Retro-orbicularis Oculi Fat Research Articles

Cicatricial Ectropion Treated by Orbital Septum Fat Combined with Retro-Orbicularis Oculi fat

Cicatricial Ectropion Treated by Orbital Septum Fat Combined with Retro-Orbicularis Oculi fat

Ultrasound-based histological differences in thickness between puffy eyelids and normal eyelids in Asian monolid women

BackgroundUpper eyelid tissue swelling is a common characteristic among Asian monolid individuals and is associated with a high incidence of complications following eyelid surgery. Currently, there is no precise definition for upper eyelid tissue swelling, necessitating further research to elucidate the specific causes contributing to upper eyelid puffiness. MethodBetween June 2023 and February 2024, we recruited 84 Asian monolid women categorized into groups based on the severity of upper eyelid tissue swelling: the puffy eyelid group and the normal eyelid group. High-frequency ultrasound was employed to capture images of the upper eyelids and measure the thickness of various tissue layers. This study aims to conduct a comparative analysis to identify the factors contributing to upper eyelid fullness, focusing on elucidating the underlying causes of this condition. ResultAll volunteers underwent bilateral upper eyelid ultrasound imaging. Significant differences were observed in the thickness of subcutaneous fat, pre-tarsal fat, retro-orbicularis oculi fat（ROOF）, and composite fat(ROOF and pre-aponeurotic fat) layer between the puffy eyelid group and the normal eyelid group. However, no significant differences were found in skin thickness or orbicularis oculi muscle thickness. Additionally, no significant differences were observed in the thickness of various layers of the upper eyelid tissue between the left and right eyes in all participants. ConclusionThickening of the upper eyelid fat layer is a primary cause of upper eyelid puffiness. In upper blepharoplasty, targeted removal of pre-aponeurotic fat, ROOF, and pre-tarsal fat can achieve precise reduction to correct upper eyelid puffiness effectively.

Eyebrow Lift: Open-Book ROOF Transposition and Orbicularis-Frontalis Sliding Maneuver.

This article delves into innovative surgical techniques, the open-book ROOF (retro-orbicularis oculi fat) transposition technique (OBRoof) and the orbicularis-frontalis sliding maneuver (OFS), designed for eyebrow and upper eyelid rejuvenation in the aging process. Emphasis is placed on understanding the dynamic changes occurring within the forehead and eyebrow envelope's five layers and their intrinsic relationships as well as the impact of the ROOF ptosis causing upper eyelid hooding. The OBRoof technique is highlighted for its effectiveness in addressing ptotic volume, offering a rejuvenated appearance by relocating volume to the supraciliary region.In the OFS, we explore the concept of extensive dissection above the upper border of the eyebrow to allow for free repositioning of the eyebrow. The stabilization is based on deep-plane facelift concepts, as the orbicularis oculi muscle corresponds to the superficial muscular aponeurotic system, and it is anchored to the deep layers (periosteum) by passing through the frontal muscle.In summary, this article provides a comprehensive exploration of innovative and minimally invasive techniques for eyebrow and upper eyelid rejuvenation, shedding light on their anatomical foundations, procedural intricacies, and the potential for achieving natural and lasting outcomes.

The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat: A New Strategy for Correction of Sunken Eyelid Deformity in Revision Upper Blepharoplasty for Asian Patients.

With an increasing number of East Asians undergoing blepharoplasty, the number of patients with secondary upper eyelid deformities is increasing. The sunken eyelid deformity is a common deformity after upper blepharoplasty in Asians due to over-resection, retraction, or atrophy of the nasal and central orbital fat pads. Herein, we present a novel procedure, the pendulum movement of orbital fat and retro-orbicularis oculi fat ("POR" technique), for correction of sunken eyelid deformity in secondary Asian blepharoplasty. Patients who underwent secondary upper blepharoplasty with the POR technique by the senior author between January 2020 and October 2021 were identified retrospectively. Those with fewer than 6 months of follow-up were excluded. Patient charts and images were reviewed for demographic data, comorbidities, concomitant eyelid deformities, and postoperative complications. Pre- and postoperative aesthetics, including degree of sunken eyelid deformity, were assessed by two independent raters and by self-reported patient satisfaction. Forty-nine consecutive patients were identified, all of whom were female and had grade I or II sunken eyelid deformity. Median follow-up was 8 months. Concomitant deformities included high tarsal crease (N = 31 patients, 63.3%), ptosis (N = 13, 26.5%), and upper eyelid retraction (N = 5, 10.2%). Almost patients had improvement in their eyelid volume, and 95.9% had improvement in their aesthetic rating. Approximately 93.9% of patients were satisfied with the outcome. The POR technique is an effective technique for correction of sunken eyelid deformity and can be utilized in conjunction with other techniques during secondary blepharoplasty. 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 .

Combined Blepharoplasty and Brow Fat Pad Transfer for the Correction of Dermatochalasis and Sunken Upper Eyelids.

Women commonly experience upper eyelid dermatochalasis and upper eyelid depression with advancing age. Blepharoplasty is a suitable method for treating dermatochalasis, but not sunken eyelid. This study proposed a novel technique for eyelid rejuvenation by simultaneously correcting dermatochalasis and sunken upper eyelids in middle-aged women. Forty patients underwent subbrow blepharoplasty combined with brow fat pad transfer. Ellipse-shaped skin and subcutaneous tissue underneath the eyebrow were measured, demarcated, and excised. The orbicularis oculi muscle beneath the subcutaneous tissue was exposed and dissected in the upper-third area. The brow fat pad was turned downward using the lower edge as the pedicle and was fixed in the layer of retro-orbicularis oculi fat to fill the depressed area in the upper eyelid. The lower muscle flap was fixed to the supraorbital rim periosteum and upper musculocutaneous flaps, thereby forming a cross flap for interlocking fixation. The surgical outcomes were evaluated using a three-dimensional imaging device and the Global Aesthetic Improvement Scale. The depth and volume of upper eyelid depression decreased significantly 3 months after the surgery and stabilized within 6 months. Global Aesthetic Improvement Scale scores significantly improved after the surgery, and the postoperative outcomes were acceptable. The novel technique is simple and effective for simultaneously correcting dermatochalasis and sunken upper eyelids in middle-aged women. The surgical outcomes are predictable and acceptable to most patients. Therapeutic, IV.

Correction of the High Fold in Difficult Secondary Blepharoplasty Through Retro-Orbicularis Oculi Fat Transposition and Augmentation in Asians.

Secondary blepharoplasty to correct a high crease is considered challenging for most surgeons, especially in patients who show overly excessive removal of eyelid tissue in Asians. Therefore, we define a typical difficult secondary blepharoplasty as when patients present too high eyelid fold with excessive tissue resection and preaponeurotic fat deficiency. This study provides the technique of retro-orbicularis oculi fat (ROOF) transferring and volume augmentation to reconstruct eyelid anatomical structure on the base of a series of difficult secondary blepharoplasty cases in Asians and assess the effectiveness of the method in the meanwhile. This was a secondary blepharoplasty cases-based retrospective observational study. From October 2016 to May 2021, a total of 206 cases were performed blepharoplasty revision surgery to correct high folds. Among them, a total of 58 cases (6 men, 52 women) diagnosed with difficult blepharoplasty were applied ROOF transferring and volume augmentation to correct high folds and were followed up on time. Depending on the distribution of ROOF of different thicknesses, we designed 3 different methods of harvesting and transferring ROOF flaps. The mean follow-up for patients in our study was 9 months, a range of 6 to 18 months. The postoperative results were reviewed, graded, and analyzed. Most patients (89.66%) were satisfied. No postoperative complications were observed, such as infection, dehiscence of incision, tissue necrosis, levator dysfunction, or multiple creases. The mean height of the mid, medial, and lateral eyelid folds decreased from 8.96 ± 0.43, 8.21 ± 0.58, and 7.96 ± 0.53 mm to 6.77 ± 0.55, 6.27 ± 0.57, and 6.65 ± 0.61 mm, respectively. Retro-orbicularis oculi fat transposition or/and its enhancement contributes significantly to the reconstruction of the physiology of the eyelid structure and provides an available surgical option for the correction of too high folds in blepharoplasty.

Diagnosis and Management of Pseudoblepharoptosis in Eastern Asians: A Commonly Observed But Easily Overlooked Type of Blepharoptosis

Pseudoblepharoptosis, which is characterized by ptotic eyelid appearance with normal levator function, is a common abnormality observed in Eastern Asians. Misdiagnosis of pseudoblepharoptosis may lead to inappropriate treatments and unwanted complications. Using the data obtained from a modified levator function examination, this study sought to improve the diagnosis and explore the appropriate treatment of pseudoblepharoptosis based on the typical eyelid anatomy of Eastern Asians. This retrospective study included patients with drooping and bulky eyelids who had been preoperatively diagnosed between January 2018 and December 2018 using a modified approach. Debulking of the retro-orbicularis oculus fat and orbital septum fat and release of the ligament-like structure were performed to correct pseudoblepharoptosis without manipulating the levator muscle. The functional and aesthetic outcomes were evaluated postoperatively. The proposed modified approach was significantly more accurate than the traditional technique. Of the patients, 78 (84.8%) and 9 (9.8%) showed good and moderate cosmetic outcomes, respectively. The margin reflex distance 1 value significantly improved from 1.74±0.87mm preoperatively to 4.56±0.71mm postoperatively ( P <0.05). Moreover, 179 (97.3%) of the 184 eyelids examined achieved adequate correction. The modified levator function examination approach used in this study may help improve the diagnosis of pseudoblepharoptosis. Surgical intervention focused on correcting the bulky and drooping upper eyelids and orbital septum may lead to satisfactory outcomes in Eastern Asians with pseudoblepharoptosis without manipulating the levator muscle.

Sub-brow skin excision Combined with retro-orbicularis fat resection: A Technique for upper eyelid bulkiness and laxity correction

Many people are characterized by a swollen appearance and loose skin of upper eyelids, especially Asians. Retro-orbicularis oculus fat (ROOF) lying in the lateral canthus area is a critical factor of the bulkiness formation. Although several approaches have been reported, most of them intend to remove orbicularis muscle and preaponeurotic fat through a double-eyelid incision, leaving ROOF untreated. Consequently, an unnatural eyelid fold is formed and the lateral supraorbital region remains bloated . Sixty-seven patients underwent sub-brow skin excision combined with ROOF resection. The key point was to excise the loose skin and thick ROOF through an incision along with the lower 1/3 of the eyebrow. Surgical outcomes were evaluated 6 months postoperatively by the heights of the designed line from the palpebral margin to the pupil center (HPPC), medial cornea (HPMC), and lateral canthus (HPLC). The pinch test, photographs, and complications were also recorded. The preoperative average HPPC, HPMC, and HPLC were 9.68±1.73, 7.68±1.24, and 6.82±1.12mm, while the postoperative average measurements were 7.25±0.51, 5.99±0.54, and 5.54±0.61mm, respectively. The result of the pinch test was improved and postoperative scarring was inconspicuous. Two patients had transient numbness in the eyebrow region that subsided within seven days. Two patients had slight asymmetry of eyebrow position but did not need a second operation. Sub-brow skin excision combined with ROOF resection is an effective technique for improving upper eyelid bulkiness and skin excess with low revision rates.

A Retrospective Study of Double Eyelid Surgery for Sunken Upper Eyelid in Chinese.

The aim of this study was to explore the effective technique of double eyelid surgery for mild, moderate, and severe sunken upper eyelid in Chinese. According to the degree of the sunken upper eyelid, different procedures were performed. For mild sunken upper eyelid, the key technique was named eyelid volume redistribution (EVR)-1 technique, which was advancing or folding the pretarsal orbicularis oculi muscle flap toward up to the upper margin of the incision. For moderate sunken upper eyelid, the EVR-2 technique included EVR-1 technique and releasing orbital fat toward the upper margin of the tarsus. The other surgical steps were the same as conventional double eyelid surgery. For severe sunken upper eyelid, 2 steps were needed. The first step was eyelid volume augmentation (EVA). This technique injected fat into the retroorbicularis oculi fat layer. The second step was conventional double eyelid surgery which was performed 3 to 6 months later. One hundred sixty-seven patients with sunken upper eyelid underwent double eyelid surgery. In addition to the ameliorative recontouring of the sunken deformity, natural double eyelid was created. All patients had no complication, such as infection, skin irregularities, and lumps. The edema, bruising, and temporary ptosis recovered in 2 weeks. The edema resulted from double eyelid surgery, which last about 2 to 3 months. Our study showed that EVR-1, EVR-2, and EVA techniques have stable surgical results for mild, moderate, and severe sunken upper eyelids in Chinese. The procedures are simple, safe, and have less complications and preferable clinical reference value.

Secondary Upper Blepharoplasty: Converting Static Folds Into Dynamic Folds.

For the patients seeking secondary upper blepharoplasty, a static double-eyelid fold featuring an immobile lower flap and depression of the fold is common. In this study, the authors propose a novel technique of reconstructing pretarsal tissue defects (PTDs) to converting static folds to dynamic folds. A total of 203 patients with static folds underwent revision surgery. After complete adhesion release of the lower flap, a PTD was identified, which was defined as an area deficient of orbicularis oculi muscle in front of the tarsal plate. If the width of the PTD was over 2 mm, tissue transfer was performed to reconstruct the PTD, usually with a free retro-orbicularis oculus fat graft or a pretarsal orbicularis oculi flap. Among the 105 patients with severe static folds, 67 received retro-orbicularis oculus fat grafts and 38 received orbicularis oculi muscle flaps. This technique converted a static fold into a dynamic fold. The surgery satisfaction rate was 86.7%. Complications included partial fold loss (n = 7, 3.4%), complete fold loss (n = 3, 1.5%), sunken upper eyelids (n = 5, 2.5%), multiple folds (n = 3, 1.5%), an unnatural curve of the double fold (n = 5, 2.5%), and asymmetric folds (n = 4, 2.0%). To convert a static fold to a dynamic fold, we devised a technique that releases adhesion of the lower flap and reconstructs the PTD with retro-orbicularis oculus fat graft or an orbicularis oculi muscle flap. Our study achieved a high patient satisfaction rate, and the resulting fold mimicked the dynamics of the congenital double-eyelid fold.

Investigation of retro-orbicularis oculi fat and associated orbital septum connective tissues in upper eyelid surgery.

To study the anatomical characteristics of retro-orbicularis oculi fat (ROOF) in the upper eyelid and to investigate its relevance in upper eyelid surgery. Thirty-eight Chinese hemifacial cadaver specimens were used. Several sagittal plane section planes were recorded from the medial canthus to the lateral canthus of the eyelid after P45 sheet plastination. ROOF and the associated orbital septum connective tissues in the 38 hemifaces were studied. According to the anatomic results, the lowest point of the junction of the orbital septum and the ROOF (SRJ) was raised for surgical dissection. We improved the intraoperative management of patients who underwent upper eyelid surgery in the plastic surgery department of the First Affiliated Hospital of Dalian Medical University in 2019. Patients were evaluated by observation and self-assessment. ROOF is fascia adipose tissue. In the upper portion of upper eyelid, ROOF fibers were observed to be extremely dense and continuous with the fascia on the surfaces of orbicularis oculi muscle, the periosteum of the orbital margin, and the orbital septum. In the middle portion, positional relationships were identified between the lowest point of the SRJ and the lowest point of the junction of the orbital septum and the levator palpebrae superioris (SAJ). Lifting the SRJ significantly increased the upper eyelid reflex distance in all 57 patients. ROOF is an important factor in upper eyelid surgery. Lifting the SRJ effectively improves the retraction force of the levator palpebrae superioris muscle (LPS).

Anatomical Continuation Between the Sub-Superficial Musculoaponeurotic System Fat and Retro-Orbicularis Oculi Fat: The True Nature of the Retro-Orbicularis Oculi Fat.

Objective: This study aims to analyze the anatomical location and continuation between the retro-orbicularis oculi fat (ROOF) and sub-superficial musculoaponeurotic system fat (subSMAS fat; named "innominate fascia") by comparing their layered structures, thereby letting us suggest a safe minimally invasive procedure guideline for the forehead and temple. Methods: Ultrasonographic scanning was performed from the upper medial eyebrow to the lateral side of the superior temporal line in 109 volunteers. Hematoxylin and eosin staining was performed on five specimens at the same area as ultrasonographic scanning. Then, four embalmed cadavers were dissected from the orbicularis oculi, frontalis muscle, superficial temporal fascia, and SMAS to confirm the location and continuation pattern of the ROOF and subSMAS fat. Results: On ultrasonography and histological images, there was a continuous fatty layer from the ROOF to the subSMAS fat. When dissecting, the ROOF, which was located deep below the frontalis muscle, also continued to the subSMAS fat, passing through the superior temporal line in the upper temporal region. Conclusions: This study confirmed that the subSMAS fat is an anatomical fat structure that is continuous with the ROOF. Since the subSMAS fat layer is known as a less vascular area, it is considered a safer layer to avoid serious complications, and injecting accurately into the subSMAS fat layer has been a goal of clinicians. Based on this study, a cannula will safely approach the subSMAS fat through the ROOF injection that named "forehead-downward approach."

Correction of Upper-Eyelid Depression Through Retro-Orbicularis Oculi Fat (ROOF) Augmentation Using Periumbilical Adipose Graft.

The authors sought to determine the efficacy of periumbilical fat block grafting to the orbital retro-orbicularis oculi fat (ROOF) layer to correct sunken-upper eyelids in Asians. All patients complained about upper-eyelid hollowness and a variety of deformities. Invasive double-eyelid procedures were performed, and periumbilical fat blocks were grafted for these patients. The core procedure of this approach was to make a separation between the orbicularis oculi muscle and septum to expose the retro-orbicularis oculi fat (ROOF) and fixate the fat grafts to the desired region of ROOF. From February 2018 to October 2019, the novel technique was performed on 38 Chinese patients (76 eyes) in our department. After follow-up of 6-15months, 35 patients (92%) showed satisfactory aesthetic results with approximately 20-40% fat absorption rate. No cases required a second procedure. Periumbilical scars remained hidden within the umbilicus area. Periumbilical fat grafting in the ROOF of the sunken upper eyelid can both fill the depression and help correct over-wide double eyelid. 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 .

Analysis of Periorbital Soft Tissue in Thyroid Eye Disease

To investigate periorbital tissue enlargement in thyroid eye disease (TED) by 3-dimensional CT volumetric analysis. Twenty-four adult subjects, 16 with TED and 8 controls, were studied. Three-dimensional volumetric calculations were performed on CT imaging of the orbit and face, focusing on the retroorbicularis oculi fat, suborbicularis oculi fat, facial muscles in periorbital region, orbital fat, extraocular muscles, and orbital volume. Analysis was performed using JMP version 12 software. Each measure was compared between the TED and control groups using Wilcoxon rank sum test. Correlations were investigated between periorbital and orbital tissue using the Spearman's correlation coefficient method. A statistically significant increase in volume was measured in TED patients in the superior and inferior periorbital fat tissue (p = 0.0044, p = 0.047), including the retroorbicularis oculi fat (p = 0.0011), suborbicularis oculi fat (p = 0.0093), and a decrease in facial muscle of superior periorbital region (p = 0.035). Strong positive correlation was noted between the muscles of superior and inferior periorbital region (rs = 0.65; p = 0.0006), and between the suborbicularis oculi fat and retroorbicularis oculi fat (rs = 0.50; p = 0.013). No correlation was observed between orbital and periorbital tissue, except between the orbital fat and the inferior periorbital fat tissue (p = 0.047). Facial fat in the periorbital region is enlarged in TED, with the superior component correlating with orbital fat tissue expansion. These findings may assist in the clinical evaluation and management of disfigurement in TED patients.Superior and inferior periorbital fat is enlarged in thyroid eye disease with the superior periorbital fat expansion correlating with orbital fat expansion.

Anatomical Study and Clinical Observation of Retro-orbicularis Oculi Fat (ROOF).

To study the anatomical location of retro-orbicularis oculi fat (ROOF) in the upper eyelid and to investigate how ROOF affects the appearance of the upper eyelid. Twenty-eight Chinese hemifacial cadaver specimens were used (14 male cadavers; age range 52-82years). In 28 hemifaces, the eyelids were dissected from the superficial to deep layers, and the appearance, location, extent, and surrounding tissue of ROOF were observed. Additionally, we observed the relationship between the upper eyelid morphology and ROOF of the upper eyelid in surgical patients who were treated in the plastic surgery department of Tongji Hospital affiliated with Huazhong University of Science and Technology in 2018. ROOF is a type of fascia adipose tissue that is located in a fat compartment between the muscles (the orbicularis oculi and frontalis muscles) and the orbital septum/frontalis fascia. In patients with hypertrophic ROOF, the upper eyelid appears as a heavy eyelid and as a drooping eyelid. And in patients with atrophic ROOF, the upper eyelid appears as a sunken eyelid. ROOF is located in the fat compartment between the orbicularis muscle and the orbital septum/frontalis fascia. ROOF covers the entire upper eyelid and appears thinner medially and thicker laterally. It is continuous with the fat under the frontalis muscle and affects the appearance of the upper eyelid. It represents an important factor in upper eyelid surgery. 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.

Dimensions and Morphologic Variability of the Retro-Orbicularis Oculi and Frontalis Muscle Fat Pad.

To quantify the complete dimensions of the retro-orbicularis oculi fat (ROOF) pad and to determine its relationship to other fat compartments of the forehead. The entire forehead of 14 hemifaces of seven fresh frozen human cadavers (four female, three male) was dissected in the subcutaneous and submuscular planes. For each plane, a ruler was placed at the facial midline, and images of the dissection plane were taken at 90° and 45°. Images were analyzed for vertical height, horizontal length, the distance to midline from the point of maximal height, and area for each hemiface of the ROOF and for the entire fat compartment contiguous with the ROOF. A two-tailed t test was conducted between ROOF and ROOF plus the extended fat plane across all measurements. A Wilcoxon nonparametric signed rank test was performed to determine equivalent fat distribution of the extended fat plane over each cadaver's respective eye. The deep fat originating from the ROOF consistently extended laterally and superiorly in each specimen, distinctly separated via septae from the deep central, deep lateral, and the deep temporal fat compartments. The color, composition, and distribution of this contiguous deep fat did not differ phenotypically from the traditional ROOF. The extended deep fat plane possessed an average vertical height of 3.09 ± 0.68 cm, average distance to midline from point of maximal height of 3.56 ± 0.53 cm, an average horizontal length of 5.37 ± 0.82 cm, and an average area of 13.40 ± 2.69 cm. The extended deep fat demonstrated a statistically significant increase in maximal height, length, and total area compared with the ROOF. A Wilcoxon nonparametric signed rank test was nonsignificant (α = 0.01) across all measurements, demonstrating that the extended fat plane was similarly distributed over each eye. A layer of deep fat originating from the traditionally defined ROOF extends superiorly and laterally beneath the frontalis muscle, separate from the deep lateral, deep central, and deep temporal fat pads. This is the first study to clearly demonstrate a contiguous superficial musculoaponeurotic system layer of fat extending under both the orbicularis oculi and frontalis muscles. This plane of fat is more appropriately described as the retro-orbicularis oculi and frontalis fat.

Local retro-orbicularis oculus fat (ROOF) resection in upper blepharoplasty: A retrospective evaluation study of 65 bilateral upper blepharoplasties

Puffy upper eyelids are normal in Asians, and full-incision blepharoplasty is commonly performed to remove some orbital fat to ameliorate the problem, but not all patients would exhibit obvious improvement. Local retro-orbicularis oculus fat (ROOF) is a layer of fibrofatty soft tissue that lies much deep into the orbicularis oculi in the upper eyelid, which is an important factor in the formation of puffy upper eyelids. This study was carried out to evaluate the clinical application (including the evaluation of photographs for the thickness of upper eyelid) of upper blepharoplasty combined with ROOF resection for correcting puffy upper eyelids. A total of 65 patients (5 males, 60 females) with puffy upper eyelids recruited from October 2015 to October 2016 were included in the study. Full-incision blepharoplasty combined with partial ROOF resection was performed on all patients. The thickness of soft tissue in the upper eyelid was measured by ultrasound biomicroscopy preoperatively and at 12 months postoperatively. All patients underwent surgery successfully, and 62 patients (124 eyes) were followed up for 12-15 months (mean 13.8 ± 2.7 months). Before the surgery, the thickness of the ROOF was 0.35±0.12 mm on the left and 0.42±0.08 mm on the right. Twelve months postsurgery, the thickness of the ROOF was 0.18±0.03 mm on the left and 0.20±0.02 mm on the right. During the follow-up period, all patients were satisfied with the esthetic effect, and no severe postoperative complications were observed. Puffy upper eyelids can be corrected effectively by local ROOF resection in esthetic blepharoplasty.

Clinical efficacy of transcutaneous triamcinolone acetonide injection for upper eyelid retraction and swelling in patients with thyroid eye disease.

AimTo evaluate the efficacy of transcutaneous triamcinolone acetonide (TA) injection for the treatment of upper eyelid retraction and swelling in thyroid eye disease (TED) patients.Patients and methodsThis is a case series. Three euthyroid TED patients with features of both upper eyelid retraction and swelling were recruited. TED signs appeared within 6 months prior to treatment. Next, 0.5 mL of TA (40 mg/mL) was transcutaneously injected targeting the orbital fat around the levator palpebrae superioris (LPS) muscle. At each visit, eyelid retraction was evaluated by palpebral fissure height and the presence of scleral show above the superior corneoscleral limbus. Eyelid swelling was judged by the appearance of upper eyelid bulging and the lack of an eyelid sulcus. In addition, the LPS muscle, orbital and retro-orbicularis oculi fat were observed using MRI before and after treatment.ResultsTwo patients had resolution of their upper lid retraction and swelling within 12 months. In the other patient who had proptosis, eyelid retraction resolved, while eyelid swelling remained mild. In all cases, MRI revealed that treatment resulted in thinner LPS muscle and reduced fat swelling. In addition, both high-intensity signals on T2 images and prolonged T2 relaxation time were normalized. No adverse signs were observed.ConclusionTranscutaneous TA injection was effective as a treatment for upper eyelid retraction and swelling in euthyroid TED patients who had signs within 6 months prior to treatment. Transcutaneous TA injection induced reduction of LPS muscle enlargement and fat tissue swelling. These reductions by transcutaneous TA injection were verified using MRI.

Correction of superior sulcus deformity and dermatochalasis with autologous fat transferto retro-orbicularis oculi fat (ROOF) through upper blepharoplasty incision

Objective To investigate an operative method of autologous fat transfer to retro-orbicularis oculi fat (ROOF) through upper blepharoplasty incision for correction of superior sulcus deformity and dermatochalasis, and to evaluate the efficacy and safety of the method. Methods ROOF lies in the lateral supraorbital area. Autologous fat transfer to ROOF through upper blepharoplasty incision was performed in patients selected by examination. The efficacy and safety were evaluated by follow-up study. Results From March 2013 to June 2017, 23 selected patients received the treatment with 3 months to 50 months (mean, 20.4 months) follow-up. The amount of fat graft for each palpebra was 0.6 to 2.0 ml, and the mean graft amount was 1.4 ml. The superior sulcus deformity improved significantly in 22 (95.7%) cases. All 23 cases achieved significant improvement of dermatochalasis. 22 (95.7%) cases were satisfied with the result. No major complications occurred. Conclusions Autologous fat transfer to ROOF through upper blepharoplasty incision is effective and safe in correction of superior sulcus deformity and dermatochalasis, The operative method should be a good choice for selected patients. Key words: Skin; Relaxation; Blepharoplasty; Autografts; Fat; Sunken; Retro-orbicularis oculus fat

Reply: Topographic Analysis of the Supratrochlear Artery and the Supraorbital Artery: Implication for Improving the Safety of Forehead Augmentation.

Sir: We are objectively addressing Dr. Hwang’s comments about our article.1 In our study, we sequentially dissected the upper face based on the conventional methods in the gross anatomy field. This is a fact. For our dissections, we injected red colored latex (Neoprene, lot no. 307L146; DuPont DeNemours, Puteaux, France) into the common carotid artery before detailed dissections.1 Among the preinjected specimens, we excluded specimens that were not injected into the ophthalmic arterial branches before the dissections. In classical anatomy textbooks, the superficial and deep branches of the supraorbital artery have been described. Nevertheless, there are no specific descriptions for their branching. Aside from some anatomical textbooks, few articles focus on the course of the supraorbital artery. It is described simply as follows: “passing through the supra-orbital foramen, supraorbital artery divides into a superficial and deep branch, which supply the integument... anastomosing with the frontal, anterior branch of the temporal, and the artery of the opposite side.” During our dissections, we recognized new branching patterns of the supraorbital artery, which did not correlate with descriptions in the textbook. The main arterial branches of the supraorbital artery ran beneath the orbicularis oculi and the frontalis after passing the supraorbital notch (or foramen). As for the layers at the eyebrow area, the retro-orbicularis oculi fat was located deep to the muscle layer and includes the supraorbital vessels and the nerve branches and the insertion of the corrugator. Clearly, the main trunk of the supraorbital artery is located within the retro-orbicularis oculi fat. Unlike the general anatomical knowledge with which one may be familiar, the extent of the retro-orbicularis oculi fat is wider within the subgaleal layer with a high upper margin from the eyebrow level. Within the retro-orbicularis oculi fat, the supraorbital artery runs singularly or divides into two branches accompanying the supraorbital nerve. We named this supraorbital artery branch within the retro-orbicularis oculi fat the deep branch of the supraorbital artery. After passing the retro-orbicularis oculi fat, the deep branch of the supraorbital artery pierces the frontalis 20.7 mm vertically from the horizontal plane passing through the superior orbital rim. From the piercing points of the frontalis, it runs superficially to the frontalis (superficial branch of the supraorbital artery), and the superficial branches anastomosed with the frontal branches of the superficial temporal artery.1 Based on our dissection experiences, we described the common and clear characteristics of the supraorbital artery courses and illustrated them in detail. In some specimens, we could observe the fine perforations supplying the skin at the upper eyebrow area. We focused on the main arterial branches in the forehead to provide clinical anatomical information. In addition, our article has shown an objective and novel supplement on the supraorbital artery course from a gross anatomy viewpoint. Regarding sample size, we dissected and collected vascular anatomy data from both Korean and Thai subjects (20 hemifaces). As mentioned in the Results section, the deep branch of the supraorbital artery was observed in every case. Simply put, the deep branch of the supraorbital artery is the constant course of the supraorbital artery within the retro-orbicularis oculi. There was no need to dissect more cadavers for clarification. I believe you have already witnessed the strongest form of evidence by means of anatomical dissections from my previous presentations at conferences. Regarding the query about the clinical technique of forehead augmentation, the recommended entry point should be lateral to the vertical plane of the supraorbital foramen to avoid vascular injury from the needle. The needle should first be inserted deep to the frontalis by bone touch to provide a proper opening and tract for the cannula. The entry point and the point where it reaches the periosteum are usually adjacent because of the thin skin and muscular layer. After that, the cannula should be guided along the supraperiosteal layer until it reaches the medial area of the forehead. At that point, the filling material should be released. We developed this technique to maximize forehead augmentation safety during vascular piercing in clinical procedures through our article. Because the needle touches the bone, it is unnecessary to take the thickness of the frontalis into consideration. DISCLOSURE None of the authors has financial or private relationships with commercial, academic, or political organizations or people that could have improperly influenced this research. All cadaveric objects in this study were legally donated to Yonsei Medical Center and Chulalongkorn University. Li-yao Cong, B.Sc.Division in Anatomy and Developmental BiologyDepartment of Oral BiologyHuman Identification Research InstituteBK21 PLUS ProjectYonsei University College of DentistrySeoul, Republic of Korea Weeranut Phothong, M.D.Department of DermatologyFaculty of MedicineSiriraj HospitalMahidol UniversityBangkok, Thailand Iksoo Koh, M.D., Ph.D.Koh Iksoo Aesthetic Clinic Hee-Jin Kim, D.D.S., Ph.D.Division in Anatomy and Developmental BiologyDepartment of Oral BiologyHuman Identification Research InstituteBK21 PLUS ProjectYonsei University College of DentistrySeoul, Republic of Korea