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  • Several proposed techniques address tear trough deformity, but one surgeon argues that Hamra's technique has not received the recognition it deserves
  • Based on a study of 71 patients, this modified technique is shown to be both a safe and effective option

Dr. Barton
The tear trough deformity has always been a challenging area for cosmetic surgeons. Techniques to maximize aesthetic outcomes for this problem vary and all are neither equally accepted nor universally adopted. However, results of a study employing a surgical technique originally proposed by Loeb and later modified by Hamra (with some slight additional modifications) seem to warrant a second look at its use in tackling this cosmetic thorn.

44-year-old female with negative vector orbit and "tear trough triad."  Patient shown (left) before and (right) six months after septal reset blepharoplasty. (Photo credit: Fritz E. Barton Jr., M.D., F.A.C.S.)
ORBIT INEQUITY "In lower lid surgery, we have come to see that not all orbits are created equal and each orbit varies in its response to standardized surgical techniques," says Fritz E. Barton Jr., M.D., F.A.C.S., of the Dallas Plastic Surgery Institute in Dallas. "In my opinion, one of the most challenging orbital deformities to correct consists of a constellation of fat herniation, prominent orbital rim depression and malar rim retrusion, producing a negative vector orbit. We term this constellation the 'tear trough triad,'" he tells Cosmetic Surgery Times . Although there are several proposed techniques that address this orbital deformity, such as arcus marginalis release and fat preservation with the addition of an anterior reset of the orbital septum, according to Dr. Barton, Hamra's technique has not received as much recognition as it deserves. Therefore, he conducted a study in a series of 71 patients with this deformity, and applied a slightly modified technique of the arcus marginalis release, fat extrusion and septal reset to examine its effectiveness and safety. Of the 71 patients enrolled in the study, 59 patients completed a six-month or greater follow-up. All patients showed a deep, sharp demarcation of the orbital cheek junction, depression of the medial maxillary orbital rim, and herniation of the lower lid orbital fat, especially medially. A scale was developed to grade the pre- and post-op results, pre-operatively showing 12, 24 and 23 patients with grades I, II and III deformities, respectively. Grade 0 was considered to be an ideal, youthful eyelid with an indistinct surface grooving over the arcus marginalis. Post-op results showed that nine of the 12 grade I patients (75 percent) improved by one grade, and three of the 12 patients (25 percent) showed no change. Of the 24 grade II patients, 14 (58 percent) and 10 (42 percent) improved by two grades and one grade, respectively. Of the 23 grade III patients, 11 (48 percent), 10 (43 percent) and 2 (9 percent) improved by three, two and one grade, respectively.

NO FEAR The study showed the surgical technique to be effective in correcting the deformity: 95 percent of patients demonstrated at least one grade of improvement post-operatively. "Our group of patients was the most resistant to conventional methods of blepharoplasty, but, interestingly, they were also the patients at the greatest risk for extensive procedures traversing the middle lamella," Dr. Barton says. One of the most important results of the study was the absence of significant middle lamella shortening or contracture, which, according to Dr. Barton, is one of the most feared complications following this procedure and may be the reason the procedure never received recognition as a viable surgical technique for the correction of the tear trough triad.

"The most appealing approach to volume enhancement of the tear trough has been relocation of vascularized orbital fat. In effect, one is taking the excess of the hill above [the protruding fat] and using it to fill the valley [rim deficiency] below. This approach offers the soft contour and reliable survival of vascularized fat under the thin, almost transparent skin," Dr. Barton explains. One of the keys of the technique's success, he says, is the anterior reset of the orbital septum. "By resetting the orbital septum along with the fat down to the anterior surface of the orbital rim, the integrity of the septal partition is restored. The vascularized fat volume is delivered to the malar depression. The release of the orbicularis-retaining ligament as part of redraping the ptotic orbicularis completes the correction of the tear trough triad," Dr. Barton explains.

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