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Volume replacement rejuvenates periorbital area

Barcelona, Spain — J. William Little, M.D., says it's high time facial cosmetic surgeons rethink traditional procedures for performing periorbital rejuvenation — the correction of the sagging areas around the eyes that give a patient a tired, aged look.

Dr. Little, clinical professor of surgery at Georgetown University in Washington, discussed his views in a lecture, "Periorbital Rejuvenation: The Role of Volume Replacement," presented during the American Society of Plastic Surgeons Biennial Plastic Surgery Cruise here in July.

"Traditional procedures for correcting old-looking areas around the eyes involve the excising of skin, muscle and fat to get rid of bags and wrinkles," Dr. Little says. "But in my opinion, that's wrong — as wrong as anything has been in our profession."

Dr. Little argues that when volume is removed from the eye area, the area may look better but it doesn't look younger; the procedure replaces one aged look with another.

"In fact, volume removal often gives the eye area a hollow look, which is as aging as bags, sagging skin or wrinkles," he says. "The difference between an old orbit and a young orbit is volume. Volume is lost over the years — you don't want to take volume out, you want to add it in order to get a truly younger look around the eyes."

Two methods Dr. Little advocates two types of procedures as alternatives to volume removal: suspension and restoration of volume.

"The key point in suspension procedures is this: What needs to be suspended is the orbicularis oculi, a sphincter-like muscle surrounding the eye," he says. "This muscle can droop with aging, and suspension is a preferred technique for lifting this muscle and correcting the sagging look."

In Dr. Little's opinion, however, when it comes to correcting sagging and drooping around the eyes, volume restoration trumps suspension procedures in terms of providing a more youthful look.

"I'm practically alone in adding volume around the eyes, but I think others are beginning to see the benefits of this technique," he says. "How I differ is that I don't remove or replace volume — I add volume. Over the last five years, I've removed fat in well under 5 percent of my patients, and they were cases that involved extreme fatty eye bags or asymmetry."

Fat grafts preferred Dr. Little says he's used a variety of fillers — such as block grafts of dermis and fat, and silicone implants — as volume replacement in periorbital rejuvenation, but now, he says, he uses structural fat grafting almost exclusively.

"The technique I've developed over the years is to use small grafts and to use smaller needles, both to harvest and inject the fat — I call it micro-grafting," he says. "I do this not in the eyelid, but over the orbital aperture or margin that surrounds the eyelid. Different zones around the orbit require different levels of injected fat, some deep, some superficial."

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