Asian Blepharoplasty: Autologous Fat Graft in Periorbital Rejuvenation and Volume Loss Prevention

Ageing of the periorbital is a multifactorial process involving volume loss (bone and soft tissue), tissue decent, and cutaneous degenerative changes. Traditionally, surgical approaches to address this area of the face have been subtractive in nature, focusing on excision of skin, muscle, and fat. However, this has frequently led to a gaunt or hollowed appearance, post operative. In recent years, there has been a shift in paradigm as contemporary aesthetic eyelid and periorbital rejuvenation move from an excisionally based surgical approach to one that prioritizes volume preservation and/or augmentation.

The development of fat grafting to the eyelids and periorbital has given surgeons viable alternative to prevent postoperative volume depletion, maintain the smooth transition of the lower eyelid to the cheek, and aid in restoring the youthful appearance desired after surgery.

Autologous Fat Graft: Misconceptions and Changing Trends

The use of autologous fat grafts in surgery is not a concept that is new in the medical field. Over the years, there have had been many publications, studies and literatures supporting the advantages and benefits of using autologous fat graft for the various areas of the body including, but not limited to, buttocks, breast and face. However, what is comparatively less common is the use of autologous fat graft for the eye - especially in the periorbital area.

One reason as to why autologous fat graft has not been favoured over other available alternatives in treating the periorbital area may be due to the fact that patients, in general, have a very misguided conception of fats. To a layman’s understanding, fats are, and have always been, something that one should get rid of. This misconception hold true at least for most patients over the past few decades or so - and this has led to many patients rejecting the idea of lipotransfer. However, in recent years, as consumption behaviour shift, patients have grown to become better informed and in turn become more accepting to autologous fat grafting procedures.

Today, patients are generally significantly more tech-savvy than generations of the past, and tend to make better informed decisions. This has thus, led to an increase in demand for the implementation of the latest and most advanced techniques for better results, even if the procedure involves having to have fat injected.

Periorbital Ageing and Fat Grafting

It is important to understand that the eyelids and the periorbit is a delicate area, and fat grating to this area is an extremely specialised surgical treatment that should be performed only by a medically trained professional.

The art of periorbital fat graft can allow a performing surgeon to restore volume and improve soft-tissue contours around a patient’s eye by filling the hollowness, sunken eyes, improve under eye creases, and periorbital dark circles.

Additionally, the use of autologous fat graft for the periorbital area can also address and correct minor eye bag problems, thinning skin and/or pronounced tear troughs by improving and restoring lost volume.

Based on the anatomy of the eye, it is thought that the ageing pattern of the eye not only starts from the depletion and loss of fullness in the periorbit, but also is one of the most obvious and earliest signs of facial ageing.

Although periorbital hollowness are often thought to be congenital, it has been reported in some studies that such indications can also be acquired (arising from trauma, disease or surgery). Furthermore, the fine and intricate tissues surrounding the eyes are also sensitive to environmental influences and will reflect physiological changes relating to general health, hydration, metabolism, hormonal status (females), as well as stress and lack of sleep - affecting the overall health as well as aesthetics of the periorbital area.

By placing autologous fat in the orbit, a performing surgeon can help patients improve their eyelid health for indications such as scarring, atrophy, lid retraction, ectropion, lagophthalmos and facial palsy - delivering a fuller, healthier soft contour of the periorbit.

Another advantage of autologous fat, aside from the fact that it eliminates risks of rejection by the body, is that it helps rejuvenate the eyelids; delivering a more attractive and appealing appearance regardless of gender.

Lower Periorbit vs. Upper Periorbit Ageing

In general, the periorbital area can be divided into two - namely, Lower Periobit and Upper Periorbit.

Lower Periorbit: The superficial area of the lower orbit is usually the first to lose volume, develop shadows, hollowness and creases making patients appear tired. Volume loss in the periorbit will also expose minor asymmetries to the bone or deeper underlying tissues, and some symptoms may include thinner skin as well as partial or generalised exposure of the lower orbital rim. This may be caused by issues of atrophy, age-related descent of the soft-tissue in the upper-cheek, or both.

Also known as 'lower periorbital hollowing’, ageing of the lower periorbit may also cause the tear-trough and orbitomalar groove to be more visible, forming a V-shaped depression at the lid-cheek junction. If structural support is compromised in the under-eye area due to changes in bone, ligaments and fat content, it can adversely affect the position, shape and function of the lower eyelids.

An option to treat lower eyelid indications is the transconjunctival lower eyelid approach, which allows precisely controlled fat repositioning and/or transplantation from the inside of the lid into creases along the lower border of the periorbital area. This technique can be combined with microsurgical fat grafting (lower eyelids) and conventional fat transfer to the upper cheek to help restore lost volume and rejuvenate the lower periorbit.

Upper Periorbit: When analysing volume loss in the upper orbit, it is important to understand and distinguish if its superficial or deep hollowness. Superficial loss of volume usually occurs simultaneously with the surrounding facial fat compartments of the brow and temple which may include, but not limited to; skin laxity, rhytids, brow deflation, brow descent and upper eyelid hooding. Advanced superficial hollowing may also cause a sunken temple and reveal the bony outline of the orbital rim.

On the other hand, deep structural fat may be more resistant to age-related deflation, hence, volume loss inside the orbit is often genetically determined with most patients indicating similar features in their parents or grand parents. Changes are also initially more pronounced in the central-inner aspect of the orbital rim (sometimes referred to as an 'A-frame deformity'). In the case of more advanced hollowness, the entire eye socket may appear sunken, forming a 'deep superior sulcus' below the orbital rim.

Due to the fine structures, treatment for deeper hollowness demands for a more detailed surgical grafting of either fat (microsurgical fat grafting and/or pearl fat grafting) or dermis (lipo-dermal graft) in order to provide a precise and layered augmentation. In addition, volume enhancing upper eyelid surgery may be required to provide improvements for lighter degrees of upper eyelid hollowness.

Although superficial and deep volume loss may occur simultaneously, they represent two distinct medical conditions, which require a different treatment approach.

Autologous Fat Graft: Periorbital Rejuvenation and Volume Loss Prevention

Autologous fat graft is extremely beneficial to patients as it not only eliminates the risks of adverse reaction due to rejection by the host body but also allows for the transfer of multi-layered living fat cells to both the superficial and deep tissue compartments. Autologous fat also has very high rejuvenative potential, and when the right technique is employed, a physician can expect to significantly help patients look more refreshed with longer lasting improvements in terms of aesthetics and function.

Treatment with autologous fat is also effective in preventing ageing related to atrophy and volume loss in and around the periorbital region. By preserving natural youthful facial contours, it reduces the likelihood for age-related changes which occurs as a result of deflation in skin laxity and descent of soft-tissue.

Hope you have enjoyed the article! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses!

References:

https://iovs.arvojournals.org/article.aspx?articleid=2350866

https://journals.sagepub.com/doi/abs/10.5992/AJCS-D-12-00009.1

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