The Anatomy of The Tear Trough-Why This is a Difficult Treatment Challenge

There are numerous instances of unhappy patients after tear trough filler injections. There seems to be a sound anatomical explanation for this. Injection of a filler deep to the muscle (as is the popular recommendation) is veritably impossible as the "overlying" muscle is firmly attached to the underlying bone in this target area (see below). In other words there is no tissue plane to accommodate the injected filler "deep to the muscle".  "Non Esiste" as the Italians may say. This does not mean that improvement by injection is impossible but it does confirm why so many tear trough injections result in complications and misery. Essentially the intended injection placement has nowhere to go other than into the muscle itself or "out the side" so to speak. The injected product ends up in the muscle, over the muscle into the subcutaeous fat plane, into the inferior orbital fat or inferior to the muscle in a fat pad know as SOOF. This will be a source of debate and conjecture among cosmetic injectors for some time to come. However anatomy is a fact rather than theory. I recently attended Australasian Society of Aesthetic Plastic Surgery-An Anatomical Basis for Non-surgical Rejuvenation seminar at Macquarie University ( www.facebook.com/asaps.org.au )  where facial human anatomy dissections were performed. I was keen to examine the controversial anatomy of the tear trough and lid-cheek junction. Essentially the following extract from a 2009 scientific paper is consistent with what I saw demonstrated in the anatomy dissections:  

"In the suborbicularis plane, the tear trough and the lid/cheek junction differ. Along the tear trough, the palpebral portion of the orbicularis oculi muscle is rigidly attached to the bone, with no dissectible anatomical plane deep to the muscle. It was not technically possible to dissect above the periosteum and below the muscular attachment. Along the lid/cheek junction, however, the orbicularis muscle has a ligamentous attachment to the bone by means of the orbicularis retaining

ligament. Unlike the tear trough region, there is a plane deep to the muscle into which material can
be injected or surgical dissection performed."

The tear trough and lid/cheek junction: anatomy and implications for surgical correction
Haddock NT, Saadeh PB, Boutros S, Thorne CH Plast Reconstr Surg. 2009 Apr;123(4):1332http://www.ncbi.nlm.nih.gov/pubmed/19337101

Another Study Supports Liposuction Safety Under Local Anaesthesia Compared To General Anaesthesia

Combination Cosmetic Surgeries, General Anesthesia Drive AEs
Laura Newman, MA
February 9, 2012 — The use of general anesthesia, the performance of liposuction under general anesthesia, and a combination of surgical procedures significantly increase the risk for adverse events (AEs) in office-based surgery, according to reviews of statewide mandatory AE reporting in Florida and Alabama. More than two thirds of deaths and three quarters of hospital transfers were associated with cosmetic surgery performed under general anesthesia, according to an article published in the February issue of Dermatologic Surgery.

The study, derived from 10-year data from Florida and 6-year data from in Alabama, "confirms trends that have been previously identified in earlier analyses of this data," write the authors, led by John Starling III, MD, from the Skin Cancer Center, Cincinnati, and the Department of Dermatology, University of Cincinnati, Ohio.

In a companion commentary, C. William Hanke, MD, from the Laser and Skin Surgery Center of Indiana, Indianapolis, presses for 3 patient safety practices: "(1) Keep the patient awake!... 2) Think twice before supporting a patient's desire for liposuction that is to be done in conjunction with abdominoplasty under general anesthesia.... 3) "[B]e advocates for prospective, mandatory, verifiable adverse event reporting...[that] should include data from physician offices, ambulatory surgical centers, and hospitals to define and quantify problems that can be largely prevented and eliminated."

The authors and editorialist are especially critical of liposuction performed under general anesthesia. The study revealed that although liposuction is perhaps one of the most common cosmetic surgical procedures, no deaths occurred in the setting of local anesthesia. "Liposuction under general anesthesia accounted for 32% of cosmetic procedure-related deaths and 22% of all cosmetic procedure-related complications," the researchers write.

The researchers analyzed mandatory physician AE reports in ambulatory surgery submitted to their respective states, encompassing 10-year data in Florida and 6-year data in Alabama. A total of 309 AEs were reported during an office-based surgery during the 10-year period in Florida, including 46 deaths and 263 reportable complications or transfers to hospital. Cosmetic surgeries performed under general anesthesia accounted for the vast majority of deaths in Florida, with liposuction and abdominoplasty the most frequent procedures.

Six years' worth of data from Alabama revealed 52 AEs, including 49 complications or hospital transfers and 3 deaths. General anesthesia was implicated in 89% of reported incidents; 42% were cosmetic surgeries. Pulmonary complications, including pulmonary emboli and pulmonary edema, were implicated in many deaths in both states.

Plastic surgeons were linked to nearly 45% of all reported complications in Florida and 42.3% in Alabama, write the researchers. Office accreditation, physician board certification, and hospital privileges all revealed no clear pattern.

One limitation acknowledged by the authors is that case logs of procedures performed under general and intravenous sedation are required in Florida, but are not public domain, and so were unavailable for analysis. In addition, investigators were not able to obtain data on the total number of liposuction procedures performed in either state. The lack of those data prevented them from calculating the overall fatality rate.

The authors and the editorialist have disclosed no relevant financial relationships.

Dermatol Surg. 2012;38:171-179. Article abstract, Commentary extract

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