New Internal Fixation Technique for Transconjunctival Fat Repositioning.

To treat tear trough deformities in young patients, transconjunctival orbital fat repositioning has been widely used. Although internal fixation of transposed fat enables more secure and stable fixation than the externalized percutaneous suture method, the latter is used more commonly because of the narrow operation field and consequent technical difficulty of the internal fixation method. We describe a novel technique using a newly devised needle (Chang's needle) that facilitates internal fixation of transposed fat pedicles.

Loeb first introduced the concept of repositioning orbital fat along the infraorbital rim to address tear trough deformity.[1] Goldberg[2] published a modified technique to reposition orbital fat compartments through a transconjunctival approach. A number of different techniques have been introduced to fix fat pedicles within the subperiosteal or supraperiosteal pocket.[3-9]

There are 2 common methods of fixation of transposed fat pedicle using transconjunctival fat repositioning: one is the internal fixation method (IFM) and the other is the externalized percutaneous suture method (EPSM). IFM is more ideal because it provides more secure fixation, has a lower risk of relapse, and is convenient for patients because there is no suture removal. However, EPSM is more widely used because placing anchoring sutures in the subperiosteal or supraperiosteal space is a difficult task due to the narrow operation field of the transconjunctival approach. The orbital fat pedicle should be fixed at the distal end of the subperiosteal or supraperiosteal pocket for optimal positioning, which is more easily accomplished via EPSM. In an effort to combine the advantages of IFM and EPSM, we devised a new needle (Chang’s needle).

SURGICAL TECHNIQUE

Chang’s needle is a 25-mm-length, 3/8 circle, bidirectional, round-type needle composed of 3 parts: the skin side end, body, and conjunctival side end. The skin side end is sharp for easy skin penetration, whereas the conjunctival side end is blunt to reduce the chances of eyeball injury. A hole is located 4 mm from conjunctival side end. There is a laser mark 3 mm from the hole for estimating the location of the hole from the skin side. Usually 5-0 or 6-0 absorbable sutures are passed through the hole and tied once (Fig. 1).

Fig. 1.

Design of Chang’s needle.

The nasojugal groove is demarcated with a marking pen in the preoperative area with the patient in an upright sitting position. The conjunctiva and nasojugal groove are infiltrated with 1% lidocaine with 1:100,000 epinephrine. An incision is made with electrocautery 3–4 mm above the fornix to a length of about 12 mm. A 6-0 traction suture is placed through the posterior conjunctival flap. Preseptal dissection proceeds to the arcus marginalis. Supraperiosteal dissection with Bovie electrocautery is used to detach the tear trough ligament and palpebromalar ligament 10–12 mm distal from inferior orbital rim. An incision is made along the inferior edge of the septum, exposing the fat pad. The extruded fat is made into a pedicle by thinning and elongating it with careful dissection of surrounding fibrous tissues, preserving the vascular supply. Chang’s needle is placed at the fat pedicle and then passed from the distal end of the dissected space to the skin while being careful not to pull it beyond the laser mark. After checking that the conjunctival side of the needle cannot be seen, the needle is passed back into the supraperiosteal dissected space, which is 2–3 mm from the original puncture point. Part of the absorbable suture is trapped in the flap, and transposed orbital fat can thus be fixed to the lowermost dissected space (Fig. 2.). Usually fixation at 2 or 3 points is performed on a case-by-case basis. No conjunctival sutures are placed. A hydrocolloid dressing is applied to reduce postoperative swelling and absorb some oozing from the needle puncture site. Patients can remove it by themselves 1 day after the operation. (See video, Supplemental Digital Content 1, which demonstrates the operative technique, http://links.lww.com/PRSGO/A537).

Fig. 2.

Illustration of internal fixation of transposed fat pedicles using Chang’s needle. A, Chang’s needle is placed at the fat pedicle and then passed from the distal end of the dissected space to the skin while being careful not to pull it beyond the laser mark. B, After checking that the conjunctival side of the needle cannot be seen, the needle is passed back into the supraperiosteal dissected space, which is 2–3 mm from the original puncture point. C, Part of the absorbable suture is trapped in the flap, and transposed orbital fat can thus be fixed to the lowermost dissected space by placing several knots.

See video, Supplemental Digital Content 1, which displays the operative technique. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A537.

DISCUSSION

Two methods of fixation of transposed fat pedicle are commonly used in transconjunctival fat repositioning, IFM, and EPSM. Although IFM is more ideal, ESPM is more widely used because it is less technically challenging.

EPSM has several advantages in addition to its ease. First, it requires a shorter incision than IFM, in which a longer incision is needed to secure space for needle holder handling in suture fixation. Second, fixation of transposed fat to the optimal position is possible. Orbital fat can be moved and secured at the caudal end of the dissected space by EPSM, whereas fixation may occur at a more cephalic position than intended in IFM due to the narrow space available for needle anchoring (See figure, Supplemental Digital Content 2, which shows fixation position of transposed fat pedicles, http://links.lww.com/PRSGO/A538). Third, in ESPM, there are no limitations regarding the dissection plane, whereas IFM is limited to the supraperiosteal plane because the orbicularis oculi muscle and suborbicular fat are insufficiently firm for anchoring. Sullivan and Drolet[6] and Youn et al.[8], who successfully performed IFM via a transconjunctival approach, typically used subperiosteal dissection.

IFM has advantages over EPSM, the most important of which is the low risk of relapse. Externalized sutures are secured over a cotton or bolster or just fixed in place using Steri-Strips and removed 3–6 days after surgery. During those days, adhesion between transposed fat and the new supraperiosteal or subperiosteal pocket is expected. However, relapse can occur if there is tension remaining on the fat pedicles due to insufficient release, or unintentional mechanical forces like rubbing on the tear trough area. Sullivan and Drolet[6] did not observe movement of fat in their long-term results, and attributed this durability to internal fixation. Youn et al.[8] mentioned that long-term maintenance of buried sutures was a prerequisite to more experienced surgeons for stability of the repositioned fat.

From the perspective of patients, IFM is much more comfortable and preferable to EPSM. For 3–6 days after ESPM, patients have trouble washing their face because of bolster or taping on their cheek. Furthermore, social activity may be limited by esthetic issues. Patients must return to the clinic to have sutures removed. Some patients suffer from skin trouble or scarring related to the placement of stitches (see table, Supplemental Digital Content 3, which demonstrates the comparison of the conventional IFM, external percutaneous suture method, and IFM by using Chang’s needle, http://links.lww.com/PRSGO/A539).

With Chang’s needle, easy internal fixation of transposed fat to an optimal position is possible without the fear of recurrence, and with greater comfort and convenience for patients.

CONCLUSIONS

This novel technique using Chang’s needle has the advantages of both the IFM and the EPSM. It guarantees stable fixation of transposed fat, is convenient for patients, and has a low risk of relapse, similar to the IFM. It is also technically easy and requires only a short incision, without limitations on the dissection plane, and optimal positioning of fat pedicles is possible.