Surgical technique

The depth of the tear trough deformity (nasojugal fold) and orbital rim hollow is evaluated preoperatively with regard to the medial and lateral extent, and depth. Preoperative assessment must also consider the distribution and contour of the medial, central and lateral fat pockets. Although the lateral orbital hollowness that is present in some patients represents an aesthetic deformity, the amount of lateral orbital fat that is available for repositioning into this area is generally inadequate to successfully correct this ‘hollow orbit deformity.’ Therefore, the lateral orbital fat is more commonly excised than repositioned, and residual lateral hollowness is treated with hyaluronic acid gel or free fat transfer.

The tear trough is marked with a surgical marking pen on the skin surface before surgery begins, in order to guide the intraoperative placement of the fat pedicle. The initial portion of the surgery is identical to any other transconjunctival blepharoplasty, with a forniceal incision and wide open sky exposure of the individual fat pockets (Fig. 19-1). The lateral and central fat pockets may be debulked as determined preoperatively.

Figure 19-1 A conjunctival incision is made 4 mm from the inferior edge of the tarsal plate, in order to expose the orbital fat pads.

Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

Next, the arcus marginalis is identified. The inferomedial orbital rim is palpated with the tips of a Stevens’ scissors and blunt dissection on the palpable bony orbital margin reveals the white tissue condensation representing the arcus marginalis (Fig. 19-2). Cutting cautery is useful to control bleeding from the small bony perforators that sometimes occupy this area, and to cut through the periosteum to reach the bony surface of the maxilla. Dissection is then carried out over the orbital rim by lifting the periosteum using a sharp elevator, taking care to keep the arcus marginalis and orbital septal attachment intact. The entire area of intended fat pedicle placement is undermined guided by the previously placed blue marks (Fig. 19-3). Some surgeons have suggested that the suborbicularis (supraperiosteal) plane is preferable. However, the subperiosteal plane has the advantage of being relatively blood free and straightforward. The periosteum in this area is fairly loose and the fat can be easily repositioned into the subperiosteal pocket.

Figure 19-2 The orbital rim is exposed at the level of the arcus marginalis, using blunt dissection.

Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

Figure 19-3 A subperiosteal pocket is dissected in the intended area of fat repositioning. Typically the dissection extends onto the face of the maxilla 1–2 cm from the orbital rim, and includes parts of the origins of the levator alaeque nasi and levator labialis superioris muscles.

Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

It is important to create an adequately large pocket, typically extending 15 to 20 mm onto the maxillary face. The extent of subperiosteal dissection is individualized to the patient as it determines the size and shape of the eventual volume redistribution. Typically, the dissection will extend onto the nasal bridge and involve release of at least part of the origin of the levator alaqui nasi muscle. Centrally, the origin of the levator labii superiorioris is typically undermined, with care taken to avoid injury to the inferior orbital neurovascular bundle that emanates from its foramen just below the origin of this muscle. The subperiosteal pocket is extended medial, and often lateral, to the infraorbital nerve.

Medial, central, and sometimes lateral fat pedicles are created using gentle dissection. Often, the largest fat pedicle is created from the medial fat pocket. Although there are some large vessels in the medial fat pad (and it is preferable to avoid cutting across them), the fat pedicle is essentially a random flap. The stalk of the pedicle should be large enough to provide reasonable blood supply, but small enough to avoid pulling on the orbital connective tissue system as the pedicle is transposed over the rim. We most often construct a ‘T’ shaped pedicle with a base measuring 5 to 10 mm in diameter. The central fat pocket is variable in size, occasionally larger than the medial pocket. The pedicles are transposed over the orbital rim and placed into the predissected pocket and distributed evenly within it (Fig. 19-4). Forced ductions of the globe are then checked to be sure that the fat is not attached by the pedicle to the motility system of the orbit: there should be no movement or tugging on the pedicle as the globe is rotated.

Figure 19-4 Central and medial fat pads are dissected into pedicles and then transposed over the orbital rim into the subperiosteal pocket.

Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

A number of different techniques are available to fixate the pedicles within their subperiosteal pocket. The pedicle can be sutured to the trailing edge of the SOOF fat using buried absorbable sutures, but exposure of the deep aspect of the pocket can be difficult. Another technique involves fastening to the tip of the fat pedicle a double armed 6-0 gut suture (or polypropylene pullout suture, without knots) in a fashion analogous to imbricating the extraocular muscles during strabismus surgery. These sutures are then externalized from the deep margin of the subperiosteal pocket out to the skin. Another method utilizes an externalized 6-0 polypropylene ‘cage’ suture to fixate the pedicle into the flap. Three or four lazy loops are passed from the lower eyelid, across the pedicle just above the bony orbital rim, and exiting on the upper cheek (Fig. 19-5). These loops form a ‘cage’ that keeps the pedicle in position during the early healing phase. The sutures are removed at three to five days.

Figure 19-5 A&B, 3–4 externalized loops are utilized to maintain the fat pedicle in position as an externalized ‘cage,’ or alternatively 3–4 individualized pull-out mattress sutures can be used.

Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

Discussion

Periorbital hollows appear with age, and must be appropriately diagnosed and treated in order to optimally rejuvenate the lower eyelid and midface. The concept of filling the inferior orbital rim trough using alloplastic implants or fat is not new.^2–9 The transconjunctival approach can be utilized to place an alloplastic implant, reposition fat, and perform a midface lift. The advantages of this approach include a decreased risk of lower eyelid retraction (since the orbital septum is not violated) and the absence of a cutaneous scar.¹⁰

In the past, the arcus marginalis release was often performed in a supraperiosteal suborbicularis plane. It was believed that this may lead to a more natural contour and perhaps a better blood supply.¹⁰ However, the supraperiosteal plane is more vascular, and bleeding from branches of the angular artery is often a problem. In contrast, the subperiosteal plane is an easier dissection plane and is essentially avascular, therefore, minimal or no bleeding is encountered. Blood supply does not seem to be a problem although in either plane, the fat pedicle probably has some degree of ischemia and variable absorption can occur. The margins of the subperiosteal pocket have a natural tapering shape due to the periosteal attachment to bone. Therefore, the subperiosteal plane provides a natural contour to the fat and may decrease the chance that the borders of the fat pedicle will create a visible demarcation.

Complications are generally similar to complications of traditional transconjunctival blepharoplasty. The most worrisome potential complication is double vision.¹¹ The orbital motility system is complex, and subtle perturbations caused by mechanical disruption or scar tissue formation can result in restriction of ocular motility and double vision. It may not be possible to completely avoid this complication, but gentle dissection, judicious use of cautery, and careful checking of globe rotation after the pedicles are transposed, may decrease the incidence of postoperative diplopia. Lower eyelid retraction is another potential competition of fat repositioning; careful dissection at the arcus marginalis, to minimize risk of injury to the orbicularis or orbital septum, may decrease the risk of lower eyelid retraction.

Options to fill the periorbital hollows include free autogenous grafts such as fat, synthetic injectable fillers, and orbital fat repositioning. When adequate orbital fat is available for transposition, the technique of fat repositioning provides a subtle but long lasting change in the contour of the lower eyelid. It is not as powerful as an alloplastic implant such as the Flowers tear-trough implant,² but has the advantage of vascularized autogenous tissue. Due to the additional dissection required to create the subperiosteal pocket, there is a longer period of postoperative edema compared to the more limited dissection of standard fat removal lower blepharoplasty. In addition, some patients may experience hardening of the fat pedicle during the first three postoperative months. This may represent a combination of postsurgical fibrosis and some degree of liponecrosis and lipogranuloma formation. This usually resolves by six months. The survival and persistence of the transposed fat is variable (Figs 19-6 to 19-8), however, almost all patients experience a long-term improvement in contour.

Figure 19-6 Example of moderate to good survival of transposed fat at 6 months. A, Preoperative view. B, Postoperative 6 months, demonstrating smooth filling of the nasojugal groove.

Figure 19-7 Example of moderate survival of transposed fat at 8 months. A, Preoperative view. B, Postoperative 8 months.

Figure 19-8 Example of minimal fat survival. A, Preoperative view. B, Minimal survival of fat at 3 months postoperative.