25 Autogenous Tissue Augmentation: Lower Eyelid Malposition
Summary
Thorough zonal physical examination of the eyelids and contiguous periorbital areas with a seven-parameter sequence enhances successful management of autogenous tissue augmentation–related lower eyelid deformities. Computer-assisted composite photographic techniques aid in documentation, evaluation, and management of eyelid and periorbital deformities.
25.1 Patient History Leading to the Specific Lower Eyelid Problem
This 35-year-old man had a previous autogenous tissue injection 1 year earlier into both nasojugal interfaces for treatment of the “tear trough deformity” (Fig. 25-1a). Tissue was harvested from the abdomen by syringe suction after saline and lidocaine solution infiltration. Fatty tissue was obtained by gravity separation, and 2 mL was injected into the subcutaneous tissues of each nasojugal interface with a 1 mL syringe and 21-gauge needle. Over the last year, the patient developed a painful, tender, and firm 2 cm by 1 cm mass on the right nasojugal region (Fig. 25-1b).
He also complained of tearing and right eye “irritation.” He desired removal of the mass and alleviation of his discomfort. He was concerned about eyelid asymmetry, scars, lower eyelid malposition, corneal exposure, tearing, and impaired vision. He had no significant other medical issues. Brain, orbits, and paranasal computed tomographic radiography without contrast revealed “diffuse thickening of right inferior lid extending from the medial canthus region laterally. This is an infiltrative process, most likely inflammatory, please clinically correlate. The adjacent osseous structures and adjacent paranasal sinus cavities are clear”.
25.2 Anatomic Description of the Patient’s Current Status with Anatomical Analysis
This patient demonstrates one of the most problematic situations of a persistent mass in an area previously augmented with injected “filler” material (Fig. 25-1b). This is a complex problem and requires thoughtful evaluation. Documentation and prevention of lower eyelid malposition is essential.
The recommended methods for evaluation are as follows:
Computer-assisted composite photographs, which document symmetry, deformity, and severity (Fig. 25-2).
Zonal anatomical analysis, which defines the region of involvement (Fig. 25-3).
A seven-step physical examination, which predicts the level of involvement (Fig. 25-4).
Fig. 25.2 Computer-assisted composite photographic analysis. (a) Right composite image. (b) Image of patient 1 year postinjection. (c) Left composite image. Note: asymmetry of midfacial compartmental volume and right lower eyelid vertical displacement. Technique for creating composite photographic images for facial analysis: define the midline of the facial image of regard (¦a ¦); divide the face into halves; make copies of right and left halves; flip horizontally and then merge to created right composite (¦a¦) and left composite images ¦(c)¦. 
Fig. 25.3(a) Zonal analysis. Zone I, upper eyelid: normal; Zone II, lower eyelid: vertical displacement, mass; Zone III, medial canthus: elevated lid margin, mass; Zone IV, lateral canthus: normal; Zone V, periorbital: nasojugal, midface, cheek mass. (b) Photograph and anatomy overlay with mass outlined. (c) Anatomy overlay with mass outlined. 
Fig. 25.4 Seven-step physical examination analysis. Palpebral aperture asymmetry, mass in Zone II, III, and V, movement restriction of medial right lower eyelid, medial canthus and cheek.
25.2.1 Composite Photographic Analysis
Note the following:
Asymmetry of compartmental midfacial volume loss.
Right lower eyelid 1 mm higher than left lower eyelid.
Minimal lower eyelid skin excess or rhytides.
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