Correction of the Tear Trough and Baggy Deformity of the Lower Lid in Asians; Orbital Fat Graft and Septal Reinforcement by an Overlapping Technique

Correction of the tear trough and baggy deformity of the lower lid in Asians; orbital fat graft and septal reinforcement by an overlapping technique

Goals/Purpose:

Aging of the lower lid in Asians with a thick skin and durable SMAS is different from those of Caucasians. It starts from the medial to the lateral side and shows less descent of malar bags. Thus, their changes are mostly confined to the medial side of the imaginary line at lateral margin of pupil, and extensive aging changes of mid-face, including malar bags, are not common even in a person of advanced age.  

We report successful clinical outcomes of a both simple and low-risk method in correction of tear trough deformity and palpebral bags in Asians by removing fat, using the removed fat as a free graft, and overlapping the incised septal flaps for septal reinforcement.

Methods/Technique:

140 retrospective, noncomparative case series of 70 patients who have undergone lower blepharoplasty over the past 7 years from October, 2001 to September, 2008 were evaluated. Patients selected showed tear trough grooves and palpebral bags. The concept of our technique is to excise orbital fat, mainly of the medial and middle part and to place free grafts of the surgically excised orbital fat below the levator labii superioris alaeque nasi muscle. Such a replacement fills and softens the tear trough groove. Overlapping the incised septal flaps serves to reinforce the thinned and flaccid septum. Ends of the upper flap of the incised septum are sutured to the levator labii superioris alaeque nasi muscle in order to stabilize the grafted fat and to achieve a smoother surface. Redundant skin and orbicularis oculi muscle are then trimmed.

Results/Complications:

The overall results obtained were satisfactory without any major complications like ectropion, scleral show, etc. Recurrence of tear trough deformity due to grafted fat absorption was not noted during the 7 months of the follow-up period. However, postoperative hematoma developed in two cases but evacuated easily.

Conclusion:

The technique we have adopted will not only prevent the secondary palpebral bulge by a septal reinforcement by overlapping thinned and flaccid orbital septum, but also the secondary concavity over infraorbital rim by an augmentation using the intraoperatively obtained(excised) orbital fat. The authors conclude that the procedure is safe and effective in selected patients, especially in Asians with thick skin and fat bulges.

Fig. 1. Intraoperative findings of free fat graft and septal reinforcement. Transcutaneous approach and myocutaneous flap elevation at medial atrophic site. Dissection between levator labii superioris alaeque nasi muscle and periosteum and making pocket for graft and trimmed excised orbital fat. Free fat graft at the previously made pocket. Free grafted excised orbital fat(asterisk). Elevation of the incised septal flaps. Ends of the upper flap of the incised septum are sutured to the levator labii superioris alaeque nasi muscle(arrow). Ovelapping and reinforcing by mattress suture of both septal flaps.

Fig. 2. A 59-year-old female. Small amount of fat removal and skin resection, septal reinforcement extended to lateral side and free fat graft to nasojugal groove was done. (Left) Preoperative view. (Right) Postoperative view in 2 months.