17.1 Patient History Leading to the Specific Problem

The patient is a 60-year-old white woman who underwent bilateral upper eyelid blepharoplasty 2 years ago (Fig. 17-1). She presented requesting more skin removal for a “tighter” upper eyelid.

17.2 Anatomical Analysis of the Patient’s Current Condition

The patient demonstrates asymmetric hollowness of the upper eyelid (A-frame deformity). The most common cause is overresection of the central fat pad and orbicularis muscle during her initial blepharoplasty. The patient’s request was initially to remove more skin to obtain a tighter upper eye lid. In this case, removal of more tissues will lead to worsening of the deformity. The condition could be remedied with addition of tissues to the upper lid. Options for reconstruction include injectable fillers, dermis fat graft, or fat graft. Fat grafting was recommended to her as the best option. The volume of fat needed will vary per side due to the existing asymmetry.

17.3 Recommended Solution to the Problem

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  Asymmetric fat injection to the upper lid (right more than left).

17.4 Technique

The procedure could be done under local or general anesthesia. In this case, the patient was undergoing additional procedures, so it was performed under general anesthesia.

Local anesthesia is injected along the superior orbital margins, 1 to 1.5 mL on each side. Preoperative pictures are used as a guide during the injection. The operative plan is to inject 2 mL on the right and 1.5 mL on the left side. In the preoperative consult, saline with lidocaine could be used to demonstrate the effect of the injection to the patient.

The fat is harvested from the abdominal area after infiltration of tumescent fluid (500 mL of saline, 50 mL of lidocaine, 0.5 mL of epinephrine 1:1,000). Only 250 mL were infiltrated in the abdominal area. The fluid was allowed to settle for 20 minutes before harvesting. The harvesting was done using the Tulip system (2-mm cannula) (Fig. 17-2). The fat was allowed to settle for separation of the fluid component; this portion is discarded before the injection. Transfer the fat between two syringes to allow a homogeneous filler to be obtained and to avoid lumps (microfat grafting). Centrifuge, PureGraft, or any other method could be used as a way to prepare the fat for injection depending on the surgeon’s practice.

A 0.9-mm blunt Tulip fat grafting cannula is used for periorbital injection. The skin puncture is done using an 18-G needle to avoid any incisions. The injection is done along the superior orbital margin (Fig. 17-3). It is aimed above the septum to minimize complications. It is done using the right hand in a retrograde manner to avoid injection into a blood vessel. The left hand is used to blend the fat along the undersurface of the bony orbit. A slight overcorrection is aimed for without creating any irregularities, which could be difficult to correct. Injection directly into the eyelid skin should be avoided and will lead to postinjection bumps (Fig. 17-4).