Gravity in Midfacial Aging: A 3-Dimensional Study.

BACKGROUND: Volume loss and volume descent are complementary aspects of facial aging, although the respective contribution of each is unclear. OBJECTIVES: The aim of this study was to quantify in 3 dimensions the effects of gravity on the midface in both upright and supine positions in an older and a younger group of patients. METHODS: A prospective study was undertaken of 53 female patients who had not undergone treatment with dermal fillers or facial cosmetic surgery. Three-dimensional photography with a VECTRA H1 camera (Canfield Scientific, Fairfield, NJ) was taken in supine and sitting positions. Volume shifts and displacement of structures in 3 dimensions were measured and analyzed. RESULTS: Morphologically, upon shifting from sitting to supine position, the tail of the brow elevated, the tear trough filled, the buccal and malar fat shifted posteriosuperiorly, the earlobe decreased in height, the nasiolabial folds and marionette lines diminished, the modiolus shifted laterally, and the jowl diminished. Volumetric analysis revealed that the infraorbital region increased in volume by a mean [SD] of 0.59 [0.55] mL, the tear trough by 0.22 [0.19] mL, and the malar region by 1.2 [1.06] mL. With subjects in the supine position, all facial topographic landmarks displaced significantly from sitting position. CONCLUSIONS: Facial aging in this cohort was predominantly due to tissue descent rather than volume loss. Reversal of the gravitational force restores the 3D position of the facial subunits and leads to volumization in desirable locations that approximates a more youthful appearance. The volume restored via redistribution of facial fat is comparable to that typically injected during direct volume transfer procedures.

Observations on the Tear Trough.

BACKGROUND: The tear trough is a prominent structure of the midface. Many surgical and nonsurgical techniques have been devised to efface this feature. OBJECTIVES: The aim of this study was to define an aesthetically pleasing tear trough and understand the effect of various surgical procedures on its appearance. METHODS: We undertook a retrospective review of "ideal" subjects (ie, young men and women as well as male and female models) as well as surgical patients undergoing lower blepharoplasty with fat excision, fat transposition, erbium laser resurfacing of the eyelids and midface, or endoscopic midface lifting. Marginal reflex distance-2, lower eyelid length, and nasojugal fold depth were measured and analyzed for all patients. RESULTS: The nasojugal fold was significantly less prominent in ideal female models than in all other groups (P < 0.0001). Lower eyelid length was significantly shorter after fat excisional lower blepharoplasty, laser resurfacing, and midface lift (P < 0.0001), and did not change after fat transpositional lower blepharoplasty. Postsurgical reduction in lower eyelid length was significantly less with fat transpositional lower blepharoplasty than in all other groups (P < 0.0001). The nasojugal fold was significantly effaced after all types of procedures (P < 0.0001), but was significantly more effaced after fat transpositional lower blepharoplasty (P < 0.01) than after all other procedures. CONCLUSIONS: A slight, medial tear trough is present in youth in many patients. The clinical tear trough is a virtual topographic structure distinct from the anatomic tear trough ligament and can be altered in a variety of ways.

Objective Comparison of Nasojugal Fold Depth and Lower Eyelid Length After Fat Excision Versus Fat Transpositional Lower Blepharoplasty.

BACKGROUND: Lower blepharoplasty is one of the most commonly performed aesthetic surgeries in the world. However, there are no studies to directly compare patients who had fat excision vs fat transposition. OBJECTIVES: The authors sought to compare and contrast aesthetic results of fat excisional and fat transpositional lower blepharoplasty. METHODS: A retrospective review was conducted of 60 patients (120 eyelids) who underwent transconjunctival lower blepharoplasty, either with fat excision or fat transposition into a preperiosteal plane. Marginal reflex distance-2, lower eyelid length, nasojugal fold depth, and pretarsal orbicularis definition were measured. RESULTS: Mean follow-up was 5.6 months. Mean marginal reflex distance-2 did not significantly differ after either fat excision or fat transposition. Mean lower lid length decreased after fat excision only (P < 0.001), and postoperative fat excision patients had a shorter lower eyelid length than patients who underwent fat transposition (13.5 ± 2.1 mm vs 16.1 ± 1.9 mm, P < 0.0001). Pretarsal orbicularis definition increased after both surgeries (P < 0.001), and the groups did not differ (1.0 ± 0.8 vs 1.1 ± 0.9, not significant). Mean nasojugal fold depth was effaced after surgery in both groups (P < 0.001), although the nasojugal fold was significantly more effaced after fat transposition (1.5 ± 0.7 vs 0.48 ± 0.6, P < 0.001). CONCLUSIONS: In lower blepharoplasty, fat excision resulted in a shorter lower eyelid, and fat transposition resulted in a more effaced lid-cheek junction. Surgeons should be able to balance both techniques to deliver a customized aesthetic result.Level of Evidence: 3.

Multimodality Management of Complex Periorbital Venolymphatic Malformations.

PURPOSE: To review a representative case series and share a stepwise approach to the diagnosis and treatment of periorbital venolymphatic malformations. METHODS: A case series of 9 patients with representative periorbital venolymphatic malformations. All patients managed at the University of California, Los Angeles Orbital Center for a vascular malformation over the last 5 years were reviewed. Cases representative of the varied pathologic findings and techniques were selected. The clinical, radiologic, and intraoperative findings are presented and a survey of techniques composed. RESULTS: Venolymphatic malformations can have protean manifestations. Characteristics vital to the understanding and management of these lesions are the classification and vascular composition of the lesion, internal flow and drainage patterns, anatomic localization and association with distant components. Options for treatment include sclerotherapy, biologic therapy, embolization, surgical excision, or some combination thereof. CONCLUSIONS: A comprehensive understanding of each patient's unique lesion is critical to a rational treatment approach. Teamwork and creativity are key to effectively managing these lesions.