Palpebral Bags Research Articles

Féminisation du regard

Eye feminization embraces surgical and non-surgical aesthetic procedures used in order to feminize upper third of the face. Eye feminization is indicated for transwomen during facial gender affirming surgery, and also for aging women. During aging, volume of facial osseous and soft tissues is decreasing, the orbit is squeletonizing, with skin sagging, evolving in a more masculine appearance of the orbital area. Upper eye area analyze (forehead, temple, eyebrow, eyelid, external canthus) as lower eye area analyze (zygoma, dark circle, palpebral bags, eyelid skin) must be assessed in preferential order in order to maximize good post-therapeutic results. Procedures include bony surgery (frontoplasty, orbitoplasty), browlift, external canthoplasty, fat grafting, and also classic eyelid surgery or aesthetic medicine injections.

Anatomical Basis for the Lower Eyelid Rejuvenation.

The tear trough, hollow concavity of the lower eyelid, is one of the recognizable signs of facial aging. Anatomical description is essential in improving tear through deformity for facial rejuvenation. Fifty cadaver were microdissected. Fat pad types, fat herniation and the fibrous support system of lower lid were investigated. The areas of the fat compartments were compared using photogrammetry method and ImageJ software. Lower lids develop palpebral bags as a result of herniation of orbital fat against a weak orbital septum in all cases (%100). The attachment of the arcus marginalis at the orbital edge is a large contributor to the middle-aged appearance of the midface in all cases (100%). The most common type is Type 1 (36%). In this type, three distinct fat pads were diverged by arcuate expansion at lateral, fascia of the inferior oblique muscle at medial, as central, medial and lateral. Type 2 specimens (20%) were observed with two fat pads. Double convexity contour is in Type 3 cases (%44). It is determined that the medial fat pads are located in larger areas. Also, herniation is particularly evident in the medial and mediocentral fat pads. Analysis of the lower lid morphology enables surgeons to apply safe and effective procedures. The inferior oblique muscle and arcuate expansion structures should be supported and not be damaged during surgical interventions. Surgeons should focus mainly on the anatomical data obtained, and in this sense, surgeons apply them during aesthetic and reconstructive procedures of the lower eyelids. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide.

Background Currently, botulinum toxin (BoNT) injections are the most commonly performed non-invasive procedure for rejuvenation on the upper face. The therapeutic use of botulinum toxin has generally been safe and well tolerated. Adverse effects are considered mild, transient, and self-limited. However, as with all other injectable procedures, this one is also susceptible to adverse events and complications. When the safety zones are respected, the chance of any of these complications is practically null.Thus, this review aims to describe the main complications of treatment with BoNT on the upper face and to present a practical guide based on current evidence on how to avoid them.Methods The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles.Results The main complications secondary to BoNT injections on the upper face are: ptosis of eyelid or eyebrow, eyebrow asymmetry, diplopia, Lakeophthalmos, Palpebral ectropion, and prominence of the palpebral bags. To avoid such complications, it is necessary to have knowledge of the anatomy of this region and adequate and individualized planning based on the existing patterns of the frontalis muscle, glabella, and crow's feet. This review presents the specificities of each of these regions and practical suggestions to obtain satisfactory results, avoiding complications.Conclusion Particularly on the upper face treatment with BoNT offers predictable results, has few adverse effects, and is associated with high patient satisfaction. However, it is suggested that the commented parameters and safety areas be incorporated into daily practice so that the possibilities of complications are minimized as much as possible.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Optimizing harvesting for facial lipografting with a new photochemical stimulation concept: One STEP technique™

Facial fat grafting for rejuvenation is one of the most popular facial aesthetic procedures in plastic surgery. It is always challenging and since there are a lot of techniques for adipose tissue (AT) harvesting, there are no standard procedures that guarantee natural and long-lasting results. We developed the selective tissue engineering photo stimulation technique (One STEP™) in which we used a novel infrared 1210-nm wavelength laser diode for fat preserved harvesting and direct fat injection that we named PicoGraft™, with no fat manipulation. This is a retrospective descriptive study in which we included all senior author’s patients that got facial fat grafting using the One STEP™ technique. We compared the AT aspirated, after laser emission (STEP-PicoGraft) and the standard assisted liposuction samples (SAL) in cultures. We study the mitochondrial activity of the ASC between STEP and SAL in fresh samples and after 24 h. The evaluation of the results included subjective changes regarding wrinkles, grooves, palpebral bags, hyperchromic spots, and fat hypotrophy of our patients. Between July 2013 and May 2018, a total of 245 patients underwent facial fat grafting using this novel technique. We observed adipocytes preserved after STEP harvesting comparing morphologic changes in SAL samples with a high concentration of inflammatory particles in cultures. ASC mitochondrial activity shows an important difference of more than 7 times in STEP samples in fresh analysis that increase 12 times in 24 h. The subjective results show a good improvement in the periorbital area. The changes on the skin and subcutaneous tissue are seen from the second month and continue to improve up to 12 months. Facial fat grafting using the PicoGraft™ obtained by One STEP™ technique gives excellent volumetric and regenerative results in a single treatment without volumetric hypercorrection, and it is a good alternative for facial rejuvenation. The fat graft obtained with this novel technique is homogenous, without lumps, and has high concentration of viable stimulated ADSC and a high number of viable adipocytes. Level of evidence: Level III, therapeutic study.

The troublesome triad: festoons, malar mounds, and palpebral bags

The troublesome triad: festoons, malar mounds, and palpebral bags

Clinical analysis and classification of dark eye circle

Dark eye circle (DEC) is a common problem that usually lacks detailed classification in the etiology and structural variations. A newly-developed DEC Assessment Score using Wood's lamp and ultrasonogram will provide a more precise evaluation of DEC for improving treatment results. Sixty-five cases, including eight males and 57 females with a mean age of 38.9 years, were enrolled. DEC were classified into pigmented (brown), vascular (blue to purple), structural, and mixed type by Wood's lamp and ultrasonogram. A scoring system with nine parameters, including brown hue, pigmented lesions, blue/pink/purple hue, periorbital puffiness, shadow hue, infraorbital palpebral bags, infraorbital grooves, blepharoptosis, and skin type, was used for clinical evaluation. Pigmented, vascular, structural, and mixed types of DEC represented 5%, 14%, 3%, and 78%, respectively. Thirty-three cases with periorbital puffiness were found to have higher "pre-septal thickness" than those of 20 controlled cases (P = 0.032). Fourteen patients with infraorbital palpebral bags were proved to have protruded retroseptal fat pads by ultrasonography. Pigmentation and vascular and structural components may play important roles in DEC. Detailed classification of DEC types will access physicians in the decision of appropriate therapeutic modalities.

Vertical Subperiosteal Mid-face-lift for Treatment of Malar Festoons

BackgroundMalar mounds may be accentuated by chronic lid edema, with the development from malar edema to malar mounds and finally to malar festoons. Because standard techniques do not seem effective and not specifically proposed for the treatment of malar festoons, subperiosteal vertical upper-midface lift associated with lower blepharoplasty overcomes these shortcomings.MethodsTwelve patients (3 males and 9 females, age = 47 ± 6 years) underwent video-assisted endoscopic subperiosteal vertical upper-midface lift (SUM-lift) in conjunction with a lower blepharoplasty between 2006 and 2007 for treatment of malar festoons. This includes simultaneous lower blepharoplasties and video-assisted transtemporal subperiosteal and sub-SMAS tissue release.ResultsAll patients healed uneventfully without any major postoperative problems. The surgical outcome was evaluated according to the analysis of photographs obtained before and after surgery and the analysis of pre- and postoperative measurements. The technique we used (SUM-lift) achieved a significant rejuvenation of the midface and the malar festoons.ConclusionSubperiosteal vertical midface lift resuspends and redrapes the facial network that originates at the level of the orbital rim. It seems to improve the permeability characteristics of the malar septum in the treatment of malar festoons and malar mounds by freeing the cheek tissue from underlying bone and redraping the malar septum. It is a reliable technique to improve malar mounds, palpebral bags, or festoons.

Transconjunctival Lower Blepharoplasty for Chinese Patients Combined With a Subciliary Incision for Skin Removal

With socioeconomic standards and life spans increasing, lower blepharoplasty is becoming one of the most popularly performed rejuvenation operations in China. Classic lower blepharoplasty includes transconjunctival and transcutaneous procedures. These procedures have been the primary solution to the common problem of palpebral bags. However, many plastic surgeons have ignored the shortcomings of the postoperative results for these surgical techniques. The lower blepharoplasty is fraught with both functional and aesthetic complications such as eyelid malpositioning, dry eye, ocular irritation, blurred vision, tearing, and poor aesthetic outcome [1, 2]. A less than excellent surgical appearance after lower blepharoplasty has resulted from a faulty operative design. Before the operation, the plastic surgeon must perform a comprehensive analysis of the patient and choose the proper rejuvenation procedure to obtain a satisfactory aesthetic result. The traditional (transcutaneous) approach to lower eyelid blepharoplasty involves excision of varied amounts of skin, muscle, and fat. This subtractive form of surgery typically is performed through a cutaneous subciliary incision with violation of several tissue planes (orbicularis muscle and orbital septum), which potentially promotes postoperative complications such as lower eyelid retraction or ectropion. The advantages of the transconjunctival procedure include the integrity and innervation of the orbicularis oculi muscle being maintained. The probability of postoperative lower eyelid retraction or ectropion is decreased [3, 4]. In contrast, excess skin and muscle and periorbital rhytides cannot be treated with transconjunctival surgery. In recent years, we have used lower lid blepharoplasty, a bilamellar surgery that addresses lower eyelid fat through a transconjunctival incision and excess skin through a subciliary skin flap alone. From January 2006 to June 2008, 80 lids in 40 patients were subjected to this operation. Most of the patients were women, and the average patient age was 53.5 years. The primary indications for the procedure are as follows:

Clinical classification and surgical management of palpebral bags

Objective To investigate the classification and surgical management of patients with palpebral bags. Methods A total of 200 cases with palpebral bags who underwent surgical treatment between May 2003 to August 2008 were retrospectively analyzed. The palpebral bags were classified according to skin flaccidness, bulging of excessive orbital septum fat and tarsus relaxation. The postoperative cosmetic results were also assessed. Results Of the 200 treated cases, the postoperative cosmetic results were assessed as very satisfactory in 178 (89 % ) cases, as satisfactory in 18 (9 % ) cases, and as dissatisfactory in4 (2 % ) cases. Conclusion Patients with palpebral bags should be treated with different surgical methods according to their different types. Key words: Palpebral bags; Classification

Lower Blepharoplasty with Capsulopalpebral Fascia Hernia Repair for Palpebral Bags: A Long-Term Prospective Study

In December of 1998, the authors published a prospective study in Plastic and Reconstructive Surgery (102: 2459, 1998) comparing standard lower blepharoplasty with lipectomy on one side and fat-preserving capsulopalpebral fascia hernia repair on the contralateral side; comparable aesthetic outcomes were demonstrated after 6 months of follow-up. In the present study, the authors report their findings on the original patient cohort with an average follow-up of 11.3 years. From 1991 to 2007, 26 patients were identified who had previously undergone lower blepharoplasty for palpebral bags, using fat removal on one side and fat preservation on the contralateral side. These patients were evaluated, and the incidence and locations of palpebral bag recurrence, lower lid hollowing, lid malposition, and eyelid dysmobility were documented. The overall recurrence rate of palpebral bags under the eyes following standard fat resection (30.8 percent) was significantly higher than for eyes following capsulopalpebral fascia hernia repair (7.7 percent) (p = 0.043). Recurrences of fat herniation, of generally less significance than the original preoperative status, were not found in any of the lower eyelid compartments in the former group, and only in the lateral compartment in the latter. At long-term follow-up, fat-preserving capsulopalpebral fascia repair for palpebral bags demonstrates superiority to standard blepharoplasty with lipectomy, with significantly lower recurrence of palpebral bags. In a small percentage of patients undergoing capsulopalpebral fascia hernia repair, limited fat resection in selected patients may eliminate hernia recurrence.

Correction of the Naso-Jugal Groove

We propose several solutions for improving deep naso-jugal grooves, starting from fat grafting, continuing with the rotation of the adipose palpebral bags themselves, to be used as flaps (Loeb's technique), proceeding with Flowers' implants and ending with the mid face lift. It is a sequential approach, thanks to which one can find the correct treatment for the various cases. Examples will be illustrated of the different procedures involved.

Lower eyelid hernia repair for palpebral bags: A comparative study: Parsa DF, Miyashiro MJ, Elahi E, et al. Plast Reconstr Surg 102:2459, 1998

Lower eyelid hernia repair for palpebral bags: A comparative study: Parsa DF, Miyashiro MJ, Elahi E, et al. Plast Reconstr Surg 102:2459, 1998

Lower eyelid hernia repair for palpebral bags: a comparative study.

The standard treatment for herniated "bags" of the lower eyelid is surgical removal of excess fat. Sachs and Bosniak in 1986 and de la Plaza and Arroyo in 1988 described a new technique for treatment of palpebral bags that consisted of returning the herniated fat to the orbital cavity and retaining it by continuous sutures of the capsulopalpebral fascia either to the dehiscent portion of the orbital septum or to the periosteum of the lower orbital rim. This article reports a prospective study of 26 patients who underwent standard blepharoplasty in one lower eyelid and capsulopalpebral fascia hernia repair in the other lower eyelid. All were evaluated at 6 weeks and at 6 months after surgery, and the outcomes were compared. The results of the two different techniques in the same patient have shown comparable aesthetic outcomes in the treatment of palpebral bags. However, results indicate that the capsulopalpebral fascia hernia repair technique carries less discomfort and pain during the operation and may be less prone to postoperative bleeding and hematoma formation. In addition, in contrast to standard lower blepharoplasty with fat resection, hollowing of the lower lid or potential sunken appearance of the globe may remain absent with capsulopalpebral fascia hernia repair beyond the 6-month period of this study.

Orbicularis Muscleplasty and Face Lift

In the course of aging, the jugopalpebral tegumentary continuity disappears, and the orbital rim becomes more visible with the appearance of the palpebrojugal fold and the wrinkles of crow's feet. The deepening crease just above the sulcus cannot be well assessed because of the palpebral bags and the depression below the cheek due to ptosis of the premalar fat pad that comes down into the nasolabial fold. Repositioning of these volumes can be ensured by raising the cutaneous muscular and fat structures en bloc. Following an anatomic study of the aging process, I propose to section the fibers of the orbicularis muscle and to include them in the large cheek flap. This manipulation of the orbicularis will consolidate a weakened orbital septum. Resectioning of the fat pads under these conditions may not be necessary or at least may be more moderate because the deserted zones will be filled, which is what is desired. The cutaneous and capillary incisions adapted to the requirements of this technique are described. The results obtained with 123 patients over a period of 3 years by the same surgeon appear to be more complete and more natural because the transitional zones between the closed techniques of face lift on the one hand and of lower blepharoplasty on the other cease to exist.

A New Technique for the Treatment of Palpebral Bags

A New Technique for the Treatment of Palpebral Bags

A new technique for the treatment of palpebral bags.

A new technique for the treatment of palpebral bags is presented. The technique consists of returning fat to the orbital cavity and retaining it by means of a continuous suture (with nonabsorbable filament) of the capsulopalpebral fascia to the periosteum of the lower orbital rim. The anatomic basis for the technique, after examination of the relevant literature and dissection on fresh cadavers, is analyzed. The procedure followed and results obtained are described in detail. Evaluation of the results suggests to the authors that this might be the method to be applied in the majority of patients.

Hypertrophy of the orbicularis muscle and its influence on the relief of palpebral bags

Hypertrophy of the orbicularis muscle and its influence on the relief of palpebral bags

Eyelid deformities caused by the injection of silicone fluid

Summary Medical grade dimethylpolysiloxane (silicone) fluid has proved satisfactory as an injectable subcutaneous tissue prosthesis in the treatment of certain deformities such as hemifacial atrophy. The injection of this material beneath the eyelid skin can result in the formation of palpebral bags because of localisation of the tissue reaction and the thinness of the eyelid skin. Surgical excision of the localised silicone mass is indicated in some patients, although total excision is usually not possible. Patients with such eyelid lesions are presented.

The senile eyelid. Aesthetic correction.

THE AESTHETIC eyelid correction in senility is nothing more than a surgical resection of the excess skin of both the upper and the lower eyelids, with simultaneous excision of the redundant adipose tissue and the reinforcement of the orbital septum. Our technique in blepharoplasty for senility differs from others in that we join the upper and lower lines of resection outside the comissure, so as to excise the wrinkes at the angle of the eye, and create sufficient space to shift the commissure outwards and upwards, thus trying to restore the appearance of the normal young eye. The etiology of palpebral bags is uncertain. In a high percentage of cases no certain etiology can be assigned. It is said that dissipation and disorderly living are important casual factors, and actually this origin can be assumed from the clinical histories of many patients. Those afflicted suffer psychological alterations that sometimes present

The treatment of palpebral bags.

The treatment of palpebral bags.