Operative Technique in Plastic Surgery – Kevin C.Chung

FIG 4 • The arcus marginalis is shown on cadaveric
dissection. It is the bony origin of the orbital septum,
orbital periosteum, and the maxillary periosteum.
■ Emerging research demonstrates facial fat is divided into discrete fat
compartments.11–13 However, the exact anatomy of the periorbital fat
compartments somewhat varies within the literature. Recent cadaveric studies
by Rohrich et al. describe two suborbicularis fat compartments: the medial
suborbicularis oculi compartment extending from the medial limbus to the
lateral canthus along the infraorbital rim and the lateral orbicularis oculi
compartment from the lateral canthus to the temporal fat pad.11 Regardless of

the exact nomenclature and anatomic boundaries of these compartments, eyelid
aesthetics needs to go well beyond the traditional retroseptal compartments and
consider the periorbital fat compartments as well (FIG 3).
■ The temporal hallows are an underappreciated yet important region when
approaching the aged face. Temporal wasting leads to an “hourglass”
appearance to the upper face that can be corrected with autologous fat grafting.
A smooth transition may be achieved between the forehead and malar region
when volume is replaced in the temporal hallow.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history and physical examination is vital to effectively approach
rejuvenation of the periorbital region. This includes a general history and
physical examination, as well as a complete ophthalmologic examination.
Anticoagulant and antiplatelet medications should be documented and stopped
prior to surgery to avoid complications due to bleeding. Assessment of all
periorbital and adjacent structures, including malar, temporal, and glabellar
regions, are vital to achieving a harmonious and balanced result.
■ The periorbital region is evaluated in detail. Upper and lower eyelid skin
quality, excess skin, and pseudoherniation of orbital fat are documented.
■ A functional examination of the orbital region is performed. Lateral canthal
descent, lid laxity, scleral show, and ectropion are all evaluated. Symmetry is
appreciated.
■ The vector between the globe and malar region is characterized as positive or
negative. This relationship aids the surgeon in assessing malar descent and
selecting patients who would benefit from malar augmentation to provide
support to the lower lid as well as restore a positive vector. When assessing
patients for correction of lower eyelid aging, it is essential to consider not
only the lower eyelid but also the cheek and the interface of the two.
Midfacial volume loss and descent lead to loss of anterior projection and
contour and decreased support to the lower eyelid.
■ The seven-step preoperative checklist, developed by the senior authors of this
chapter, is used for preoperative planning for blepharoplasty patients.14 This
examination included seven key findings: vector analysis, snap, distraction,
scleral show, canthal tilt, lateral canthal-orbital rim distance, midface position,
and vertical restriction. This standardized physical examination characterizes
the severity of hollowing, skin quality, and descent of the periorbital region to
guide treatment (FIG 5).

■ Periorbital aging is a combination of volume loss, soft tissue descent, and
cutaneous changes.1,2 Brow descent with atrophy of superior orbital fat and
hollowing lead to a tired, aged appearance. The extent of these changes needs
to be considered when evaluating patients.
NONOPERATIVE MANAGEMENT
■ Hyaluronic acid fillers are an effective temporary alterative to autologous fat
grafting for periorbital rejuvenation. This approach is a nonpermanent option
for patients who wish to achieve added volume of the periorbital region and
wish to avoid surgical intervention. The best candidates for hyaluronic acid
injection are those with good skin tone and minimal skin laxity with minimal to
moderate volume loss in the periorbital region.15 These characteristics help
minimize the injection volume required and risk of palpable or visible
deformities that are associate with fillers in this region.
SURGICAL MANAGEMENT
Positioning
■ The patient is positioned supine.

FIG 5 • The 7-step checklist for blepharoplasty planning.
This examination included seven key findings: vector
analysis, snap, distraction, scleral show, canthal tilt,
lateral canthal-orbital rim distance, midface position,
and vertical restriction.
T E C H N I Q U E S
■ Fat Harvest and Injection Technique
■ Autologous fat is most commonly harvested from the anterior abdomen or
the medial or lateral thigh or anterior abdomen. The patient is positioned
supine, and these locations are easily accessed for fat harvest.

■ Autologous fat may be processed according to surgeon preference. The
authors of this paper prefer harvesting with 10-cc syringes under negative
suction, allowing for gravitational sedimentation. Fat is then transferred to 1-
cc syringes for injection with 0.9-mm blunt cannulas. Fat is deposited deep at
the level superficial to the periosteum. Fat may be injected in multiple passes
of small aliquots into the individual compartments.1
■ Eye Brow and Temporal Region
■ Fat grafting of the eyebrow and temporal is routinely performed in our
practice to achieve facial rejuvenation.
■ The upper brow and temporal region may be accessed approximately 15 to
20 mm above the central brow. For treatment of the eyebrow region, fat is
injected deep in the supraperiosteal plane into the central and lateral brow.
This not only provides volume but also has a “lifting” effect on the brow.
Typical volumes are approximately 1 to 3 mL in this region, depending on
the overall aesthetic goals.
■ Lipostructural fat grafting to the temporal region can also be achieved
through this port site or accesses via a separate point along the lateral
forehead hairline. The layer of injection is targeted between the superficial
and deep temporal fascia to minimize risk of visible deformity while still
achieving an added volume effect on the surface.
■ Upper Eyelid
■ Fat grafting in the upper eyelid corrects hollowing due to aging, however
more commonly treats secondary deformity due to over-resection during
prior blepharoplasty.
■ The upper eyelid fat compartments are accessed by a port site located 10 to
15 mm lateral to the lateral canthus.1 Fat is injected into the preseptal space,
directly beneath the orbicularis muscle, as to avoid obvious irregularities of
superficial injection beneath the thin eyelid skin. This injection is placed at
the edge of the orbital rim.
■ Lower Eyelid/Malar Fat Grafting

■ Fat grafting to the malar compartments is performed using a technique
modified from Surek et al.16 The deep medial cheek compartment is accessed
via the “nasolabial insertion port” located 1.5 to 2 cm inferolateral to the
ipsilateral alar base within the nasolabial fold and the lateral cheek
compartment via the “lateral cheek insertion port” located 1.5 to 2 cm
inferolaterally to the lateral canthus, as described (TECH FIG 1).
■ An alternative approach practiced by the authors of this paper is the use of a
single port (nasolabial insertion port) to access the malar and lower eyelid fat
compartments. Adding volume of the deep medial cheek provides anterior
projection to the midface as well as effacement of the nasojugal groove. Via
the nasolabial port, a blunt cannula is used to inject 1 to 2 cc of autologous
fat. The lateral cheek compartment is accessed, and a 1 to 2 cc of autologous
fat is injected.
TECH FIG 1 • Malar fat grafting port sites for injection.

The nasolabial, nasojugal, and lateral cheek port sites
are shown. Alternatively, all three cheek
compartments may be accessed via a single port
(lateral cheek port site).
■ Arcus Marginalis Release
■ Arcus marginalis release in conjunction with fat grafting may be an effective
means of treating a severe tear trough deformity. This is performed with a
horizontal incision 8 mm from the posterior lower eyelid margin through the
conjunctiva and capsulopalpebral fascia to access the retroseptal space
(TECH FIG 2A).
■ Retroseptal fat is retracted to visualize the arcus marginalis, which is sharply
released from the medial canthus along the infraorbital rim to the level of the
mid-pupil.17 The origin of the preseptal and orbital orbicularis oculi muscle is
also released with this maneuver (TECH FIG 2B).
TECH FIG 2 • A. Arcus marginalis on cadaveric
specimen is shown after release from the medial

canthus along the infraorbital rim to the level of the
mid-pupil. B. Color map analysis of clinical patient
following lower blepharoplasty with fat excision
followed by arcus marginalis release. Color spectrum
shows change in surface projection as compared to
the baseline surface. Color spectrum ranges from no
change (green) to most significant volume loss (red)
and volume gain (blue). Note volume loss during fat
excision (red) and a volume gain following arcus
marginalis release (less red medially) and maximum
volume following malar fat grafting (blue).
PEARLS AND PITFALLS
Indications
■ Periorbital volume loss contributes to aging in the upper face.
■ Brow descent, upper eyelid hollowing, temporal hollowing, malar
descent, and a prominent nasojugal groove (or “tear trough
deformity”) may be addressed by way of autologous fat grafting to
various facial fat compartments.
Advantage
■ Volume addition of the periorbital restores youthful contour and may
provide support to the lower eyelid and brow.
■ Hyaluronic acid fillers are an effective yet temporary option for
patients to be reserved for patients with good skin quality and minimal
to moderate volume loss.
■ Patients with moderate to severe periorbital atrophy and descent of
the upper and midface benefit for autologous fat grafting.
■ Arcus marginalis release in conjunction with fat grafting may be an
effective means of treating a severe tear trough deformity.
■ A single port (nasolabial insertion port) may be used to access the
malar and lower eyelid fat compartments.
Pitfalls
■ A thorough history and physical examination, including
ophthalmologic examination, are vital to successful patient selection
and outcomes in periorbital rejuvenation.
■ Anatomical knowledge of facial fat compartments permits precise
placement of fat and reproducible results.

POSTOPERATIVE CARE
■ Patients should maintain head of bed elevation of at least 45 degrees for the
first 24 hours postoperatively.
■ Cool compresses may be applied for comfort.
■ Patients may resume preoperative physical activity by 3 to 4 weeks
postoperatively.
■ Postoperative photographs are taken at 3 and 6 months and at 1 year follow-
up.
OUTCOMES
■ See FIGS 6 and 7.
FIG 6 • 3D color map of clinical patient following malar
augmentation to the deep medial cheek, medial SOOF,
and lateral SOOF. Note the characteristic “boomerang”
shape with the gradient of projection from the boundary
in red (1 mm) to maximal projection in blue (4 mm).18
COMPLICATIONS

■ Complications from autologous fat grafting to the periorbital region are rare
but may be significant.
■ Contour irregularities, particularly in areas of thin eyelid skin, may arise.
■ Complications during fat harvest include pain, ecchymosis, and perforation of
the abdominal wall and intra-abdominal viscera.
FIG 7 • Representative patient example following
periorbital rejuvenation. This patient underwent
autologous fat grafting to the MSOOF, LSOOF, DMC,
and temporal hollows.
■ Periocular complications following hyaluronic acid filler injections are
exceedingly rare and due to retrograde displacement of product into the central
retinal artery. Ptosis, ophthalmoplegia, enophthalmos, and blindness have been
reported.19
REFERENCES
1. Massry GG, Azizzadeh B. Periorbital fat grafting. Facial Plast Surg.
2013;29(1):46-57.
2. Hamra ST. Arcus marginalis release and orbital fat preservation in midface
rejuvenation. Plast Reconstr Surg. 1995;96(2):354-362.

3. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of
orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg.
2000;105(2):743-748.
4. Carraway JH. Volume correction for nasojugal groove with blepharoplasty.
Aesthet Surg J. 2010;30(1):101-109.
5. Hester TR Jr, Ashinoff RL, McCord CD. Managing postseptal fat in
periorbital rejuvenation: anatomic intraorbital replacement using passive septal
tightening. Aesthet Surg J. 2006;26(6):717-724.
6. Lambros V. Observations on periorbital and midface aging. Plast Reconstr
Surg. 2007;120(5):1367-1376.
7. Lambros VS. Hyaluronic acid injections for correction of the tear trough
deformity. Plast Reconstr Surg. 2007;120(6 suppl):74S-80S.
8. Coleman SR. Structural fat grafting. Aesthet Surg J. 1998;18(5):386-388.
9. Coleman SR. Facial augmentation with structural fat grafting. Clin Plast Surg.
2006;33(4):567-577.
10. Coleman SR. Structural fat grafting: more than a permanent filler. Plast
Reconstr Surg. 2006;118(3 suppl):108S-120S.
11. Rohrich RJ, Arbique GM, Wong C, et al. The anatomy of suborbicularis fat:
implications for periorbital rejuvenation. Plast Reconstr Surg.
2009;124(3):946-951.
12. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation
of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr
Surg. 2008;121(5):1804-1809.
13. Stern CS, Schreiber JE, Surek CC, et al. Three-dimensional topographic
surface changes in response to compartmental volumization of the medial
cheek: defining a malar augmentation zone. Plast Reconstr Surg.
2016;137(5):1401-1408.
14. Tepper OM, Steinbrech D, Howell MH, et al. A retrospective review of
patients undergoing lateral canthoplasty techniques to manage existing or
potential lower eyelid malposition: identification of seven key preoperative
findings. Plast Reconstr Surg. 2015;136(1):40-49.
15. Hirmand H. Correction of the tear trough deformity with hyaluronic acid.
2009.
16. Surek C, Beut J, Stephens R, et al. Volumizing viaducts of the midface:
defining the beut techniques. Aesthet Surg J. 2015;35(2):121-134.
17. Wong CH, Mendelson B. Facial soft-tissue spaces and retaining ligaments of
the midcheek: defining the premaxillary space. Plast Reconstr Surg.

2013;132(1):49-56.
18. Schreiber JE, Terner J, Stern CS, et al. The “Boomerang Lift”: a 3-step
compartment based approach to the youthful cheek. Plast Reconstr Surg.
2018;141(4):910-913.
19. Myung Y, Yim S, Jeong JH, et al. The classification and prognosis of
periocular complications related to blindness following cosmetic filler
injection. Plast Reconstr Surg. 2017;140(1):61-64.

37
CHAPTER
Indications and Techniques
for Upper and Lower
Blepharoplasty with Microfat
Injections
Nuri A. Celik
DEFINITION
Upper Blepharoplasty
■ Upper blepharoplasty is considered an easy operation; however, depending on
your level of expertise and ability to systematically analyze the inherent
problems, it might be considered one of the most complex operations of
aesthetic surgery practice.
■ The complex component is the patient evaluation. There is more to a
periorbital rejuvenation than just excision of fat, muscle, and skin. We should
be able to answer the question: what makes an eye beautiful?
■ The upper blepharoplasty evaluation should always involve the brow level and
shape considerations. Although a high and arched eyebrow is a common
feature in female beauty, transverse and low eyebrows are a masculine
characteristic in the majority of the male models.
■ One should always keep in mind that the facial skeleton also plays a major role
in the perception of beauty.
■ A convex area beneath the middle and lateral brow:
■ A surgeon should always examine the lateral brow mobility before
performing an upper blepharoplasty. There are conflicting reports about the
brow positional changes following an upper blepharoplasty.1,2 The author has
two main criteria for this assessment.
• The lateral brow response to a downward pull. This is a sure sign that the

skin resection at the end of the upper blepharoplasty procedure will easily
displace the lateral brow tissues to a lower position.
• Any skin excess lateral to the lateral canthus. This is an indication for a
brow lift by the author who never extends the upper blepharoplasty incision
beyond the lateral orbital rim, because in thick skin individuals, scars lateral
to the rim are visible.
■ The fullness beneath the lateral brow area is a beauty feature in women3 and
can also be a positive factor of masculinity in a low running male eyebrow.
The fullness in this area is related to the fullness over the lateral orbital rim,
and this can be surgically achieved with fat injection into the area (FIG 1)
and also dermofat grafting (FIG 2).
■ A short supratarsal distance is a significant feature of youth. It is directly
associated with the periorbital soft tissue volume and an indicator of the upper
sulcus fat content and the levator function.
■ The skeletonized upper sulcus becomes prominent in the elderly (FIG 3), and
the majority of these patients have an increased supratarsal distance. This
shows the necessity of the addition of the intraseptal fat management and the
levator procedures in our upper blepharoplasty practices.
FIG 1 • A,B. A 45-year-old female who underwent upper
blepharoplasty and lateral brow lift with fat injection.
The levator advancement technique was used to
correct the ptosis. C,D. The 2-year postoperative brow

contour is achieved with the help of lateral
subperiosteal brow lift and fat injection of lateral
infrabrow area.
FIG 2 • A,B. A 42-year-old female patient before-after
pictures. Upper eyelid ptosis corrected with levator
advancement. Notice the raised lateral brow and the
fullness of the infrabrow area. C,D. She had lateral
brow lift through the upper blepharoplasty incision and
dermofat grafting of the upper lateral orbital rim and the
upper sulcus. The periorbital contours were obtained
with 42-cc fat injection.
■ The almond shape of the eye aperture:
■ In young individuals, the medial portion of the eye aperture has a higher
measurement vertically than the lateral half.
■ The better support offered by the lateral canthus during early decades of life
provides a higher lateral lower eyelid topography. This decreases the angle of
convergence at the lateral corner of the eye and narrows the aperture in the
lateral half.
■ The aging changes of the inferolateral orbital rim bone and dimension are
mainly responsible for the sagging of the lateral part of the lower eyelid
resulting in the change in shape of the eye to oval.4,5
■ An upper eyelid covering 1 to 2 mm of the limbus:
■ This is maintained with intact levator function and proper attachment of the
aponeurosis on the anterior surface of the upper tarsus.
■ The upper eyelid level should be evaluated in conjunction with the frontalis

muscle activity because the frequent transverse horizontal wrinkles of the
elderly show involvement of this muscle as a compensation for the failure of
the levator system.
■ Lateral and medial canthal position and stability:
■ The effect of the lateral canthal placement and resistance on the position of
the lower eyelid is well documented in the literature.
■ The lateral canthal laxity is not age specific; it might be present in the young
(FIG 4A), and surprisingly, the lateral canthus might have good stability in
the elderly (FIG 4B).
■ The medial canthal position and symmetry are also significant factors in the
lower eyelid stability because the lower tarsus is attached to both canthi.
FIG 3 • A 64-year-old female presenting with the typical
superior sulcus fat deficiency, ptosis of the upper
eyelids, and asymmetrically elevated eyebrows due to
frontalis muscle compensation further accentuating the
upper eyelid deformity.
■ Slight asymmetries of the medial canthal origin will alter the hammock-type
support of the lower eyelid, interfering with the postoperative results.
■ The occasional patient who has slight displacement of the medial canthal
attachment should be informed preoperatively that the possibility of obtaining
perfectly symmetric lower eyelids is compromised (FIG 5).
■ Medial and lateral canthal laxity is responsible for the majority of
postoperative complications and should be taken into account to achieve
good results with lower eyelid surgery.

■ Nasojugal fold:
■ It is important to obtain a smooth pass from the lower eyelid to the cheek to
decrease the shadows that increase with age.
■ The transformation of the orbital cavity with the aging process decreases the
support to the lower lateral orbital rim and the lateral canthus with increased
fat herniation and degree of negative factor.6
Lower Blepharoplasty
■ Lower blepharoplasty is a challenging operation because there are many
factors that affect the outcome of surgery. The most important factors are
medial and lateral canthal stability, presence of negative vector of the lower
orbital rim, and orbital prominence or a shallow orbit.
■ The need for a concomitant lateral canthal procedure during lower
blepharoplasty procedure is not debatable in the author’s opinion.7 It is the
author’s experience that patients with a medial canthal attachment at or below
the level of the inferior limbus are at increased risk for lower eyelid retraction,
no matter what type of maneuver is used for the lateral canthal support.8
Fat Injection
■ As mentioned before, the telltale sign of periorbital aging is skeletonization;
decreased subcutaneous fat fails to camouflage the upper and lower orbital rim
bony contours.
■ With the concomitant brow lift procedures, the relatively thin eyelid skin is
pulled superiorly, leaving a depression over the superolateral orbital bony rim.
■ This area needs augmentation in conjunction with the sub-brow area, and the
relative prominence of this fill creates a need for temporal hollow, glabellar,
and frontal regions and, in select cases, zygomatic arch and midface to be
augmented with fat injections.9

FIG 4 • A. A surprisingly slack lower eyelid in a 24-year-
old male patient. Notice the curved contour of the lower
eyelid and excessive scleral show for his age. B. A 67-
year-old male with good lateral canthal support.
ANATOMY
■ The upper eyelid is a complex structure that consists of multiple tissue layers
that seem to adhere to each other around the upper anterior tarsal surface.
■ When the skin and muscle layers are incised and a skin muscle flap is elevated
as a superiorly based flap, one notices a thin layer of adipose tissue on top of
the upper orbital septum that is more defined medially and somewhat less
laterally.
■ The increased convexity of the globe is possibly responsible for this uneven
distribution of the fat layer. The underlying septum should always be incised
laterally and higher than the upper tarsal border in order not to injure the
levator mechanism inadvertently.
■ There usually is a preaponeurotic fat pad present, if not previously excised or
developmentally absent.
■ Under the fat pad, toward the upper orbital rim, one can find the vertically
oriented fibers of the levator muscle. The surgeon should always keep in mind
that, immediately below the levator aponeurosis, there is the vertically oriented
arterial loop of the supratarsal arch that might resemble the fibers of the levator
muscle.
■ The lower eyelid has similar tissue layers converging and attaching to the
lower end of the lower tarsus, mainly the septum under the muscle and, in
deeper layers, the lower lid retractors and the conjunctiva.
■ The lower half of the orbital septum is almost always attenuated and the lower
eyelid fat pads are herniated in individuals with protruding fat pockets.
■ One important surgical landmark is the periosteal attachment of the orbicularis
oculi muscle that extends around 1 cm along the medial part of the lower
orbital rim.9
■ The middle and lateral portions of the surface of the bony rim periosteum are
covered by the SOOF to a variable degree in every individual. This creates two
separate surgical dissection layers: around the midportion of the lower orbital
rim, the medial part elevation should always be subperiosteal, whereas the

more lateral portions allow a supraperiosteal dissection.
PATHOGENESIS
■ Many complex mechanisms are involved in the aging process with various
contributions from different tissue layers presenting as the individual aging
patterns seen in different races and skin types.
FIG 5 • A,B. A 44-year-old male seeking correction for
his asymmetric ptosis, scleral show, and premature
facial aging. Notice the low insertion of the medial
canthi in relation to the lower limbus. This puts the
patient in a “surgical risk” category. C,D. The patient
was informed of the asymmetry of his medial canthal
insertion and possibility of lower eyelid level and shape
mismatch. The postoperative level of the right lower
eyelid is slightly lower than the left due to lower
insertion of the medial canthus on that side.
■ Camirand’s paper10 deals with mainly the soft tissue changes, whereas recent

investigations4–6 point to concomitant bony topographical alterations.
■ With time, the ligaments attenuate and the subcutaneous thinning ensues,
whereas the compensatory powerful muscle contractions create furrows and
lines.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The variable pattern of the individual aging process makes it impossible to
specifically organize the deformities that the patients present with.
■ There are patients who present mainly with tissue loss as well as the ones
who complain of increased fat pockets around the eyes (FIG 6).
■ Although the thin-skinned patients mainly complain of wrinkles, the thick-
skinned individuals would like more of a “lift” because of the higher
incidence of sagging of the periorbital tissues.
■ It is advisable to obtain pictures of patients from their early decades of life.
This gives the surgeon the ability to assess the aging changes and the pattern
and shed light to a sound surgical planning.
DIFFERENTIAL DIAGNOSIS
■ Myasthenia gravis
■ Thyroid disease
NONOPERATIVE MANAGEMENT
■ There are many different treatment options for this area, including lasers,
ultrasonic devices, peels, and fillers.
SURGICAL MANAGEMENT
Preoperative Planning
■ Consider
■ Skin thickness
■ Brow ptosis: horizontal frontal wrinkles

FIG 6 • A,B. A 72-year-old female before and after face-
lift with upper and lower blepharoplasty 7 years ago.
She was treated with 200-cc single-stage periorbital
and perioral fat grafting and upper lip shortening of 7
mm.
■ Upper eyelid ptosis
■ Loss of upper eyelid curve
■ Asymmetric or high supratarsal fold
■ Upper eyelid fat and skin
■ Lateral canthal ligament laxity
■ Medial canthal ligament laxity
■ Medial canthal ligament insertion variations
■ Any asymmetry
■ Lower eyelid fat pads, pretarsal muscle activity, and tone
■ Nasojugal fold
Positioning
■ Patient is operated supine and in a reverse Trendelenburg position.
Approach
■ The upper blepharoplasty incision follows the natural curve of the supratarsal
crease and is situated at 8 mm from the eyelash border in the middle, closing to
a 5-mm distance at both corners. The lateral extension should not go beyond
the lateral orbital rim.
■ The lower blepharoplasty incision is a subciliary incision and does not cross

the level of the lateral corner of the eye.
T E C H N I Q U E S
■ Upper Blepharoplasty
Preparation
■ The surgery starts with the upper blepharoplasty markings (TECH FIG 1)
and the injection of a freshly prepared local anesthetic and adrenalin mixture.
TECH FIG 1 • Upper blepharoplasty marking.
Incision
■ It is important to wait for at least 7 minutes for vasoconstriction, and then a
superficial skin incision is performed with the surgical blade (TECH FIG
2A). A Colorado tip cautery is used to incise the dermis and the muscle to
prevent bleeding.

TECH FIG 2 • A. Dermal incision performed with
Colorado tip cautery to prevent bleeding. B. Injection
of local anesthetic into the muscle.
TECH FIG 3 • A. Orbicularis oculi muscle preseptal
portion elevated off of the upper orbital septum. B.
Injection of saline into the preaponeurotic cavity. C.
Upper orbital septum opened medially to reveal
preaponeurotic fat pad. D. Upper orbital septum
opened at its full width. E. Medial fat pad resected.
■ After incision of the full thickness of the muscle, the local anesthetic is

injected into the superior flap superficially (TECH FIG 2B).
Dissection
■ Then, the dissection continues immediately adjacent to the undersurface of
the orbicularis muscle layer on top of the upper orbital septum (TECH FIG
3A).
■ With time, one recognizes a very thin layer of fatty tissue on top of the
septum, more pronounced medially and laterally. It is advisable to use loupe
magnification and start the submuscular dissection either medially or laterally
to be able to distinguish the tissue layers.
■ The elevation of the muscle flap also allows easy access to the plane of the
corrugator for resection and the brow region for brow fixation.
■ The upper orbital septum and levator aponeurosis layers lie almost adjacent
to each other in the area of our incisions, so it is advisable to inject 1 cc of
saline into the subseptal space for hydrodissection (TECH FIG 3B).
■ This facilitates the separation of the layers, and a laterally placed incision of
the septum is then advanced to completely open the preaponeurotic space.
The fat pads lie in this layer (TECH FIG 3C).
■ The preaponeurotic fat pad is gently dissected free from the underlying
levator muscle (TECH FIG 3D), and if necessary, levator procedure is
performed.
■ The medial fat pad, almost always excessive, is dissected and excised
(TECH FIG 3E).
■ There is no need for preaponeurotic fat pad resection except in very rare
cases. Instead, the upper sulcus needs to be augmented in the majority of the
aging patients.
Suturing
■ The resected medial fat pad is used to graft the middle upper sulcus, and for
a better take, the fat graft is placed under the existing fat pad (TECH FIG
4A–C).

TECH FIG 4 • A. Upper orbital septum opened. B.
Resected medial fat pad brought on site. C. The
medial fat pad is grafted to the upper middle sulcus to
treat the superior sulcus fat deficiency. D. Intraseptal
fat graft in place. E. Septum is closed over the graft.
■ The upper edge of the septum is then found and pulled down with a forceps
to cover over the upper orbital fat pad, and the fullness and convexity are
checked to obtain a smooth pass from the brow to the upper eyelid (TECH
FIG 4D).
■ The upper orbital septum is then sutured with a 6-0 poliglecaprone suture
(TECH FIG 4E).
Closure
■ The skin muscle flap is pulled down and skin excess is marked.
■ The muscle fibers of the orbicularis muscle of the upper eyelid are more
condensed around the supratarsal area (TECH FIG 5), and unfortunately, this
is the region where we resect the skin and muscle at the end of our
blepharoplasty procedures.
■ This may interfere with proper eye closure in the early postoperative
period. This is the reason why the author prefers to de-epithelialize the skin
and leave the muscle intact to turn in during closure, also helping with the

upper orbital sulcus fullness.
TECH FIG 5 • The skin is de-epithelialized and the
orbicularis muscle left intact. The orbicularis oculi
fibers are more condensed in the area of resection in
conventional blepharoplasty.
■ The closure of the skin is done with 6-0 nylon sutures.
■ Lower Blepharoplasty
Preparation
■ The upper and lower eyelids are sutured together at the start of the lower
blepharoplasty procedure, and this suture is used for traction.
■ Similar to the upper blepharoplasty technique described above, the injection
of the local anesthetic and epinephrine solution is followed by the subciliary
incision.
Incision
■ The thin skin of the lower eyelid is then separated from the underlying
orbicularis muscle fibers with the help of the Colorado needle tip cautery for
10 to 15 mm to facilitate muscle and skin excision at the time of the closure
(TECH FIG 6A).

TECH FIG 6 • A. The skin is elevated off of the
orbicularis fibers through a subciliary incision at the
start of the lower blepharoplasty. B. The pretarsal
portion of the orbicularis is protected, and the muscle
is cut below the level of the lower rim of the tarsal
plate.
■ The lower pretarsal muscle is marked, and an incision is performed with the
cautery to reach the preseptal space of the lower eyelid (TECH FIG 6B).
Dissection
■ The dissection is continued to reach the lower orbital rim. The lower eyelid
septum is most often attenuated in this region, so it is better to stay close to
the fibers of the orbicularis muscle during the dissection.
■ Once the surgeon reaches the lower orbital rim, the attention is focused on
the most medial portion of the rim first.

■ The insertion of the orbicularis muscle on the periosteum of the medial
orbital rim forms the nasojugal fold (TECH FIG 7), and therefore, the
dissection continues in a subperiosteal plane medially to reach the level of the
nasal bone suture line, creating a pocket.
Suturing
■ A fat flap is formed with the already herniated medial fat pad, and it is then
advanced to this space to prevent the attachment of the muscle again.
■ The fat flap is sutured to the periosteum medially with 5-0 nylon sutures.
The suture should be strong enough to hold the fat flap in position to cover
the medial lower orbital rim.
TECH FIG 7 • The dissection reveals the anatomy of
the medial lower orbital rim. The arrow points the
orbicularis muscle insertion on the periosteum.
TECH FIG 8 • A. At the time of closure, the lower
eyelid muscle layer is pulled up and the excess

orbicularis is marked. B. The excess orbicularis
muscle. C. The excess muscle is elevated as a
laterally based Anderson flap, and the edges of the
lower orbicularis muscle are sutured together.
■ This effective fat transposition fills the nasojugal fold depression that is
caused by the orbicularis attachments on the rim periosteum.12
■ The lateral fat pad is almost always excessive and is excised.
■ The lower eyelid is then pulled up with the help of the traction suture. The
decision of skin and muscle excision should be done in this position to
prevent complications.
Closure
■ The muscle is pulled up gently and excess muscle is marked, if there is any
(TECH FIG 8A).
■ It is advisable not to resect the muscle (TECH FIG 8B) and, instead, prepare
it as a laterally based Adamson flap (TECH FIG 8C) to suture to the lateral
rim periosteum to act as an efficient canthopexy in individuals with a proper
canthal tilt.
■ If the patient does not have a proper canthal tilt to start with preoperatively,
then a transpositional type of canthal surgery should be undertaken.
■ The cut edges of the muscle are then sutured with 6-0 inverted polydioxanon
suture to prevent muscle retraction in the early postoperative period. With the
help of this measure, it is possible to see early intact pretarsal muscle activity
in the lower blepharoplasty patients (TECH FIG 9).
■ There usually is no need for skin excision other than a marginal correction.
■ The subciliary incision is then closed with 6-0 nylon sutures.

TECH FIG 9 • A,B. The patient force closes the eyes
on the 5th postoperative day. Notice the upward
movement of the lower eyelid. This is due to the early
intact function of the lower eyelid orbicularis muscle,
possibly due to the atraumatic technique and suturing
of the muscle edges together to prevent avulsion.
■ Periorbital Fat Injection
■ Injecting fat in the periorbital area is a sculpting measure to help with the
surgical fat preservation and reorganization principle observed during the
upper and lower blepharoplasty.
■ Midfacial, frontal, glabellar, root of the nose, zygomatic, and brow fat
injections are done at deeper tissue layers, over the periosteum.
■ The temporal area injections are superficial in the subcutaneous plane.
■ The microfat grafts pass through tuberculin syringes and are used to directly
inject into the wrinkles (TECH FIG 10).
■ It is advisable to use an average of 45 to 60 cc of fat grafting in the
periorbital area.
TECH FIG 10 • A,B. A 47-year-old female underwent
a periorbital lift with upper and lower blepharoplasty
with fat preservation and additional fat injection. C,D.
The profile view of the patient. Notice the change in
the periorbital and perioral profile as a result of the
brow and midface lift, upper lip shortening, and 60 cc

of facial fat grafting.
PEARLS AND PITFALLS
Hemostasis
■ Hemostasis is the key to the success of the surgical dissection and
tissue healing.
■ Stop any coagulants 3 weeks before surgery.
■ Postoperatively, use only opioids for pain.
Incisions
■ Never extend incisions beyond the level of the lateral canthus;
estimate skin excess at the end of the procedure.
Technique
■ Use loupe magnification and Colorado tip cautery.
■ Do not aim excision; plan to preserve fat and muscle.
■ Assess lateral and medial canthal stability before surgery and plan
necessary measures to increase lower eyelid support.
■ Skin and muscle excision of the lower eyelid is performed with the
lid pulled up.
FIG 7 • A,B. A 62-year-old male presented with medial
fat pad herniation of the ptotic upper eyelids, periorbital
skeletonization, lower eyelid medial and lateral fat pad
herniation, midfacial atrophy R greater than L, lower
eyelid laxity, and rather low medial canthal attachment.
He was treated with resection of only the medial fat pad
of the upper eyelid and the lateral from the lower. The
medial fat pad of the lower eyelid was maintained and
advanced subperiosteally to efface the nasojugal fold.

Periorbital and midfacial fat injection helped achieve
better contours. Levator advancement procedure
corrects his upper eyelid senile ptosis, and a tensor
fascia lata suspension of the lower eyelid overcomes
the possible complications.
POSTOPERATIVE CARE
■ The head of the bed is elevated.
■ No NSAID at any time, intra- or postoperatively.
■ Constant application of ice for 5 days over a wet sponge.
■ Suture removal 3 to 5 days.
OUTCOMES
■ The principles of fat and muscle preservation, judicious fat grafting help
accomplish good results with upper and lower blepharoplasty surgery.
■ The surgeon’s awareness before surgery about the inherent problems of the
medial and lateral canthal position and stability will help prevent the possible
complications of lower eyelid surgery (FIGS 7 and 8).
COMPLICATIONS
■ The most common complication of the upper eyelid surgery is caused by
excessive removal of the fat pads. This causes superior sulcus fat deficiency
and increased supratarsal fold distance and is a telltale sign of poor surgical
evaluation (see FIG 8).
■ The fibrosis associated with the poor technique when performing a lower
blepharoplasty will increase the fibrous tissue (FIG 9) and exert a pull and
cause shortening of the lower eyelid causing scleral show.

FIG 8 • A. A 44-year-old female S/P upper and lower
blepharoplasty and brow lift and six consecutive
revisions. Notice the fat deficiency of the upper eyelid
sulcus. She also has sagging of the right lower eyelid.
B. The patient 2 years after dermofat grafting of the
upper eyelids, tensor fascia lata suspension
reconstruction of the lower eyelid, and periorbital fat
grafting. The right upper eyelid still needs more fatty
tissue support.
FIG 9 • A,B. The surgical dissection findings of a lower
blepharoplasty complication. Notice the significant
fibrous thickening of the orbital septum, shortening the
lower eyelid.
REFERENCES
1. Nakra T, Modjtahedi S, Vrcek I, et al. The effect of upper eyelid
blepharoplasty on eyelid and brow position. Orbit. 2016;35(6 suppl):324-327.
2. Hassanpour SE, Khajouei Kermani H, Brow ptosis after upper blepharoplasty:
findings in 70 patients. World J Plast Surg. 2016;5(1 suppl):58-61.
3. Shaw RB Jr, Katzel EB, Koltz PF, et al. Aging of the facial skeleton: aesthetic
implications and rejuvenation strategies. Plast Reconstr Surg. 2011;127(1
suppl):374-383. doi:10.1097/PRS.0b013e3181f95b2d.5).
4. Kahn DM, Shaw RB Jr. Aging of the bony orbit: a three-dimensional
computed tomographic study. Aesthet Surg J. 2008;28(3 suppl):258-264.

5. Richard MJ, Morris C, Deen BF, et al. Analysis of the anatomic changes of
the aging facial skeleton using computer-assisted tomography. Ophthalmic
Plast Reconstr Surg. 2009;25(5 suppl):382-386.
6. DiFrancesco LM, Anjema CM, Codner MA, McCord CD. Evaluation of
conventional subciliary incision used in blepharoplasty: preoperative and
postoperative videography and electromyography findings. Plast Reconstr
Surg. 2005;116(2 suppl):632-639.
7. Rohrich RJ, Arbique GM, Wong C, et al. The anatomy of suborbicularis fat:
implications for periorbital rejuvenation. Plast Reconstr Surg. 2009;124(3
suppl):946-951.
8. Hwang K, Kim HJ, Kim H, et al. Origin of the lower orbicularis oculi muscle
in relation to the nasojugal groove. J Craniofac Surg. 2015;26(4 suppl):1389-
1393.
9. Camirand A, Doucet J, Harris J. Eyelid aging: the historical evolution of its
management. Aesthetic Plast Surg. 2005;29(2 suppl) 65-73.
10. Carraway JH. Volume correction for nasojugal groove with blepharoplasty.
Aesthet Surg J. 2010;30(1 suppl):101-109.

38
CHAPTER
Indications and Technique
for Fat Grafting for
Periorbital Rejuvenation
Dino Elyassnia and Timothy Marten
DEFINITION
■ The hallmark of a youthful, attractive orbit is fullness. It has become clear that
fat atrophy is a significant component of periorbital aging that results in
volume loss and a hollow appearance around the eyes.
■ Traditional blepharoplasty procedures have focused on treating skin laxity, fat
herniation, canthal laxity, and levator dehiscence but have largely ignored fat
atrophy. Often, blepharoplasty procedures aggressively remove fat from the
eyelids, further compounding the problem of volume loss.
■ Periorbital fat grafting represents a new paradigm in eyelid aesthetics that
focuses on volumetric rejuvenation of the upper and lower eyelids. This
approach produces a full, healthy appearance to the eyes that has not been
possible with traditional blepharoplasty techniques.
ANATOMY
■ In recent years, a great amount of work has been done to beautifully elucidate
the detailed fat compartments of the face.1
■ Although this work has been a great contribution to further understanding of
facial anatomy, it plays a smaller role in technically carrying out periorbital fat
grafting because the goal is not to inject fat in such a way that we aim to
“refill” each deflated fat compartment.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A focused history should include any ophthalmologic conditions, previous
blepharoplasties, or other aesthetic treatments including filler use. As

hyaluronic acid filler tends to last especially long in the upper and lower
eyelids, knowledge of its use must be obtained so a decision can be made
whether to dissolve the material prior to fat grafting.
■ Physical exam of the eyelids should include looking for the presence of ptosis,
dermatochalasis, lower lid fat herniation, canthal laxity, orbital vector, and
degree of fat atrophy of the eyelids, midface, and cheek. If problems other than
fat atrophy are present such as significant lower lid fat herniation or excess
skin, traditional blepharoplasty techniques may need to be combined with fat
grafting.
■ A significant advantage of periorbital fat grafting over traditional lower lid
blepharoplasty is that fat grafting is very safe in the setting of dry eye or the
presence of canthal laxity, whereas these problems represent relative
contraindications for lower blepharoplasty.
■ Regarding fat harvest, thin patients should be examined at the time of their
consultation because patients with limited fat stores often present significant
challenges. Extra time and effort will be required to obtain fat from them.
Anesthesia and OR times must be calculated accordingly.
■ Although the abdomen is often cited as the “best” and most convenient site for
fat harvest, in our practice, the hip, waist, and outer thigh are the harvest sites
of choice. The abdomen typically has thinner, less forgiving skin than the hip,
waist, and outer thigh (especially in the face-lift age group) and is readily open
to detailed inspection by the patient after the procedure. As such, it can be
problematic as a sole donor site in many cases if more than a small amount of
fat is needed. The hip, waist, and outer thigh taken together by contrast
typically provide more volume and are less subject to surface irregularities, and
fat harvest from these areas generally provides more overall improvement in
the patient’s silhouette.
IMAGING
■ Typically, radiographs are not necessary for periorbital fat grafting.
■ All patients should have standardized photographs taken preoperatively, and
any markings made preoperatively on patients should be photographed as well.
■ These photos should be used intraoperatively to help guide precise placement
of fat injections.
NONOPERATIVE MANAGEMENT
■ Fillers to the periorbital area are a viable alternative to fat grafting and have

helped patients understand how volume loss contributes to the periorbital and
facial aging process.
■ Advantages of fillers are they have minimal downtime, they are easily
adjustable, they can be reversed (if hyaluronic acid is used), and they last
particularly long in the periorbital area compared to other regions of the face.
■ Disadvantages are they require ongoing maintenance; they are time-
consuming, painful, and expensive; and they can look unnatural requiring a
high level of precision during injection.
SURGICAL MANAGEMENT
■ Whether the result of illness, aging, or previous overzealous surgical
treatment, filling the hollow upper orbit can produce a remarkable rejuvenation
of the upper eyelid and eliminate an unnaturally hollow and elderly appearance
sometimes referred to by patients as “nursing home” or “owl” eyes (FIG 1).
■ Like the upper orbit, fat grafting the infraorbital area allows comprehensive
correction of age-associated hollowness that lends the face an ill or haggard
appearance, “shortens” the apparent length of the lower eyelid, and produces a
youthful, attractive, and highly desirable smooth transition from the lower
eyelid to the cheek. This effect is generally unobtainable by traditional lower
eyelid surgery, fat transpositions, “septal resets,” midface lifts, free fat grafts,
and other like means (FIG 2).
FIG 1 • Correcting upper orbital hollowing. A. Patient
with an unnaturally hollow upper eyelid appearance
(“owl eyes”) following blepharoplasty performed by an
unknown surgeon. B. Same patient seen after fat
injections to the upper orbit. A healthier, more youthful

appearance can be seen (procedure performed by
Timothy Marten, MD, FACS—Courtesy of Marten Clinic
of Plastic Surgery).
■ Although the primary goal of fat harvest is to obtain the “best” tissue for the
fat grafting procedure, fat harvesting should be thought of as an opportunity to
improve the patient’s figure. Thus, harvest must be undertaken in a thoughtful
and artistic manner and generally in a bilateral and symmetrical fashion.
Although any area can theoretically be used for a donor site, the hip, waist, and
outer thigh are our primary choice for the reasons detailed above.
Preoperative Planning
■ Fat grafting cannot be performed casually, and deficient areas and key
landmarks must be marked preoperatively with the patient in an upright
position. Marking will require concentration and focus and is best carried out in
an area that is free from distractions.
■ Creating a proposed plan on a full-page laser print of the patient’s face is
helpful in organizing the treatment plan and facilitates confirming with the
patient the areas that will be treated.
■ If the patient wishes, marks can be made while she or he holds a hand mirror.
Once markings are complete, a new series of photographs are taken and printed
up for use during the procedure. These photographs typically provide the best
information to the surgeon intraoperatively.
FIG 2 • Filling the hollow lower orbit with fat. A. Patient
with an unnaturally hollow and elderly infraorbital
appearance. The lower eyelid appears “long,” and there

is a distinct line of demarcation between the lower
eyelid and the cheek. B. Same patient seen after face-
lift and fat injections to the infraorbital area. There is a
smooth transition from the lower eyelid to the cheek,
and the patient has a healthier, youthful, and attractive
appearance (note: the upper orbit, radix, cheek, and
nasolabial crease have also been treated with fat
injections, and the patient has undergone ptosis
correction) (procedure performed by Timothy Marten,
MD, FACS—Courtesy of Marten Clinic of Plastic
Surgery).
■ Regarding fat harvest, an estimate should be made as to the amount of fat that
will be used and thus the amount that needs to be harvested. In estimating the
amount that one needs to harvest, a helpful guideline is that after
centrifugation, approximately 50% of what was harvested will be obtained as
usable processed fat.
■ If one wishes to perform the fat grafting procedure predominantly with “stem
cell”–rich fat (the bottom 2 cc of fat in the centrifuged 10-cc syringe consisting
of high-density adipocytes), only 20% of what is harvested fat will be available
for injection, and the total amount harvested will have to be adjusted
accordingly.
■ As in the case of formal liposuction, the patient’s torso must be marked
preoperatively while she or he is standing if optimal contours are to be created
and if irregularities are to be avoided at the harvest sites. Once markings are
complete, marked areas should be photographed and the photos printed up for
use during the harvesting part of the procedure.
Positioning
■ Fat is harvested after anesthesia is initiated but before prep and drape of the
face. A complete prep of the torso is not necessary, and in all but the unusual
case, a limited prep of the marked area is made and a sterile field is established.
■ If fat is to be harvested from the hip or lateral thigh, the patient is turned into a
semilateral decubitus position; prep, drape and harvest is performed; and the
patient then is turned to the opposite side where a similar procedure is

performed.
■ This position can be used to simultaneously harvest fat from multiple sites
including the hip, waist, flank, upper buttocks, outer and inner thigh, and knees
(FIG 3). With practice, a well-organized OR team can complete this process
expeditiously without undue delay of the procedure.
FIG 3 • Positioning patient for fat harvest. If the patient
is carefully positioned in a semilateral decubitus
position, fat can be simultaneously harvested from
multiple sites including the hip waist, flank, inner knee,
outer and inner thighs, buttocks, and inner knee.
Obtaining fat from multiple sites is particularly important
in thin patients with minimal fat stores or when multiple
site fat grafting is being performed. Following harvest
from one side, the patient is turned to the other where a
similar harvest is performed.
■ The patient is then returned to the supine position for fat grafting the
periorbital area.
Approach
■ For upper orbit fat grafting, small stab incisions are made in the brow with a
no. 11 blade scalpel or a 20-gauge needle. These incisions are so small that
they will not require suturing upon completion of the procedure.
■ Injecting from two separate injection sites at the medial and lateral ends of the

brow allows “crisscrossing” of cannula passes during graft placement parallel
to the superior orbital rim.
■ This “crisscrossing” provides smoother fat infiltration and helps avert a “row
of corn” effect that may result if injection is made from only one site.
■ Unlike the upper orbit, however, experience has shown that for the lower orbit,
fat is best and most easily injected perpendicular to the infraorbital rim from
stab incisions in the midcheek or perioral area. When this is done, lumps and
irregularities are far less common. Fat should not be injected parallel to the
lid-cheek junction in the infraorbital area.
T E C H N I Q U E S
■ Fat Harvest
■ Areas from which fat is to be harvested are infiltrated with a dilute 0.1%
lidocaine with 1:1 000 000 epinephrine solution using a multiholed
infiltration cannula (TECH FIG 1), and an adequate time is allowed for a
proper anesthetic and hemostatic effect.
■ Approximately 1 cc of this solution is injected for every 3 cc of anticipated
fat removal. It is not necessary or desirable to infiltrate in a “tumescent”
fashion as overwetting the tissue will result in an overdilute harvest and more
time spent in the harvesting process.
■ Local anesthetic should be injected even if general anesthesia is used to limit
stimulation of the patient and the overall amount of general anesthetic
needed.
■ Fat is harvested with a special harvesting cannula (see TECH FIG 1)
ranging in size from 2.1 to 2.4 mm and 15 to 25 cm long attached to a 10-cc
syringe using gently applied syringe suction to minimize vacuum barotrauma
to the tissue.
■ Sharp hypodermic needles should not be used to harvest fat.
■ In general, and as mentioned previously, at least twice as much fat is
harvested as is anticipated will be used to ensure an adequate amount of
processed fat will be available for use on the face.
Processing Harvested Fat

■ Our preferred method of processing fat is centrifugation.
■ Before centrifugation is commenced, a sterile disposable plastic cap is
placed on the end of the syringe to keep its contents inside it, and the syringe
plunger is removed from the syringe barrel.
■ Capped syringe barrels containing unprocessed fat are then loaded into the
centrifuge in a balanced fashion and spun for 1 to 3 minutes at 1000 RPM.
■ Many centrifuges available for this purpose have variable speed adjustments
and rotors that can be sterilized so that the syringes the fat is in remain sterile
and can be handled by the scrubbed surgical team. Other centrifuges have
sterile tubes that fit into the rotor for this purpose (TECH FIG 2). The typical
spin speeds of approximately 3500 RPM used by most single-speed desktop
centrifuges sold for fat processing are said to not cause injury to fat or
compromise its “take.”
■ Once centrifuged, syringe barrels containing spun fat are removed,
centrifuged fat will be seen to contain an upper oil (ruptured fat cells), central
fat, and lower “water” (blood, lidocaine) components (TECH FIG 3).
■ The often blood-tinged “water” (local anesthetic) component is discarded by
simply removing the syringe tip cap and allowing it to run out. The oil
fraction is then poured off out of the top of the syringe. Telfa sponges can
also be placed inside the syringe barrel to wick up the small amount of
residual oil present after the majority of it has been poured off.
■ A laboratory “test tube”–type rack to hold and organize the syringes
containing fat greatly facilitates fat processing activities (TECH FIG 4).
TECH FIG 1 • Fat harvesting instruments. A. Specially
designed harvesting cannulas ranging in size from 2.1
to 2.4 mm are attached to 10-cc Luer-Lok syringes

and are used to extract fat from donor sites using
gentle syringe suction. Fat harvested with these
cannulas easily passes through injection cannulas as
small as 0.7 mm. Shown from top to down: (a) 10-cc
Leur-Lok syringe, (b) 1.6-mm Coleman local
anesthetic infiltration cannula, (c) 2.4-mm Tulip “Tri-
Port” harvesting cannula, and (d) Coleman harvesting
cannula. B. Close-up of instrument tips. Shown from
top to down: (a) 10-cc Leur-Lok syringe, (b) Coleman
infiltration cannula, (c) Tulip harvesting cannula, and
(d) Coleman harvesting cannula.
TECH FIG 2 • Centrifuging fat. Harvested fat is
generally not uniform in character as extracted from
donor sites as each syringe will contain a variable
amount of fat, blood, local anesthetic, and ruptured fat
cells (“oil”), and some type of processing is necessary
to obtain uniform material for injection. Centrifugation
allows separation of the “oil” and “water” fractions from
the fat cells and concentrates high-density adipocytes
(“stem cells”). A. Small portable countertop centrifuge
(). B. Close-up view of
centrifuge rotor being loaded with unprocessed fat in
10-cc syringes. Note that the syringe tip has been

sealed with a disposable plastic cap. The removable
and sterilizable metal sleeves shown to fit into rotor to
keep syringe barrels containing fat sterile and allow
them to be handled on the sterile field after spinning.
Some centrifuges are designed to allow the entire
rotor to be sterilized.
■ After centrifugation and the separation and discarding of the resulting oil and
water components have been accomplished, the resultant fat is transferred
into 1-cc Luer-Lok syringes using a transfer coupler (TECH FIG 5). Proper
infiltration of fat requires injection in very small amounts that cannot be
reliably made with a 10-cc, 5-cc, or even 3-cc syringes.
■ The bottom 2 cc of fat in the syringe containing the highest concentrations of
high-density adipocytes (or adipose-derived regenerative cells [ADRC]) is
segregated and is used preferentially in the procedure.
Upper Orbit Fat Grafting
■ First, nerve blocks are performed with 0.25% bupivacaine with epinephrine
1:200 000 local anesthetic solution. It is typically not necessary to directly
infiltrate areas to be treated with local anesthetic, if nerve blocks are properly
performed and adequate sedation has been administered.
TECH FIG 3 • Centrifuged fat. Harvested fat seen after
centrifugation. Three layers can be seen in the
centrifuged material: an upper “oil” layer (ruptured fat

cells), a middle layer of intact fat cells, and a bottom
layer of blood and local anesthetic. Unlike straining of
fat through a sieve, centrifugation may allow
separation of the “oil” and “water” fractions from the fat
cells with minimal loss of “stem cells,” “growth factors,”
and “cellular messengers.”
TECH FIG 4 • Syringe rack. A “test tube” rack to hold
the syringes containing fat greatly facilitates fat
processing activities. On the left, syringes containing
unprocessed fat are present. In the center, syringes
containing centrifuged fat can be seen. The rack also
conveniently holds 1-cc syringes, syringe
components, and other equipment used in the fat
grafting procedure.
■ Once nerve blocks have been administered, small stab incisions are made in
the medial and lateral extent of the eyebrow.
■ Infiltration is made in multiple passes injecting on both the in and out
strokes. Approximately 0.05 cc or less should be injected per pass. This
corresponds to 20 to 40 back and forth passes or more for each 1-cc syringe
of processed fat.
■ The goal is to inject the fat in a way that optimizes its chance of developing
a blood supply and surviving, and the mental model should be one of
scattering tiny particles of fat into the recipient site in multiple crisscrossing

fine trails in such a way that each particle sits in its own compartment and
has maximal surface contact with perfused tissue.
■ Advancement and withdrawal of the injection cannula will typically be made
slowly by the beginning injector, but as familiarity with the technique is
acquired, the movements can and should be made faster. Ultimately, all other
things being equal, faster movements are desirable in that if the injection
cannula is constantly in motion, intravascular injection is less likely, and the
likelihood that an accidental bolus injection into one area will be made is
reduced.
■ How the syringe is held is also important in avoiding overinjection and
controlling the volume injected with each pass. If the syringe is held in the
manner one would traditionally use to give an injection with the thumb on the
end of the syringe plunger, it is easy to inject too much fat if tissue resistance
changes or injection cannula resistance suddenly decreases. More control can
generally be maintained, and overinjection more easily avoided, if the syringe
is held with the end of the plunger in the palm of the hand (TECH FIG 6).
Held in this manner, a slight closing of the hand results in a small amount of
fat only being expressed from the cannula, and overinjection into any one
area can more readily be avoided.
■ To allow for the deposition of tiny aliquots of fat per pass, very fine cannulas
must be used when fat grafting around the eyes. Currently, a 4-cm-long 0.7-
mm (22-gauge) cannula is preferred. These newer fine cannulas have made
injecting the upper orbit easier and more predictable than in the past as they
can be advanced more smoothly and accurately through tissues.
TECH FIG 5 • Transferring centrifuged fat to 1-cc
syringes. Fat is transferred from 10-cc Luer-Lok

syringes into 1-cc Luer-Lok syringes after
centrifugation, and the oil and water fractions have
been discarded using a transfer coupling. Proper
injection in the very small quantities that are needed in
the face cannot be made with larger syringes. A. 10-
cc Luer-Lok syringe, 1-cc Luer-Lok syringe, and Luer
to Luer transfer coupling. B. Transfer coupling in use.
■ A common misconception in treating the hollow upper orbit is that fat is
needed and should be grafted into the preseptal portion of the eyelid itself.
The hollow upper eyelid is however more properly and practically restored
by placing fat in a deep submuscular/preperiosteal position along the inferior
margins of the supraorbital rim. The process is best conceptualized as one of
lowering the supraorbital rim and filling the upper orbital area to push skin
that has retracted up into the orbit down onto the preseptal eyelid to create a
full and appropriately creased upper eyelid (TECH FIG 7).
■ Once one accepts that improvement is obtained by grafting of the orbit, and
not the eyelid itself, it becomes apparent that larger volumes than might
otherwise be expected are required. In general, 2 to 3 cc of fat must be placed
in each upper orbit to achieve the improvement typically sought.
■ When grafting the upper orbit, it must always be remembered that when one
is working in very close proximity to the eye, and although the injection
cannulas are blunt tipped, they are easily capable of perforating the ocular
globe.
■ Fat grafting the upper orbit and “eyelid” is advanced in difficulty, and
treatment of this area should be made only after experience has been gained
treating more forgiving areas.

TECH FIG 6 • Method of holding syringe to control
volume expressed during injection. If the syringe is
held in the way one would traditionally use to give an
injection, it is easy to inject too much fat if tissue or
injection cannula resistance suddenly decreases.
More control can be maintained, and overinjection
better avoided, if the syringe is held with the end of
the plunger in the palm of the hand. Held in this
manner, a slight closing of the hand results in a small
amount of fat only being expressed.
■ Once that experience is obtained, fat grafting the upper orbit can be one of
the most artistically rewarding uses of autologous fat and one that is likely to
become a routine part of rejuvenating the upper eyelid in the future.
Lower Orbit Fat Grafting
■ First, nerve blocks are performed as is done in the upper orbit.
■ Unlike the upper orbit, for the lower orbit, fat is best and most easily injected
perpendicular to the infraorbital rim through stab incisions placed in the
midcheek or perioral area (TECH FIG 8). When this is done, lumps and
irregularities are far less common.
■ Like the upper orbit, fat grafting of the infraorbital area is typically
performed with a 4-cm-long 0.7-mm (22-gauge) injection cannula with a
focus on placing very small aliquots of fat per pass using the same basic
injection technique described above.

■ Also like the upper orbit, fat need not and should not be grafted in the
pretarsal lower eyelid. Fat should be injected deep in a
submuscular/preperiosteal plane, and the technical goal of the procedure
should be thought of as raising up and anteriorly projecting the infraorbital
rim rather that filling the lid itself.
■ It is wise to avoid any subcutaneous injection in the infraorbital area due to
the extremely thin skin present and the likelihood of creating visible lumps
and irregularities. Thus, it is best to limit injections to a
preperiosteal/suborbicularis oculi plane. The purported benefit of superficial
injections—improving skin texture and color—is too small an improvement
in most cases for all but the expert injector to offset the all too likely
occurrence that visible and difficult-to-correct irregularities will result.
TECH FIG 7 • Incision sites and plan for injecting fat
into the upper orbital (“upper eyelid”) area. Fat grafting
of the upper orbital area is typically performed with a
4-cm 0.7-mm (22-gauge) cannula, and fat is placed
deep in a suborbicularis oculi/preperiosteal plane.
Typically, 2 to 3 cc of fat is placed in each upper orbit.
Level of difficulty: advanced.