https://orcid.org/0000-0001-6962-4784
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We very much enjoyed reading the manuscript entitled “The Management of Lumps, Bumps, and Contour Irregularities (LBC) of the Lower Eyelid and Cheek After Poor Outcome Fat Transfer.” This manuscript serves as a valuable addition to our literature, and sheds light on a very important yet challenging area in facial aesthetic surgery. The eyelid-cheek junction has long been an area of both great interest and frustration for aesthetic surgeons. Various approaches to create a more youthful appearance have been described, ranging from excision of fat, redistribution of fat, addition of volume (ie, filler, fat), or some combination of these. In recent years, fat grafting has gained favor among patients and surgeons alike due to the relative ease of fat harvest, minimal downtime, and long-lasting results. Despite fat grafting being considered a relatively minimally invasive procedure, it is a highly nuanced technique that is not without risk, with the most common complications being visibility and palpability.
In this manuscript, the authors provide guidance for addressing periorbital fat grafting complications, including nomenclature and recommendations for diagnosis and treatment.1 The authors refer to unwanted visible fat following fat transfer to the lower eyelid and cheek as lumps, bumps, and contour irregularities (LBCs). The authors further categorize LBCs into groups based on their location relative to the inferior orbital rim (above and below) as well as their topographic distribution (solitary nodule, diffuse enlargement, multiple nodules, and mixed picture). Given the popularity of facial fat grafting and the myriad of ways that complications may present, it is important that consistent terminology be applied in our field when discussing this phenomenon. The authors offer an important nomenclature system to consider when evaluating these lumps based on their location and/or distribution and do an excellent job of illustrating that not all LBCs are the same. To our knowledge, this is one of the first studies to provide a systematic approach to define contour irregularities following fat grafting to the periorbital region.
Having introduced their classification system for LBCs, the authors retrospectively review their experience managing LBCs that presented to their practice following periorbital fat grafting from outside surgeons. They report a cohort of 48 patients over a period of 5 years; 65% of patients presented with LBCs manifesting above the inferior orbital rim (AR) and 35% of patients presented with LBCs above and below the inferior orbital rim (AR/BR). Of note, there were no patients who presented with LBCs isolated below the inferior orbital rim (BR). The contour irregularities manifesting in these patients were most commonly solitary nodules (54%) followed by a mixed picture presentation (23%), diffuse enlargement (17%), and multiple nodules (6%). The majority of patients exhibited bilateral LBCs (88%).
Although the authors of this study did not specifically focus on elucidating the potential etiologies of LBCs, they do raise important questions as to what may have led to these complications in the first place. As noted above, the authors use the inferior orbital rim as a key landmark in defining LBCs. All of the patients in their study had LBCs either AR, BR, or AR/BR, yet it is intriguing as to why no case of LBCs were found isolated to BR only. This is particularly interesting to our group which has previously shown that volumization of the cheek is well controlled when limited to below the arcus marginalis. In a cadaver study, the senior author (O.T.) demonstrated that fat injected into the deep compartments of the malar region does not cross the orbital retaining ligament unless this is surgically released.2 Our previous findings, along with the current findings that LBCs did not exist solely BR, support the notion that fat injections placed deep at or below the arcus marginalis may indeed limit potential issues of visibility postoperatively.
Another interesting finding from this manuscript was that the authors also noted the majority of patients presented with bilateral LBCs (88%). This heavily skewed bilateral distribution strongly suggests a consistent variable may exist that increases the risk of LBCs. For instance, certain patients may be particularly prone based on their underlying anatomy. On the other hand, provider technique may also be a potential underlying risk factor, with certain surgeons representing the cases of bilateral LBCs. Unfortunately, the authors do not provide us with data on the original treating physicians, thus making it difficult to draw any such conclusions.
We also wonder if there were any trends in unilateral cases, specifically in regards to a higher incidence on a particular side. This raises the question as to whether there is something about the mode of delivery that may cause LBCs to potentially present more frequently on one side. In other words, if we assume most surgeons are right-handed, is there something about the method of delivery (ie, injecting fat towards the body on the patient's side and away on the left) that is making LBCs more likely to occur on one side more than the other. This information would be clinically helpful to potentially alter the surgical approach to periorbital fat grafting to avoid this challenging complication.
Although it is of clinical value to better understand possible causes of LBCs, the primary purpose of this study is to help guide treatment of unwanted fat following periorbital and cheek fat grafting. The authors point out that physical exam, one of the basic tenets of medicine, is of the utmost importance when faced with this condition. The authors describe a valuable maneuver called “depress and roll” which they utilize in the physical exam to better delineate the extent of the mass causing the contour irregularity. This technique proved helpful to highlight the full extent of the lesion, which can be larger than expected by observation alone. Implementing techniques that more extensively demarcate LBCs allow for more accurate surgical planning and help avoid suboptimal resection.
In addition to valuable diagnostic tools, the authors share valuable surgical pearls in the study. For instance, the authors note the difference in appearance between grafted fat and native suborbicularis oculi fat. The authors point out that grafted fat is yellower and has a texture that is more lobular when compared to native suborbicularis oculi fat. This advice is valuable for surgeons considering excision but who have concerns that these irregularities may not be surgically visible or hard to pinpoint during surgery. We also can’t help but wonder whether the difference in fat consistency they describe also holds true for fat grafted in other regions. If so, this might be a useful metric when addressing unwanted fat elsewhere in the body.
Another interesting and technically useful maneuver the authors describe in the treatment of LBCs is controlled lipolysis. In the LBCs the authors categorized as diffusely enlarged, targeted excision can be quite difficult and may not be feasible. To overcome this, the authors implemented controlled lipolysis, which they describe as the use of a monopolar cautery, set on pure coagulation mode, moving in a side-to-side motion to melt away the grafted fat in an even distribution.
One piece of surgical advice we question is their transconjunctival approach to surgically manage LBCs. Although the senior author (O.T.) prefers a transconjunctival approach for most lower lid cases, it would seem logical that a transconjunctival approach in the management of a single nodule may be unnecessary and less desirable. This is especially true given that the authors describe the need for canthal release in some cases (27%). In our experience, isolated LBCs can be easily removed with a limited direct transcutaneous approach to the lower eyelid.
In summary, we very much enjoyed reading this article and thank the authors for sharing their perspective and experience on the characteristic patterns of grafted fat to the eyelid-cheek junction. Fat grafting to this area has proven to be an effective means of achieving aesthetic improvements in this area. Despite its efficacy, it is not without risk. The authors remind us of the importance of considering the potential of unwanted fat and provide valuable insight into clinical management of this challenging complication.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
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