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Periocular reflation creates better facial rejuvenating effect
Addressing periocular deflation can avoid pitfalls of fat removal or repositioning.
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I would like to share some thoughts straight from the fall meeting of the American Society of Ophthalmic Plastic and Reconstructive Surgery, where the buzz in oculoplastics was on periocular reflation.
 Julian D. Perry |
Just as a review, earlier concepts regarding rejuvenation of the aging face mainly dealt with tissue laxity — what we used to call prolapsed fat of the orbital septum. The idea was to remove this fat, or extra tissue, through blepharoplasty. It was all about tissue removal. And so we would remove fat and a little bit of skin anteriorly.
Yet removal of tissue did not address tissue descent, and I would argue that patients who have had a lot of this prolapsed fat removed still look aged and do not really look rejuvenated. This is because blepharoplasty does not address brow descent, cheek descent of other gravitational changes.
Newer concepts sought to address these gravitational changes and included cheek lifting and brow lifting techniques. These surgeries address the gravitational changes of the structures adjacent to the eyelids. However, they do not address a major component of the aging eyelid: tissue deflation. The latest concept in periocular rejuvenation centers on the idea of tissue deflation. We see this in many of our aging patients, those with hollow upper eyelids, hollow lateral brows and hollow areas at the lower eyelid-cheek junction. A new concept involves addressing this periocular deflation.
Fat repositioning
Fat repositioning was developed several years ago to address cheek descent and deflation at the lower eyelid-cheek junction. These techniques involve creation of a pedicle of flap of “blepharoplasty fat” and advancing it into the periorbital hollow.
Implants are another option; placement of various alloplast implants can augment this area of tissue paucity between the deflated lower eyelid and the descended cheek. These techniques certainly have a place in periocular rejuvenation, but they involve downtime, are technically challenging and have some significant risks.
So the surgeon can address tissue laxity, redundant tissues and gravitational changes, but the patient can still look aged because of deflation.
When you really examine this photograph (Figure), what really shows signs of aging? It is the area of hollowness with the cheek descent and deflation of the superior tissues. The lower eyelid itself actually does not really look hollow. It is really the tissues underneath the eyelid. So the new concept is not one of tissue removal, as it is one of tissue reflation.
At the ASOPRS meeting, there were a few studies that centered around this buzz. Nancy Tucker, MD, of Toronto looked at performing lower blepharoplasty in conjunction with fat re-injection. Again, this avoids some of the morbidity associated with fat repositioning, which was en vogue a couple of years ago.
Dr. Tucker looked at 30 patients undergoing lower blepharoplasty. She performed standard blepharoplasty to remove some of the excess fatty tissues. But then she re-injected fatty tissues into the periorbital hollow region, also called the teardrop region, to address both contours.
Once the fat is removed, it is then processed in a variety of ways: It can be centrifuged and placed in syringes, it can be placed using a blunt cannula, or it can be placed using a 25-gauge syringe.
The idea is to remove the fat in the area of redundancy and replace it in the area of deflation.
There are variations regarding re-inflation of the periorbital hollows. We can inject fat. We can harvest it from the abdomen. We can harvest it from excess tissues from upper blepharoplasty, lower blepharoplasty and brow lift. And without performing blepharoplasty, we can simply re-inject some of these areas along the periorbital hollow.
Again, we can use hyaluronic acid products such as Restylane (Medicis) or Juvederm (Allergan) to perform re-inflation of this area without blepharoplasty. For patients who are concerned about aged appearance in the lower eyelids but who do not require blepharoplasty, simply re-inflating some of these areas may be the best treatment.
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Image: Perry JD |
Re-inflation of temporal brow area
There were a few papers from ASOPRS on performing re-inflation of the temporal brow area. This has actually made me critically reassess patients preoperatively to look at this area, not as one of excess tissue, but actually one of deflated tissue.
David E. Holck, MD, Jill A. Foster, MD, and colleagues described how they performed a brow lift, either open or endoscopic, and they used some excised scalp tissue. They removed the upper layers of the epidermis and used dermis fat grafts to allow for re-inflation of the lateral brow.
John P. Fezza, MD, did a similar procedure, again using superficial musculoaponeurotic system (SMAS) tissues, either from facelifts or from the temporal region, and placing these SMAS grafts in the glabella musculature and orbital rim.
One of the problems with removing a lot of the glabella musculature during a brow lift is that it separates the brows, and it also causes a little hollow indentation in the area of the glabella. Patients may require less Botox (botulinum toxin type A, Allergan) after this type of treatment, but it has some downsides.
In using some SMAS tissues to fill in deflated areas, Dr. Fezza spaced the material so as to prevent the glabella musculature from reforming. Volume augmentation can actually help defy gravity and act as a pillar holding a roof to contribute to a longer-lasting brow lift. It has a take rate of about 60% or 80%.
With this technique, I have been using Restylane to act as a pillar on the lower lids as well. In some patients who come in with a classic post-blepharoplasty lid retraction, where we would typically perform a cheek lift, I have found that by injecting Restylane in the lower lids we can improve the contour of the hollowed area. It also acts as a pillar to lift up the lower eyelid.
Again, just as with the lower lid and tear trough area, we can perform fat injection without doing a brow lift, without blepharoplasty, in order to rejuvenate this area.
Deflation of bony tissues
Not only are we now talking about deflation of the soft tissues, we are also talking about deflation of bone. The bony tissues actually undergo changes that may allow for better rejuvenating procedures.
Carrie Morris, MD, and colleagues looked at 100 three-dimensional CT scans of the aging face. They found a few important things that I believe might help us address rejuvenation surgery in a new, different way.
They found that the forehead actually rotates forward and down with age, while the cheek rotates up and posteriorly. This contributes to more acute angles in the face. By understanding this, we may be able to address these aging changes with either soft tissue or bony approaches.
In summary, the new buzz word in oculoplastics over the last few months has been, not just tissue laxity and gravitational changes with cheek lift and brow lift, but volume deflation and how addressing this may help us affect rejuvenation changes of the aging face.
For more information:
- Julian D. Perry, MD, can be reached at Cole Eye Institute, Department of Ophthalmic and Plastic Orbital Surgery, 9500 Euclid Ave., Dept. I-20, Cleveland, OH 44195; 216-444-3635; e-mail: perryj1@ccf.org. Dr. Perry has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.