Lower eyelid blepharoplasty is one of the most commonly performed aesthetic procedures. According to different placement of incisions, it can be divided into subciliary transcutaneous and transconjunctival approaches.1,2 For patients with little excess skin or orbicularis oculi muscle, the transconjunctival approach is usually performed. With age, the youthful convexity between the lower lid margin and the oral commissure separates into a double convexity with a demarcation at the intersection of the lower lid and midface.3 Traditional surgical procedures for transconjunctival lower blepharoplasty involves only removal of the herniated intraorbital fat, giving rise to increased concavity of the lower eyelid. Further, the tear trough deformity cannot be properly corrected.4
For patients with visible bulging of orbital fat and the tear trough deformity, either free fat grafting or transposition of the pedicled orbital fat is conducted after release of the orbicularis oculi muscle. As for fat grafting, the unpredictable resorption rate is a major concern, let alone subsequent adverse events like palpable induration or discoloration.5,6 And as for orbital fat repositioning, the outcomes are generally excellent due to a sufficient blood supply of the fat pedicle. Though in occasional cases, patients would undergo temporary edema or ecchymosis, it usually lasts no more than 2 months.
Generally, there are 2 ways to fix the repositioned fat pads in transconjunctival lower eyelid blepharoplasty. One is to tie transcutaneous through a foam bolster or other substitutes; the other is to anchor the fat flap in situ through several internal sutures.7–9 Long term maintenance of buried internal fixation without suture removal tend to provide stability for the repositioned fat, and the suture material persists for a relatively long time before absorption.5 Internal fixation also have a visually more pleasing appearance. However, based on our former experience, direct suture of the fat pedicle using a round-bodied needle is relatively difficult to manipulate in such a narrow space, and the details of how to operate were barely mentioned. In this paper, we present our experience using the hypodermic needle-guided buried suture to fix the repositioned fat tissue in transconjunctival lower eyelid blepharoplasty. The method is simple and effective, and the learning curve is short for skilled practitioners.
Thirty-six consecutive patients underwent fat repositioning transconjunctival lower blepharoplasty from August 2016 to January 2018. All the patients were primary cases. The average age was 33.2 years (range, 26–43 years). Follow-up time ranged from 6 months to 2 years. Patients with predominant protrusions of intraorbital fat and tear trough deformity were included in the series. Patients with excess lower lid skin or muscle laxity were excluded. Preoperative and 6-months post-operative photographs were taken. Consent to publish identifiable photographs had been obtained and was archived with the authors. Institutional ethical committee approval was obtained and the research adhered to the tenets of the Declaration of Helsinki as amended in 2008. The severity of tear trough deformity were evaluated according to Barton grading system by 2 independent plastic surgeons through patients’ pre-operative and 6-month post-operative photos (front view, oblique and lateral views). The points would be recorded only if a consensus was reached between the 2 assessing doctors. Grade 0: absence of medial or lateral lines demarcating the arcus marginalis or the orbital rim and a smooth, youthful contour without a transition zone at the orbit-cheek junction. Grade I: mild, subtle presence of a medial line or shadow; smooth lateral transition of lid-cheek junction. Grade II: moderate prominence of a visible demarcation of the lid-cheek junction, extending from medial to lateral. Grade III: severe demarcation of the orbit-cheek junction, with an obvious step between the orbit and the cheek. Pre-operatively, 22 eyes were categorized as Grade I, 43 eyes as Grade II, and 7 eyes as Grade III. All data were analyzed with the Wilcoxon rank-sum test in SPSS 17.0 (Statistical Product and Service Solutions). A P value < 0.05 was considered statistically significant.
Bulged fat tissue, tear trough and arcus marginalis were marked preoperatively with the patient upright (Fig. 1A). The procedure was performed under local anesthesia with 2% lidocaine and 1:100,000 epinephrine. A transconjunctival incision approximately 15 mm in length was made several millimeters below the tarsal plate (Fig. 1B). Dissection was carried out in the preseptal plane all the way down to the arcus marginalis. Then, after release of the orbicularis oculi muscle, a blunt dissection was carried on in a supraperiosteal plane. To avoid damage of the infraorbital nerve, the dissection range should be no more than 8 mm below the orbital rim. After that, the orbital septum was incised open and the intraorbital fat was exposed (Fig. 1C). The medial, central and lateral fat pads were developed accordingly and released circumferentially to allow flexible advancement. Care must be taken not to injure or tether the inferior oblique muscle. Then, the detachable stainless steel needle of a typical plastic medical syringe was applied to assist fat pads fixation. Generally, a 23-gauge × 32 mm hypodermic needle was used. First, the curved needle on a 6–0 nylon suture was cut off and the suture was kept. The 6–0 nylon suture was passed through the shaft of the hypodermic needle from the sharp tip (Fig. 2A). Then the hypodermic needle was pierced through the cheek skin at the level about 5 to 8 mm below the orbital rim all the way into the dissected pocket (Fig. 2B), the needle was next pulled out and pierced through the same pinhole but different pathways into the dissection pocket again (Fig. 2C). Next, the hypodermic needle was curved accordingly and passed through the lower surface tissue of the pocket, after that, the hypodermic needle was taken out (Fig. 2D). Till now, one end of the nylon suture was inside the dissection pocket, and the other end was outside. Next, the middle of the nylon suture was grasped by an ophthalmic forceps and the outside end was pulled into the dissected pocket slowly (Fig. 3A). Two ends of the 6–0 nylon suture were both brought out through the transconjunctival incision (Fig. 3B). One end of the nylon suture was sewed through the free margin of the fat pedicle with an extra 3/8, 4 × 12 curved needle (Fig. 3C). Then, it was tied tightly with the other end with the help of a cotton swab for the limited operating space. The fat pads were transferred and blended well with midface fat (Fig. 3D). The fat pads can be transposed individually or as a unit. Redundant fat tissue was trimmed. Last, the mucosal margins were approximated properly and left unsutured. No oral antibiotics or antivirals were prescribed unless there was a specific indication. Given that the process of the operation was difficult to shoot precisely due to limited view, a schematic illustration of the technique was provided step by step.
Several things should be paid attention to when using this technique. First, avoid overbending of the shaft of the hypodermic needle, otherwise, it may be split into pieces and injure the surrounding vessels accidentally. Second, for that most of the fixation process is performed blindly, make sure the out-point of the skin properly match with the in-point of the periosteum, which is the premise that the free margin of the fat pedicle be placed evenly.
From August 2016 to January 2018, 36 consecutive patients underwent fat repositioning transconjunctival lower blepharoplasty in our department. Out of 36 patients, 30 patients came back to us for a return visit, and 6 patients received a We-Chat follow-up. Nineteen eyes (86.4%) improved from Grade I to 0, and 3 eyes showed no improvement. Thirty-six (83.7%) eyes improved from Grade II to 0, 7 (16.3%) improved from Grade II to I. 5 (71.4%) eyes improved from Grade III to 0, 1 (14.3%) improved from Grade III to I, and 1 (14.3%) improved from Grade III to II. There were significant difference in preoperative and post-operative tear trough deformity grades (P < 0.5). Comparison of preoperative and post-operative tear trough deformity grades were displayed in the Figure 4. All patients recovered very well without significant complications. Two patients suffered mild chemosis, it lasted no more than 2 weeks. Three patients had transient mild to moderate lumpiness over the tear trough area, which were all resolved spontaneously eventually. No steroid injection was given. One patient complained of retained fat tissue, and a revision surgery was given. Most of the patients (27 out of 36) showed an improvement in the appearance of dark circles. No severe hematoma, diplopia, scleral show, or ectropion was seen in any patients. Distribution and incidence rate of post-operative complications was listed below in Supplementary Digital Content, Table 1, http://links.lww.com/SCS/B443. Typical cases were shown in Figures 5 and 6.
Lower eyelid blepharoplasty was one of the most popular but complex aesthetic surgeries. Traditional surgeries mainly focused on the excision of skin, muscle and fat tissue through a subciliary approach, which may bring potential long-term risks including lower lid malposition, scleral show and hollowing over the lower eyelid area.10–12 Modern lower blepharoplasty emphasizes more on fat restoration and lower lid support through either a transcutaneous or transconjunctival incision.13,14 For patients with mild or no skin excess, transconjunctival lower eyelid blepharoplasty tends to be more appropriate due to invisible scarring compared to the transcutaneous method.
The tear trough deformity is a common sign with age, extending laterally from the medial canthus to the mid-pupillary line. The lid/cheek junction, or palpebromalar groove, extends the lateral half of the inferior orbit. In the subcutaneous plane, the tear trough correlates with the junction of the palpebral and orbital portions of the orbicularis muscle medially, and the orbicularis muscle attaches directly to the bone medially without any retaining structures. Later, the lid/cheek junction is related to the orbicularis retaining ligament. Haddock found out that the orbicularis retaining ligament originated from a point 4 to 6 mm below the orbital rim and indicated that any surgical intervention to correct the tear trough and lid/cheek junction must extend significantly below the infraorbital rim.6 Camirand relocated the orbital fat by using a capsulopalpebral flap and sutured it to the orbital rim periosteum, however, the nasojugal fold, also known as the tear trough, remained.15 To sufficiently correct the tear trough deformity, the absolute release of the orbicularis oculi muscle is necessary. And selective release of the orbicularis retaining ligament laterally is indicated based on preoperative lid-cheek contour.16 In addition, many less invasive approaches had been developed to treat the tear trough deformity. Since our study mainly focused on surgical procedures and fixation of the repositioned fat pads, fat grafting or other fillers were not discussed here.
Exposure of the repositioned fat pads is relatively difficult with the transconjunctival route compared to the subciliary incision, let alone effective fixation of the repositioned fat tissue. In the published literature, 2 types of methods were presented: external fixation or buried internal sutures. Grant preferred transcutaneous fixation and the sutures were secured in place with either a flesh-colored tape or tied over a small piece of rubber tubing.15 Mohadjer used 5–0 nylon sutures to fix the central and medial fat pads and tied them on the skin over a foam bolster.17 Wong placed excised fat tissue under the tear trough ligament as free fat graft after release and secured it with percutaneous sutures.18 Core used both internal and transcutaneous sutures depending on the cases, and both methods seem to work well. Actually, the external sutures may carry a potential risk of fat pedicle displacement after sutures’ removal if not properly anchored.8 Chiu applied internal sutures to help fix the repositioned fat pedicle and pointed out long-term maintenance of buried sutures can provide relatively long maintenance of stability before absorption.5 However, they anchored the middle of the fat pedicle with the lower edge of the orbital septum to the periosteal surface approximately 3 to 5 mm below the inferior orbital rim and extended the free end of pedicled fat farther below the infraorbital margin unfixed. In a way, it reflected the difficulty to anchor the free end of repositioned fat pedicles as far as needed below the infraorbital rim through the transconjunctival incision. Chen used a half-circle, round-bodied needle to fix the released fat onto the infraorbital periosteum directly, however, in our experience, due to anterior restriction of the lid margin, direct suture of the fat pedicles using a regular round-bodied needle was difficult to manipulate in such a limited space.19,20 Kawamoto and Bradley fixed the transposed fat pedicles through direct horizontal mattress suture without any external suture or bolsters. Similarly, a short curved needle was difficult to manipulate as the dissection pocket deepened.15 In our case, a hypodermic needle, a long straight hollow one, was used to guide the sutures pierce through the skin all the way into the premaxillary space. The shaft of the needle can be curved properly to adjust to the surface of the maxillary bone for easy pass through the lower surface tissue of pre-dissected pocket. After that, a surgical knot was tied to fix the fat pedicle. We provide an alternative method for internal fixation of repositioned fat pedicles for patients undergoing transconjunctival lower lid blepharoplasty. With the guiding needle, the free end of repositioned fat pedicle could be fixed as far as needed without much space limit. And the learning curve is relatively short for skilled practitioners.
In general, patient satisfaction rates were high and no significant complications had taken place. Three patients had mild to moderate lumpiness, which were all resolved spontaneously eventually. There were several possible reasons. First, the skin and orbicularis muscle were relatively thin, then the contour irregularities underneath were easily revealed. The fat pedicles should be placed evenly and can be slightly trimmed to accommodate the pocket. Second, it may be due to the temporary ischemic state of the fat pedicles. Enough width and absolute release of the fat pedicles should be assured to prevent the above situations. One patient complained of retained fat tissue and a revision surgery was given. Similarly, the fat pedicles can be slightly trimmed to adjust to the dissected pocket, especially for the lateral fat pad. Last, though it was both easy and effective to fix the repositioned fat pads using a regular hypodermic needle, a specialized hypodermic guiding needle might be more appropriate for widespread use in clinical practice. We are now working on it and hope the customized product will meet our needs. We also hope that it can be incorporated in an oculoplastic surgeon's armamentarium.
In summary, we offered a new, simple and effective approach to help fix the repositioned fat pads in transconjunctival lower lid blepharoplasty. It enables precise fixation of fat pedicles under the tear trough and upper part of the premaxillary space without much space limit, which is the premise of favorable post-operative outcomes.
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