Introduction

1. JAMA Facial Plastic SurgeryJournal Club Slides:3-D Volume Assessment AfterFat Repositioning Lower Blepharoplasty Miller TR. Long-term 3-dimensional volume assessment after fat repositioning lower blepharoplasty. JAMA Facial Plast Surg. Published online February 4, 2016. doi:10.1001/jamafacial.2015.2184.

2. Introduction • Pseudo–fat herniation in the lower eyelid area is a common reason lower eyelid blepharoplasty is performed. • Surgical techniques that are commonly used to correct pseudo–fat herniation can typically be categorized as fat preservation or fat subtractive. • Fat repositioning lower blepharoplasty is a fat preservation technique that offers distinct advantages, namely effacing the tear trough by releasing the tethering orbicularis retaining ligament with the subsequent addition of volume to the tear trough and upper malar area.

3. Purpose • The purpose of this study was to determine the long-term volumetric effects that the lower blepharoplasty fat repositioning technique provides to the tear trough and deep fat compartments of the periorbital area and upper cheek.

4. Relevance to Clinical Practice • Pseudo–fat herniation in the lower eyelid area is a common reason for lower blepharoplasty because the condition can impart an unwanted tired or sad appearance. • Fat repositioning lower blepharoplasty offers distinct advantages, especially when recognizing the relationship between periorbital aging and periorbital and midface anatomy. • The fat repositioning technique involves the use of vascularized pedicles of orbital fat and repositions these fat pedicles within the adjacent prezygomatic and premaxillary spaces, which have been theorized to offer the best plane and areas for augmenting and rejuvenating the periorbital and malar areas. • Techniques based on removing orbital fat do not provide this benefit.

5. Description of Evidence • A retrospective electronic medical record review was performed to identify patients who underwent only primary lower blepharoplasty with fat repositioning. • Three-dimensional (3D) images were taken of patients the day of surgery and at least 10 months postoperatively (range, 10-16 months). • The area selected for volume analysis was based on the areas typically affected by fat repositioning lower blepharoplasty. • The area selected on the preoperative 3D image was then identically duplicated on the patient’s 3D postoperative image, and calculations of volume differences were performed. The average volume gain in the area of study was 0.64 mL.

6. Description of Evidence Preoperative Postoperative Three-dimensional untextured images preoperatively and postoperatively (12 months after fat repositioning). Results illustrate long-term volume augmentation of the tear trough and anterior cheek. Three-dimensional colorimetric analysis 12 months after fat repositioning. According to the corresponding scale on the left of the image, blue represents increased volume.

7. Description of Evidence A B C D Same patient as in previous slide.A, Preoperative 2D image. B, Postoperative result (12 months after fat repositioning). C, Black line outlining the preoperative facial contour of the patient. D, Black line emphasizing the postoperative contour change.

8. Controversies and Consensus • Recent cadaveric studies have shown that the face is divided into several discrete superficial and deep fat compartments. Changes in these fat compartments are responsible for many of the differences observed when comparing the aging and youthful face. • The deep fat compartments of the periorbital and upper midface areas consist of the deep medial fat and the medial and lateral suborbicularis fat compartments. • Surgical techniques that are commonly used to correct pseudo–fat herniation of the lower eyelids can typically be categorized as fat preservation or fat subtractive. The fat repositioning lower blepharoplasty is a fat preservation technique.

9. Controversies and Consensus • Fat repositioning lower blepharoplasty is a surgical technique that reduces the prominence of the lower eyelid fat pads (pseudo–fat herniation) while simultaneously effacing the tear trough and providing supplemental volume augmentation to the fat compartments of periorbital and upper cheek areas—the deep medial fat and medial and lateral suborbicularis fat compartments. • Fat subtractive techniques may address pseudo–fat herniation by removing fatty tissue, but these techniques do not address the other signs of periorbital and midface aging (eg, direct improvement, or “leveling” of the tear trough and volume augmentation of the deep fat compartments).

10. Controversies and Consensus • 3D imaging is increasing in popularity in plastic surgery and in scientific studies. • Comparing preoperative and postoperative 3D images entails many steps, including patient positioning, registering of landmarks, and computer mathematical models and calculations. • As a result, each step has the potential for measurement errors; future advancements in the expanding field of 3D imaging and analysis could reduce these errors.

11. Comment • The fat repositioning technique requires a more thorough grasp of anatomical knowledge, surgical proficiency, and operating time; however, the current study shows that the results can be aesthetically beneficial and long lasting. • It is difficult to determine how the increased volume after fat repositioning mathematically compares with the volume of injected free fat grafts or a hyaluronic acid filler. • The volume expansion by filler or fat transfer may not exhibit a 1:1 correlation to repositioned fat during lower blepharoplasty. Further studies are required.

12. Comment • Different techniques have been described for fat repositioning lower blepharoplasty. • Specifically, the author uses a subperiosteal plane but transitions from this plane at the level of the levator labii superioris muscle. Other surgeons may use a supraperiosteal plane. • Recent studies (not using 3D imaging) have shown no significant differences in aesthetic outcomes based on planes of dissection during fat repositioning lower blepharoplasty. • Future studies need to be performed using 3D imaging analysis to evaluate the volumetric effects when different planes of dissection are used.

13. Conclusions • The lower blepharoplasty fat repositioning technique is an effective procedure for improving lower eyelid pseudo–fat herniation while simultaneously improving the aging effects often seen in the periorbital and upper cheek areas. • The aesthetic improvement is explained by the release of ligaments and direct volume augmentation of specific areas that have recently been defined by anatomical studies.

14. Contact Information • If you have questions, please contact the corresponding author: • Timothy R. Miller, MD, Refreshed Aesthetic Surgery, 2 Journey, Ste 208, Aliso Viejo, CA 92656 (drtimothymiller@gmail.com). Conflict of Interest Disclosures • None reported.