Cosmetic Surgery Times: Fat Grafting Eye-Opener

For some patients with tear trough deformity, autologous fat may be the best material to use for lower eyelid augmentation, according to Sherrell J. Aston, M.D.

In my experience, autologous fat grafting in the lower eyelid has been associated with low morbidity and good to excellent short-term results, says Dr. Aston, professor of plastic surgery, New York University School of Medicine, and chairman, department of plastic surgery, Manhattan Eye, Ear & Throat Institute. However, while there is some proof that fat grafts remain viable in the face and can grow, there are no scientific data on survival rates and no way to predict resorption in the individual patient or the longevity of the results.

PREVIOUS EXPERIENCES Dr. Aston says he first considered using autologous fat for lower-eyelid augmentation several years ago based on good results reported by respected colleagues at various meetings. However, he changed his mind after a patient came to him seeking revision after previous fat grafting.

The woman gave a history of having fat injected into the lower lids five years earlier and receiving additional fat injections subsequently to address lumpiness. When seen by Dr. Aston, she presented with irregularities and discoloration of the lower lids. Dr. Aston performed surgical correction that proved difficult because the fat had been injected above, within and under the muscle, and the patient developed a lower-lid ectropion, which was temporary and resolved over time with conservative management. He says he co-authored a case report on this patient as a cautionary tale warning against autologous fat grafting to the lower lid until more objective data became available (Spector JA, Draper L, Aston SJ. Aesthetic Plast Surg. 2008;32(3):411-414).

Consequently, Dr. Aston says he began to think instead about using hyaluronic acid as a filler material for tear trough deformity. He changed his mind again when a patient treated by a dermatologist with hyaluronic acid gel presented dissatisfied with her appearance. She had received filler injections into the lower and upper lids that resulted in a Tyndall effect. She was treated with hyaluronidase and improved over time, he says.

Thereafter, Dr. Aston undertook autologous fat grafting into the lower eyelid, and he says he has achieved good results in improving the tear trough deformity and blending the infraorbital rim. Injecting deep, right onto the periosteum, is the key to minimizing the risk of surface irregularity, he says.

Persistence of the benefit of the augmentation procedure has been variable as demonstrated by the outcomes in a series of cases. While some patients were maintaining improvement of their appearance with follow-up to 18 months, another patient was beginning to show some loss of the effect at seven months.

TALKING TECHNIQUE For harvesting the fat, Dr. Aston says he uses a harvesting cannula measuring 2.7 mm in diameter that has multiple 1 mm holes at the end. He introduces it through a 2 mm stab incision after first injecting a small amount of lidocaine at the stab site. The most frequently used donor sites are the upper medial thighs and abdomen, he explains.

The aspirated fat is placed on top of a stack of Telfa pads (Kendall) and is then rolled back and forth into a sausage shape using a wooden blade before being drawn into a 1 cc syringe, Dr. Aston says.

For delivering the fat, Dr. Aston uses a 3 cm, 20 gauge injection blunt tip cannula that he says was designed with his input (Sherrell Aston Robust Cannula, Wells Johnson). The instrument features a shallow elongated opening and increased wall thickness.

This design does not alter the fat stream that emerges from the opening, which is governed by the amount of pressure put on the plunger, but it affords greater tip strength, which is helpful when working in the lower eyelid where the cannula is pushed along the periosteum, he explains.

The injection cannula is also available in a 19 gauge size that Dr. Aston uses for autologous fat injections elsewhere on the face.

Fat is injected into the lateral orbital rim, the tear trough and along the infraorbital rim when necessary. The entry site for the cannula is created just below the orbital rim using a No. 11 blade to puncture through the orbicularis muscle (see figure 1). Before it is introduced, the cannula is first primed so that fat will be delivered as soon as pressure is placed on the plunger. The cannula is placed under the muscle onto the periosteum, and the fat is injected as the cannula is withdrawn. The area is massaged to smooth the contour and more fat is injected as needed.

Disclosures: Dr. Aston reports no financial interest in the Sherrell Aston Robust Cannula. He is a consultant to Black & Black Surgical.