Fat or fillers: The dilemma in eyelid surgery

Table 2 Summary of studies on eyelid surgery

Technique	Type of study	Number of cases	Region treated	Comparison/follow-up	Outcome	Rate complications	Results	Type of fat	Conclusions	Ref.
Fat graft	Original article	1047	Upper eyelid; eyebrow	Median follow-up 3 months	Volume enhancement, exhophtalmos and ptosis correction	26 out of 1047	See rate of complications	Microfat	Discussion on “ugly” results trying to minimize complications and unsatisfaction	Benslimane et al[45], 2021
	Original article	98	Perioral, periocular,chin, malar region, temporal fossa	Avereage 6 months follow-up	Volume enhancement, rhytids reduction, skin quality	0.039	Volume restoration was evaluated by 2 senior authors rated the results independently as good in 62 patients (63%) and excellent in 36 patients (37%)	Superficial enhanced fluid fat injection	The fat administered by SEFFI is easily harvested via small side-port cannulae, yielding micro fat that is rich in viable adipocytes and stem cells. Both volumes of fat (0.5 mL and 0.8 mL) were effective for treating age-related lipoatrophy, reducing facial rhytids, and improving skin quality	Bernardini et al[78], 2015
	Original article-retrospective	200	Periocular area	6 month-1 yr follow-up	Volume and contour	< 2%	Nearly all patients had improvement in periocular contour, but variable loss of volume was observed by 1 yr. Patients who presented initially with scleral show often had noticeable improvement. At 1 yr, only 3 patients experienced contour irregularities comprising soft bulges, similar to fat hernias. Two patients showed fat accumulation after substantial weight gain later than 1 yr postoperatively	Properly diluted fat	Preparation and periocular delivery of PDF by the described techniques yield good contour with a low risk of visible masses occurrence	Pelle-Ceravolo et al[79], 2020
	Original article	31	Upper periorbital area	Average total follow-up period was 15.33 months (± 4.821 months; range 12-28 months)	The primary result was the quantitative volume difference in the superior sulcus region before and after grafting. This was evaluated through three-dimensional VECTRA® imaging. The secondary results included the aesthetic quantitative evaluation results (upper lid area and pretarsal space ratio), GAIS score, and complications	Bruises 12 (38.7%); edemab 6 (19.4%); infection 0; palpable granules 0; asymmetry 2 (6.5%); ptosis 0	The median preoperative pretarsal space and upper lid area ratio was 1.010 (± 0.150). The median postoperative pretarsal space and upper lid area ratio at 1 year was 0.159 (± 0.031) (n = 62; P < 0.0001), indicating a significantly reduced sunken appearance. The average GAIS score was 2.174 (± 0.391). All patients were satisfied with their surgical outcomes. The reoperation rate was 12.9%	SVF gel	SVF gel is safe and effective for the treatment of a mild-to-moderate sunken superior sulcus and is associated with satisfactory clinical outcomes and short recovery times	Ding et al[72], 2023
	Original article	99	Periorbital	5 groups based on follow-up length	Volume enhancement, aesthetic rating	-	Independent evaluators correlation, k = 0.316	Enriched centrifugated fat	Autologous periorbital lipotransfer remains a valid and effective technique for periorbital rejuvenation and demonstrates long-term potential effectiveness	Yeh et al[66], 2011
	Clinical trial	96	Tear trough	Hyaluronic vs Lipo-filling	Aesthetic	-	Tear trough grade improvement in both groups. One year after treatment, while patients treated with HA start having a regression of correction, all patients of group treated with lipofilling keep a stable result	Centrifugated fat	Both HA and lipofilling are effective treatments for tear-trough depression, though lipofilling provided a higher grade of improvement of the deformity as well as prolonged effects	Pascali et al[65], 2017
							In patients with grades 1, 2, and 3 deformities, lipofilling resulted in significantly greater grade improvement, compared with HA filling
	Editor’s invited commentary	-						Centrifugated fat	Graft should be placed under orbicularis oculi muscle; subcutaneous plane should be avoided to reduce risk of irregularities	Marten et al[46], 2018
	Meta-analysis	> 4000							FG is a procedure with high satisfaction rate (90.9%) and low complication rate	Yang et al[42], 2021
	Review	> 1000							FG is easy to perform and achieved satisfactory and sustainable results with few complications. However, a wide disparity exists in fat harvesting, purification, and re-injection techniques	Boureaux et al[26], 2016
	Review	-							FG in comparison to major surgery is a minimally invasive method with lower post-operative pain and fewer complications	Çetinkaya et al[43], 2013
Hyaluronic Acid	Original article	147	Periorbital hollows	Long-term follow-up (at least 5 yr)	Volume enhancement; omplications	17 patients had malar edema; 46 blue-gray dyschromia; 45 contour irregularity/orbital ridge	See rate of complications; no statistically significant difference in the mean volumes injected by severity grading of each measured complication		The vast majority of cases of malar edema, blue-gray dyschromia, and contour irregularities are mild and do not require intervention. Injection should be pre-periosteal, deep to the orbicularis oculi muscle, to avoid compression to lymphatic structures as well as decrease the risk of Tyndall effect	Mustak et al[59], 2018
	Original article prospective single blind	600	Tear trough by means of cannuala or needle	Average follow-up time was 12 months ± 1 months	Hirmand’s classification improvement	Tyndall effect, a blue-gray dyschromia, and contour irregularities are the most frequently reported complications with injection into this site, being referred in up to 30.5% of cases. With respect to the results here presented, post-injection complications encountered with needle use occurred in 5.1% of cases, compared to cannula use in 11.0% of cases, and they are usually transient and self-limited within hours (swelling, bruising, redness and pain)	Improvement mostly seen in younger patients unde 50 yr old and d improvement duration up to 1 yr		HA injection of the tear trough is most effective in patients between 30 and 40 years of age, while its benefits extend to up to 50 years old; afterward, it should no longer be the treatment of choice. This confirms that correction of tear trough with hyaluronic acid injections may provide an option to achieve immediate and durable results for up to one year after the injection	Diaspro et al[56], 2022
	Original article retrospective	101	Infraorbital hollows	Mean follow-up 12 months	FACE-Q with eyes and decision survey	Adverse effects include bruising [in 10 (10%), contour irregularities 2 (2%), swelling 3 (3%), and Tyndall effect 1 (1%)]	Overall mean (SD) patient satisfaction (based on FACE-Q scores) was 71.1% (27.3) and 65.6% (31.3), respectively. (eyes and decision survey)			Hall et al[55], 2018
	Original article retrospective	45	Tear trough inferior to lateral orbital thickening	Yes	Improvement in tear trough grade (classified according to Hirman)	-	The improvement was I grade 29 patients and II grades in 16 patients. The improvement lasted (10.8 ± 2.3) months. No severe adverse events were noted		See results	Wollina et al[52], 2021
	Clinical trial	151	Preperiosteal tear trough	Follow-up (1 month)	Treatment safety	At the first visit post-treatment on 151 patients: Swelling in 22 patients (mild 10, moderate 2, missing data 10); Bruising in 17 patients (mild 9, moderate 2, severe 1, missing data 5); Redness in 32 patients (mild 12, moderate 3, severe 1, missing data 16); Pain in 1 patient (mild); Blued discoloration in 4 patients (moderate 2, missing data 2); Other (itching, hollow) in 1 patient (1 missing data)	Most patients (97%) described marked or moderate satisfaction with the treatment; see complications		Effective use of semi-cross-linked HA gel in tear-trough rejuvenation. It has excellent patient tolerability and satisfaction and minimal complications	Berguiga et al[49], 2017
						At follow-up 1 month (visit 2) on 112 patients; Swelling in 13 patients (mild 4, moderate 2, severe 1, missing data 6); Bruising in 12 patients (7 mild, moderate 1, missing data 4); Redness in 7 patients (mild 3, missing data 4); Blue discoloration in 1 patient (1 missing data); Other (itching, hollow) in 2
	Observational study	150	Tear trough	Follow-up immediate, 1 wk, 1, 3, 6, and 12 months)	Treatment efficacy	Immediately after injection: 12/150 patients (8.0%) had swelling, redness in 6/150 patients (4.0%), pain in 3/150 patients (2.0%), bruising in 3/150 patients (2.0%)	Approximately 90% at all time points rated their results as “very” or “exceptionally” improved. Adverse events were short term and included swelling, redness, pain, and bruising. No adverse events seen after the 1-wk visit. No Tyndall effect was noted throughout the study and no filler required removal		For tear-trough deformity treatment, simplified, quantifiable HA injection technique in 3 areas (medial, central and lateral infraorbital) with predictable and satisfactory outcome and low complication rate	Hussain et al[50], 2019
						After 1 wk post-treatment: 7/147 patients had swelling (4.7%), bruising in 2/147 patients (1.4%)
	Comment	-							Hyaluronic acid functions as an osmole, attracting and capturing large amounts of water. It is also known to act as an antioxidant, and by stretching tissue, it indirectly stimulates neocollagenogenesis	Sisti et al[48], 2019
	Systematic review	-							Patient satisfaction after the procedure is high (85%-90%) and with a duration of effect between 8-12 months	Trinh et al[47], 2022
	Review	-							Hyaluronic acid fillers are minimally invasive and suitable for periorbital area, also because they can be easily dissolved with hyaluronidase. Low-viscosity HA is safe for tear-trough region	Montes et al[63], 2021
	Review	-							Hyaluronic acid has the most evidence to support its efficacy in periorbital area, with good safety profile. Most adverse events are mild and transient	Mandal et al[32], 2021
	Review	-							Vascular compromise is rare but could happen especially in the glabellar area, probably due to the presence of small vessels and a lack of good collateral circulation	Lee et al[61], 2017

PDF: Properly diluted fat; GAIS: Global aesthetic improvement scale; FG: Fat graft; HA: Hyaluronic acid; SVF: Stromal vascular fraction; SEFFI: Superficial enhanced fluid fat injection.