Discussion: Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty

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Drs. Miranda and Codner present their experience using free orbital pearl fat grafts to fill the tear trough hollow in conjunction with blepharoplasty. The article describes a retrospective data set, without a carefully measured outcome, and with a cohort of patients disadvantaged by lack of long-term follow-up. Two-dimensional frontal photographs, particularly if there is some inconsistency of lighting as noted in their Figure 5, are not the ideal tool with which to carefully assess changes in orbital rim volume. However, the series does represent the observation of a highly experienced practitioner.
There is wide consensus that filling the medial orbital hollow (“tear trough deformity”) is an appropriate aesthetic goal in patients whose periorbital surface anatomy is characterized by orbital hollowing. As the authors point out, a number of techniques have been used in pursuit of this goal, including alloplastic implants, injection of fat harvested by liposuction, injectable fillers, transposition of a vascularized pedicle of orbital fat, and free fat grafting. It is beyond the scope of their article, and of this Discussion, to review the relative advantages and disadvantages of these various techniques. Suffice it to say that each has its adherents and roles in individual patients.
I have personally had a 30-year experience with periorbital pearl fat grafting. Drs. Henry Baylis and Norman Shorr, influenced by Richard Ellenbogan1 and others, have made this a core part of the training program at the University of California, Los Angeles. We have seen similar good results from periorbital pearl fat grafting.2,3
However, pearl fat grafts are not without their limitations. In particular, and in common with any free graft anywhere in the body, they are vulnerable to necrosis related to incomplete vascularization. In the case of periorbital fat grafts, this leads to lipogranuloma formation. I have been unsuccessful in placing fat grafts in the periorbital region without occasional granuloma formation. I have also seen many such cases in consultation. Periorbital granulomas are not a trivial problem. For some reason, they seem to make patients unhappy out of proportion to the sometimes mild bump or firmness.
What is the optimal size of a fat graft to become adequately vascularized? Traditional teaching is that a 5-mm pearl fat graft can vascularize to the center and avoid any liponecrosis. In contrast, proponents of fat injection often note that the fat should be in tiny parcels, each surrounded by potential blood supply, to optimize survival. Many of us have watched injected fat globs that came out of the syringe too quickly turn into firm granulomas, and yet these “lumps” of fat are smaller than a pearl fat graft. Furthermore, the pearl fat grafts, as demonstrated in the accompanying video, are placed into the pocket in a way that they touch each other, forming a fairly confluent dollop of fat. This may have the effect of presenting for vascularization a volume larger than the 5-mm individual pearls.
The main alternative to excising the orbital fat and grafting it as pearl fat grafts is fat transposition on a vascular pedicle. Pedicles have the obvious advantage of carrying a blood supply (although the orbital fat flap that is created is a weakly vascularized random flap, and may not in fact be substantially more vascularized than a free fat graft). Free pearl fat grafts, in contrast, are technically easier to harvest, avoiding the orbital dissection that is required to create a pedicle. They can be flexibly distributed in any desired pattern. If there is inadequate orbital fat, the volume can be further augmented with fat from the superior orbit (if this is going to be excised) or even submental or abdominal fat.

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