Tear Trough Ligament Research Articles

Percutaneous External Fixation of Redistributed Orbital Fat in Transcutaneous Lower Eyelid Blepharoplasty.

While percutaneous external fixation has gained popularity in transconjunctival blepharoplasty due to its simplicity and minimal incision, internal fixation remains the standard approach in transcutaneous blepharoplasty. This study aims to assess the safety and effectiveness of percutaneous external fixation specifically in transcutaneous fat repositioning blepharoplasty. From May 2022 to December 2023, a consecutive cohort of 97 patients underwent this surgical technique. Building upon the principles of transconjunctival fat repositioning, the procedure involved a minimal incision targeting the muscle layer, a conservative release of the tear trough ligament, and the repositioning of fat secured with percutaneous external fixation. Surgical outcomes were evaluated using the Barton grading system and FACE-Q scales for patient-reported outcomes. Following a mean follow-up of 7.2 months (ranging from 6 to 17 months), a resolution of tear trough deformities and eyelid bags was achieved in over 92% of cases. Notably, significant improvements (P < 0.05) were observed in lower eyelid aesthetics as measured by the FACE-Q scale, with a concomitant enhancement in patients' social confidence (P < 0.05). Overall, patients expressed satisfaction with their decision to undergo the procedure (71.0±19.1). Complications necessitating revision surgery included isolated cases of hematoma evacuation, fat injection, excision of excess fat, and skin excision. External fixation in transcutaneous blepharoplasty is technically less complex and minimally invasive, effectively securing transposed fat pedicles safely, presenting a viable alternative to conventional fixation techniques.

Orbital fat graft retroseptal transconjunctival blepharoplasty for treatment of groove in the infraorbital region.

To investigate the efficacy of the retroseptal transconjunctival blepharoplasty together with tear trough ligament (TTL) and Orbicularis retaining ligament (ORL) release with orbital fat graft in the management of groove in the infraorbital region (GIR). A prospective study of 80 eyes of 40 patients that underwent retroseptal transconjunctival lower blepharoplasty together with TTL and ORL release and resected orbital fat grafting. An ophthalmic examination includes lower eyelid evaluation and Barton's Tear trough deformity grading was done at baseline, 2weeks, 3months, and 6months after the surgery. Patient satisfaction was evaluated using Global aesthetic improvement scale (GAIS) and Blepharoplasty outcomes evaluation (BOE). Baseline tear trough defects were graded into grade 1, 2, and 3 in 12(15%), 39(48.75%) and 29(36.25%) eyes, respectively. While at 6months follow-up, grade 0 was recorded in 63(78.75%) eyes, and grade 1 was recorded in 17(21.25%) eyes. The amount of fat removed was 0.52 ± 0.04mL per eye, whereas the amount of injected fat graft was 0.24 ± 0.04. The mean operative time was 33.2 ± 4.1min per eye. GAIS showed degree 1, 2, and 3 in 8(20%), 29(72.5%), and 3(7.5%) patients at 6months follow-up, respectively. The mean baseline BOE increased significantly from 36.5 ± 5.9 to 86.9 ± 5.5 at 6months follow-up. Our cohort highlights the beneficial effects of TTD/ORL release with resected orbital fat grafting in the management of GIR and infraorbital hollow.

A novel description of the supporting system of the orbicularis oculi muscle in the infraorbital area: Tear trough muscle fiber.

The aim of this study was to elucidate the anatomical structures of supporting system of the infraorbital area. Forty-four hemifaces from eleven Korean and eleven Thai cadavers were used to dissect the infraorbital area. Based on the dissection and previous histologic results, they were analyzed. The orbicularis oculi muscle (OOc) had two portions (palpebral and orbital portion) and four subparts (pretarsal, preseptal, prezygomatic, and premaxillary part). The elliptical muscle fiber of OOc was supported by circumferential connective tissue including skin ligament, orbicularis retaining ligament, zygomatic ligament, and zygomatic cutaneous ligament. The vertical muscle fiber, the tear trough muscle fiber, and medial muscular band directly attached to the skin. Full of subcutaneous tissue in the tear trough groove, strong attachment to the bone by tear trough ligament and to the skin by tear trough muscle fiber would multiply result in the tear trough on the face.

Transconjunctival Fat Repositioning Blepharoplasty: Is Excess Fat Herniation a Prerequisite?

The fat repositioning technique has been widely used for the treatment of tear trough deformity, and there is a strong belief that excess fat herniation is a prerequisite for the procedure. The purpose of this study was to evaluate its effect in patients with minimal or no excess fat herniation. A total of 232 patients underwent the procedure and met the inclusion criteria. Of them, 198 were primary cases, and 34 had a hisory of fat removal for blepharoplasty. The amount of infraorbital fat was evaluated preoperatively by palpation. Release of the tear trough ligament and fat redistribution were sequentially performed as described previously. Surgical outcome was assessed based on the Hirmand grading system and the FACE-Q scales. Tear trough deformities were eliminated in more than 85% of cases. Aesthetic results were comparable between the primary and secondary surgery groups. The percentage of patients who complained of extremely or moderately severe tear trough deformities decreased from 86.3% preoperatively to 34.0% postoperatively. The scores of the lower eyelid FACE-Q decreased significantly ( P < 0.05). Patients were satisfied with their decision to undergo blepharoplasty (78.2 ± 18.7). Undercorrection of the tear trough occurred in 30 patients. Other complications included 12 cases of transient conjunctiva bleeding, two cases of eyelid numbness, and six cases of dry eye. These resolved spontaneously. Fat repositioning is a feasible and effective technique for the treatment of tear trough deformities in patients with minimal or no excess orbital fat herniation, provided that a fat pad is palpable. Therapeutic, IV.

Internal Fixation of Redistributed Orbital Fat in Transconjunctival Lower Eyelid Blepharoplasty.

Fat redistribution combined with release of the tear trough ligament in transconjunctival lower blepharoplasty is widely performed to correct lower eyelid bags and tear trough deformities, but suturing the released fat in such a narrow, dissected space remains a challenge. The purpose of this study was to introduce a new surgical technique of internal fixation that advances and sutures the pedicled orbital fat firmly to the midcheek through premaxillary and prezygomatic spaces. Twenty-two patients (age range, 22 to 39 years) with predominant orbital fat prolapse and tear trough deformity without noticeable lower eyelid skin laxity were treated with this method, all of whom had impressive correction of the eyelid bags and tear trough deformities and were pleased with the aesthetic results during an average follow-up of 11.8 months (range, 10 to 14 months). No patient had postoperative hematoma, ectropion, or midface numbness. The maneuver of internal fixation of redistributed orbital fat provides a novel and safe approach to correct eyelid bags and tear trough deformities without additional percutaneous sutures in transconjunctival lower eyelid blepharoplasty. Therapeutic, IV.

Novel treatment protocol for combined tear through ligament stretching and injection.

Complex anatomical changes have been the main challenges for optimal treatment results of tear trough deformities through hyaluronic acid (HA) injections. This study presents a novel technique consisting of a pre-injection tear trough ligament stretching (TTLS-I) leading to its release, and compared its efficacy, safety and patient satisfaction to tear trough deformity injection (TTDI). This was 4-year retrospective single-center cohort study of 83 TTLS-I patients, with a follow-up period of one year. One hundred and thirty five TTDI patients served as a comparison group.Outcome analyses included the analysis of possible risk factors for adverse outcome, as well as comparative statistics between the complication and satisfaction rates among the two groups. TTLS-I patients received significantly less hyaluronic acid (HA) (0.3cc (0.2cc-0.3cc)) than TTDI patients (0.6cc (0.6cc-0.8cc), p<0.001). The injected HA amount was a significant predictive factor for complications (p<0.05).Complication rates assessed during the follow-up visit for hematomas, edema, as well as the need for corrective hyaluronidase injection were low in both groups, with no significant differences among both groups. TTDI patients had significantly higher rates (5.1%) of lump surface irregularities during follow-up compared to 0% in the TTLS-I group (p<0.05).After one year of follow-up, 98.8% of TTLS-I patients were satisfied whereas TTDI patients were satisfied in 95.6%, with no significant difference. TTLS-I is a novel, safe and effective treatment method, necessitating significantly less HA compared to TTDI. Moreover, it leads to very high satisfaction, as well as very low complication rates.

Tear trough ligament reset as a new method for tear trough deformity and dark circles correction

Tear trough deformities and dark circles are important parts of periorbital aging. In this study, the tear trough ligament was reset to correct the tear trough deformity, and its effect on dark circles was analysed. The medical records of 60 patients who underwent eye bag plastic surgery between January 2021 and February 2022 were analysed (30 had traditional eye bag plastic surgery and 30 had the tear trough ligament reset). The tear trough deformity score and the dark circle score showed that the corrective effect on the tear trough deformity in the reset group was better than in the traditional surgery group at six-month follow up (mean (SD) tear trough rating scale (TTRS) score = 4.82 (0.95) vs 5.92 (1.00), p < 0.0001; L* value 55.27 (2.90) vs 47.51 (3.00), p < 0.0001). The satisfaction of patients in the reset group was significantly higher than it was in the traditional surgery group (25/30 vs 18/30, p = 0.045). Tear trough ligament reset is a safe and effective surgical method of periorbital rejuvenation, especially for beauty seekers with obvious tear trough deformities.

Tear Trough Ligament Release and Autologous Fat Injection as a New Method for Tear Trough Deformity Correction.

Even though the tear trough (TT) deformity is only 2cm in length, it can give a worn, even haggard appearance on the face. The authors developed a novel approach and presented findings from the clinical effect. Between February 2018 and January 2021, the medical records of patients treated with autologous fat injection for TT deformity were researched. The fat was placed under the orbicularis oculi muscle with a sharp cannula. During that period, the TT ligament was also released with the cannula. After the fat was injected entirely, we still needed to repeatedly puncture this ligament to release it until there was no puncture resistance. Improvement was evaluated by measuring patients' and investigators' global aesthetic improvement scale. 152 of 173 patients completed the follow-up plan and were enrolled in this study. The most common complications reported were temporary swelling and lumpiness. At 1 month, 3 months, 6 months, 12 months, and 24 months, the satisfaction rate of patient self-assessment was 93.4%, 89.5%, 86.8%, 84.3%, and 82.4%, respectively. The Investigator Global Aesthetic Improvement Scale showed 94.1% of patients' improvement after one month, 83.6% after three months, 78.3% after six months, 75% after 12 months, and 71.8% after 24 months. Fat injection based on TT ligament release to correct TT deformity is a novel, easy and effective treatment that deserves to be further used. 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 .

Use of Buried Guide Needle to Fix Inferior Eyelid Orbital Septum Fat for Tear Trough Depression Filling.

Fat fixation is a key step in filling tear trough depression with inferior eyelid orbital septum fat. The ideal position for inferior eyelid fat fixation is to cross the tear trough ligament causing tear trough depression and the orbicularis retaining ligament, with the distal end fixed at the farthest end of the dissected lacuna deep down the inferior orbicularis oculi muscle. Traditional suturing is difficult in the deep narrow lacunae, but a buried guide needle can be used to suture and fix the fat in the deepest lacuna. In this study, 264 patients who underwent tear trough filling using a buried guide needle to fix the released inferior eyelid orbital septum fat from 2017 to 2020 were followed up. The preoperative and postoperative imaging findings were compared to evaluate the effectiveness of the operation and postoperative complications. The inferior eyelid bulging, loose skin, and tear trough depression significantly improved than that before the operation. None of the patients had any severe complications, such as inferior eyelid ectropion, lagophthalmos, scar hyperplasia, and diplopia, in the long term (6 months) postoperatively. Five patients showed mild eyelid-eyeball separation and recovered in 1 month. Four patients had diplopia, and 3 patients had chemosis; all recovered in 7 days. The tear trough depression was not corrected completely in 2 patients. The operation showed satisfactory results in the improvement of tear trough depression in addition to alleviation of inferior eyelid bulging and loose inferior eyelid skin that is caused by the traditional inferior eyelid pouch removal.

Novel technique of non-surgical rejuvenation of infraorbital dark circles.

Infraorbital dark circles are a common esthetic concern which can be challenging to treat given their multifactorial nature. Under-eye darkcircles are seen in all skin types, with a strong familial component in darker skin types. Other major contributing factors include soft tissue and bony changes, skin changes, lifestyle contributions, and allergies. Involutional periorbital volumetric changes cause volume loss in the tear trough, naso-jugal and palpebro-malar grove, skin and subcutaneous tissues with tethering of the eyelid skin to the tear trough ligament, giving a sunken and hollow appearance to the lower lid. Associated prolapse of the orbital fat and thin skin can worsen the appearance of a dark circle. Hyaluronic acid fillers placed in the pre-periosteal plane in the tear trough, palpebro-malar and naso-jugal grooves, give good results in patients with thick eyelid skin and negligible fat prolapse. However, in patients with thin skin and moderate fat prolapse, authors have reported worsening outcomes with risk of Tyndall (blue-gray discoloration) and contour irregularities from visible lumps. To describe a novel technique to improve dark circles caused by a diffuse valley-type pre-septal tear trough deformity in patients with thin eyelid skin. Retrospective case note review of 330 eyelids treated with microdroplet subdermal placement of filler in the preseptal tear trough area by a single surgeon. This novel technique shows good esthetic outcomes in patients with dark circles, with good longevity and a low risk of complications.

Tear Trough Treatment with Orbicularis Oculi Muscle Suspension.

Blepharoplasty is a very requested surgery for aesthetic rejuvenation of the eyes with grateful results. Lower blepharoplasty involving a variety of different techniques can be considered to refresh the oculopalpebral area. The approach of the treatment of the tear trough as releasing the tear trough ligament and plication of orbicularis oculi muscle in the palpebral portion to fill the tear trough concavity is essential in our surgical technique demonstrated here. From July 2014 to January 2020, 435 patients were submitted to blepharoplasty surgery for rejuvenation of the eyes. Lower blepharoplasty was performed with releasing of the tear trough ligament and suspension and fixation of the palpebral part of the orbicularis oculi muscle in the medial part of orbital bone corresponding to the tear trough area. The follow-up was 12months. Patient satisfaction was high, and no complications were observed. Ten patients (2.2%) needed the addition of hyaluronic acid fillers in the tear trough 12months after the surgery. We conclude that the use of the orbicularis oculi muscle suspension improves the long-term aesthetic results for the tear trough and the technique is easy to perform. 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 .

Observations on the Tear Trough.

The tear trough is a prominent structure of the midface. Many surgical and nonsurgical techniques have been devised to efface this feature. The aim of this study was to define an aesthetically pleasing tear trough and understand the effect of various surgical procedures on its appearance. We undertook a retrospective review of "ideal" subjects (ie, young men and women as well as male and female models) as well as surgical patients undergoing lower blepharoplasty with fat excision, fat transposition, erbium laser resurfacing of the eyelids and midface, or endoscopic midface lifting. Marginal reflex distance-2, lower eyelid length, and nasojugal fold depth were measured and analyzed for all patients. The nasojugal fold was significantly less prominent in ideal female models than in all other groups (P < 0.0001). Lower eyelid length was significantly shorter after fat excisional lower blepharoplasty, laser resurfacing, and midface lift (P < 0.0001), and did not change after fat transpositional lower blepharoplasty. Postsurgical reduction in lower eyelid length was significantly less with fat transpositional lower blepharoplasty than in all other groups (P < 0.0001). The nasojugal fold was significantly effaced after all types of procedures (P < 0.0001), but was significantly more effaced after fat transpositional lower blepharoplasty (P < 0.01) than after all other procedures. A slight, medial tear trough is present in youth in many patients. The clinical tear trough is a virtual topographic structure distinct from the anatomic tear trough ligament and can be altered in a variety of ways.

The Long-Term Static and Dynamic Effects of Surgical Release of the Tear Trough Ligament and Origins of the Orbicularis Oculi in Lower Eyelid Blepharoplasty.

Release of the tear trough ligament and the origins of the orbicularis oculi is a key maneuver with many lower blepharoplasty techniques. The long-term static and dynamic effects of this release have not been studied previously. From December of 2012 to June of 2017, 105 patients were treated with the extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution as described previously. The long-term effect of the release was assessed by evaluating the effectiveness in correcting the tear trough deformity, the effect on the lower eyelid position, and the dynamic changes of the patient's smile. The mean patient age was 41 years (range, 23 to 62 years). The mean follow-up was 31 months (range, 12 to 53 months). The tear trough was effectively corrected with this maneuver. This release did not compromise the tarsoligamentous support of the lower eyelid, with no increase in scleral show in 99 percent of patients and with no patients developing ectropion. Functionally, the change in the action of the orbicularis oculi as a result of detachment of its origins resulted in a change in appearance of the smile. Elimination of the tethering at the tear trough ligament and the downward pull toward the medial suborbital maxilla resulted in elevation of the lid-cheek junction with smiling. Reduced efficiency of orbicularis contraction resulted in a diminished pretarsal bulge and in reduction of crow's feet with smiling. The maneuver is effective in correcting the tear trough deformity while not weakening the lower eyelid tarsoligamentous support. Functionally, the patient's smile became more youthful and rejuvenated, with less wrinkling and elevation of the lid-cheek junction with smiling. Therapeutic, IV.

Refinements in Tear Trough Deformity Correction: Intraoral Release of Tear Trough Ligaments: Anatomical Consideration and Clinical Approach.

Correction of tear trough (TT) deformity is a crucial aspect of facial rejuvenation. Because the anatomical origins of TT deformity lie in the TT ligaments, which firmly attach the dermis to the periosteum, the release of TT ligaments should be considered when performing an etiological correction. The aim of this paper is to propose an alternative method for TT deformity correction, comprising use of filler together with the release of TT ligaments. This technique was compared to the procedure of only percutaneous filler. From January 2014 to December 2015, 10 patients were enrolled in the study for recurrence of TT deformity. All the patients underwent TT ligament release and filler injections; all had been previously treated with percutaneous hyaluronic acid injection without ligament release. Under local anesthesia, the TT ligaments were detached using a blunt cannula introduced directly in the supra periosteal plane through an intraoral access. Once the ligament was released, the TT depression was evenly recontoured with a very small amount of filler. The clinical data, digital images, evaluations of outcomes, including patient satisfaction rates were collected and compared. Adding the procedure of TT ligament release to filler injections showed satisfactory results, avoiding an unnatural puffy appearance. The comparison between the two different methods showed improved outcomes and increased patient satisfaction with minor patient discomfort among those who underwent TT ligament release. Because TT ligaments are among the etiologic factors of TT deformity, they have a strong impact on procedures that are designed to improve TT deformity; therefore, TT ligament release should always be considered to obtain satisfactory, natural results. 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 .

Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution

Sir: In the August of 2017 issue of Plastic and Reconstructive Surgery, Wong and Mendelson published an interesting article in which the authors described in detail their methods of subtotally releasing the tear trough ligament and the orbicularis retaining ligament and redistributing the free orbital fat for the correction of the tear trough (lacrimal groove, nasojugal crease) and palpebromalar groove (lid-cheek junction) through the transconjunctival approach.1 Because the authors and we have similar treatment subjects (mainly Asians), and the periorbital rejuvenation is a subject on which we have worked intensively, we would like to share our thoughts about this technique. Wong and Mendelson have been consistently committed to studies of the anatomy of the periorbital region and midcheek and the antiaging treatments of the middle face.1–4 Their research achievements and surgical techniques of course contribute to better understanding the structures of these regions and choosing the optimum surgical procedure. The tear trough deformity is considered to be directly associated with the tear trough ligament, and the formation of the palpebromalar groove is mainly attributable to the orbicularis retaining ligament.2 It is also well known that the degree of infraorbital groove depends on the status of the tissue above (i.e., eye protrusion, prominence of the orbital fat pads, and looseness of the orbicularis oculi muscle and skin) and below (i.e., atrophy and descent of the malar fat pad and retrusion of maxillary) this furrow. Once the groove is seen, does it have to deal with the region? Everyone has the structure of the tear trough ligament (although it may be fragile and thus invisible), and almost all of the patients with eye bags have different degrees of prominence of the nasojugal crease. With these factors in mind, it is important for us to classify the tear trough deformity according to the morphologic features of the lacrimal groove and the situations of the surrounding tissue (because of the limit of article length, this section is not described here in detail). In other words, a judgment of which factor (i.e., the tear trough ligament, the surrounding tissues, or a combination of them) plays the major role in increasing the prominence of the tear trough must be correctly made preoperatively. In the article by Wong and Mendelson,1 the extended transconjunctival lower eyelid blepharoplasty with ligament release was performed on the patient (shown in Fig. 11) who had a mild eye bag and a slight tear trough even when smiling on the frontal view. According to our experience, we usually attribute the formation of this type of crease to the protruded orbital fat compartment. We do believe that transconjunctival blepharoplasty only with orbital fat removal can achieve a similar effect. The tear trough deformity that is visible in the static condition should be treated by ligament release, as shown in Figures 6 through 10. However, the surgical approach should be appropriately selected based on the laxity of the orbicularis oculi muscle and skin. Thus, we think that a transcutaneous approach may be preferential for the patient shown in Figure 10. Skin removal and tightening/suspending the orbicularis oculi can be performed simultaneously for better cosmetic outcome. It has been widely accepted that lifting is an essential step after releasing the tear trough ligament and orbicularis retaining ligament for treatment of the aging middle face, and that tissue suspension or repositioning seems unnecessary following the release of the two ligaments when aiming at correcting the periorbital groove. Although releasing the ligament does not lead to tissue ptosis in young patients or in short-term follow-up (as most of the cases presented in previously published articles), it is uncertain whether such a release procedure without suspension or repositioning will contribute to tissue ptosis over a long observation period such as 10 or 20 years. After all, a ligament, although it may create a depression or a crease/groove, may play a role in balancing the related tissue and preventing ptosis of tissue. DISCLOSURE The authors declare no potential conflicts of interest with the respect to the research, authorship, or publication. Qianwen Wang, M.D., Ph.D.Jiaqi Wang, M.D.Head & Neck Cosmetic Surgery CenterPlastic Surgery HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing, People’s Republic of China

Ageing of the bony orbit is a major cause of age-related intraorbital fat herniation

We evaluated the relationship between infraorbital fat herniation and age-related changes in the bony orbit and orbital fat density using computed tomography. Two hundred and sixty-five patients were enrolled (60 patients were evaluated for changes in the bony orbit and 205 for changes in orbital fat density). Five measurements using parasagittal sections and one measurement using three-dimensional images were obtained. Intraorbital fat herniation length was positively correlated with orbital rim inclination. Lowering of the inferior orbital rim, which is connected to the orbicularis retaining ligament, tear trough ligament and orbital septum, can cause mechanical stretching of the lower eyelid and may contribute to infraorbital fat herniation. A strong and significant negative correlation was observed between orbital fat density and age, indicating that existing orbital fat can accommodate an enlargement in bony orbit volume without orbital fat hyperplasia/hypertrophy. In other words, an increased orbital fat volume may be a by-product of the adaptation of orbital fat to changes in bony orbit volume. Mechanical stretching of the lower eyelid due to ageing of the bony orbit and weakening of the lower eyelid due to age-related factors such as dermal/fat/muscle atrophy and loss of muscle tone can together result in anterior drooping of the lower eyelid. Therefore, age-related changes in the bony orbit contribute to intraorbital fat herniation.

Extended Transconjunctival Lower Eyelid Blepharoplasty with Release of the Tear Trough Ligament and Fat Redistribution.

The transconjunctival lower eyelid blepharoplasty is advantageous for its quick recovery and low complication rates. Conventional techniques rely on fat removal to contour the lower eyelid. This article describes the authors' extended transconjunctival lower eyelid blepharoplasty technique that takes dissection beyond the orbital rim to address aging changes on the midcheek. From December of 2012 to December of 2015, 54 patients underwent this procedure. Through a transconjunctival incision, the preseptal space was entered and excess orbital fat pads were excised. Medially, the origins of the palpebral part of the orbicularis oculi, the tear trough ligament, and orbital part of the orbicularis oculi were sequentially released, connecting the dissection with the premaxillary space. More laterally, the orbicularis retaining ligament was released, connecting the dissection with the prezygomatic space. Excised orbital fat was then grafted under the released tear trough ligament to correct the tear trough deformity. When the patients had significant maxillary retrusion, structural fat grafting was performed at the same time. The mean follow-up was 10 months. High satisfaction was noted among the patients treated with this technique. The revision rate was 2 percent. Complication rates were low. No chemosis, prolonged swelling, lower eyelid retraction, or ectropion was seen in any patients. The extended transconjunctival lower blepharoplasty using the midcheek soft-tissue spaces is a safe and effective approach for treating patients presenting with eye bags and tear trough deformity. Therapeutic, V.

Abstract: Deep Pyriform Space: Anatomical Clarifications and Clinical Implications

BACKGROUND: To define the anatomical boundaries, transformation in the aging face and clinical implications of Ristow’s space. We propose a title of deep pyriform space for anatomical continuity. METHODS: The deep pyriform space was dissected in 12 hemifacial fresh cadaver dissections. Specimens were divided into 3 separate groups. For group 1, dimensions were measured and plaster molds were fashioned to evaluate shape and contour. For group 2, the space was percutaneously injected with dyed hyaluronic acid to examine proximity relationships to adjacent structures. For group 3, the space was pneumatized to evaluate its cephalic extension. RESULTS: The average dimensions of the deep pyriform space are 1.1 cm x 0.9 cm. It is bounded medially by the depressor septi nasi and cradled laterally and superficially in a “half-moon” shape by the deep medial cheek fat and lip elevators. The angular artery courses on the roof of the space within a septum between the space and deep medial cheek fat. Pneumatization of the space traverses cephalic to the level of the tear trough ligament in a plane deep to the pre-maxillary space. CONCLUSION: The deep pyriform space is a midface cavity cradled by the pyriform aperture and deep medial cheek compartment. Bony recession of the maxilla with age lends this space as a potential area of deep volumization to support overlying cheek fat and draping lip elevators. The position of the angular artery in the roof of the space allows safe injection on the bone without concern for vascular injury. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Deep Pyriform Space: Anatomical Clarifications and Clinical Implications.

The purpose of this study was to define the anatomical boundaries, transformation in the aging face, and clinical implications of the Ristow space. The authors propose a title of deep pyriform space for anatomical continuity. The deep pyriform space was dissected in 12 hemifacial fresh cadaver dissections. Specimens were divided into three separate groups. For group 1, dimensions were measured and plaster molds were fashioned to evaluate shape and contour. For group 2, the space was injected percutaneously with dyed hyaluronic acid to examine proximity relationships to adjacent structures. For group 3, the space was pneumatized to evaluate its cephalic extension. The average dimensions of the deep pyriform space are 1.1 × 0.9 cm. It is bounded medially by the depressor septi nasi and cradled laterally and superficially in a "half-moon" shape by the deep medial cheek fat and lip elevators. The angular artery courses on the roof of the space within a septum between the space and deep medial cheek fat. Pneumatization of the space traverses cephalic to the level of the tear trough ligament in a plane deep to the premaxillary space. The deep pyriform space is a midface cavity cradled by the pyriform aperture and deep medial cheek compartment. Bony recession of the maxilla with age predisposes this space for use as a potential area of deep volumization to support overlying cheek fat and draping lip elevators. The position of the angular artery in the roof of the space allows safe injection on the bone without concern for vascular injury.

Midcheek Lift Using Facial Soft-Tissue Spaces of the Midcheek

This article describes a preperiosteal midcheek lift technique performed by means of the midcheek soft-tissue spaces by precise release of the retaining ligaments that separate the spaces. From November of 2009 to June of 2014, 184 patients underwent this procedure. A transcutaneous lower eyelid blepharoplasty incision was used to access the preseptal space. Medially, the orbicularis oculi origins and tear trough ligament are released sharply, connecting the dissection with the premaxillary space. More laterally, the orbicularis retaining ligament is released, connecting the dissection with the prezygomatic space. With this release, the entire midcheek can be effectively lifted. The fat pads were managed by transposition, excision, or with septal resets as indicated. Canthopexy is performed routinely to provide lower eyelid support. Superolateral traction on the orbicularis oculi elevates the entire midcheek, and this was secured to the lateral orbital rim periosteum. In patients with significant volume loss in the midcheek, structural fat grafting is performed. All patients demonstrated a significant rejuvenation of the midcheek with elimination of the eye bags and elevation of the lid-cheek junction and the cheek prominence and improvement of the nasolabial folds. The majority of the patients (96 percent) were satisfied with the procedure. Complication rates were low. Ectropion occurred in 1 percent of patients, and lower lid retraction occurred in 1 percent of patients. The midcheek lift by means of the facial soft-tissue spaces is safe, effective, and long lasting. As the dissection is atraumatic, recovery is quick and complications are minimized.