Blepharoplasty with fat removal
Fat removal alone may allow some improvement in periorbital hollows. In particular, a full lateral fat pad can cause the "Charlie Brown" lateral orbital hollow, and debulking the fat can lessen the appearance (Figure 6). However, fat removal alone does not address the hollow itself.
Figure 6. The lateral "Charlie Brown" hollow forms between the lateral orbital fat pad and the adjacent malar fat. Upper: Debulking the puffy lateral fat pad with blepharoplasty will improve the contour, here combined with midface lift. Lower: another treatment option is to fill the hollow using a conservative, feathered pattern.
Blepharoplasty with fat transposition
The medial and central fat pads of the lower eyelid can be repositioned over the orbital rim. This effectively addresses the contour by reducing the fullness of the fat and simultaneously filling the adjacent tear trough and orbital rim hollow.
A transcutaneous approach has been described by Hamra (Plast Reconstr Surg 2004) and others, but is less often used by oculofacial specialists.
A transconjunctival approach allows the fat pads to be isolated and converted into pedicles. When creating the fat pedicles, the surgeon should find a balance between adequate release to disengage the pedicles from the orbital motility system and excessive release to preserve maximal blood supply to the pedicle.
The fat can be transposed into a subperiosteal plane (Goldberg, Plast Reconstr Surg 2000). The subperiosteal plane is easily dissected, relatively blood free, and provides maximal tissue coverage over the pedicle. Technical points include releasing the levator labii superioris, and preserving the infraorbital neurovascular bundle.
Alternatively the fat can be transposed into a submuscular (SOOF) plane. This plane can be more bloody and sometimes more difficult to define. The submuscular plane may have the advantage of releasing the orbital rim ligament, allowing the orbicularis to elevate and perhaps effacing the eyelid-cheek junction (Mohadjer OPRS 2006 and Yoo, JAMA Fac Plast Surg 2013).
Fixation of the pedicle can be accomplished with a buried suture (more difficult to place) or a suture externalized to the cheek skin (easier to place, but potentially annoying to the patient).
Filling periorbital hollows
Synthetic fillers are the workhorse for periorbital filling (Kane, Aesth Plast Surg 2005; Goldberg OPRS 2006; Goldberg, Aesth Surg J 2006; Lambros, Plast Reconstr Surg 2007; Berros, Plast Reconstr Surg 2013).
- Hyaluronic acid gels are well tolerated, relatively safe, and predictable.
- Calcium Hydroxyapatite fillers are trickier because they cannot be dissolved, the white material can show below thin skin, and lumps or contour problems are not easily treated.
- PLLA fillers are less predictable in the periorbital area and not commonly used.
- Permanent fillers have substantial risk and most experts recommend against their use.
The periorbital area is tricky for filling because the skin is thin and the 3-dimensional contours are complicated.
- If patients can avoid blood thinners such as aspirin for several weeks before the procedure, bruising may be lessened.
- Consent should include discussion of rare catastrophic risks including loss of vision or stroke.
- Although the actual risk is low, most practitioners will not administer fillers to pregnant patients.
- Strong topical anesthetics are useful to improve the comfort of the procedure: particularly for cosmetic treatments, patients should not experience pain. Handholding, distraction techniques, music, aromatherapy, and warm engagement by all staff are examples of measures that can improve the patient experience.
- Sterile preparation of the skin is appropriate because the filler represents an implanted device and there is a risk of biofilm formation. Options include alcohol, chlorhexidine, and betadine.
- Small volumes of filler (sometimes less than 0.5ml per side) and a careful, detailed, feathered pattern of filling are important (Figure 7).
- The filler should be placed deep to the orbicularis oculi muscle, adjacent to the bony rim.
- The practitioner and assistant should be alert to hematoma formation, which is addressed with immediate firm pressure over the bleeding vessel, held for at least 90 seconds, to reduce bruise formation.
- Some practitioners use a blunt cannula in order to reduce bruising and perhaps decrease the risk of intra-arterial injection.
- After the procedure, the patient can resume normal activities. It may be prudent to avoid heavy massage or pressing on the area for one week.
Figure 7. Patient before and after filling the periorbital hollows, 1ml Restylane split between the sides. Blue: orbital rim hollow. Purple: Zygomatic hollow.
Follow-up is generally in 3–6 months, although new patients may benefit from an early post-treatment visit to help with bonding and positive reinforcement.
- The hyaluronic acid gel fillers can last a long time in the periorbital area, sometimes even years. As the effect fades, patients are candidates for maintenance injections.
Periorbital fat injections
Periorbital fat injections are another option for filling. The thin skin of the periorbital region is prone to lumpiness and contour irregularities, which can be very difficult to treat. Therefore periorbital fat transfer should be performed with optimal surgical technique, and in patients who have some tolerance for complications. Technique is detailed in another article.