Long Term 3D Volume Assessment after Fat
Repositioning Lower Blepharoplasty
Miller TR.
Private Practice, Refreshed Aesthetic Surgery, Aliso Viejo, CA.
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Introduction
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Pseudo-fat herniation in the lower eyelid area is a common reason lower
eyelid blepharoplasty is performed.
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Surgical techniques that are commonly used to correct pseudo-fat
herniation can typically be categorized as fat preservation or fat subtractive.
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Fat repositioning lower blepharoplasty is a fat preservation technique that
offers distinct advantages, namely effacing the tear trough by releasing the
tethering orbicularis retaining ligament with the subsequent addition of
volume to the tear trough and upper malar area.
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Purpose
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The purpose of this study was to determine the long term volumetric effects
that the lower blepharoplasty fat repositioning technique provides to the tear
trough and deep fat compartments of the periorbital area and upper cheek.
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Relevance to Clinical Practice
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Pseudo-fat herniation in the lower eyelid area is a common reason for lower
blepharoplasty because the condition can impart an unwanted tired or sad
appearance.
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Fat repositioning lower blepharoplasty offers distinct advantages, especially
when recognizing the interrelationship between periorbital aging and
periorbital and midface anatomy.
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The fat repositioning technique involves the use of vascularized pedicles of
orbital fat and re-positions these fat pedicles within the adjacent
prezygomatic and premaxillary spaces, which has been theorized to offer
the best plane and areas for augmenting and rejuvenating the periorbital
and malar areas.
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Techniques based on removing orbital fat do not provide this benefit.
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Description of Evidence
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A retrospective electronic medical record chart review was performed to
identify patients who underwent only primary lower blepharoplasty with fat
repositioning.
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Three-dimensional (3D) images were taken of patients the day of surgery
and at least 10 months post-operation (range 10-16 months).
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The area selected for volume analysis was based on the areas typically
affected by fat repositioning lower blepharoplasty.
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The area selected on the before 3D image was then identically duplicated
on the patient’s 3D post-operative image and calculations of volume
differences were performed. The average volume gain in the area of study
was 0.64 cc.
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Description of Evidence
Before
After
Three-dimensional untextured image. 12 months after fat
repositioning. Results illustrates long term volume
augmentation of tear trough and anterior cheek.
Three-dimensional colorimetric analysis. Blue color
representing increased volume at 12 months postoperation.
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Description of Evidence
Same patient in previous slide
12 months after fat repositioning. Before (top left) and 12 month
post-operative result (top right). Black line outlining and emphasizing
contour change, before (bottom left) and after (bottom right).
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Controversies and Consensus
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Recent cadaveric studies have shown the face is divided into several
discrete superficial and deep fat compartments. Changes in these fat
compartments are responsible for many of the differences observed when
comparing the aging and youthful face.
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The deep fat compartments of the periorbital and upper midface areas
consists of the deep medial fat, and the medial and lateral sub-orbicularis
orbital fat (SOOF) compartments.
•
Surgical techniques that are commonly used to correct pseudo-fat
herniation of the lower eyelids can typically be categorized as fat
preservation or fat subtractive. The fat repositioning lower blepharoplasty is
a fat preservation technique.
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Controversies and Consensus
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Fat repositioning lower blepharoplasty is a surgical technique that reduces
the prominence of the lower eyelid fat pads (pseudo-fat herniation), while
simultaneously effacing the tear trough and providing supplemental volume
augmentation to the fat compartments of periorbital and upper cheek areas:
the deep medial fat and medial and lateral SOOF compartments.
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Fat subtractive techniques may address pseudo-fat herniation by removing
fatty tissue, but these techniques do not address the other signs of
periorbital and midface aging (e.g., direct improvement, or “leveling” of the
tear trough and volume augmentation of the deep fat compartments).
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Controversies and Consensus
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Three-dimensional (3D) imaging is increasing in popularity in plastic surgery
and use in scientific studies.
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Comparing three-dimensional (3D) images (i.e., before and after images)
entails many steps including patient positioning, registering of landmarks,
and computer mathematical models and calculations.
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As a result, each step has the potential for measurement errors that may be
further reduced with future advancements in the expanding field of 3D
imaging and analysis.
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Comment
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The fat repositioning technique requires a more thorough grasp of anatomic
knowledge, surgical proficiency and operating time; however, the results
have been shown in the current study to be aesthetically beneficial and the
results long lasting.
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How the increased volume after fat repositioning mathematically compares
to the volume of injected free fat grafts or a hyaluronic acid filler is difficult to
determine.
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The volume expansion by filler or fat transfer may not exhibit a 1:1
correlation to repositioned fat during lower blepharoplasty. Further studies
are required.
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Comment
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Different techniques have been described for the fat repositioning lower
blepharoplasty.
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Specifically, the author uses a subperiosteal plane but transitions from this
plane at the level of the levator labii superioris muscle. Other surgeons may
use a supra-periosteal plane.
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Recent studies (not using 3D imaging) have shown no significant
differences in aesthetic outcomes based on planes of dissection during fat
repositioning lower blepharoplasty.
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Future studies need to be performed, using 3D imaging analysis, to
evaluate the volumetric effects when different planes of dissection are used.
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Conclusions
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The lower blepharoplasty fat repositioning technique is an effective
procedure for improving lower eyelid pseudo-fat herniation, while
simultaneously improving the aging effects often seen in the periorbital and
upper cheek areas.
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The aesthetic improvement is explained by the release of ligaments and
direct volume augmentation of specific areas that have recently been
defined by recent anatomical studies.
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Contact Information
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If you have questions, please contact the corresponding author:
– Timothy R. Miller, M.D.
Refreshed Aesthetic Surgery,
2 Journey, Suite 208, Aliso Viejo, CA. 92656
e-mail: drtimothymiller@gmail.com
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