Suborbicularis Oculi Fat Research Articles

Posterior medial canthal thermoplasty in facial palsy: A simplified technique

Abstract Purpose: The purpose of this study was to describe a new, simple, quick, reproducible, and minimally invasive surgical technique for medial canthal tendon (MCT) dehiscence and deformity in patients with facial palsy. Methods: A retrospective study of 10 patients having medial ectropion and MCT laxity in patients with facial palsy was included in the study. All patients underwent the simplified technique of posterior medial canthal thermoplasty and anchorage with 6/0 Vicryl. Ancillary procedures such as lateral tarsal strip, lower lid spacer, suborbicularis oculi fat lift, upper lid blepharotomy, and mullerectomy were also performed where warranted as a holistic treatment approach. Results: The study cohort included 10 patients. All patients had satisfactory outcomes concerning medial canthus position and lid-to-globe apposition. 9/10 patients had satisfactory punctum alignment. Conclusions: This technique is a safe alternate and reproducible procedure compared to the conventional open technique of anchoring the lid to the posterior lacrimal crest which is a challenging procedure even in experienced hands.

Post-Treatment Displacement of Facial Soft Tissue Fillers-A Retrospective Ultrasound-based Investigation of 382 Zygomatic Regions.

Clinical and ultrasound experience has revealed that after soft tissue injections of the lateral cheek, the filler may displace from the zygoma to the caudal temporal area. To obtain more data to provide insight into product distribution when soft tissue fillers are injected in the zygomatic region. Two hundred patients were examined with facial ultrasound imaging of the zygomatic and temporal region. Inclusion criteria were simply a positive response on the screening questionnaire as to whether or not they had filler injections placed in their lateral cheek. Control injections were also performed to the zygomatic regions of a body donor and in 10 patients ultrasound-guided. A correlation was found between the layers in which filler was detected on the zygoma and where it was ultimately found in the temples. Four different redistribution patterns were observed: (1) migration of filler within the superficial muscular aponeurotic system (SMAS) on the zygoma into the superficial temporal fascia. Migration of filler from the lateral suborbicularis oculi fat to (2) the deep interfacial plane of the temple or (3) to the superficial temporal fat pad; (4) migration from the supraperiosteal layer of the zygoma to the superficial temporal fat pad. Body donor and patients: filler deposits injected on the zygoma were witnessed to shift during injection into the caudal part of the temple. Soft tissue filler aliquots may be redistributed into the temples after injections of the lateral side of the zygomatic arch. The displacement follows a distinct pattern depending on the initial layer of injection.

Thin-Film Buckling Theory and Clinical Application of the Mechanism of Double Eyelid Formation.

The mechanism underlying the formation of upper eyelid creases has been the subject of extensive study and ongoing debate. This research aims to elucidate the principles of upper eyelid creases formation, leveraging the membrane bending theory from engineering mechanics. We developed an anatomical model of the eyelid and implemented the finite element analysis. Preprocessing and mesh division were conducted using HyperMesh, followed by computational analysis with Abaqus. This approach enabled the observation of dynamic changes in the upper eyelid during eye opening and closing. The study reveals that natural upper eyelid crease formation is influenced by multiple factors. These include the softer texture of the upper eyelid skin and the suborbicularis oculi fat, reduced rigidity at the eyelid crease, optimal contraction force of the upper eyelid, and the strategic placement of the pre-tarsal fat pad just above the eyelid crease. Ultimately, our findings demonstrate the effectiveness of finite element analysis, grounded in membrane bending theory, in elucidating the dynamics of upper eyelid crease formation. 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 .

Lower Blepharoplasty With Fat Transposition and Three-Vector Suspension Technique

The aging appearance of the lower eyelids is multifactorial, involving changes in the skin, orbital fat, orbicularis muscle, soft tissue of the midface, tear trough, and tear valley. Traditional techniques of lower blepharoplasty are based on transcutaneous or transconjunctival approaches with skin removal, followed by adjunctive procedures, such as canthal suspension, fat resection, or repositioning. However, these approaches can hardly achieve excellent transitions simply because they do not effectively address every age-related issue affecting the lower eyelid. Conversely, the approach presented herein, focuses on blending the lid-cheek junction by means of skin resection, fat transposition, and three periosteal suspension vectors, including canthal, skin-muscle flap, and sub-orbicularis oculi fat (SOOF) suspensions. It provides adequate volume restoration in the tear trough and tear valley, along with enhanced support and stability to the eyelid with canthopexy, double muscle flap, and SOOF suspension. The aim of this article is to provide a detailed step by step description of this technique along with the results of 269 patients who underwent this procedure from 2019 to 2023. This technique offers a safe and effective solution for lower eyelid aging, yielding long-lasting aesthetic results with excellent transitions.

Stromal Vascular Fraction Gel (SVF-Gel) Combined with Nanofat for Tear Trough Deformity.

Tear trough deformity makes patients appear tired. Patients with less severe tear trough deformity prefer a less invasive method to correct the deformity. The infraorbital area is a multilayered tissue, and the aging of various components leads to tear trough deformity. To this end, we utilized the different characteristics of different fat derivatives to correct tear trough deformity. Thirty-two patients with Barton Grade I/II tear trough deformity were enrolled in this study between September 2020 and March 2021. We injected Stromal Vascular Fraction Gel (SVF-Gel) into the suborbicularis oculi fat layer and Nanofat into the subcutaneous. After 12 months of follow-up, we evaluated the changes using standardized clinical photogrammetric techniques, volume, global aesthetic improvement scale, and patient self-evaluation. There were no major complications in any of the 32 patients. The measured data points demonstrated improvements in all aesthetic parameters. The width of the tear trough and the distance from the pupil to the tear trough improved. The Global Aesthetic Improvement Scale (GAIS) showed a high score (2.45±0.64 points), with patient self-assessment showing satisfactory results. SVF-Gel combined with Nanofat injection can effectively correct tear trough deformities. 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 .

U-type soft tissue lifting: A new composited technique for reversing lower eyelid and midfacial aging.

Facial rejuvenation is becoming more and more popular, particularly among middle-aged persons. There are currently many techniques for improving the aforementioned situations, but each has its drawbacks. Our study aimed to discuss the treatment effect of a composited technique for reversing both lower eyelid and midface aging. The patient's face was designed and measured before surgery. During surgery, a traditional lower blepharoplasty incision was made. The layer between the orbital septum and the orbicularis oculi muscle was separated to approximately 4-5mm below the infraorbital, then the orbital septum and orbicularis retaining ligament were found to be released. A self-made suspension curving needle subconsciously passed through the brim of the superficial cheek fat pad via the "U-type" path and raised them to the proper location. Then sutured them to the infraorbital rim periosteum, as well as the suborbicularis oculi fat (SOOF) and the orbital septum fat. Secured the outside canthus to keep the lower lid position stable. From February 2020 to November 2022, 106 patients underwent the new surgical procedure and were successfully followed up for 20±6.5 months postoperatively. The mean GAIS score was 2.42±0.78, patient satisfaction rate was 95%. All of the Barton grades were decreased. The nasal base level suspension points were elevated to a level of 5±2mm. 3D measurement data revealed significant improvements. The composited technique is a safe and effective way to reverse the aging of the lower eyelid and midface.

Histomorphological analysis of the superficial musculoaponeurotic system in Macaca mulatta species

IntroductionThe superficial musculoaponeurotic system (SMAS) is a well described facial functional unit in humans. SMAS connects mimic musculature to the skin having many implication in facial mimic expression. One of the various morphological and physiological analogies in human and Macaca mulatta species is the facial mimic. The present study analyzed Macaca mulatta species SMAS morphology and its facial topographical differences and compared this with human SMAS tissue morphology. Material and methodsMacaca mulatta full-graft tissue blocks of skin, subcutaneous tissue and mimic muscles from five topographical different facial regions (Regio Temporalis, Regio Buccalis, Regio Infraorbitalis, Regio Angulus Oris and Regio Mandibularis) were collected postmortem from eight individuals (n = 8) at the German Primate Center, Leibniz Institute for Primate Research in Göttingen (DPZ) and studied histologically. Haematoxylin-eosin and azan stained histological serial sections of full-graft tissue blocks were analyzed and SMAS topographical differences evaluated. ResultsSMAS typical tissue morphology was recognized in all Macaca mulatta histological serial sections (n = 780). Regio Infraorbitalis Macaca mulatta SMAS (MmSMAS) morphology was similar to human infraorbital SMAS morphology (type I SMAS). Suborbicularis oculi fat pad was recognized in Macaca mulatta samples. Human type I similar SMAS morphology was demonstrated over Macaca mulatta Regio Temporalis and Regio Buccalis. Regio Angulus Oris and the cranial area of the Regio Mandibularis presented human type II similar SMAS morphology. Type IV MmSMAS was closely related to the parotid gland tissue presence. The cervical area of the Regio Mandibularis presented human type V similar SMAS morphology. ConclusionsSMAS is a complex fibro-musculo-adipose tissue network and probably an important pivot in Macaca mulatta facial system supporting mimic expression. This study provided insights into MmSMAS typology and similarity with human SMAS tissue morphology.

Filler in the Tear Trough and Lid-Cheek Junction: A Cadaveric Evaluation of Filler Type and Manipulation Technique

Abstract Goals/Purpose The tear trough and lid-cheek junction demonstrate among the earliest and most noticeable signs of aging as a result of thin periorbital skin and loss of volume causing shadowing and darkness of the infraorbital region. Thus, rejuvenation of this area is commonly requested by patients. Soft tissue filler injections are the second most common non-surgical cosmetic procedure performed in the U.S, with over 2.6 million procedures reported in the 2020 Plastic Surgery Statistics Report. As such, there is a high demand for filler injection in the infraorbital area. However, there is currently only one FDA-approved filler for the tear trough, Juvéderm Volbella XC, although many practitioners also use Restylane-L. Interestingly, these two products differ significantly in their rheology (G’, cohesivity, and flexibility), and the Juvéderm Vycross is smooth gel while the Restylane NASHA is particulate. Despite the high demand of filler in the infraorbital area, there remains debate on injection practices and precise anatomical placement leading to several prior cadaveric examinations of the region. We herein aimed to contribute to the anatomic understanding of infraorbital filler injection via a cadaveric study using Juvéderm and Restylane products with different constitutions and manipulation techniques. Methods/Technique Institutional approval for cadaveric study was obtained. Six cadaveric cephalus specimens were used for filler injection and dissection. All fillers were dyed with food coloring. The Juvéderm products Volbella XC (tear trough, red) and Voluma XC (malar, blue) were used together in hemi-faces (Juvéderm pair), and Restylane products Restylane-L (tear trough, purple) and Restylane-LYFT (malar, green) were used together in separate sets of hemi-faces (Restylane pair). All filler injections were performed by the senior author as follows: 0.5 cc of filler was injected into the malar region in the deep fat compartment above the maxilla both medial and lateral to the infraorbital foramen. In the tear trough region, the orbit was protected with the nondominant hand and 0.3 cc of filler injected just superficial to the infraorbital rim. One hemi-face was injected with the original constitution of filler product and the other was injected with filler blended with 0.2 cc of saline. In two cadavers, after injection the hemifaces were massaged and compared to those which remained unmanipulated. All hemi-faces were then dissected from medial to lateral in the subcutaneous plane and between the superficial and deep facial fat compartments by a single author. All photographs and videography were taken by a single author. All hemi-faces were subjectively analyzed by all authors. Results/Complications All cadavers were in excellent condition, and the subcutaneous tissue, superficial fat, and deep fat compartments were dissected in clear planes. Volbella was found on the periosteum of the infraorbital rim and along the orbicularis retaining ligament (ORL) and crossed into the sub-orbicularis oculi fat (SOOF) and the subcutaneous fat while the Restylane-L did not leech into the fat and remained as a distinct mass on the rim and ORL. Voluma was found in the deep medial cheek compartment and crossed into the superficial medial cheek and superficial nasolabial compartments and subcutaneous fat. In contrast, Restylane-LYFT remained mostly within the deep medial cheek compartment without spreading into the superficial fat pads (Figure). Dilutional manipulation by blending with saline and physical manipulation by massaging both increased spread of all products within the anatomical planes. However, Restylane products appeared to remain distinctly within the anatomical planes they were injected in despite the manipulations. Conclusion This cadaveric study was successful in demonstrating the behavior of different hyaluronic acid fillers injected in the infraorbital region. Tear trough and malar region filler injections just above the periosteum resulted in precise anatomical placement along the infraorbital rim/ORL and in the deep medial cheek fat compartment, respectively. The Juvéderm products appeared to spread across anatomical planes more freely than Restylane products. This may be explained by the lower elastic modulus (G’) of the Juvéderm fillers. Manipulation of the filler product including blending and post-injection massage appeared to spread the fillers medially and laterally within the injected anatomical planes compared to unmanipulated filler. Of note, there are limitations to this study including the cadaver model as this does not allow for hydrophilic swelling of the filler nor spread and integration of the products as in live patients. The results of this study provide information about filler products commonly used in the infraorbital region and the effects of manipulation using blending or massage. Confirmation of precise anatomical placement of the fillers and improved knowledge of their behavior in situ through this cadaver study may assist clinical practitioners’ selection of rheological properties of fillers, method of constitution, and manipulation technique depending on patient-specific anatomy.

The Management of Lumps, Bumps, and Contour Irregularities of the Lower Eyelid and Cheek After Poor Outcome Fat Transfer.

The increasing popularity of fat transfer (FT) to the lower eyelids has led to an increase in unwanted lumps, bumps, and contour irregularities (LBCs). Few studies have addressed the management of LBCs. The aim of this study was to address the management of LBCs. In this retrospective review, charts of all patients presenting for evaluation of LBCs following FT procedures to the lower eyelid were reviewed. Clinical characteristics on presentation and surgical findings were evaluated. Patient postoperative clinical course and complications were also documented. Forty-eight patients were included (45 women and 3 men), with an average follow-up of 14 months (range, 5-24 months). In 65%, LBCs manifested above the lower orbital rim (AR) and in 35% they were noted AR and below the rim (AR/BR). The type of contour deficits noted were a solitary nodule (SN) in 54%, a mixed picture (MP) in 23%, diffuse enlargement (DE) in 17%, and multiple nodules (MNs) in 6%. Combining lesion location and type of contour deficit, the most common presentation was an SN-AR in 22 patients (46%), followed by an MP-AR/BR in 8 patients (17%), and a DE-AR/BR in 5 patients (10%). Surgical findings revealed that grafted fat is consistently found separate from native eyelid/orbital fat, and within the orbicularis muscle when AR, and within the orbicularis muscle or the deep suborbicularis oculi fat when BR. LBCs tend to manifest in characteristic patterns with a predilection for an AR location. Recommendations on the diagnosis and management of these lesions are provided.

Rejuvenation of the Lower Eyelid and Midface with Deep Nasolabial Fat Lift in East Asians.

Correcting infraorbital hollowness is an important procedure for midface rejuvenation. Sub-orbicularis oculi fat lift is a commonly used method. However, adipose tissue, which has been thought of as sub-orbicularis oculi fat, has recently been controversial. The objective of this study was to introduce a method of midface rejuvenation using deep nasolabial fat lift (MRDN) by means of lower blepharoplasty and to compare surgical outcomes between MRDN and lower blepharoplasty with fat transposition (LBF). The medical records of patients who had undergone midface rejuvenation with lower blepharoplasty between 2013 and 2020 were retrospectively reviewed. Questionnaires, digital photographs, and charts were used to evaluate the surgical outcomes and complications. The degree of aging was graded as mild, moderate, or severe. LBF and MRDN were used for mild and severe grades, respectively. For the moderate grade, the preferred surgical method of the two methods was selected and surgical outcomes were compared. The MRDN technique included LBF. Postoperative satisfaction was significantly higher ( P < 0.001), recurrence rate for tear trough ( P = 0.046) and fat bulging ( P = 0.005) was significantly lower, duration of swelling ( P < 0.001) was significantly longer, and incidence of chemosis ( P = 0.024) was significantly higher in the MRDN group than in the LBF group. Regarding lid malposition, transient retraction was higher in the LBF group, whereas cicatricial ectropion was higher in the MRDN group; however, these differences were not significant. MRDN is associated with higher patient satisfaction and surgical longevity without serious complications than LBF. Therapeutic, III.

Filler-based correction of tear trough depressions and eye bags in Japanese patients: A classification system and treatment algorithm.

Tear trough depressions are widely treated with fillers. However, it is questionable whether the same strategies can always be used for Caucasian and Japanese patients, owing to differences in bone and skin structures and epithelial thickness. To assess a novel classification system and treatment algorithm for correcting tear trough depressions and eye bags in Japanese patients. Tear trough depressions can be classified into three types according to the presence or absence of a "negative vector" based on retrusion of the maxilla relative to the anterior corneal surface, with or without eye-bag protrusion when smiling. Type 1 patients (without the negative vector) can be treated simply by filling the depression in the tear trough and the palpebromalar groove region. Type 2 patients (with a negative vector and no eye-bag protrusion on smiling) also require volume restoration in the mid-cheek (deep medial cheek fat, suborbicularis oculi fat, and pre-maxillary space); this not only enables volume recovery but also compensates for maxillary deficiency. Type 3 patients (with a negative vector and eye-bag protrusion on smiling) require an additional step, based on placing a filler in front of the eye bags and pushing orbital fat backward. Case presentations demonstrate the utility of the techniques involved. This system provides a simple and practical method for classifying and treating Japanese patients with tear trough depressions and eye bags. Further studies are warranted.

The Deep Fascia of the Infraorbital Region, Deep Plane, and Suprafibromuscular Facelift: New Anatomy for Safer Facelifting.

Deep-plane rhytidectomy, first described by Skoog, has had a resurgence in popularity and is in high demand today. We describe anatomical findings that establish the presence of a true deep fascia in the midface, we named as Chiara's fascia, like the first author's first name, which helps to form the facial ligaments and is contiguous with the superficial layer of the deep temporal fascia. This fascia inserts on the periosteum of the inferior orbital rim at the arcus marginalis and separates the suborbicularis oculi fat (SOOF) from the preperiosteal fat. This distinct fascial layer lies under the superficial fascia or superficial musculoaponeurotic system (SMAS) and represents the floor of what is commonly termed the "deep plane." When this fascial highway is identified intraoperatively, blunt dissection immediately superficial to this layer will protect facial nerve branches overlying the muscles lifting the upper lip such as the zygomaticus. Subsequent dissection over the middle and lower face can usually be performed bluntly. Over a 10-year period, a total of 100 hemifaces were dissected with a 100% success rate of identifying this fascia in all specimens. This work was further validated by examining histologic specimens that clearly demonstrate this unique fibrofatty fascial layer. These dissections and new anatomical findings were then correlated to over 300 intraoperative deep-plane facelift cases by the primary and senior authors. We term this operative technique as the suprafibromuscular facelift. Dissection in this plane allows for safe release of facial retaining ligaments with protection of facial nerve branches.

Extending the Indications for Direct Transcutaneous Lower Blepharoplasty With an Infraorbital Incision to Tear Trough Deformities, Suborbicularis Oculi Fat, Festoons, and Revision Blepharoplasty.

Introduction: Treatment of high-grade lower eyelid deformities with massive skin laxity and retroseptal fat pads can be challenging. Common techniques such as the transconjunctival approach and transcutaneous technique performed through a subciliary incision are associated with increased complication rates. Direct excision of the lower eyelid through an infraorbital incision is an alternative technique that allows safe treatment of dermatochalasis and pigmentation and correction of tear trough deformities, suborbicularis oculi fat, and festoons. This study aimed to determine whether direct transcutaneous blepharoplasty with an infraorbital incision could be indicated for these conditions instead of the established operative methods. Methods: A retrospective study of 21 patients with Fratila grades 9 or 10, Hirmand grade 3, and Barton grade 3 who underwent direct transcutaneous lower eyelid blepharoplasty via an infraorbital incision under local anesthesia was performed. All patients underwent surgery during a 9-year period from January 2010 to December 2018. The follow-up period was 12 months. Results were rated postoperatively using Barton grading. Results: Of 21 consecutive patients (13 women and 8 men), 18 required retroseptal fat pad removal, 3 had laxity of the skin and orbicularis muscle, and 5 had triangular cheek festoons. Combined lower and upper blepharoplasty was performed for 12 patients. All patients were satisfied with their surgical results and major improvements were observed. Scar quality was considered good by all patients. Conclusion: Direct transcutaneous lower blepharoplasty of the orbital rim can be indicated for different tear trough deformities, suborbicularis oculi fat laxity, and festoons.

Three-Dimensional Topographic Surface Changes in Response to Volumization of the Lateral Suborbicularis Oculi Fat Compartment.

Autologous fat grafting is an increasingly preferred method for aesthetic facial rejuvenation. The authors' group previously described the concept of "lipotopography" as topographic surface changes that occur with fat grafting to discrete facial fat compartments. The purpose of this study was to define the "augmentation zone" of the lateral suborbicularis oculi fat compartment to understand the topographical surface changes following augmentation. Nine cadaver hemifaces were injected with fat analogue at intervals from 1 to 4 cc. Three-dimensional photographs were taken at baseline and following each 1-cc incremental injection. The interval surface changes were calculated using three-dimensional software including perimeter, diameter, and projection. The augmentation zone of the lateral suborbicularis oculi fat compartment was characterized by a consistent shape and boundary. The shape was an elongated oval bound superiorly by the lid-cheek junction and inferiorly at the level of the zygomaticocutaneous ligament. Vertical and horizontal diameter and perimeter showed initial increases between 1 and 2 cc and then a plateau between 2 and 3 cc. Projection changes demonstrated an initial slow increase from 1 to 2 cc injection followed by nearly linear growth from 2 to 4 cc. Three-dimensional photography and computer analysis provide tools to understand the surface anatomy change in response to fat grafting specific facial fat compartments. Targeted volumization of the lateral suborbicularis oculi fat compartment also results in a unique surface change with consistent shape and anatomical boundaries. The lid-cheek junction and zygomaticocutaneous ligament were observed to restrict the expansion of fat analogue for all injection volumes. Therapeutic, V.

Thickness of Retro- and Sub-Orbicularis Oculi Fat in Thyroid Eye Disease: Comparison With Controls and Its Influential Factors.

To compare the thickness of the retro- and sub-orbicularis oculi fat (ROOF and SOOF) between patients with thyroid eye disease (TED) and controls via MRI and to determine factors influencing fat thickness. This retrospective, comparative, case-control study included 136 patients (272 sides) with TED and 50 control patients (50 sides). The thickness of the ROOF and SOOF was measured on the quasi-sagittal plane through the optic nerve (the central plane) and 6 mm lateral and medial to the central plane at the level through the superior orbital rim and at the level just below the orbital septum in the lower eyelid, respectively. The ROOF and SOOF were thickest on the lateral plane (p < 0.050; Tukey Kramer post hoc test) and were significantly thicker in patients with TED than controls on all planes (p < 0.050; Student t test). Multivariate stepwise analysis showed that age, sex, clinical activity score, Hertel exophthalmometric values, and number of enlarged extraocular muscles are significant predictors of the ROOF and SOOF thickness in patients with TED (p < 0.050). Patients with TED had thicker ROOF and SOOF on all planes than controls with various factors influencing the thickness. These results may be helpful in planning rehabilitative blepharoplasty with removal of the ROOF and SOOF for correction of eyelid fullness in TED.

An Alternative Periorbital Treatment Option Using Calcium Hydroxyapatite for Hyperpigmentation Associated with the Tear Trough Deformity.

The nasojugal groove or tear trough (TT) area deformity produces visible, pigmented, difficult-to-treat hollows. Hyaluronic acid (HA) filler-based correction yields variable results and complications. We developed an alternative, minimally invasive treatment for this area. Patients with significant, visible TT area pigmentation, and/or those requiring corrections for TT filler removal, were given lignocaine-diluted calcium hydroxyapatite (CaHA) fillers. CaHA boluses were placed deep on the bone, under the origin of the orbicularis retaining ligament, and under the sub-orbicularis oculi fat. Diluted CaHA was used as a subcutaneous biostimulatory wash. Efficacy and complications were assessed using the Global Aesthetic Improvement Scale and a modified Tear Trough Rating Scale, at 4 and 18 months. Twelve patients, between 25 and 52 years of age, were treated and showed immediate improvements in hyperpigmentation due to light reflection and some visibility of the filler through skin. Lower eyelid swelling and redness occurred a few days postinjection but resolved spontaneously. Over 4 to 6 months, hyperpigmentation and skin tone, thickness, and color improved noticeably. Global Aesthetic Improvement Scale and modified Tear Trough Rating Scale scores indicated that all patients experienced satisfactory improvements. Three prior HA patients required a second CaHA treatment at 4-6 months for a satisfactory correction, one of whom required a third CaHA "wash" at 10 months. Some mild redness was observed for up to 12 weeks in a few patients; however, no differences in the degree of redness were observed between those treated for dark circles or post-HA correction. One patient experienced a persistent, dull erythema for 8 months; another had overt erythema and swelling following a chest infection which resolved with antibiotics and hydrocortisone cream. No nodules developed in any patient. We developed an alternative TT deformity treatment that leverages CaHA unique rheology and neocollagenesis-stimulating ability, which lifted and supported the prolapsing orbicularis retaining ligament, improved skin quality, and rejuvenated the periocular area without direct injections into the TT.

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.

The Surface-Volume Coefficient of the Superficial and Deep Facial Fat Compartments: A Cadaveric Three-Dimensional Volumetric Analysis.

Soft-tissue filler injections for the treatment of facial aging can result in different skin surface effects depending on the targeted facial fat compartment and fascial plane. This work investigates the tissue response of defined amounts of soft-tissue filler material injected into superficial and deep facial fat compartments by means of the calculation of the surface-volume coefficient. Four fresh frozen cephalic specimens obtained from human donors (three female and one male; mean age, 74.96 ± 22.6 years; mean body mass index, 21.82 ± 6.3 kg/m) were studied. The superficial and deep lateral forehead compartments, deep temporal fat pad, sub-orbicularis oculi fat compartment, and deep medial cheek fat compartment were injected with aliquots of 0.1 cc of contrast-enhanced material and scanned using three-dimensional surface imaging, resulting in a total of 226 injection and scanning procedures. The sub-orbicularis oculi fat compartment revealed the highest correlation coefficient (rp = 0.992; p < 0.001) and the highest surface-volume coefficient (0.94). The compartment with the lowest tissue response was the deep medial cheek fat compartment (rp = 0.745; p < 0.001; surface-volume coefficient = 0.29), followed by the deep lateral forehead compartment (rp = 0.814; p < 0.001; surface-volume coefficient = 0.68), superficial lateral forehead compartment (rp = 0.824; p < 0.001; surface-volume coefficient = 0.74), and deep temporal fat pad (rp = 0.947; p < 0.001; overall surface-volume coefficient = 0.64). These results, confirmatory in their nature to current injection strategies, provide evidence for the validity and reliability of the surface-volume coefficient. Injection procedures should be targeted in terms of facial fat compartments and fascial planes for a desired aesthetic outcome, as each fat compartment and fascial plane has unique tissue responses to injected soft-tissue fillers.

The Functional Anatomy of the Deep Facial Fat Compartments: A Detailed Imaging-Based Investigation.

Injection of soft-tissue fillers into the facial fat compartments is frequently performed to ameliorate the signs of facial aging. This study was designed to investigate the functional anatomy of the deep facial fat compartments and to provide information on the effects of injected material in relation to age and gender differences. Forty fresh frozen cephalic specimens of 17 male and 23 female Caucasian body donors (mean age, 76.9 ± 13.1 years; mean body mass index, 23.6 ± 5.3 kg/m(2)) were investigated. Computed tomographic and magnetic resonance imaging procedures were carried out using colored contrast-enhanced materials with rheologic properties similar to commercially available soft-tissue fillers. Anatomical dissections were performed to guide conclusions. No statistically significant influences of age or gender were detected in the investigated sample. Increased amounts of injected contrast agent did not correlate with inferior displacement of the material in any of the investigated compartments: deep pyriform, deep medial cheek, deep lateral cheek, deep nasolabial (located within the premaxillary space), and the medial and lateral sub-orbicularis oculi fat. Increasing volume in the deep midfacial fat compartments did not cause inferior displacement of the injected material. This underscores the role of deep soft-tissue filler injections (i.e., in contact with the bone) in providing support for overlying structures and resulting in anterior projection.

The Boomerang Lift: A Three-Step Compartment-Based Approach to the Youthful Cheek.

Autologous fat grafting is an important tool for plastic surgeons treating the aging face. Malar augmentation with fat is often targeted to restore the youthful facial contour and provides support to the lower eyelid. The existence of distinct facial fat compartments suggests that a stepwise approach may be appropriate in this regard. The authors describe a three-step approach to malar augmentation using targeted deep malar fat compartmental augmentation, termed the "boomerang lift." Clinical patients undergoing autologous fat grafting for malar augmentation were injected in three distinct deep malar fat compartments: the lateral sub-orbicularis oculi fat, the medial sub-orbicularis oculi fat, and the deep medial cheek (n = 9). Intraoperative three-dimensional images were taken at baseline and following compartmental injections (Canfield VECTRA H1). Images were overlaid between the augmented and baseline captures, and the three-dimensional surface changes were analyzed, which represented the resulting "augmentation zone." Three-dimensional analysis demonstrated a unique pattern for the augmentation zone consistent across patients. The augmentation zone resembled a boomerang, with the short tail supporting the medial lower lid and the long tail extending laterally along the zygomatic arch. The upper border was restricted by the level of the nasojugal interface, and the lower border was defined medially by the nasolabial fold and laterally by the level of the zygomaticocutaneous ligament. Lateral and medial sub-orbicularis oculi fat injections defined the boundaries of the boomerang shape, and injection to the deep medial cheek provided maximum projection. This is the first description of deep malar augmentation zones in clinical patients. Three-dimensional surface imaging was ideal for analyzing the surface change in response to targeted facial fat grafting. The authors' technique resulted in a reproducible surface shape, which they term the boomerang lift.