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.
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 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.
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).
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.
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.
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.
Patients provided written consent for the use of their images.
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