24.1 Introduction

Volume loss is one of the hallmarks of facial aging. It involves the eyelids and cheeks, in addition to changes in lid tone and skin, and accounts for the visible changes. Options for restoration of the volume include fillers, dermis fat grafts, and fat. Since most of the volume loss with age is secondary to fat loss, it is appropriate that autologous fat be grafted to replace this volume. Though fat atrophy occurs most commonly with advancing age, it can also be drug-induced, iatrogenic, or idiopathic. The periorbital hollows are very susceptible to this change and can become very apparent. Autologous fat transfer to these hollows is an important step in the process of periorbital rejuvenation. It can be performed in isolation or as an adjunct to lower lid blepharoplasty in patients with significant nasojugal grooves and tear troughs. Fat transfer alone will improve the nasojugal groove, the tear trough, and the skeletonization of the lid–cheek junction in patients with no excess skin and minimal or no eyelid bags. However, patients with excess skin and herniated fat pads are better candidates for a lower blepharoplasty. Besides acting as the ideal filler, autologous fat has other applications. Infiltration of fat into the lower lid can provide structural support, thereby correcting mild cases of scleral show. Patients with thin, wrinkled lower lid skin will also see an improvement in the quality of their skin after fat grafting. One of the concerns is that placement of the fat must be superficial, which makes the patient more susceptible to postoperative irregularities. Fat transfer can improve dark circles around the lower eyelids. This is achieved by adding volume to concave areas and producing smoother transition lines, thereby reducing eyelid shadows.

However, transfer of fat into the lower eyelid is not without complications. Even surgeons with vast experience in this area claim that the lower eyelid is one of the most difficult areas for fat grafting because of the possibility of irregularities and lumping of the fat. Even though there are guidelines to reduce the risk, postoperative irregularities are still the most common complication after fat grafting to the lower eyelids.

24.2 Patient History Leading to the Specific Problem

This patient presented for consultation after injections of excessive amounts of autologous fat into the lower periorbital area (Fig. 24-1). The injections were at all levels. In addition to the obvious overinjection of fat, she has lid retraction more noticeable on the right than the left. Given the unpredictability of the survival of the grafted fat, this is not an uncommon occurrence. In most patients, transconjunctival and transcutaneous fat removal have proven to be a relatively straightforward and effective procedure for correction of this problem. However, we have encountered patients in whom excessive fat infiltration into the orbicularis has proven challenging to remove.

In this patient, the transcutaneous approach was chosen so that her lid retraction and skin excess could also be addressed, along with removal of excess injected fat. The injected fat bears little resemblance to the periorbital fat and maintains the appearance and morphologic character of the area from which it was harvested (Fig. 24-2). Typically, the fat is whiter in color and very fibrous. In this patient, most of the offending fat was deep to the orbicularis and relatively easy to remove. In addition to the removal of the fat, the patient underwent a canthal reanchoring and subperiosteal midface lift Fig. 24.3.

As removal of the excess fat can be challenging, preventive measures should always be taken when transferring fat to the periorbital region to avoid postoperative irregularitiesFig. 24.4). These measures include the following:

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  Injection of small quantities of fat with every withdrawal (0.03–0.05 mL): In the rest of the face, 0.1 mL of fat with every withdrawal is accepted. Due to the thin skin of the lower lid, this amount of fat can leave visible lumps. To prevent this, half to one-third of this amount (0.03–0.05 mL) should be injected with every pass through the periorbital hollows.

  
  
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  Placement of the fat in a deep plane (suborbicularis, against the periosteum): The lower eyelid skin contains a very thin dermis and the subcutaneous compartment is practically inexistent. The only true protective layer against visible lumps is the orbicularis muscle. The placement of fat in the submuscular plane decreases the chances of postoperative irregularities.

  
  
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  Do not overcorrect: Since the lower periorbital area has very little movement, most of the fat that is transferred to this region survives. For the lower eyelids, 1 to 3 mL of fat is usually enough for each side.

  
  
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  If visible lumps are seen after infiltration, take immediate measures to correct this: If lumps are noticed immediately after infiltration, digital pressure is usually effective. However, fat should never be placed with the idea that pressure can change the lid shape after transfer. Big lumps that do not flatten easily might need liposuction.

  
  
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  For superficial injection, consider nanofat grafts, which consist of further processing, emulsification, and filtering of the lipoaspirate. These samples have low adipocyte viability but are rich in adipose-derived stem cells, which account for its positive effects on skin rejuvenation.