title: A novel technique for repositioning lower eyelid fat via the transoral approach in association with midface lift.
abstract: BACKGROUND
  Orbital fat repositioning in association with subperiosteal midface elevation has been variably described via both the transconjunctival and skin muscle flap approaches. Poor visualization, middle and posterior lamellar cicatricial fibrosis, technical difficulty, and incomplete release are disadvantages commonly ascribed to the transconjunctival approach. Lower eyelid malposition and retraction also are commonly seen in association with skin muscle flap approaches. A simple technique using the intraoral approach to release the orbital septum and postseptal fat is described in this report. This procedure avoids complications associated with the violation of key lower eyelid anatomic structures and markedly improves visualization through an incision allowing a much larger access.
  
  
  METHODS
  A retrospective review of six patients who underwent endoscopically assisted midface elevation in combination with lower eyelid fat repositioning via a transoral approach since 2009 and were followed up for at least 1 year is presented. A pre- and postoperative assessment of tear trough depth, lower eyelid fat herniation, and midface descent is made. Four of the six patients presented also underwent concurrent additional facial rejuvenation procedures including endoscopically assisted brow-lift, genioplasty, structural fat grafting to the nasolabial folds, and lower eyelid "pinch" blepharoplasty. Standard upper buccal sulcus access incisions were used for subperiosteal midface elevation and exposure of the lower orbital septum. Fat redraped over the orbital rim was not secured with fixation sutures as is commonly performed using lower eyelid approaches. Human cadaveric dissection with endoscopic visualization also was performed to demonstrate the reported technique.
  
  
  RESULTS
  During this study, one complication developed for a single patient who experienced a temporary dense right zygomatic and frontal branch nerve palsy lasting 8 weeks. No evidence of lower eyelid malposition, ectropion, entropion, incomplete release, or asymmetry was otherwise encountered. Improvement in tear trough appearance, lower eyelid herniation, and midface descent was noted in all six patients.
  
  
  CONCLUSIONS
  A novel approach for lower eyelid fat transposition in combination with midface lift using the intraoral approach is presented. Excellent visualization, decreased operative times, technical ease, and improved outcomes all are potential advantages of this technique over standard approaches in which access to lower eyelid fat is achieved through the conjunctiva or a skin muscle flap.
authors.affiliation: Division of Plastic Surgery, University of California San Diego, 4150 Regents Park Row Suite #300, La Jolla, San Diego, CA 92037, USA. drmofid@mofidplasticsurgery.com
authors.forename: M Mark
authors.initials: MM
authors.lastname: Mofid
mesh_terms: D000273:Adipose Tissue / Q000601:surgery*; D000328:Adult; D019882:Blepharoplasty / Q000379:methods*; D005260:Female; D006801:Humans; D008875:Middle Aged; D012189:Retrospective Studies; D015361:Rhytidoplasty / Q000379:methods*; D013524:Surgical Flaps