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Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty

Miranda, Suzette G. M.D.; Codner, Mark A. M.D.

Plastic and Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1335–1343
doi: 10.1097/PRS.0000000000003356
Cosmetic: Original Articles
Discussion
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Background: The tear trough deformity is challenging in lower eyelid rejuvenation. Surgical treatment has evolved, with more modern techniques preserving orbital fat and using autologous fat transposition. The senior author (M.A.C.) reviewed his own experience in targeting the tear trough in lower lid blepharoplasty and presents a new technique that incorporates the addition of micro free fat grafts that adds direct volume to the underlying anatomical depression using a transcutaneous skin-muscle approach.

Methods: Medical records of lower lid blepharoplasty patients performed from February of 2011 to February of 2016 were reviewed. Patients who had tear trough deformities with the addition of micro free fat grafts were included. Standard patient characteristics were collected, complications were identified, and assessment of postoperative results was performed.

Results: There were 32 patients included in the study, with a median follow-up of 392 days (range, 45 to 1709 days). Scleral show requiring operative correction occurred in one patient (3 percent). Additional complications included chemosis in four patients (13 percent), which resolved in all patients. No patients had infections, ectropion, lid retraction, or palpable or visible grafts.

Conclusion: The use of micro free orbital fat grafts is an effective and safe technique to treat the tear trough deformity without increased complication rates and good patient and surgeon satisfaction and should be considered a surgical adjunct during an open blepharoplasty technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Supplemental Digital Content is available in the text.

Atlanta, Ga.

From private practice and the Emory University School of Medicine.

Received for publication July 14, 2016; accepted December 15, 2016.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

Mark A. Codner, M.D., 1800 Howell Mill Road, Suite 140, Atlanta, Ga. 30318, macodner@gmail.com

According to the American Society of Plastic Surgeons, blepharoplasty continues to be one of the most common plastic surgery procedures, with more than 203,000 performed in 2015.1 Lower blepharoplasty, which treats periorbital aging, continues to be varied, with distinct approaches and with a range of challenges and benefits.2,3 Transcutaneous blepharoplasty with a skin-muscle flap has the advantage of addressing lower lid skin excess and herniated orbital fat pads.4,5 Routine canthal support during lower blepharoplasty has been advocated to minimize the risk of lid retraction and ectropion.6,7 In addition, transcutaneous blepharoplasty provides direct access to the orbitomalar ligament for the correction of the tear trough deformity.

The aesthetic goals in periorbital rejuvenation include blending the lid-cheek junction by release of the orbitomalar ligament and fat transposition or fat grafting. The tear trough has contributed to this lower eyelid contour deformity and has been defined by many authors. Loeb8 first designated the nasojugal groove; others, including Flowers, Lambros, and Hirmand, have subsequently defined the tear trough.9–11 The herniation of lower lid fat pads accentuates the tear trough, which appears as a concavity in the medial periorbital area (Fig. 1). Both nonsurgical and surgical options have been described to provide a solution to this problem. Surgical options range from minimally invasive closed needle autologous fat injection12 to repositioning fat and elevating the midface,13,14 and include transconjunctival micro fat grafting from abdominal fat,15 transconjunctival blepharoplasty with fat repositioning,16,17 and the tear trough transconjunctival repositioning of orbital unipedicled fat procedure.18

Fig. 1

Fig. 1

Another useful technique includes transcutaneous lower blepharoplasty with a skin-muscle flap and canthal support with the addition of micro free fat grafting from lower lid excess orbital fat to redistribute fat from the lateral and central compartments into the released tear trough. The purpose of this study was to present a new technique of using autologous fat from periorbital compartments to the tear trough after release of the orbitomalar ligament as micro free fat grafts. All patients with the preoperative appearance of a tear trough were treated. The procedure moves micro fat grafts (which are defined as 2 to 3 mm in size) into areas that are necessary for contour deficiency. The secondary goal was to evaluate whether preservation and redistribution of orbital fat with micro fat grafting is safe and aesthetically pleasing with a minimal risk of complications.

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PATIENTS AND METHODS

Study Design and Patient Population

A retrospective cohort study was performed on all patients who underwent transcutaneous lower blepharoplasty with a skin-muscle flap from February of 2011 to February of 2016 performed by the senior author (M.A.C.). The criteria for inclusion were patients who had tear trough deformities with Barton classification grade I or higher. The micro free fat grafts were used in place of fat transposition of pedicled fat to address contour irregularities of the lower eyelid during the blepharoplasty procedure. Photographic documentation by two independent observers was used to evaluate patients after a minimum 6-week follow-up.

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Surgical Technique/Intervention

Clinical assessment of the patient is made with the patient in the sitting position preoperatively during the markings on the day of the operation to define the location of the tear trough. The patient is marked in the supine position. During the procedure, the preoperative markings are used for location of the tear trough. Corneal protectors are routinely placed. After induction of general anesthesia, lidocaine with 2% epinephrine is infiltrated into the lower eyelid to the level of the lower lid-cheek junction for vasoconstriction. The transcutaneous technique uses a subciliary incision with a lateral extension 4 to 5 mm from the lateral canthal angle within a skin tension line.6 A skin-muscle flap is elevated in a stairstep approach, preserving the pretarsal orbicularis muscle. The subciliary incision is completed with straight iris scissors beveled away from the pretarsal orbicularis oculi muscle. A skin-muscle flap is dissected anteriorly to the orbital septum to the level of the infraorbital rim. Using cutting electrocautery, the medial origin of the orbicularis muscle is released from the maxilla at the tear trough and the anterior lacrimal crest for 2 to 3 mm. The orbitomalar ligament, which is the osteocutaneous ligament originating from the orbital rim and inserting onto the inferior tear trough and malar skin, is divided at the preperiosteal level 3 to 4 mm below the orbital rim. This technique opens the tear trough concavity for grafting and allows greater mobility of the anterior lamella for tightening. A complete release of the orbital malar ligament is performed. This maneuver creates a space for the micro free fat grafts to be placed. Release of the origin of the orbicularis at the orbitomalar ligament is performed in a conservative fashion, and one should stop if the levator alaeque nasi and the levator labii superioris contract, as these muscles are not necessary for release. The orbital septum is excised to decrease the risk of septal scarring. A conservative resection of lower orbital fat is performed from the three compartments, depending on the distinct need and preoperative assessment as part of the routine blepharoplasty. The resected fat is carefully placed on a moist sponge and then minced with scissors into 2- to 3-mm grafts (Fig. 2). These fat grafts are then strategically placed in areas of irregularity to correct these deformities, ranging from hollowness in the infraorbital area to the tear trough (Figs. 3 and 4). A 0.5-mm forceps is used to handle the micro free fat grafts. The grafts are placed in a manner to be contiguous and not stacked or placed as fewer larger grafts. Stacking the grafts or using larger grafts for similar volume could theoretically cause complications such as fat necrosis, contour irregularities, or resorption because of lack of blood supply from the decreased surface area. Temporary redraping of the skin to assess the results and the amount of fat needed is performed by grasping the skin-muscle flap and tightening superiorly and laterally, similar to the final blepharoplasty tension. (See Video, Supplemental Digital Content 1, which illustrates the micro free fat grafts that have been carefully placed on a moist sponge. A 0.5-mm forceps is used to handle the micro free fat grafts and placed in a manner to be contiguous and not stacked. This is done after the orbital malar ligament has been released, which creates the space for placement of these micro grafts within the tear trough deformity. Temporary redraping of the skin is used to assess the results, and the amount of fat needed is performed by grasping the skin muscle flap and tightening superiorly and laterally, similar to the final blepharoplasty tension, http://links.lww.com/PRS/C170.) Subsequently, attention is turned to the laxity of the lower lid. If there is less than 6 mm of tarsoligamentous laxity of the lower lid on gentle lid distraction, a lateral canthopexy is performed with a 4-0 polydioxanone or a double-armed 4-0 Mersilene (Ethicon, Inc., Somerville, N.J.) suture. The canthopexy suture is placed as a mattress suture through the lateral tarsal plate and lateral retinaculum beginning 3 to 4 mm from the lateral commissure, and both ends are brought out deep to the skin and muscle at the level of the commissure. The lateral canthus is sutured to the periosteum of the lateral orbital rim at the level of the pupil posterior to the orbital rim so the lid will follow the curve of the globe. With a double-armed suture, 2 mm is preserved between the posterior periosteal placement, and the needle is brought out just at the lateral orbital rim in a mattress fashion with a similar 2-mm separation. This can also be performed with a single needle. Anterior lid distraction is performed with Brown forceps. If there is greater than 6 mm of lid distraction and significant tarsoligamentous laxity, a lateral canthoplasty should be considered. Although there are numerous canthoplasty techniques, we perform a lateral canthotomy of the inferior canthal ligament and cantholysis for release and elevation of the lower lid. Generally, 2 mm of full-thickness lower lid is resected, removing the skin, muscle, and ligament and thereby exposing the tarsal plate for suture placement. A similar mattress suture is placed and the lateral lid is sutured to the periosteum. To avoid webbing, before tightening the canthoplasty suture, a 6-0 Vicryl (Ethicon) suture is used to realign the gray line at the lateral lid commissure. After canthal support, excess skin and muscle are advanced superior and laterally to achieve the desired aesthetic result. A triangle of skin and muscle is resected and the orbicularis is resuspended to the periosteum at the level of the pupil just lateral to the canthopexy suture. A 4-0 Vicryl suture is used as a three-point suture to resuspend the superior muscle, the inferior muscle, and the periosteum, which takes the tension off of the lower lid. Very little skin is then removed parallel to the lid margin, 2 to 3 mm in most cases, to minimize the risk of ectropion. A tension-free closure is achieved with interrupted 6-0 plain catgut; 6-0 nylon is used if there is concern for lateral skin dehiscence. A continuous 6-0 plain catgut suture is used along the subciliary incision.

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Video

Video

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Data Collection

Data regarding standard patient characteristics were collected, including age, race, date of surgery, follow-up, simultaneous upper blepharoplasty, previous lower lid surgery, and previous filler injection. Operative technique was also assessed in patients with canthopexy, canthoplasty, and which type of suture was used. Standardized photographs were evaluated by two observers to identify the presence of a tear trough deformity, defined as a soft-tissue diagonal groove overlying the inferomedial orbit. Because of the limited number of patients, the tear troughs were not graded. The appearance of surgical improvements was made independently and then compared. There were no findings of discrepancy between the two observers, with improvement of all patients. Complications were evaluated, including lid retraction, ectropion, scleral show, chemosis, fat necrosis, and infection. Fat necrosis was defined as a hard palpable mass that was present during the postoperative period. In addition, the aesthetic delta, or the change from before and after photographs, was defined by the effect of the micro free fat graft placement under the tear trough. Finally, clinic notes and photographs were analyzed from the initial preoperative visit and the 6-week visit, through the last clinic visit, by the independent observers to assess whether there was graft visibility, palpability, or resorption in addition to aesthetic improvement. Partial resorption was defined as partial volume loss from previous examination. Complete resorption was defined as complete volume loss and recurrence of the preoperative tear trough.

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RESULTS

Between February of 2011 and February of 2016, 181 patients underwent lower blepharoplasty. Of these, 35 had a tear trough deformity and were enrolled in the study. Placement of micro orbital free fat grafts to the tear trough deformity was performed by the senior author (M.A.C.), and the patients were followed according to protocol after surgery. Three patients were excluded because they did not meet the minimum follow-up criterion of 6 weeks, leaving 32 patients for final analysis. Table 1 lists the baseline demographic and preoperative morphologic characteristics. The mean age of the study population was 51 years (range, 25 to 75 years), and 68.8 percent of the patients were women. Ninety-one percent of the patients were of Caucasian descent. Analysis of the preoperative photographs demonstrated that 97 percent of the patients had excess fat and 100 percent of this group of patients had a range of tear trough deformities. Furthermore, 6 percent of the patients had previous lower lid surgery and 6 percent of patients had previous filler injections in the lower lid in a failed attempt to correct the tear trough deformity.

Table 1

Table 1

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Operative Management

Table 2 lists the variations in operative management. Thirty-eight percent of patients had simultaneous upper lid blepharoplasty. One patient had unilateral fat graft placement for asymmetry. Lateral canthal support was performed using canthopexy in 91 percent of patients, and 9 percent of patients had a lateral canthoplasty. Mersilene was used as the canthal support suture in 81 percent of the patients. Vicryl and polydioxanone were used as the canthal support suture in 19 percent of patients.

Table 2

Table 2

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Postoperative Complications

The average follow-up period was 392 days (range, 45 to 1709 days). Table 3 lists the rates of postoperative complications and revisions. No infection, ectropion, or fat necrosis occurred in this study. One patient (3 percent) required surgery for mild lid malposition. Chemosis occurred in four patients (12.5 percent) and resolved in all four patients (100 percent) by 6 weeks. Postoperative treatment of chemosis consisted of ophthalmic ointment, including Pred Forte (Allergan, Inc., Irvine, Calif.) drops during the day and TobraDex (Alcon Laboratories, Inc., Fort Worth, Texas) ophthalmic ointment at night. Partial graft resorption occurred in three patients (9 percent), and no patients had complete graft resorption. Furthermore, no patients had palpable or visible graft fat necrosis or granulomas. Two patients had previous lower lid surgery and they did not develop any complications. Patients that underwent upper and lower lid blepharoplasty had a complication rate of 17 percent (two of 12 patients) compared with patients that had only lower lid surgery [three of 20 (15 percent); p = 0.9, analysis of variance single factor test]. Furthermore, 75 percent of patients that had chemosis had concurrent upper and lower blepharoplasty, although this was not statistically significant and was likely because of the overall increased periorbital edema (p = 0.1).

Table 3

Table 3

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DISCUSSION

The tear trough deformity is an entity that makes lower eyelid rejuvenation more challenging. Overall, the surgical treatment of the tear trough deformity has evolved and different techniques have been described. Standard lower blepharoplasty techniques, which do not address the tear trough, leave patients more hollow and sunken in the medial, inferior orbit, which often exacerbates the dark circles that motivated the patient to seek plastic surgery. Modern techniques of preserving orbital fat with limited resection to restore the cosmetic contour of the lower eyelid have also been described.19 Ellenbogen described the use of free autologous fat grafts for a number of indications involving facial soft-tissue defects, including “eyelid depressions.”20 In addition, some other methods use autologous fat transposition and grafting to restore the lid-cheek junction and obliterate the periorbital hollow with good long-term success.

A number of techniques have been described to treat the tear trough deformity. Nonsurgical treatments such as hyaluronic fillers have been used for patients who want to avoid surgery with a “noninvasive” treatment, but this should be reserved for patients that have limited volume loss and for younger patients who want to pursue a nonoperative option. Transcutaneous hyaluronic acid filler injection has been associated with acceptable but subtle short-term results.11,21–23 The disadvantage of this technique is the need for repeated treatment and expense. Furthermore, lower lid tear trough injection with filler or fat is not without significant risk of complications. The contour irregularities or granulomas that may form often require surgical correction with lower blepharoplasty, which the patient was trying to avoid initially. In addition, the risk of visible contour irregularities is high.11,24 Autologous fat transfer is a nonsurgical simple alternative that can be performed during lower blepharoplasty with eyelid fat with good long-lasting results.25 However, one should become familiar with the technique to minimize the risk of contour irregularities.26 One should be mindful of the risk of intravascular injection and the risk of blindness and cerebral infarction, which have been reported in approximately 40 patients with facial and periorbital injections.27–29

Surgical options, albeit more invasive, have offered longer lasting correction of the tear trough. Transconjunctival techniques described by Goldberg, Kawamoto and Bradley, Hidalgo, and Freeman have also been reported to achieve excellent results.17,18,30,31 Transcutaneous approaches have been reported by Hamra, Barton et al., and Carraway.19,23,32 In addition, periorbital skeletal augmentation is another method of treating the tear trough deformity. Yaremchuk and Kahn, Flowers and Nassif, and Terino and Edwards have all described unique tear trough implants to treat the tear trough deformity.33–35

Each technique can offer advantages and disadvantages for a certain category of patients. Patients with skin laxity, orbital fat herniation, and deep tear troughs can benefit from the technique described in the article. The senior author (M.A.C.) has developed a transcutaneous skin-muscle flap with the use of micro free fat grafts to treat the trough deformity during lower blepharoplasty (Figs. 5 through 7). The potential advantage of this technique over the myriad of others is that one can address the skin laxity and the preservation of eyelid shape with a transcutaneous approach and lateral canthal support. The orbital fat herniation is addressed with excision and repositioning of orbital micro fat grafts into areas of hollowness—specifically, within the tear trough—that is easily accessible during the blepharoplasty procedure once the retaining ligaments and limited orbicularis are released. Other techniques such as transposed, vascularized fat can be used to correct the tear trough deformity; however, this technique is limited by the position to which the graft reaches. Micro free fat grafts have the advantage of being able to be more accurately placed into the deep medial area of the trough, which can be challenging with transposed vascularized fat because of tethering of the pedicle. Fat injections from distant locations have also been described, and the micrografting of orbital fat has the advantage of being physiologic, biocompatible, and autologous without the risks associated with fat injections from distant locations of the body. In addition, previous studies have shown that there is less absorption and longer survival of smaller fat grafts when compared to liposuction aspirate.36 Recent advances in stem cell research and technology could potentially lead to viable options for fat grafting; however, clinical experience is lacking.

Fig. 5

Fig. 5

Fig. 6

Fig. 6

Fig. 7

Fig. 7

Micro fat grafting has been shown to be safe, with a minimal risk of complications, similar to the risks of lower blepharoplasty alone. Chemosis was the most common complication, occurring in 12.5 percent of the patients, with all cases resolving within 6 weeks. Patients who had both upper and lower eyelid surgery simultaneously had higher chemosis rates; however, this was not statistically significant. Interestingly, we reported a very similar chemosis rate of 12.1 percent in a large series of 264 patients who were treated with primary transcutaneous lower blepharoplasty with routine lateral canthal support without fat grafting.7 This suggests that the modification of micro free fat grafts for patients with tear trough deformities did not alter chemosis rates. Furthermore, in this series, the revision rate was 3 percent because of one patient with mild scleral show. In the previous series, the revision rate for lid malposition was 3.5 percent. Inherent in this new technique is the potential risk of the fat graft resorption. We did note this phenomenon in three patients. However, none of the patients required revision surgery or fillers. There were no fat granulomas or overgrafting, which is commonly seen with percutaneous tear trough fat injection. This is because the orbitomalar ligament is released, which creates a precise pocket for the micro fat grafts.

It is important to mention that although our complications were similar to those of our previously published study, these procedures were all performed by the experienced senior author. This study has the inherent limitations of a retrospective review. For example, grading of the tear drop deformity was not performed postoperatively to the level of a prospective evaluation. Therefore, photographs had to be used for evaluation, limiting our ability to accurately grade based on the Barton classification. Furthermore, because of the relatively small number of patients, we could not draw definitive conclusions with regard to specific risk factors for complications or compare different classifications of tear trough deformities. A significant limitation of this study is the follow-up period. A period of 45 days was used as an inclusion criterion because the senior author has a national referral practice pattern and some of these patients do not routinely follow up past the 6-week time point. Interestingly, all of the complications that were noted occurred within the first 6 weeks. As with many of the previously described techniques, it is critical to proceed with caution when using a technique for the first time, as improper use or poor patient selection can lead to suboptimal outcomes and complications with any surgeon. A way to become familiar with this specific transcutaneous blepharoplasty technique would be to attend a cadaver course or lecture series or consider visiting a surgeon who has experience with this procedure.

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CONCLUSIONS

Lower eyelid rejuvenation surgery with treatment of the tear trough deformity can be challenging. The use of micro free orbital fat grafts is an effective and safe technique to treat the tear trough deformity without increased complication rates and provides good patient and surgeon satisfaction. This should be considered as a surgical adjunct during an open blepharoplasty technique using 2- to 3-mm particles of removed orbital fat from areas of excess, which can include upper lid fat, and placing them with a fine forceps under direct vision into the area that requires volume augmentation without overcorrection.

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PATIENT CONSENT

Patients provided written consent for the use of their images.

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REFERENCES

1. American Society of Plastic Surgeons. 2015 plastic surgery statistics report. Available at: http://www.plasticsurgery.org/Documents/news-resources/statistics/2015-statistics/top-five-cosmetic-plastic-surgery-procedures-2015.pdf. Accessed May 10, 2016.
2. Zoumalan CI, Roostaeian J. Simplifying blepharoplasty. Plast Reconstr Surg. 2016;137:196e–213e.
3. Kikkawa DO, Kim JW. Lower-eyelid blepharoplasty. Int Ophthalmol Clin. 1997;37:163–178.
4. Beare R. Smith B, Converse JM. Surgical treatment of senile changes in the eyelids: The McIndoe-Beare technique. In: Proceedings of the Second International Symposium on Plastic and Reconstructive Surgery of the Eye and Adnexa. 1967:St. Louis: Mosby; 362–366.
5. Castaneres S. Blepharoplasty for herniated intraorbital fat: Anatomical basis for a new approach. Plast Reconstr Surg. 1951;8:46–58.
6. Klatsky SN, Manson P. Goldwyn R, Cohen M. Blepharoplasty. In: The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 2001:3rd ed. Philadelphia: Lippincott Williams & Wilkins; 847–879.
7. Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous lower blepharoplasty with routine lateral canthal support: A comprehensive 10-year review. Plast Reconstr Surg. 2008;121:241–250.
8. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg. 1981;8:757–776.
9. Flowers RF. Tear trough implants for correction of tear trough deformity. Clin Plast Surg. 1993;20:403–415.
10. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120:1367–1376; discussion 1377.
11. Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg. 2010;125:699–708.
12. Coleman S. Periorbital rejuvenation. Aesthet Surg J. 2001; 21:337–343.
13. Persing JA, Knoll B, Shin J. The shade procedure: For lower lid deformities. Plast Reconstr Surg. 2008;121:1398–1404.
14. Atiyeh BS, Hayek SN. Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation. Aesthetic Plast Surg. 2004;28:197–202.
15. Seiff SR. The fat pearl graft in ophthalmic plastic surgery: Everyone wants to be a donor! Orbit 2002;21:105–109.
16. Goldberg RA, Edelstein C, Shorr N. Fat repositioning in lower blepharoplasty to maintain infraorbital rim contour. Facial Plast Surg. 1999;15:225–229.
17. Goldberg RA. Transconjunctival orbital fat repositioning: Transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg. 2000;105:743–748; discussion 749.
18. Kawamoto HK, Bradley JP. The tear “TROUF” procedure: Transconjunctival repositioning of orbital unipedicled fat. Plast Reconstr Surg. 2003;112:1903–1907; discussion 1908.
19. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg. 1995;96:354–362.
20. Ellenbogen R. Free autogenous pearl fat grafts in the face: A preliminary report of a rediscovered technique. Ann Plast Surg. 1986;16:179–194.
21. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg. 2005;29:363–367.
22. Airan LE, Born TM. Nonsurgical lower eyelid lift. Plast Reconstr Surg. 2005;116:1785–1792.
23. Espinoza GM, Holds JB. Evaluation and treatment of the tear trough deformity in lower blepharoplasty. Semin Plast Surg. 2007;21:57–64.
24. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue fillers. Aesthet Surg J. 2002;22:555–557.
25. Carraway JH. Volume correction for nasojugal groove with blepharoplasty. Aesthet Surg J. 2010;30:101–109.
26. Spector JA, Draper L, Aston SJ. Lower lid deformity secondary to autogenous fat transfer: A cautionary tale. Aesthetic Plast Surg. 2008;32:411–414.
27. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol. 1989;107:85–87.
28. Egido JA, Arroyo R, Marcos A, Jiménez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993;24:615–616.
29. Feinendegen DL, Baumgartner RW, Schroth G, Mattle HP, Tschopp H. Middle cerebral artery occlusion AND ocular fat embolism after autologous fat injection in the face. J Neurol. 1998;245:53–54.
30. Hidalgo DA. An integrated approach to lower blepharoplasty. Plast Reconstr Surg. 2011;127:386–395.
31. Freeman MS. Transconjunctival sub-orbicularis oculi fat (SOOF) pad lift blepharoplasty: A new technique for the effacement of nasojugal deformity. Arch Facial Plast Surg. 2000;2:16–21.
32. Barton FE Jr, Ha R, Awada M. Fat extrusion and septal reset in patients with the tear trough triad: A critical appraisal. Plast Reconstr Surg. 2004;113:2115–2121; discussion 2122.
33. Yaremchuk MJ, Kahn DM. Periorbital skeletal augmentation to improve blepharoplasty and midfacial results. Plast Reconstr Surg. 2009;124:2151–2160.
34. Flowers RS, Nassif JM. Mathes SJ. Aesthetic periorbital surgery. In: Plastic Surgery. 2006:Vol. 2. Philadelphia: Saunders Elsevier; 77–126.
35. Terino EO, Edwards MC. Alloplastic contouring for suborbital, maxillary, zygomatic deficiencies. Facial Plast Surg Clin North Am. 2008;16:33–67, v.
36. Choo PH, Carter SR, Seiff SR. Lower eyelid volume augmentation with fat pearl grafting. Plast Reconstr Surg. 1998;102:1716–1719.

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