Adipose compartments of the upper eyelid: anatomy applied to blepharoplasty

Many authors have indicated the presence of ectopic or accessory upper eyelid fat pads, but the effective rate of eyelid fat variations and the corresponding clinical features are still unclear. The purpose of this study was to evaluate the variability of upper lid fat and to define the anatomical landmarks of the adipose pockets of the upper lid. From January of 1998 to January of 2002, the authors investigated the upper eyelid fat compartments of 47 patients who underwent upper blepharoplasty. To support surgical findings, 11 fresh cadavers were also investigated; the anatomy of the intraorbital fat and of the upper eyelid fat compartments was reviewed. Ten patients (21.3 percent) showed an accessory fat pad in the upper lid, which was found on both sides in nine cases. In all patients, the third fat pad was situated lateral to the two classic compartments described by Castanares, behind the orbital septum. Surgical dissections demonstrated that this fat pad derived from the preaponeurotic fat. Anatomical dissections in three cadavers demonstrated an accessory fat compartment protruding under the inferior border of the lacrimal gland. This protruding fat derived from the preaponeurotic fat in all cases and might justify the clinical appearance of a bulge or fullness in the lateral third of the upper eyelid. In the authors' experience, the presence of an accessory upper eyelid fat pad was a frequent finding during blepharoplasty; it could be found and actually resected in about 21 percent of all cases. Surgical and experimental findings put this element as a lateral physiological extension of the preaponeurotic fat that can anteriorly protrude under the inferior border of the lacrimal gland toward the orbital septum. The clinical appearance may be a bulge or fullness in the upper eyelid, and its resection can better define the lateral one third of the supratarsal fold.     

Reconstruction of both eyelids following electrical burn

A case of severe electrical burn of the unilateral upper and lower eyelids is reported, together with the surgical technique of reconstruction. A 25-year-old man suffered an electrical burn on his left eyelids. On admission, his left upper and lower eyelids were subtotally necrotic. Total eyelid reconstruction was performed 2 1/2 months later. A chondromucosal graft taken from the nasal septum was utilized as the deep layer of the upper eyelid, which was covered by sliding down the remaining levator muscle and connective tissues to maintain the blood supply to the composite graft. The outer layer of the upper lid was reconstructed with a free split-thickness skin graft. The lower lid was reconstructed with a local flap lined with a free mucosal graft. This sandwich method using the levator muscle as a core was found useful for reconstructing both the upper and lower eyelids.     

Surgical treatment of thyrotoxic exophthalmos

Conservative treatment of thyrotoxic exophthalmos has not given satisfactory results. Our observations, modifications of the standard surgical technique, and the results of orbital decompression for this condition are presented. Through a transverse incision close to the lower eyelid margin, the floor and the lateral orbital wall are explored. The posterior part of the orbital floor and the zygomatic part of the lateral orbital wall, as well as the periorbital fat, are removed. Through an incision made over the medial margin of the orbit, the medial orbital wall is explored and its ethmoidal part is removed. By the same approach, further retrobulbar fat is removed. Through an upper eyelid incision, fat is removed from the eyelid region and the levator aponeurosis is divided. This produces satisfactory symmetrical decompression of the orbit with good correction of exophthalmos and a significant decrease in the signs and symptoms of this condition.     

The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation

Resetting of the septum orbitale over the orbital rim, or "septal reset," is the latest step in achieving periorbital rejuvenation in composite rhytidectomy. The first significant step was the addition of orbicularis repositioning to conventional lateral vector deep plane rhytidectomy, followed by orbital fat preservation using the arcus marginalis release and fat transposition over the orbital rim. Those early procedures have been further refined to include the zygomaticus muscles with the orbicularis oculi in the composite flap, or zygorbicular cheek flap, and a septal reset. The septum orbitale reset has distinct advantages over transposition of orbital fat alone, as it creates a firmer undersurface for the lower eyelid. This maneuver will create a truly youthful lower eyelid-cheek complex, as the normal concave aging skeletonization of the periorbit is transformed to a convex contour of youth. The effectiveness of this operation can be demonstrated in most variations of human anatomy, whether congenital or iatrogenic, allowing the plastic surgeon to utilize the septal reset in virtually every patient undergoing and desiring a harmonious facial rejuvenation.     

Transblepharoplasty lower eyelid and midface rejuvenation: part I. Avoiding complications by utilizing lessons learned from the treatment of complications

Transblepharoplasty midface elevation has become a common aesthetic procedure in recent years. As new techniques have been utilized, complications have arisen. Management of these referred complications has resulted in the development of a technique that elevates the midface and restores the normal position and shape to the lower eyelid with minimal postoperative problems. Four principles must be followed to achieve satisfactory results. The orbicularis oculi/orbital septum bond must not be altered in midface surgery. The lateral canthus must be reattached to its normal anatomic location at the lateral orbital rim if there is lateral canthal tendon laxity. The orbital fat should be addressed via a transconjunctival approach, when necessary, to prevent middle lamella inflammation and orbital septum retraction. A suture at the inferior lateral orbital rim simulating the orbitomalar ligament, as well as orbicularis oculi muscle sutures, elevates the midface. Utilizing these steps, the midface and lower eyelid can be satisfactorily repositioned with minimal complications. This surgical approach can be utilized in all appropriate candidates but is especially useful in reoperative cosmetic surgery patients and the older patient population.     

Eyelids and eye socket reconstruction using the expanded forehead flap and scapha composite grafting.

After trauma or excision of malignant tumor, it is difficult to achieve satisfactory results when reconstructing deformed eyelids and the socket for an ocular prosthesis. The authors demonstrate examples of successful reconstruction for a prosthetic eye that provided adequate and aesthetic soft-tissue support achieved by applying a three-step surgical procedure of reconstruction of the eye socket, the eyelids, and the tarsus and eyelid margin. Because it is highly vascularized and its distal end can be divided into two or three portions for easy three-dimensional reconstruction, the expanded forehead flap alone, with a galea flap, or with a free rectus abdominis muscle perforator flap was used. The expanded forehead flap also provides excellent thin upper lid contour and good color-matching with a recipient site. For the eye socket, sufficient volume of tissue was provided from the expanded forehead flap with or without a galea or a free rectus abdominis muscle perforator flap, and a deep and convex fornix was formed. This resulted in a good fit and in stability of the ocular prosthesis. The surface and the inner lining of the eyelids were reconstructed using portions of the expanded forehead flap. For the tarsus and eyelid margin, conventional reconstruction techniques use cartilage of the concha, which has limitations of length and which does not fit the shape of the tarsal margin. The authors used the scapha composite graft, and a natural shape and good elasticity resulted.     

Conjunctival cul-de-sac reconstruction with radial forearm free flap in anophthalmic orbit syndrome

Contracted eye socket is a constant cosmetic embarrassment to the patient. It not only renders patients unable to maintain an eye prosthesis, but it becomes a source of chronic discharge and irritation. Eye socket reconstruction with free skin, mucous membrane, cartilage, or dermis-fat usually remains unsatisfactory in many cases, due to secondary graft contracture. Traumatic injuries to the orbit and neighboring soft tissue frequently lead to a contracted eye socket. This condition results from the need for removal of the traumatized conjunctiva at the time of the enucleation, along with the traumatized eyeball, for satisfactory wound closure. In traumatic anophthalmos patients, a radial forearm free flap was used for conjunctival cul-de-sac reconstruction. Eye socket beds were developed as hinge-shaped flaps and used as lining for the upper and lower palpebrae. The authors conclude that the radial forearm flap is a useful alternative in the treatment of traumatic anophthalmos.     

Revascularization determines volume retention and gene expression by fat grafts in mice

Autologous fat transplantation is a popular and useful technique in plastic and reconstructive surgery. The efficiency and survival of such grafts is predictable in many cases, but there are still issues to be resolved, such as how to improve graft volume retention. To address the issue of volume retention, we studied the effect of revascularization from the recipient on the size and function of adipocytes in fat grafts. Treatment of mice with TNP-470, an angiogenesis inhibitor, reduced blood flow from the recipient into the graft after subcutaneous transplantation of epididymal fat. The weight of transplanted tissues and the size of adipocytes in the grafts were significantly lower in mice treated with TNP-470 (TNP mice) than in control mice. Expression of genes for enzymes related to lipid accumulation was decreased in the grafts of TNP mice compared with control mice. Moreover, the expression of adipocyte-derived angiogenic peptides, VEGF and leptin, was significantly lower in the grafts of TNP mice than in grafts from control animals. The expression of VEGF and leptin by cultured human adipocytes was increased in the presence of conditioned medium from cultured vascular endothelial cells. These results show that the inhibition of the revascularization of fat grafts after transplantation reduces graft volume retention and cellular function. Early and adequate revascularization may be important for both the supply of nutrients and vasoactive interactions between vascular endothelial cells and adipocytes in graft.     

The bare area of the upper conjunctiva: a closer look at the anatomy of transconjunctival upper blepharoplasty

Transconjunctival upper blepharoplasty is a novel technique for which the overall experience has been limited. The authors have used this technique in 42 patients for eyelid rejuvenation, with predictable results and low morbidity. The authors previously described the "bare" area in the medial upper conjunctiva, which was initially noted during their clinical series. This area serves as an anatomic window to access the medial upper eyelid fat pad with a high degree of safety. To clarify the anatomy of this approach, an anatomic study of the upper medial eyelid was performed on the orbits of 10 cadavers (20 orbits). The bare area was further elucidated during these dissections and its microscopic components described in detail. Its spatial relationship to the medial orbital wall and trochlea was also examined during this study. The authors hope that these findings will aid surgeons planning to use this technique.     

Full-thickeness anterior blepharotomy and transpalpebral fat decompression in Graves' orbitopathy

A chief morbidity of Graves eye disease is eyelid retraction and exophthalmus. Transpalpebral orbital fat removal accomplished with full thickness anterior blepharotomy was performed in 4 patients (5 orbits). Preoperative and postoperative ocular exposure symptoms, visual acuity, upper eyelid retraction and proptosis were evaluated. In all 5 operated orbits preoperative symptoms resolved; good results were achieved from the functional and cosmetic point of view. Full-thickness anterior blepharotomy combined with fat decompression is a safe and effective surgery for patients with upper eyelid retraction and exophthalmus due to enlarged orbital fat compartment.     

Transcoronal blepharoplasty.

Some of the patients requesting blepharoplasty have a combination of excessive eyelid fat and brow ptosis but little or no dermatochalasis. Coronal brow lift, combined with transcoronal fat removal, serves these patients well. The prelevator fat pocket is easily entered from above by incising the periosteum of the anterior orbital roof just inside the orbital rim. Since the orbital septum and anterior lamella of the eyelid rim remain undisturbed, the result appears natural. Contraindications to the procedure include significant medical pocket fat and hair patterns that would exclude a coronal or hairline incision. Two complications, unilateral ptosis and unilateral chemosis, were temporary and totally reversible. Minor changes in the procedure have prevented the recurrence of these problems.     

Bioactivation of free-fat transfers: a potential new approach to improving graft survival.

A new approach to free-fat autotransplantation resorption was evaluated experimentally in a rat animal model. Bioactive fat grafts were created by the addition of basic fibroblast growth factor delivered by dextran beads to the grafts and compared with free fat alone, free fat plus beads, and free fat plus beads and a control solution in the same animal. The grafts were assessed by weight and histology at 1 and 12 months postoperatively in 40 animals. A graded response in weight retention was observed at 1 and 12 months, with the growth factor-treated grafts exhibiting near complete weight maintenance after 1 year. All other bead-containing grafts had an intermediate response, with free fat alone averaging more than one-half graft weight loss after 1 year. Histologically, the bead-containing grafts had good fibroblastic ingrowth, but extensive intercellular collagen formation and the occurrence of small-sized adipocytes among the larger adipocytes were seen only in the growth factor-treated grafts. These findings indicate that graft manipulations that affect the preadipocyte cells of the graft or fibroblastic components of the recipient site, either through polypeptide stimulation or surface charge attraction, may offer a viable approach to postoperative fat-graft volume maintenance.     

Reduction of lower palpebral bulge by plicating attenuated orbital septa: a technical modification in cosmetic blepharoplasty

Bulging of the lower eyelid is regarded as a sign of aging. "Herniation" of the periorbital fat pads is traditionally regarded as the factor responsible for the change. Excision of fat pads, therefore, has been the mainstay of treatment in reducing the palpebral bulge in cosmetic blepharoplasty. The surgical excision of"excess" and "herniated" fat pads, however, causes problems such as lid ecchymosis, chemosis, lid contour irregularity, ectropion, and retrobulbar hematoma formation. The author proposes that the loss of fat pad support caused by the attenuation of the orbital septa, not herniation of the excess fat pads, is the major factor responsible for the bulge. The author further proposes that the functional integrity of the orbital septum can be restored by plicating the attenuated orbital septa with 5-0 absorbable sutures. This technique of invaginating the protruded fat pad was performed in 138 individuals (276 lower eyelids). The operation was technically simple, and the approach was "tissue friendly." The results obtained, with the exception of a mild degree of puffiness encountered soon after the surgery, were satisfactory. Morbidity was minimal.     

Surgical management of the anophthalmic orbit, part 2: post-tumoral

Ablative surgery for tumors of the globe and its adnexal structures is frequently the cause of major orbitofacial deformity. Radiotherapy compounds the problem because it suppresses skeletal growth in the growing patient and induces a contraction of the remaining soft tissues in the orbit. Goals for reconstruction in these patients include the restoration of orbital structures to allow the fitting of an ocular prosthesis and the correction of distorted orbitofacial relationships. The authors present a series of 53 patients (mean age, 29 years; 28 male) who were treated over the past 18 years by composite reconstruction of the post-tumoral anophthalmic orbit. The follow-up ranged from 5 months to 18 years (mean, 7.75 years). Four patients were treated primarily (immediate reconstruction after tumor ablation), and 49 were treated secondarily (mean oncological follow-up since ablative surgery, 14.8 years). Twenty-eight patients underwent orbital enucleation (including three bilateral cases), 23 underwent orbital exenteration, and two underwent evisceration. Forty-two patients received radiotherapy, including 20 enucleation patients, 15 exenteration patients, and seven others in whom details of primary therapy were incomplete. A staged reconstruction was undertaken in each case; it considered, in turn, the bony orbital volume (orbital remodeling and cranial bone grafts), orbital contents (implant, temporalis muscle transposition, cranial bone grafts, and dermafat grafts), conjunctival sac (mucosal and skin grafts), ocular prosthesis, eyelids (local flaps and skin grafts), and additional procedures to restore orbitofacial symmetry. The authors conclude that the long-term results of post-tumoral orbital reconstruction are favorable, and they particularly recommend the use of autogenous tissues in irradiated orbits.     

Enhancing the take of injected adipose tissue by a simple method for concentrating fat cells

Injection of aspirated fat for the correction of tissue defects is a common procedure in plastic surgery. The reported rates of fat cell survival vary greatly in the medical literature, and different techniques of harvesting, processing, and reinjecting the fat cells are claimed to be responsible for these differences. However, there is no agreement concerning the best way to process the harvested fat before reinjection. The present study was initiated to examine and evaluate the effect of a simple method of isolating the fat particles on the outcome of fat graft survival. In this study, the nude mouse model was used to examine the survival and take of the fat graft concentrated before injection by the cumbersome recommended closed centrifugation technique in comparison with the authors' recommended open method, using an operating room cotton towel as a platform for concentrating the fat cells and separating them from fluids, oil, and debris. One milliliter of concentrated human fat cells preprocessed by towel separation was injected into the nuchal subcutis of 11 nude mice in the study group, and the same amount of fat that was preprocessed by centrifugation was injected into 11 control mice. Injected fat survived in both groups. No significant differences were found regarding fat graft weight and volume, although a tendency for better survival was noticed in the experimental group. Histologic evaluation of the grafts revealed significantly less fibrosis within the study group, meaning that the quality of the fat grafts was better. The authors found this method to be simple, cheap, and friendly to the surgeon in comparison with traditional processing using the centrifuge.     

Upper eyelid skin grafting: an effective treatment for lagophthalmos following blepharoplasty

Patients who have undergone upper blepharoplasty occasionally develop anterior lamellar insufficiency, which can result in lagophthalmos, corneal decompensation, and even blindness. Historically, skin grafts in the upper eyelid have been considered a last-resort procedure because of poor cosmetic outcomes. Poor cosmetic outcomes result from the traditional practice of placing the skin graft above the eyelid crease. This article describes a surgical technique for upper eyelid skin grafting in which the graft is placed in a supraciliary position. Presented are results of a retrospective study of 20 patients (31 eyelids) who underwent supraciliary upper eyelid skin grafting. The postoperative results were evaluated by examining the improvement in lagophthalmos, the improvement of keratopathy and comfort of the patient, and the cosmetic appearance of the graft. Upper eyelid skin grafting using this surgical technique is an effective and cosmetically acceptable method to improve corneal integrity and comfort in patients who have corneal exposure from insufficient anterior lamella after upper eyelid or eyebrow surgery.     

Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket

Rejuvenation of the lower eyelid complex is based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. When a deep groove is present along the orbital rim in the area of the tear trough deformity, it is advantageous, rather than removing orbital fat, to reposition the fat over the orbital rim through the opened arcus marginalis onto the superior face of the maxilla. Orbital fat repositioning can be accomplished through a transconjunctival approach. The arcus marginalis is exposed and incised, and a subperiosteal pocket is created over the superior face of the maxilla. The subperiosteal pocket shape and location are customized based on the desired location of the orbital fat pedicle; often the origins of the levator superioris labialis and the levator alae nasi muscles are partially dissected. Medial and central fat pedicles are created and rotated over the orbital rim into the subperiosteal pocket. A 6-0 polypropylene externalized sutured is used to fixate the fat pedicle in position. The suture can be removed after 3 to 5 days. Twenty-four patients were followed clinically after orbital fat repositioning, with follow-up ranging from 6 to 30 months. Although the fat pedicle undergoes some variable resorption, the viability of the graft, the texture and contour of the repositioned fat after a healing period of 1 to 2 months, and the excellent patient acceptance are indicative of the viability of orbital fat repositioning.     

Lymphedema of the eyelids

Lymphedema of the eyelids is a relatively rare condition whose main effect is to obstruct vision, and it is unsightly. We present 3 cases in which the edema was treated by excision and skin grafting of the eyelid, with satisfactory functional and cosmetic results. It is suggested that a split-skin graft be used for the upper eyelid and a full-thickenss graft for the lower eyelid. The lower eyelid skin can be "de-fatted" and used as a graft, but in the more severe cases we suggest a postauricular skin graft be used.     

Lip enhancement: surgical alternatives and histologic aspects

This study included 66 consecutive patients, 58 women and 8 men, who underwent 86 surgical procedures on the lips during 1989-1998. Lip enlargement was performed in 59 patients, and lip reduction was performed in 7 patients. Indications were purely aesthetic in 61 cases and reconstructive in 5 cases. The following surgical techniques were used for lip augmentation: implantation of crystal silicone, polyacrylamide hydrogel, Gore-Tex tubes, autologous fat, and dermis-fat graft. A new instrument originally designed by the author, the dermis-fat graft passer, significantly speeded up and facilitated execution of the latter procedure. Other operations included V-Y plasty, lip lifting by buffalo horn excision, lip lengthening by frenulum plasty, and lip reduction by wavy tangential excision. Eighty-six percent of patients could be followed up; the mean length of follow-up was 4.2 years. Use of silicone microparticles (Bioplastique) was abandoned because of the tendency for lumping. Polyacrylamide gel is promising because of its ease of use, and Gore-Tex tubes are promising because of their ability to create and accentuate the Cupid's bow form for the upper lip. However, these products are new, and follow-up studies with longer observation times are needed to reach definite conclusions. Of these studied methods, autologous fat transplant was found to be particularly useful for enlargement and restoration in cases of age-related atrophy of the lips and perioral tissues. Dermis-fat grafting was the most efficient, versatile, and reliable method of lip enlargement. Long-term survival of transplanted autologous tissues was confirmed by histologic studies of biopsy specimens.     

Apoptotic pathways in adipose tissue

To treat the ever growing number of obese patients, reduction of adipocyte number by apoptosis may complement other therapeutic options. On the other hand in free fat grafts, apoptosis along with necrosis is responsible for long term volume reduction. To ensure successful soft tissue reconstruction it is mandatory to keep apoptosis on a low level in adipocytes, adipose-derived stromal cells and others cells of the fat graft. Apoptotic pathways have been sufficiently studied in various tissues, but the knowledge about apoptotic pathways in adipocytes is surprisingly scarce. Current knowledge about apoptotic pathways in adipose tissue is elaborately reflected in this review as well as the association of cancer with obesity. Possibilities to induce and reduce adipose tissue apoptosis in animal models are discussed as well as clinical implications of fat cell apoptosis. Mechanisms of apoptosis induction have been studied in animal models and suggest that a tight control of apoptosis induction is necessary because otherwise detrimental metabolic effects of fat mass loss will occur that may mimic lipodystrophic diseases. At present, targeted induction of adipocyte apoptosis appears to be of some concern related to increased blood lipid concentrations, ectopic lipid storage and other detrimental metabolic effects. Treatment of autologous adipocytes used for lipofilling procedures with appropriate substances may result in more satisfactory long-term outcomes as well as stimulation of stem cell differentiation in a strictly local manner.