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Fat grafting represents the most important new addition to surgical procedures to rejuvenate the orbit since the inception of the "blepharoplasty" technique. Traditional blepharoplasty procedures do not always address the changes that occur with age in the orbital area and can actually degrade the appearance of the eye. Fat grafting allows treatment of age-associated loss of periorbital volume not addressed by traditional blepharoplasty procedures. Fat grafting is an artistically powerful method to rejuvenate the periorbital orbital area that often provides a more healthy, fit, youthful, and sensual appearance than traditional blepharoplasty procedures.

Transconjunctival lower lid blepharoplasty is a safe and effective procedure with a low complication rate. Success with this procedure depends on proper patient analysis and selection. The lower lid periorbital fat can be resected, or preserved, and draped over the orbital rim or used as free fat grafts, depending on the clinical presentation. The lower lid skin can be resurfaced with a peel, with a laser, or by skin pinch depending on surgeon preference.

Unilateral recurrent maxillary sinusitis is a common sinunasal pathology, mostly related to the ostiomeatal complex dysfunction. Although sinusitis can potentially spread to the adjacent structures, orbital cellulitis remains an exceptionally rare sequela.The authors report the unusual case of a patient who presented with recurrent maxillary sinusitis complicated by cyclic episodes of periorbital cellulitis related to ostiomeatal complex obstruction from herniated periorbital fat through an unnoticed medial orbital wall fracture. To the best of our knowledge, no other similar case has previously been reported. The possible explanation for such an unusual association is discussed.

There is no secret to achieving successful results with lower belpharoplasties; as is the case with any surgical procedure, proper patient evaluation and development of a comprehensive, anatomic-based treatment plan are prerequisites for success. For situations in which a patient has little lid laxity and pseudoherniated periorbital fat, transconjunctival lower blepharoplasty is the treatment of choice. Transconjunctival lower blepharoplasty enables the surgeon to reposition fat, effectively blending the lid-cheek junction and filling the tear trough deformity. In order to better enable clinicians to achieve optimal outcomes, the authors advocate an anatomic-based approach for patient evaluation and treatment planning.

Facial cosmetic surgery techniques are constantly updated to meet the expectations of patients who demand less invasive procedures and less recovery time. Current trends in lower eyelid surgery call for periorbital fat repositioning instead of excision of fat. Controversies still exist in chin augmentations regarding osseous genioplasty versus alloplastic chin implant. The benefits, disadvantages, and considerations of these procedures are discussed.

The aim of this study was to determine the particle size, temperature, and amount of released fat for safe periorbital fat grafts. From 28 patients, fat was suctioned from the abdomen (large particles [LPs]) and from the inner thigh (small particles [SPs]) using a 2.1-mm harvesting cannula with a diameter 3.2 × 1.4-mm hole and a 1-mm hole, respectively. The 10-mL syringes full of fat were then put into a centrifuge for 3 minutes (LP) and 1 minute (SP) at 3000 revolutions/min. Fat was then transferred to a 1-mL syringe with Luer-Lock adapters and a blunt cannula of 0.9-mm diameter. The force needed to push the fat out of the cannula was measured with a force gauge. The force was measured within the different groups according to particle size of the fat, temperature of the fat, and released amount of fat. The force needed to push the SP fat out of the cannula into the air with minimal amount (MA) (0.01-0.02 mL) injected at room temperature (25 °C) (1.75 ± 0.82 N) was significantly greater (P = 0.000 [t test]) than at body temperature (BT, 33 °C) (1.27 ± 0.38 N). At BT, the force needed to push the SP fat into subcutaneous pig tissue (2.30 ± 1.46 N) was significantly lesser (P = 0.000 [t test]) than LP fat (6.54 ± 2.39 N). At BT, the force needed to push the MA of SP fat into pig subcutaneous tissue (1.38 ± 0.26 N) was significantly lesser (P = 0.000 [t test]) than the force needed to push the usual amount (0.03-0.04 mL) of SP fat (3.83 ± 1.78 N). The force needed to push the fat into human lower eyelids at room temperature (4.06 ± 2.26 N) was significantly greater (P = 0.000 [t test]) than at BT (2.11 ± 0.96 N). At BT, the force needed to inject an MA of SP fat into human lower eyelids (1.55 ± 0.83 N) was significantly lesser (P = 0.000 [t test]) than the force needed to inject a usual amount of fat (2.78 ± 1.03 N). We suggest injections of the SP (1-mm hole diameter harvesting cannula) fat with MAs (0.01-0.02 mL) by means of fragmented incremental injections stored at BT (33°C) to reduce the injection pressure.

Introduction: Recently there has been an evolving paradigm shift toward the treatment of facial volume loss either alone or in conjunction with more traditional modalities. Although volume augmentation is commonly used in rejuvenation of the upper orbital sulcus and brow, the effect on the upper eyelid has not yet been documented. This article describes one clinician's experience (A.N.K.) with autologous fat grafting to the upper orbital sulcus and the effect on upper eyelid position. Materials and Methods: After a detailed clinical evaluation of the periorbital region including overall facial aging, brow position, and eyelid laxity, 7 patients underwent autologous fat transfer to the periorbital region. Comparison of photos taken before and after the procedure showed a clear increase in the upper eyelid height. Results: All 7 patients described in this study demonstrated objective increase in upper lid height after periorbital autologous fat transfer, ranging from 0.41 mm to 2.08 mm, with a mean of 1.00 mm. Discussion: Periocular volume augmentation and its effect on lower eyelid position have been described previously. An attempt to alter upper eyelid height with volume augmentation directly to the upper eyelid has also been described recently. However, to the authors' knowledge, this is the first report of volume augmentation to the periorbital region affecting upper eyelid position in this manner. The clinical application of this observational data is not yet clear. However, the potential exists for extension of this modality to upper eyelid malposition such as ptosis.

Haemangioma of infancy is a common birthmark. As spontaneous involution is the rule, it is usually treated conservatively. Periorbital haemangiomata may require intervention if symptomatic and this may be early or late, where plastic surgery may be required. It has not previously been recognised that deep periorbital lesions may lead to a baggy appearance of the eyelids because of excess fatty tissue. The management of this condition is described in different clinical presentations illustrated by three female patients with a history of infantile periorbital haemangioma. Two were treated by blepharoplasty, during which an excess of fatty tissue was found, deep to the orbital septum. Birthmark stigmata were eradicated and symmetry was achieved.

The decision of whether to perform a blepharoplasty is based upon consideration of a number of physical characteristics, including the presence of excess eyelid skin, of thick rugal folds, and of pads of herniated periorbital fat. Patients whose problem is thick rugal folds wil benefit most from a facelift and chemical peel; for those with weathered skin alone, a chemical peel may be sufficient to improve the appearance. In the absence of significant herniated periorbital fat of the lower lid, lower blepharoplasty is rarely indicated. In most cases, an upper blepharoplasty with a face-lift provides a satisfactory solution.

Periorbital aging is a multifactorial process involving volume loss (bone and soft tissue), tissue decent, and cutaneous degenerative changes. Traditional approaches to surgery on this area of the face have been subtractive in nature, focusing on excision of skin, muscle, and fat. This has frequently led to a gaunt or hollowed postoperative appearance. Contemporary aesthetic eyelid and periorbital rejuvenation has undergone a paradigm shift from an excisionally based surgical approach to one that prioritizes volume preservation and/or augmentation. The development of fat grafting to the eyelids and periorbita has given the eyelid surgeon a viable surgical 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. This article will focus of periorbital fat grafting and touch upon fat preservation techniques as primary restorative procedures or as surgical adjuncts.

Contemporary esthetic facial rejuvenation has undergone a paradigm shift from what was once a primarily excision-based approach to one with an emphasis on volume preservation and augmentation. Nowhere on the face is this more evident than in the periorbital region. Fat grafting has become an accepted and pivotal component of volume augmentation strategies. Over the last decade, fat grafting has become not only a critical surgical adjunct, but also a primary stand-alone procedure to restore the youthful lower lid and its interface with the cheek. While this transition has been slower in regard to the upper lids, we are now seeing a similar progression in this area. Successful outcomes are dependent on a critical knowledge of periorbtial aging, establishing appropriate patient expectations, and on implementing a conservative approach as one gains increasing experience with the technique.

Prostaglandin F2 alpha (PGF2a) analogues including bimatoprost and travoprost are used worldwide, often as first line topical treatments for glaucoma. We present 2 cases of a newly described side effect of both these topical agents in terms of periorbital fat atrophy. This visually noticeable side effect had features demonstrable on MRI scanning. The periorbital fat atrophy is most apparent with uniocular use and both doctors and patients need to be aware of this side effect before commencing treatment. The effects, however, appear to be reversible with treatment cessation.

The authors present a case of chronic recurrent sinusitis of rare etiology in a man submitted previously to a facial peeling. The computed tomography and the sinusal endoscopy revealed periorbital fat in the maxilary sinus. There was a history of old orbital floor fracture.

Several approaches may be used for access to the orbital limbus and floor for the management of orbital trauma: transconjunctival, subciliary, subtarsal, and subpalpebral.1–4 All of these methods have advantages and disadvantages, and the choice is usually a matter of personal experience. From the purely aesthetic point of view, the transconjunctival method leaves no skin scars, but the periorbital fat frequently prevents proper reconstruction of the orbital floor. Therefore, it is often necessary to widen the surgical access by lateral canthotomy, which does leave a scar and nullifies the advantage of this method over others. The subciliary, subtarsal, and subpalpebral methods provide excellent access to the lower orbital limbus, part of the lateral limbus, and the entire orbital floor, leaving a scar that is covered by the ciliary shadow and becomes imperceptible. However, some problems remain in relation to scleral show and sometimes ectropion.5–7 To eliminate these complications, we use the technique of suspending part of the orbicularis oculi muscle, as described by Adamson et al8 for blepharoplasty, to combat scar contraction and to prevent ectropion and the appearance of a round eye.

In the last 4 years, there have been a few reports concerning unconventional management of the fat posterior to the orbital septum (intraorbital) as well as periorbital fat located superficial to the orbital septum in a plane both superficial and deep to the orbicularis oculi muscle. With reference to intraorbital fat, some reports suggest that this fat be preserved and mobilized to other areas to recontour the lower lid, while other authors suggest repositioning the fat within the bony orbit. To address these new concepts, a discussion of the theories behind these approaches is needed.

Three basic surgical techniques exist for lower-lid blepharoplasty: (1) the skin flap, (2) the transconjunctival approach, and (3) the skin-muscle flap. Each addresses the problems of excessive skin, muscle, and infraorbital fat either alone or in combination. None of these procedures will correct fine wrinkles. In fact, in some patients the lower-lid wrinkling appears far worse after fat removal. We describe a "fourth option" to lower-lid blepharoplasty which corrects the problem of fine wrinkling, periorbital fat herniation, and mild skin excess. For these patients, we remove the fat through a transconjunctival approach and peel the lower lid using full-strength Baker's phenol solution. To date, we have performed this procedure in 17 patients with excellent results. There have been no complications. Our longest followup is 30 months. This procedure is indicated for patients with both excess infraorbital fat and lower-lid skin with associated fine wrinkling. Only the experienced surgeon should attempt this procedure. Caution should be exercised with patients who have previously undergone blepharoplasty as severe ectropion has been reported with chemical peel around the eyelids. Lower-lid chemical peel after a modified skin-muscle flap has been described, but we believe that peeling after a transconjunctival approach is safer. We feel that with more knowledge and experience using the "fourth option" of lower-lid blepharoplasty, it will become the procedure of choice for select patients.

A clinical study on the surgical anatomy of the upper-eyelid fat pads was performed on 55 consecutive patients who underwent a blepharoplasty. It was confirmed that the periorbital fat is encapsulated in compartments and that the number of fat pads varies. In 56% of the cases there were two fat pads and in the 44% three fat pads in the upper eyelid. The third fat pad is anatomically and histologically an accessory medial extension of the lateral fat pad. However, for the sake of clarity, the term central fat pad of the upper eyelid is proposed as a denominator of this structure. The purpose of this article is to make the less experienced surgeons aware of variations in the configuration of the periorbital fat and to remind them that after two fat pads are removed from the upper eyelid there might still be a third.

Pseudoptosis, caused by skin laxity or by herniation of periorbital fat, can be remedied by the usual cosmetic blepharoplasty. If there is a concomitant mild senile ptosis due to levator weakness, however, we recommend levator muscle plication during the course of the blepharoplasty. While blepharoptosis of significant degree is best treated by resection of the levator, plication works well in a mild degree of senile (or atonic) ptosis (when there is no more than two to 4 mm of droop). It is a simple and effective maneuver, easily performed in association with a cosmetic blepharoplasty.