin and hyaluronic acid (humectants that bind water) and petrolatum (occlusives which trap water). Those with sensitive skin should avoid products containing fragrances and additives, and those with oily or acne-prone skin might prefer light noncomedogenic moisturizers containing silicone oils. Daily sun protection is imperative; it prevents premature aging of the skin and the development of skin cancer and postoperatively will decrease post-inflam- matory hyperpigmentation. An SPF of 30 with broad-spectrum protection against both UVA and UVB should be worn on a daily basis.
Preoperative Skin Care
Topical agents can be used as an adjunct to cosmetic procedures. Prescription retinoids (tretinoin, tazarotene, adapalene) improve the appearance of photodamaged skin. They help smooth tone and texture, reduce
391
392 D.S. Berson
pigmentation, and improve the appearance of fine lines and wrinkles.
Regular use of topical retinoids before resurfacing procedures, such as chemical peeling and lasers, aids in reepithelialization. Retinoids are usually applied to the skin at bedtime. Cosmeceuticals can be used along with sun protection to prevent sun-induced inflammation and to further improve the appearance of photodamaged skin. Antioxidants protect the skin against the effects of free radicals formed by ultraviolet light radiation. These include vitamins C, E, and B, vitamin A (retinol), green tea, co-enzyme Q10, idebenone, and soy. Products containing collagenstimulating pentapeptides are another option. The combination of cosmeceuticals in the morning with prescription retinoids at bedtime helps to protect and repair the skin and is continued after healing for maintenance.
Patients who may be at risk for developing postinflammatory hyperpigmentation after surgery are prescribed topical bleaching agents, such as hydroquinone, for a few weeks preoperatively. This includes patients with darker skin tones and those with photodamage undergoing ablative procedures. The ideal preoperative regimen for these patients would include a bleaching agent and SPF in the morning, along with a prescription retinoid at bedtime.
Skin Care After Rejuvenation Procedures
Intensive wound care is essential after ablative procedures such as chemical peels and laser resurfacing. Recovery can take up to 2 weeks. Soaking the affected areas with water, saline, or 0.25% acetic acid every few hours will help loosen crusting and remove debris. Occlusive bland emollients containing petrolatumis used for the first few days. This enhances barrier function, retards water loss, and aids in reepithelialization, thus facilitating repair and recovery. It also ensures an optimal outcome and minimize undesirable effects such as discomfort, redness, swelling, and crusting. Areas that are itchy, inflamed, or irritated can be soothed with milk, cold water, and ice compresses. Gentle cleansing is resumed after
1–2 days, and as healing progresses emollient ointments are switched to lighter moisturizers.
During the postoperative period patients should be instructed to minimize facial manipulation; traumatizing wounded areas will increase the incidence of infection, postinflammatory hyperpigmentation, and scarring. Daily sun protection prevents persistent erythema and hyperpigmentation. After the skin has healed, camouflage makeup is used to help conceal redness, discoloration, and scars.
Posttreatment skin care and a maintenance regimen with mild cleansing and moisturizing, combined with sun protection and appropriate topical cosmeceuticals, bleaching agents, and prescription retinoids enhance the cosmetic outcome of surgery.