Historical background

The importance of the lower eyelid-cheek junction has been appreciated by plastic surgeons over the past decade. In the early 1970s and 1980s, the standard surgical treatment for ‘tired eyes’ consisted of removal of fat and skin or skin and muscle from the lower eyelids.⁶ This universally produced either an unattractive vertical shortening of the lower lid or an accentuated hollowness under the eyes or both (Fig. 20-5). By the 1990s patients and surgeons alike began to realize that this original technique contributed to a haggard, unattractive periorbital appearance of aging.

Figure 20-5 A&B, Examples of surgical blepharoplasty results from the 1970s and 1980s removing both fat and skin from the lower eyelids.

Suborbital maxillary volume/malar suborbital deficiences

A medial sulcus just lateral to the nasal pyramid, which extends distally for 2.5 cm obliquely towards the angle of the mandible, has been termed a ‘nasojugal’ sulcus or ‘tear trough.’^7,8 However, either by heredity or mainly with aging changes, this suborbital depression continues beneath the entire lower eyelid. This volume deficiency is not at the level of the inferior orbital rim as originally thought by plastic surgeons. Instead, it occurs consistently at a measured distance of 8 to 10 mm below the orbital rim. This observation was made by me early in the 1980s, when postoperative blepharoplasty patients began complaining about their more tired, ‘hollow’ look.

The etiology of why such a depression in this area appears as early as the third decade of life and certainly by the late 40s and early 50s has been unclear. Recently, however, largely through the photographic and computer studies of Lambros,⁴ it is now agreed upon that a true atrophy or involution of fat occurs in the upper two-thirds of the face and largely in the periorbital region. This disappearance of fat correlates with the increased appearance of a suborbital hollowness, which creates a tired, haggard appearance.

When indeed, as in many instances, weakening of the orbicularis oculi muscle and orbital septum occurs, permitting the intraorbital fat to protrude forward into what has been commonly called ‘fat bags,’ the suborbital hollow sulcus is accentuated even further. Ambient light creates a highlight on the top of the fat bag ‘mountains’ while a shadow is created in the suborbital ‘valley.’ The juxtaposition of the positive and negative contours enhances the tired ‘ring’ appearance at the lid–cheek junction.

This suborbital sulcus is further accentuated by relative and absolute anatomic skeletal bony deficiencies of the inferior orbital malar zygomatic complex.

The treatment of the suborbital sulcus has been evolving for at least 25 years. In 1983, prompted by complaints of patients about the increased hollowness of their orbital region from traditional blepharoplasty I began transplanting autogenous tissues such as fat, temporalis fascia, temporalis muscle, and galea into the suborbital region below the orbital rim behind the orbicularis oculi muscle and over the SOOF tissues⁹ (Fig. 20-6). This area has now become recognized as the true area of deficiency, which produces a tired appearance from the fat atrophy, which accompanies aging.

Figure 20-6 A, Pieces of temporalis fascia, temporalis muscle and galea. B, Aspirated autologous fat.

These transplanted tissues were successful because they improved most people while in others that they left something to be desired.

Overall, this experience proved to the author that there was a true need for a more permanent augmentation of this region.

Recognizing the limitations of autologous techniques (resorption and shrinkage) I felt that an implant could be designed to fit the suborbital region to improve contours from either aging or heredity, which gave an unattractive appearance.

My tissue transfer technique when a lower blepharoplasty was performed for ‘fat bags,’ the fat was excised tangentially from lateral to medial canthus, leaving a medial vascular pedicle. A small instrument such as a curved hemostat was introduced beneath the orbicularis muscle to tunnel from lateral to medial, grasping the fat pedicle and pulling it into the suborbital sulcus. When upper eyelid surgery was performed simultaneously, the strip of orbicularis muscle routinely removed, was also placed into the suborbital sulcus in a similar fashion. When combined with rhytidectomy, the author often used segments of temporalis fascia including muscle or even large amounts of galea and on occasion ear cartilage (Fig. 20-7). These procedures were performed in 150 to 200 patients at that time.

Figure 20-7 A, Auricular cartilage graft from the ear. B, Same graft placed in suborbital location.

Although these transplantation methods could be demonstrated in the long-term (see photographs at six months to one year, Figs 20-8 & 20-9) the results were only partially successful in improving the suborbital sulcus with volume addition, assessed at a 50–70 percent improvement, 50–70 percent of the time. Lumps and irregularities using these tissue transplantation techniques were infrequent because the tissues were carefully distributed beneath the thickness and padding of the intact orbicularis muscle.

Figure 20-8 A&B, Patients circa 1985 exhibiting long-term improvement in the lid–cheek junction from autologous tissue transplantation.

Figure 20-9 A, Pre-op markings of site of placement of autologous tissue transplants into suborbital sulcus in 1985. B, Significant improvement at 1 year following transplantation.

In 1998 Hamra¹⁰ (evolving from the work of Loeb),¹¹ developed zygo-orbicular complex dissection techniques. At the same time subperiosteal midface suspension procedures evolved.² These newer dissections elevated the orbicularis in the cheek above or below the periosteum and fat could be transposed over the orbital rim and sutured into the SOOF.¹² A further refinement was the release and reset of the orbital septum.¹³

Elimination of the ‘tired look’ is very adequately accomplished with upper midface suspension because it provides the advantage of elevating the lower, thicker tissues of the cheek up over the thin suborbital sulcus adding additional thickness to the transposed fat thus providing a most consistent and excellent blending of the lid-cheek junction (Figs 20-10 & 20-11). A suborbital tear trough malar implant with transverse dimensions of 6 cm, a vertical dimension of 3.2 cm and a thickness of 3 or 4 mm will also blend the lid–cheek junction well without the need for an extensive midface submalar and lateral orbital temple brow dissection required for an upper and mid face ‘lifting’ procedure.

Figure 20-10 A&B, An upper midface suspension as well as fat transposition provides a two-layer superimposed padding to improve the suborbital sulcus, left preoperative, right postoperative, one year following upper midface suspension, fat transposition, and lateral canthopexy.

Figure 20-11 A&B, Another example of the successful technique of upper midface suspension combined with fat rearrangement over the orbital rim to improve the lid–cheek junction, left preoperative, right 10 months postoperative, upper midface and lateral upper midface suspension, fat transposition and lateral canthopexy.

The alloplastic solution

Deficiencies of the facial skeleton in the suborbital malar zygomatic region can be hereditary or posttraumatic. My original experience which motivated investigations into corrections of these deficiencies began with maxillofacial deformities resulting from poorly reduced suborbital or trimalar fractures.

In the late 1960s utilization of alloplastic materials such as hand-carved Silastic sponge could produce a very successful improvement towards normal. This positive experience prompted me to develop alloplastic anatomic contour silastic implants for the malarzygomatic midface region.

In the early 1980s, I conceived of an implant designed to fill the inferior orbital rim and suborbital sulcus. Flowers by the 1990s⁸ carried this thought forward and his present day tear trough implants were developed and are obtainable through Implantech Corporation, Ventura, California.