Part III Periorbital Rejuvenation

Dino Elyassnia and Timothy Marten

Abstract

The hallmark of a youthful, attractive orbit is fullness. It has become clear that fat atrophy is a significant component of periorbital aging, which results in volume loss and a hollow appearance around the eyes. Traditional blepharoplasty procedures have focused on treating skin laxity, fat herniation, canthal laxity, and levator dehiscence but have largely ignored fat atrophy. This chapter will present a detailed approach to periorbital fat grafting, which represents a new paradigm in eyelid aesthetics. This approach produces a full, healthy appearance to the eyes that has not been possible with traditional blepharoplasty techniques.

Augmentation blepharoplasty – periorbital fat grafting – lower eyelid fat grafting – upper eyelid fat grafting – blepharoplasty – periorbital fat atrophy – periorbital rejuvenation

32 Periorbital Fat Grafting

Key Points

The hallmark of a youthful, attractive orbit is fullness.
It has become clear that fat atrophy is a significant component of periorbital aging, which results in a hollow appearance around the eyes.
Traditional blepharoplasty techniques have generally not addressed volume loss.
Periorbital fat grafting represents a new paradigm in eyelid aesthetics, which focuses on volumetric rejuvenation of the upper and lower eyelids (Fig. 32.1a, b).

32.1 Preoperative Steps

32.1.1 Analysis

A focused history should include any ophthalmologic conditions, previous blepharoplasties, or filler use.
As hyaluronic acid filler tends to last especially long in the upper and lower eyelids, knowledge of its use must be obtained so that a decision can be made whether to dissolve the material prior to fat grafting.
Physical examination of the eyelids should include looking for the presence of ptosis, dermatochalasis, lower eyelid fat herniation, canthal laxity, orbital vector, and degree of fat atrophy of the eyelids, midface, and cheek.
If problems other than fat atrophy are present such as significant lower eyelid fat herniation or excess skin, traditional blepharoplasty techniques may need to be combined with fat grafting.

**Fig. 32.1** **(a, b)** Patient with hollow upper and lower orbits before and after fat grafting to the upper and lower orbits (note: the patient also had fat grafting to the midface, cheek, and temple, along with a temple lift and facelift). (Procedure performed by Dino Elyassnia, MD, FACS.)

32.2 Operative Steps

See Video 32.1.

32.2.1 Fat Harvest

Our preferred areas for fat harvest include the waist, hip, and outer thigh, performed with a limited prep in the semilateral decubitus position (Fig. 32.2).
Areas from which fat is to be harvested are infiltrated with a dilute 0.1% lidocaine with 1:1,000,000 epinephrine solution using a multiholed infiltration cannula.
Approximately 1 cc of this solution is injected for every 3 cc of anticipated fat removal. Over-wetting the tissue will result in an over-dilute harvest and more time spent in the harvesting process.
Fat is harvested with a special harvesting cannula ranging in size from 2.1 to 2.4 mm and 15 to 25 cm long attached to a 10-cc syringe using gently applied syringe suction.
Sharp hypodermic needles should not be used to harvest fat.
At least twice as much fat is harvested as is anticipated to be used to insure an adequate amount of processed fat will be available.

**Fig. 32.2** Positioning patient for fat harvest in a semilateral decubitus position.

32.2.2 Processing Harvested Fat

Our preferred method of processing fat is centrifugation.
First, a sterile disposable plastic cap is placed on the end of the syringe and the syringe plunger removed from the syringe barrel.
Capped syringe barrels containing unprocessed fat are then spun for 1 to 3 minutes at 1,000 rpm.
Many centrifuges available for this purpose have rotors that can be sterilized or sterilizable tubes that fit into the rotor so that the syringes containing the fat remain sterile and can be handled by the scrubbed surgical team.
Once centrifuged, spun fat will be seen to contain an upper oil (ruptured fat cells), central fat, and lower “water” (blood, lidocaine) components.
The blood-tinged “water” (local anesthetic) component is allowed to run out after removing the cap while the oil fraction is then poured out of the top of the syringe. Telfa sponges can be used to wick up the small amount of residual oil present.
A laboratory “test tube” type rack to hold and organize the syringes containing fat greatly facilitates fat-processing activities.
The resultant fat is transferred into 1 cc Luer lock syringes using a transfer coupler.
The bottom 2 cc’s of fat in the syringe containing the highest concentrations of high-density adipocytes are segregated and are used preferentially in the procedure.