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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 106  |  Issue : 4  |  Page : 223-225

Preperiosteal suborbicularis oculi fat lift blepharoplasty


Department of Ophthalmology, Ain Shams University, Cairo, Egypt

Date of Submission15-Mar-2013
Date of Acceptance09-Sep-2013
Date of Web Publication28-Apr-2014

Correspondence Address:
Thanaa H Mohammed
MD, 91 St. Sheratoon Building Airport Saker Qurish. Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.131560

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  Abstract 

Aim
The aim of this study was to determine the effect of preperiosteal suborbicularis oculi fat (SOOF) lift blepharoplasty in the treatment of tear-trough (nasojugal) deformity.
Patients and methods
A prospective interventional case study was carried out on 10 eyelids (five patients; four women and one man), age range 40-70 years (mean ± SD, 58.0 ± 11.0); all of them had tear-trough deformity as a part of midfacial aged appearance with prolapsed orbital fat. A preperiosteal SOOF lift blepharoplasty was performed under local or general anaesthesia, adding a preseptal orbicularis oculi muscle sling and lateral canthal resuspension in cases of lower lid laxity. The tear-trough deformity was observed objectively and subjectively, and reported over the following 6 months.
Results
All patients showed improvement in the tear-trough deformity 1 month postoperatively. None of the patients required repeat surgery at the end of the follow-up period (6 months). Early postoperative complications (1 day postoperative) included periorbital oedema, ecchymosis and conjunctival chemosis (10 eyes, 100%), subconjunctival haemorrhage (two eyes, 20%), brownish skin pigmentation (four eyes, 40%) and epiphora (four eyes, 40%). Lid retraction was observed in one eyelid (10%, 1 month postoperative) and numbness of the ipsilateral cheek in six eyelids (60%).
Conclusion
SOOF elevation can be used as a part of a routine lower lid blepharoplasty for the treatment of the tear-trough deformity. It may be considered a safe addition to other techniques of midfacial rejuvenation.

Keywords: Suborbicularis oculi fat (soof), blepharoplasty, tear-trough deformity


How to cite this article:
Elwan S, Rashad S, Mohammed TH, Farweez YA. Preperiosteal suborbicularis oculi fat lift blepharoplasty. J Egypt Ophthalmol Soc 2013;106:223-5

How to cite this URL:
Elwan S, Rashad S, Mohammed TH, Farweez YA. Preperiosteal suborbicularis oculi fat lift blepharoplasty. J Egypt Ophthalmol Soc [serial online] 2013 [cited 2017 Oct 23];106:223-5. Available from: http://www.jeos.eg.net/text.asp?2013/106/4/223/131560


  Introduction Top


Suborbicularis oculi fat is designated by the acronym SOOF. The SOOF is a periorbital fat pad similar to the retro-orbicularis oculi fat pad in the brow [1].

SOOF is located immediately deep to the orbital portion of the suborbicularis oculi muscle, immediately inferior to the inferior orbital rim and directly posterior to the suborbicularis oculi muscle [2].

With age, there is a gradual descent of both the orbicularis and the SOOF. This results in the typical appearance of an involutional midface ptosis with a prominent palpebral-malar fold, where there is sagging cheek skin and hollowing in the infraorbital region between the eyelid and the cheek [1]. This contributes towards the double-convexity and tear-trough deformity (nasojugal fold) noted with age [3].

Conventional lower eyelid procedures continue to include removal of orbital fat in most cases. The unfortunate results of these traditional procedures are becoming easy to recognize. The lower eyelid contour becomes deeper, and often a hollow appearance develops. Removal of eyelid fat simply transforms the 'double-convexity deformity' into a 'concavity-convexity deformity'. This, combined with the lateral vector facelift techniques, produces the pulled 'operated' appearance [4].

Rejuvenation of the lower eyelid complex should be based on the principle that the contour changes characteristic of aging involve not only prolapse of orbital fat but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear-trough groove [5].

Repositioning (raising) the SOOF helps to elevate the overlying tissues, which in turn helps to elevate the lower eyelid tissues because they are a continuum [1].

Although the necessity of preserving fat and repositioning the soft tissues of the midface has been widely accepted, there is wide disagreement among authors as to the best approach and surgical technique [6].

This article describes the midfacial rejuvenation though a preperiosteal SOOF lift blepharoplasty using a full-access transcutaneous approach.


  Patients and methods Top


A prospective interventional case study was carried out on 10 eyelids (five patients), all of them with tear-trough deformity as a part of midfacial aged appearance with prolapsed orbital fat. The patients were followed up for 6 months (first day postoperative, 1 week, 2 weeks, 1 month, 3 months and 6 months).

Surgical technique

Prominent fat pads and tear trough were first marked. Four patients (eight eyes) received local anaesthesia and one patient (two eyes) received general anaesthesia. Incision was placed 2 mm inferior to the lashes starting several millimetres temporal to the punctum, along the lid margin towards the lateral canthus and extending laterally towards the orbital rim in a pre-existing rhytid.

A musculocutaneous flap was then developed. Blunt dissection through the submuscular space was carried out to the infraorbital rim laterally and inferiorly [Figure 1]a. The orbitomalar ligament was divided along the entire infraorbital rim. The medial origins of the orbicularis oculi, levator labii superioris and levator alaeque nasi muscles were released from the inferior orbital rim to relieve a tear-trough deformity.
Figure 1:

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Once the orbitomalar ligament was released, the SOOF became visible. Dissection superficial to the periosteum was performed 10 mm below the orbital rim, preserving the zygomaticofacial and zygomaticotemporal nerves [Figure 1]b.

SOOF was then plicated using one to two 5/0 nonabsorbable polyester green braided sutures. These were attached to the periosteum of the orbital margin (arcus marginalis) [Figure 1]c.

Excess herniated fat was then excised taking care of the inferior oblique muscle as it passes between the medial and lateral fat compartments.

The preseptal orbicularis oculi muscle was then pulled laterally and superiorly and sutured to the periosteum of the lateral orbital rim in a position superior to the lateral canthus attachment.

The previously undermined skin was redraped over the lower eyelid to assess the amount of redundant skin that will be superior to the infraciliary incision, and excision of the excess skin was performed. Skin incision was closed using interrupted 6/0 silk sutures.


  Results Top


Ten eyelids (five patients) were studied; there were four women (80%) and one man (20%). Their ages range was 40-70 years (mean ± SD, 58.0 ± 11.0).

All patients showed improvement in tear-trough deformity 1 month postoperatively. None of the patients required repeat surgery at the end of the follow-up period (6 months). Early postoperative complications (1 day postoperative) included periorbital oedema, ecchymosis and conjunctival chemosis (10 eyes, 100%), subconjunctival haemorrhage (two eyes, 20%), brownish skin pigmentation (four eyes, 40%) and epiphora (four eyes, 40%). Lid retraction was observed in one eyelid (10%, 1 month postoperatively) and numbness of the ipsilateral cheek in six eyelids (60%). Resolution of postoperative complications occurred as follows: periorbital oedema and ecchymosis within 3-6 weeks (mean ± SD, 4 ± 1.15), conjunctival chemosis within 1-8 weeks (mean ± SD, 3.7 ± 2.6) and subconjunctival haemorrhage within 1-2 weeks (mean ± SD, 8.6 ± 3.65).

Brownish skin pigmentation necessitated application of topical bleaching cream (hydroquinone 4%) to resolve within 1-2 months. Mild lid retraction resolved spontaneously after 4 months with daily skin massage. Epiphora disappeared in 2 months. Numbness resolved in 2-4 weeks (mean ± SD, 3 ± 0.93) [Figure 2].
Figure 2:

Click here to view



  Discussion Top


With age, the SOOF and superficial musculoaponeurotic system attachments to the zygomaticus muscles deteriorate and the orbicularis oculi fibres become stretched. The orbicularis muscle migrates inferolaterally and becomes crescent shaped, contributing towards malar bags and festoons [2].

By grasping the SOOF and elevating it to the level of the infraorbital rim, the entire cheek can be mobilized [2].

Turk and Goldman [7] used the regular subciliary incision and combined the arcus marginalis release with septal reset, SOOF lift in the preperiosteal plane, lateral retinacular canthopexy and skin muscle resection. They {9} reported their technique to be easily modifiable to handle a variety of clinical situations.

Atiyeh and Hayek [6] described a technique of subsuperficial musculoaponeurotic system fat pad (SOOF) plication as an alternative to vertical pulling. They used the combined arcus marginalis release, preseptal orbicularis muscle sling and SOOF plication for midfacial rejuvenation. They sutured the exposed lower part of the fat pad to the periosteal flap folding the fat on itself. They reported that it resulted in the desired midface elevation and malar augmentation with minimal vertical vector pull. Lower placement of the plication sutures simulates the cheek imbrication described by Ramirez [8].

Atiyeh and Hayek [6] criticized the SOOF lift blepharoplasty, consisting of a primary vertical suture suspension of the fat pad, that, on dissection of the fat pad in the preperiosteal plane fatty tissues, does not provide a stable grip for suspension and will invariably stretch with time and sag. Although gripping the fat pad intraoperatively is not as easy as it sounds, we observed clinical stability of the suspended fat pad through the 6-month follow-up period.

Postoperative brownish skin pigmentation that occurred in four eyelids developed because these patients had very thin skin, which is probably the cause of reactionary pigment deposition. Excessive cauterization, performed to control the severe intraoperative haemorrhage that occurred in one eyelid of patient number 4, was probably the cause of lid retraction in this eyelid. Epiphora that occurred in four eyes was mostly because of the marked conjunctival chemosis that occurred in these four eyes that led to mild anterior displacement of the lower lid, thus interfering with the adequate drainage of tears.

One limitation of the present study is the absence of a control group. Control patients would undergo the same technique but without elevating and fixing the SOOF. Although not evidence based, we believed that all patients here had to undergo SOOF elevation to enhance cosmesis. A controlled, randomized study is still needed to assess the actual need for SOOF elevation in lower eyelid blepharoplasty for tear-trough deformity.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Olver JM. Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy. Br J Ophthalmol 2000; 84 :1401-1406.  Back to cited text no. 1
[PUBMED]    
2.Shorr N, Perry JD. Lower blepharoplasty and midface descent, chapter 11. In Chen WP, editor. Oculoplastic surgery, the essentials. New York: Thieme Medical Publishers, Inc.; 2007. 147-164.  Back to cited text no. 2
    
3.Mohadjer Y, Holds JB. Cosmetic lower eyelid blepharoplasty with fat repositioning via intra-SOOF dissection: surgical technique and initial outcomes. Ophthal Plast Reconstr Surg 2006; 22 :409-413.  Back to cited text no. 3
    
4.Hamra ST. Prevention and correction of the ′face-lifted′ appearance. Facial Plast Surg 2000; 16 :215-229.  Back to cited text no. 4
[PUBMED]    
5.Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105 :743-748.  Back to cited text no. 5
[PUBMED]    
6.Atiyeh BS, Hayek SN. Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation. Aesthetic Plast Surg 2004; 28 :197-202.  Back to cited text no. 6
    
7.Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty. Facial Plast Surg 2001; 17 :37-48.  Back to cited text no. 7
    
8.Ramirez OM. Three-dimensional endoscopic midface enhancement: A personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg 2002; 109:329-340.  Back to cited text no. 8
[PUBMED]    


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Abstract
Introduction
Patients and methods
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