Transconjunctival lower eyelid blepharoplasty with "super released" orbital fat in correction of tear trough and palpebromalar groove depression / 中国修复重建外科杂志

OBJECTIVE@#To investigate effectiveness of transconjunctival lower eyelid blepharoplasty with "super released" orbital fat in correction of lower eyelid pouch protrusion and tear trough and palpebromalar groove depression.@*METHODS@#A clinical data of 82 patients (164 sides) with lower eyelid pouch protrusion and tear trough and palpebromalar groove depression, who met the selection criteria between September 2021 and May 2022, was retrospectively analyzed. Of the included patients, 3 were males and 79 were females, with an average age of 34.5 years (range, 22-46 years). All patients had varying degrees of eyelid pouch protrusion and tear trough and palpebromalar groove depression. The deformities were graded by the Barton grading system as gradeⅠ in 64 sides, grade Ⅱ in 72 sides, and grade Ⅲ in 28 sides. The orbital fat transpositions were performed through the lower eyelid conjunctival approach. The membrane surrounding the orbital fat was completely released, allowing the orbital fat to fully herniate until the herniated orbital fat did not retract significantly in a resting and relaxed state, which is regarded as the "super released" standard. The released fat strip was spread into the anterior zygomatic space and the anterior maxillary space, and percutaneous fixed to the middle face. The suture that penetrates the skin was externally fixed by adhesive tape pasting without knotted.@*RESULTS@#There were 3 sides with chemosis after operation, 1 side with facial skin numbness, 1 side with mild lower eyelid retraction at the early stage after operation, and 5 sides with slight pouch residue. No hematoma, infection, or diplopia occurred. All patients were followed up 4-8 months, with an average of 6.2 months. The eyelid pouch protrusion, tear trough, and palpebromalar groove depression were significantly corrected. At last follow-up, the deformity was graded by Barton grading system as grade 0 in 158 sides and grade Ⅰ in 6 sides, with a significant difference compared to the preoperative score ( P<0.001). Patient's self-evaluation satisfaction reached very satisfied in 67 cases (81.7%), satisfied in 10 cases (12.2%), generally satisfied in 4 cases (4.8%), and dissatisfied in 1 case (1.2%).@*CONCLUSION@#The "super released" orbital fat can effectively prevent the retraction of orbital fat, reduce the probability of residual or recurrence of eyelid pouches, and improve the correction effect.

Efficacy of orbital fat pedicle on correcting eyebags with tear trough and palpebromalar groove deformity / 中华医学美学美容杂志

Objective:To investigate the clinical experience of using orbital fat pedicle to correct eyebags with the tear trough and palpebromalar groove deformity.Methods:From February 2020 to May 2021, 35 patients with lower blepharoplasty combined with orbital fat-release were treated in the Facial and Neck Plastic Surgery Center of the Plastic Surgery Hospital of Chinese Academy of Medical Sciences, including 4 males and 31 females. Their age ranged from 35 to 63 years, with an average age of 47.5 years. Different degrees of lower eyelid skin laxity, orbital fat herniation, moderate and severe tear trough, palpebromalar groove deformity were observed in all patients. Preoperative examination showed no symptoms such as lower eyelid ectropion and lower eyelid retreat ment. All 35 patients were treated with transcutaneous incision blepharoplasty, in which the orbital septal fat was released, pulled downward and internally fixed to the appropriate position to fill the tear trough and palpebromalar groove.Results:All patients obtained primary healing, no complications such as hematoma, and infection occured. Postoperative follow-up lasted from 3 to 18 months, with an average of 8.6 months. 35 patients′ eye bags with tear trough and palpebromalar groove deformity were obviously alleviated. Unilateral mild eye bag remained in 2 patients in postoperative 1 month, and 2 cases appeared mild lower eyelid ectropion postoperatively, none of these patients received special treatment and recovered after 3 months.Conclusions:Lower blepharoplasty combined with orbital fat release can effectively repair eye bags and correct tear trough and palpebromalar groove deformity.

Research on the effect of nanofat combined with granular fat injection in the treatment of mixed dark circle at lower eyelid / 中华整形外科杂志

Objective@#To investigate the clinical effect of subcutaneous injection of nanofat combined with autologous fat into tear trough deformity to improve the mixed dark circle at lower eyelid, and the feasibility of using L*a*b* value to objectively evaluate the improvement of skin color at the lower eyelid with dark circle.@*Methods@#A total of 14 patients with the mixed dark circle at lower eyelid, admitted by Union Hospital of Tongji Medical College of Huazhong University of Science and Technology from November 2017 to August 2018 were selected. They were all female, aged between 21 and 46 years old. Thigh or abdomen was selected as the fat donor area. Autologous fat was filled into the tear trough deformity. The prepared nanofat was injected into the subcutaneous layer of the lower eyelid with dark circle. Photoes were taken under the same condition and same room temperature for patients before operation and 6 months after operation. Photoshop, CS7 exposure correction, as well as 64 Image J software measurement were adopted to evaluate the skin L* a* b* value at dark circle of lower eyelid. SPSS 20.0 rows of data statistical analysis was applied with paired t test(P<0.05).@*Results@#All patients were followed up for 6 months after the operation, and a satisfactory effect was achieved after one injection, with an overall satisfaction rate of 78.6% (11/14). The color and skin fine wrinkles at the dark circle of the lower eyelid were improved in 14 patients, and the contour of the injection area was smooth without obvious complications. 6 months after the operation, the L* value of the skin at the lower eyelid with dark circle was 55.13±5.56, which was 7.74±2.39 higher than the preoperative value of 48.23±5.63, showing significant difference(t=12.089, P=0.00). Six months after surgery, the a* value was 14.68±2.84, which decreased by 0.11±0.60 compared with 14.79±3.04 before surgery, showing no statistically difference(t=-0.71, P=0.49). Six months after surgery, the b* value was 19.77±3.45, which increased by 0.27±1.03 compared with 19.50±3.45 before surgery, showing no statistical difference (t=0.98, P=0.35).@*Conclusions@#Subcutaneous injection of nanofat combined with autologous fat injection for tear trough deformity is effective in the treatment of lower eyelid with mixed dark circle. The L*a*b* value can objectively evaluate the improvement of skin color at the lower eyelid with dark circle.

Discussion: correction of palpebral bags and tear trough deformity by orbital fat repositioning through premaxillary and prezygomatic space with intraoral fixation / 中华整形外科杂志

In order to fully demonstrate the clinical significance of the article " Correction of palpebral bags and tear trough deformity by orbital fat repositioning through premaxillary and prezygomatic space with intraoral fixation" [Gao Wei, Lin Xiaoxi, Jin Yunbo, et al.Chin J Plast Surg, 2019, 35(12): 1240-1245], the editor invited professor Xiaolei Jin to write a discussion/review on this paper. Professor Xiaolei Jin affirmed the innovation and practicability of this technique in solving the problem of " the infraorbital edema with mid-face depression" , and proposed that the following questions should be investigated further: (1) indications and contraindications for this procedure.(2) the technical details of the transfer and fixation of orbital septal fat flap.(3) issues for controlling the potential risk of infection. (the editor)

Correction of palpebral bags and tear trough deformity by orbital fat repositioning through premaxillary and prezygomatic space with intraoral fixation / 中华整形外科杂志

Objective@#To explore and evaluate the approach of fat repositioning into premaxillary and prezygomatic spaces combined with intraoral fixation in transconjunctival lower blepharoplasty.@*Methods@#17 patients (2 males and 15 females) who underwent this approach from Aug, 2018 to Feb, 2019 were reviewed. Their average age was 36.88±8.80 years old (range, 24 to 55 years old). A 1.0-1.5 cm transverse transconjunctival incision was made. After blunt dissection of premaxillary and prezygomatic spaces, orbital fat were released and sutured with 1-2 absorbable sutures. Via the guidance of astraight needle through the a forementioned spaces, a small incision was made at the upper vestibular labial side. The orbital fat was pulled down according to the consensus between surgeon and patient and fixed upon the small intraoral incision. All incisions didn′t need to be sutured.@*Results@#The mean follow up was 3.53±1.71 months (range, 1 to 6 months), transconjunctival and intraoral incisons healed well. Palpebral bags and tear trough deformity were obviously improved. Postoperatively, 2 patients felt a transient tractive feeling in the midface region 1 week after surgery, which spontaneously recovered within 1 to 2 weeks. One patient had red, swollen and painful skin beside the right nasal alar one month after the operation, and the symptoms disappeared after 3-day intravenous infusion of cefradine. No lower eyelid retraction, ectropion, hematoma and other complications were observed.@*Conclusions@#This novel approach can achieve periorbital rejuvenation and improve the contour of the lower eyelid and mid-face for patients of all the ages with eyelid bags, tear trough deformity, and midfacial depression, but without severe skin laxity.

Correction of palpebral bags and tear trough deformity by orbital fat repositioning through premaxillary and prezygomatic space with intraoral fixation / 中华整形外科杂志

Objective@#To explore and evaluate the approach of fat repositioning into premaxillary and prezygomatic spaces combined with intraoral fixation in transconjunctival lower blepharoplasty.@*Methods@#17 patients (2 males and 15 females) who underwent this approach from Aug, 2018 to Feb, 2019 were reviewed. Their average age was 36.88±8.80 years old (range, 24 to 55 years old). A 1.0-1.5 cm transverse transconjunctival incision was made. After blunt dissection of premaxillary and prezygomatic spaces, orbital fat were released and sutured with 1-2 absorbable sutures. Via the guidance of astraight needle through the a forementioned spaces, a small incision was made at the upper vestibular labial side. The orbital fat was pulled down according to the consensus between surgeon and patient and fixed upon the small intraoral incision. All incisions didn′t need to be sutured.@*Results@#The mean follow up was 3.53±1.71 months (range, 1 to 6 months), transconjunctival and intraoral incisons healed well. Palpebral bags and tear trough deformity were obviously improved. Postoperatively, 2 patients felt a transient tractive feeling in the midface region 1 week after surgery, which spontaneously recovered within 1 to 2 weeks. One patient had red, swollen and painful skin beside the right nasal alar one month after the operation, and the symptoms disappeared after 3-day intravenous infusion of cefradine. No lower eyelid retraction, ectropion, hematoma and other complications were observed.@*Conclusions@#This novel approach can achieve periorbital rejuvenation and improve the contour of the lower eyelid and mid-face for patients of all the ages with eyelid bags, tear trough deformity, and midfacial depression, but without severe skin laxity.

Definitions of groove and hollowness of the infraorbital region and clinical treatment using soft-tissue filler

Clarification is needed regarding the definitions and classification of groove and hollowness of the infraorbital region depending on the cause, anatomical characteristics, and appearance. Grooves in the infraorbital region can be classified as nasojugal grooves (or folds), tear trough deformities, and palpebromalar grooves; these can be differentiated based on anatomical characteristics. They are caused by the herniation of intraorbital fat, atrophy of the skin and subcutaneous fat, contraction of the orbital part of the orbicularis oculi muscle or squinting, and malar bone resorption. Safe and successful treatment requires an optimal choice of filler and treatment method. The choice between a cannula and needle depends on various factors; a needle is better for injections into a subdermal area in a relatively safe plane, while a cannula is recommended for avoiding vascular compromise when injecting filler into a deep fat layer and releasing fibrotic ligamentous structures. The injection of a soft-tissue filler into the subcutaneous fat tissue is recommended for treating mild indentations around the orbital rim and nasojugal region. Reducing the tethering effect of ligamentous structures by undermining using a cannula prior to the filler injection is recommended for treating relatively deep and fine indentations. The treatment of mild prolapse of the intraorbital septal fat or broad flattening of the infraorbital region can be improved by restoring the volume deficiency using a relatively firm filler.

Clinical application of orbital fat autograft for tear trough deformity through tranconjunctival approach / 中华整形外科杂志

Objective@#To discuss the orbital fat autograft for lower baggy eyelid with tear trough deformity and its therapeutic effect through tranconjunctival approach.@*Methods@#The patients with lower eyelid bag and tear trough deformity were included into the study. The included 32 patients met the following criterias: ①less than 40 years old; ②lower eyelid skin was not relaxed; ③less than 1 s in Snap test; ④Hirmand type Ⅰ and Ⅱ. They were treated with tranconjunctival lower blepharoplasty combined with the tears ligament relaxation. The orbital fat was repositioned on the depression site above orbital periosteum to correct tear trough deformity. The effect was evaluated through Tear Trough Rating Scale (TTRS) and satisfaction degree.@*Results@#Three cases with Hirmand type Ⅱ didn’t have good effect. Among them, the baggy eyelid was corrected in 2 cases, while the tear trough deformity need additional hyaluronic acid injection. One patient underwent secondary lower blepharoplasty through cutaneous incision. Good effect was achieved in the other 29 cases with no depression deformity and eyelid withdrawal. The TTRS scores 6 months after operation was significantly improved(P<0.01). Satisfaction degree was 100%(14/14) and 83.3%(15/18) in type Ⅰ and Ⅱ patients.@*Conclusions@#The technique can simultaneously improve lower eyelid bag and the tear trough deformity. It can be applied in periorbital rejuvenation for middle-aged and young patients.

Application of microgranular fat transplantation in repair of tear trough deformity / 中华医学美学美容杂志

Objective To explore the clinical effect of microgranular fat obtained by mechanical injection of autologous fat tissues in the treatment of lacrimal trough deformity.Methods Ten patients in this group were women,and the average age was 28 years.With tumescent technique,the thigh fat granules were aspirated;after the separation and purification using cell sorting screen,fat particles were obtained with uniform size and without fibrous tissue.Through mechanical pushing of the fat particles,the fat granules became chylomicron-like.The fat particles without fibrous tissue were injected into the superficial layer and deep layer of the orbicularis oculi muscle with depressed deformity.3-12 months after operation,the clinical efficacy was evaluated by doctors,patients and the third party.Results In 10 cases of lacrimal groove deformity,9 cases were transplanted once,and 1 case did twice.After 3 to 12 months follow-up the appearance of tear trough deformity was significantly improved,the texture of the ditch of eyelid and cheek skin was soft,and appeared young plump appearance.There were no complications,such as infection,hematoma,fat liquefaction,pigmentation and induration,and satisfactory results were obtained.Conclusions Ultrafine particles of fat are obtained using improved purification method in the treatment of lacrimal groove deformity,and the efficacy is satisfactory.

Study on blepharoplasty stripping arcuate margin of orbicularis oculi muscle used in patients with tear trough and palpbromalar groove / 中国基层医药

Objective To explore divest arcuate edge orbicularis muscle surgery reconstructive treatment of the symptoms of clinical efficacy and recovery.Methods 80 patients with tear trough and palphromalar groove pouch,according to the operation method,were divided into group A and group B.The patients received stripped arcuate margin of orbicularis oculi muscle operation and true orbital fat too much fat operation,operation treatment,respectively.The satisfaction and revisit the rebound rate of the two groups after surgery were compared.Results Of 40 patients in A group,37 cases (92.5％)were satisfied with the treatment,general satisfaction in 3 cases (7.5％),0 case (0.0％) was not satisfactory.In B group,28 cases (62.5％)were satisfied with the treatment,general satisfaction in 9 cases (22.5％),3 cases (15.0％)were not satisfactory.The clinical efficacy between the two groups was significantly different(Z =18.481,P ＜ 0.01).During follow-up,in A group,one case (2.5％)relapsed.In B group,7 cases (17.5％) relapsed after 2 years.The postoperative recurrence rate between the two groups had significant difference (Z =7.314,P ＜ 0.05).Conclusion For patients with tear trough and palpbromalar groove pouch,treatment by stripping arcuate margin of orbicularis oculi muscle operation method can effectively correct the tear trough and palabromalar groove deformity postoperative reduction performance,has high degree of satisfaction,the recurrence rate is low,the clinical effect is significant,it is worthy of further clinical application and research.

Blepharoplasty and periorbital surgical rejuvenation.

The periorbital region forms the epicenter of facial aging changes and receives highest attention from physicians and patients. The concern about visual function, clubbed with the need for hidden incisions, makes the periocular region a highly specialized surgical area, most appropriately handled by an ophthalmic plastic surgeon. The article provides an overview of cosmetic eyelid and facial surgery in the periocular region. Common aesthetic surgical procedures as well as ocular side-effects of commonly performed periocular injections are discussed from the dermatologist's point of view.

Sectional anatomy of tear trough deformity and palpbromalar groove deformity caused by aging / 中华医学美学美容杂志

Objective To study the mechanism of tear trough deformity and palabromalar groove deformity.Methods Four old cadavers (2 male,2 female,an average age of 67.2 years) with obvious tear trough deformity and palpbromalar groove deformity and 4 young cadavers (2 male,2 female,an average age of 23.5 years) without tear trough deformity and palpbromalar groove deformity were selected and dissected and histological observation were performed on lower eyelid and periorbital region.Results Compared to young specimens,the skin and orbicularis oculi muscle of old specimens were atrophy and relaxed.Tear trough deformity and palabromalar groove deformity overlaid the junction of thinner eyelid skin and thicker cheek skin.The superior border of the malar fat pad covered the junction of the palpebral and orbital portions of the orbicularis muscle,and correlated with the tear trough and palpbromalar groove,but the superior border of the malar fat pad in young cadavers was found above the tear trough and palpbromalar groove line.The orbicularis retaining ligament arose from the orbital rim and caudal to the junction of the palpebral and orbital portions of the orbicularis muscle,and it was relaxed in old group than that in young group.Conclusions Tear trough deformity and palabromalar groove deformity result from combination of age-related relaxation,atrophy and descent of layers of tissues.The orbital septal and the orbicularis retaining ligament prevent tissues from descending,which makes tear trough deformity and palabromalar groove deformity more visible.

Correction of the Tear Trough Using Orbital Fat Graft from the Lower Lid

Lower palpebral bags and tear trough grooves are the common signs of aging. Weakness of the orbital septum, atrophy of the orbicularis oculi muscle, slackness and laxity of the lower lid skin are the main causes of these aging changes. Tear trough groove with skeletonization of the lower orbital rim can not be corrected easily by the conventional lower blepharoplasty, but the augmentation of the volume, can be an effective method. Lower lids provide a well vascularized recipient site, which is vital for proper grafting of fat to occur. We treated tear trough groove with free fat graft of surgically removed orbital fat. Surgical excision of the fat pad and septal reinforcement with free fat graft below the levator labii superioris alaeque nasi muscle were performed to correct tear trough groove. This technique was performed in 29 consecutive individuals from October, 2001 to January, 2005. Palpebral bags and tear trough groove were corrected concomitantly and obtained a youthful attractive midface with no secondary hollowness of lower lid and irregularity. The overall results obtained were satisfactory without any complications. Recurrence of tear trough deformity due to grafted fat absorption was not noted during the 7 months of the follow-up period. The authors conclude that the procedure is safe and effective in selected patients.

The Treatment of Palpebral Bags by Repositioning of Orbital Fat into a Subperiosteal Pocket

Baggy eyelids or palpebral bags of the lower eyelids are mainly caused by weakening of the orbital septum, atrophy of the orbicilaris oculi muscle and slackness of the skin. These palpebral bags are usually combined with a depression along the inferior orbital rim which is called a tear trough groove and a tear trough groove can be divided into a nasojugal groove and a palpebromalar groove. Excision of the protruded orbital fat as a treatment for palpebral bags may contribute in the long term to the senile enophthalmos due to a volume reduction of the intraorbital adipose tissue. Authors treated palpebral bags and tear trough grooves by reposition of orbital fat flaps into a subperiosteal pocket of the inferior orbital rim. Myocutaneous flaps from the lower eyelids were elevated through subciliary incisions to expose the inferior orbital rim and subperiosteal pockets were made on the orbital rim. The orbital fat flaps protruded through the incised orbital septum near the arcus marginalis were repositioned into the subperiosteal pockets by two or three horizontal mattress sutures. Nine patients with palpebral bags and tear trough grooves were operated with this technique and follow-up range was between 6 to 14 months(an average of 11 months). Palpebral bags and tear trough grooves were corrected well and youthful looking eyes were obtained. The main advantages of this technique are that; the first, we can get wide operative field and easy repositioning of orbital fat into the subperiosteal pocket through the transcutaneous approach than the transconjunetival approach, the second, subperiosteal repositioning of the orbital fat can make more even and smooth skin surface over the periorbital region than the supraperiosteal repositioning of the orbital fat due to coverage of the irregular fat lobules by the periosteum and the third, lower blepharoplasty can be combined with this technique.