"It rejuvenates the lower eyelid complex wonderfully," says Paul S. Nassif, M.D., F.A.C.S., who, along with Guy G. Massry, M.D., has performed approximately 150 of these procedures in the past four years. Drs. Nassif and Massry are in private practice at Spalding Drive Cosmetic Surgery and Dermatology, Beverly Hills, Calif.
Dr. Nassif began performing the technique in response to patients who previously had transcutaneous and transconjunctival lower eyelid blepharoplasties, but became dissatisfied when the final results left them looking gaunt or hollow.Tear trough deformity Age is a major contributor to the tear trough deformity that fat repositioning addresses so adeptly.
"The cheek descends inferiorly with age and produces a depression at the medial inferior orbital rim, resulting in a double convexity deformity. The first convexity around the lower eyelid fat is pseudo herniating or bulging, and the next convexity is the cheek or the mid face, and this is a sign of the tear trough deformity and the natural evolution of aging," Dr. Nassif says. Another contributor to the tear trough deformity, he points out, is a bony deficiency of the maxilla.
Dr. Nassif uses a transconjunctival approach to reposition the medial and the central lower lid herniated fat into the nasal- jugal fold to prevent hollowness and fill in the tear trough deformity.
"There are some disadvantages to this technique because there is a steep learning curve," he says. Potential complications include diplopia, fat granuloma, soft tissue irregularities and prolonged edema. "Fat granulomas are rare but can occur with even the best surgical technique possible," he adds.
Dr. Nassif described his technique at the annual meeting of the American Academy of Facial Plastic and Reconstructive Surgery.
The vast majority of patients in Drs. Nassif and Massry's series had excellent outcomes.
"Four years after surgery, the majority of these patients have no hollowness and the area looks very smooth," Dr. Nassif says. Two patients had fat granulomas; one is ongoing and has become persistent, and the other was temporary and has been resolved, he says. A few patients had prolonged swelling in the lower eyelid area for two to three months, which also resolved.
Technique A critical part of Dr. Nassif's technique relies on identifying the inferior oblique muscle.
"Once that's accomplished, I then dissect the fat and the soft tissue from the fat that's attached to the muscle away from it so that the fat essentially has no attachment to the muscle," he explains.
Once a fat pad pedicle is created and all soft tissue attachments to the inferior oblique muscle are eliminated, he performs an arcus marginalis release and subperiosteal dissection nasal to the infraorbital nerve.
"Then we perform an out-to-in transcutaneous suture into the subperiosteal space, into the fat pedicle with a horizontal mattress suture and then into the subperiosteal space and out to the skin," Dr. Nassif explains.
"When I place the fat into the subperiosteal pocket, I spread it out and make sure it's not folded on itself and flat. Then I tie the stitch over a cotton bolster; perform force ductions to make sure there's no tethering of the inferior obliquemuscle, and after five days I remove the suture." Once the technique is perfected, according to Dr. Nassif, the outcomes far exceed just removing the fat.