Fat Grafting in the Hollow Upper Eyelids and Volumetric Upper Blepharoplasty

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We read with great interest the article entitled “Fat Grafting in the Hollow Upper Eyelids and Volumetric Upper Blepharoplasty” by Ramil.1 In this study, the author first proposed a classification for the hollowness in the upper eyelids according to the cause and extension of the hollow. Volumetric upper blepharoplasty and/or fat grafting were then performed based on the classification. The presented techniques were proven to be effective methods for periorbital rejuvenation. Because periorbital rejuvenation is a subject about which we have thought a great deal and on which we have worked intensively, we would like to offer our own thoughts about the associated techniques. Moreover, because there are significant differences in anatomy and the patient’s desires and expectations between Westerners and Asians, cosmetic operations in Asians can be quite different from operations in Western patients. In this communication, we would like to share our experience.
The author defined the upper eyelid ratio as the ratio between the infrabrow and the pretarsal area, using the supratarsal sulcus, the uppermost crease, or the shadow under the superior orbital rim as the demarcation point. The preoperative and postoperative ratios were then compared to demonstrate the effectiveness of the technique. However, in our opinion, this measurement has many variables, and there is no reference to verify its reliability. Direct observation on the photographs may be more objective, and analysis with the help of three-dimensional scanning may be more accurate. Moreover, photographs with eyes closed are necessary for the analysis of the cosmetic outcomes because some drawbacks can only be detected under this condition.
Westerners have a more prominent supraorbital arch, and the distance between the eyebrow and the upper eyelid margin is usually quite close. Based on these features, the fat injection in the hollow upper eyelid should be performed with the aim of lowering the supraorbital rim and filling the upper orbital area to push the skin that has retracted up into the orbit down onto the preseptal eyelid. This procedure may less likely make the eyelid be uneven or swollen. However, in Asians, the projections of the supraorbital arch and eye are similar, and the eyebrow is usually some distance away from the eye. Lipoinjection in the hollow upper eyelid, which has the above characteristics, is a procedure of filling fat in the sunken region of the eyelid to push the deep-set skin up. This type of fat grafting is a procedure with very high technical difficulty. Irregularity, lumps, and pachynsis may occur if the fat is placed too superficially (subcutaneously and even submuscularly). Deep injection may cause ptosis of the upper eyelid because the grafted fat increases the weight of the eyelid and limits the motion of the levator palpebrae superioris.2 For these reasons, lipoinjection in Asian eyelids must strictly follow the principle of less rather than more.
Some modifications should be made when performing volumetric upper blepharoplasty on the hollow upper eyelids of Asians. Because of a lack of fascial attachments of the orbicularis oculi, levator aponeurosis, or orbital septum into the dermis, the orbicularis oculi muscle should be resected, rather than plicated, with the purpose of forming a definite upper eyelid crease. In addition, the orbital fat can still be released to some extent in some Asians with hollow eyelids. The released fat can be used to fill the hollow area during the blepharoplasty procedure. If the orbital fat is inadequate, fat grafting can be carefully and accurately performed through this open approach. Fat is primarily and mainly placed under the orbicularis oculi muscle. The degree of the relaxation of the orbital septum should be examined.

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