Atiyeh Bishara, Hakim Christopher-Roland, Oneisi Ahmad, Ghieh Fadi, Chahine Fadel
Annals of Burns & Fire Disasters, Plastic & Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
6th Year Surgical resident in Plastic & Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
Aesthetic Plast Surg. 2023 Feb;47(1):199-214. doi: 10.1007/s00266-022-03183-0. Epub 2022 Dec 1.
Tear trough deformity is a hallmark of periorbital aging. It is not, however, an exclusive feature of old age. While protruding orbital fat results in lower lid bags that are traditionally corrected by excision, correction of TTD can constitute a real challenge requiring volume enhancement in addition to addressing prolapse of orbital fat and descent of cheek tissues. Described therapeutic options include minimally invasive soft tissue augmentation with fillers or structural autologous fat transfer as well as invasive surgical procedures concomitantly with lower lid blepharoplasty or other facial rejuvenation procedures.
Six eponyms have been used in the literature to describe the condition: (1) naso-jugal fold, (2) naso-jugal groove, (3) naso-jugal ditch, (4) tear trough, (5) tear trough deformity, and (6) tear trough depression. A separate PubMed database search of each of the 6 terms was conducted in addition to an advanced literature and systematic PICO searches to identify all described clinical retrospective or prospective, comparative or simple cohort studies related to surgical correction of TTD. An additional screening of references of retrieved clinical studies was performed to identify any missed reports.
A total of 435 publications were identified with the initial search. After excluding all none relevant studies, 44 papers were selected for review. 6 additional studies were identified by screening relevant references.
Almost all authors agree on the necessity to release the tear trough retaining ligament together with volume enhancement. Transconjunctival and transcutaneous incisions are reported. Most recommend repositioning of the protruding orbital fat for volume enhancement to mostly subperiosteal, or pre-periosteal pockets. Other reported options include pedicled buccal fat pad transposition, segmental fat grafting, and minced micrografts. Internal as well as external fixation of repositioned fat flaps have been described. Despite lack of solid objective evidence, several of these techniques when properly executed for the proper indication in selected patients are reported to result in a rewarding and long-lasting outcome. Unfortunately, it is difficult to determine the most appropriate technique that would universally yield the most pleasant and harmonious facial contour without creating an unnatural puffy appearance. It remains for the surgeon to identify the safe surgical approach that does not compromise lower eyelid function and achieves the most pleasing aesthetic outcome with the least complications and downtime.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
泪沟畸形是眶周衰老的一个标志。然而，它并非老年所特有。虽然眶脂肪突出会导致下睑眼袋，传统上通过切除来矫正，但泪沟畸形的矫正可能是一项真正的挑战，除了处理眶脂肪脱垂和颊部组织下移外，还需要增加容量。所描述的治疗选择包括使用填充剂进行微创软组织填充或结构性自体脂肪移植，以及与下睑眼袋整形术或其他面部年轻化手术同时进行的侵入性手术。
文献中使用了六个特定名称来描述这种情况：（1）鼻颧皱襞，（2）鼻颧沟，（3）鼻颧沟纹，（4）泪沟，（5）泪沟畸形，（6）泪沟凹陷。除了进行高级文献检索和系统的PICO检索以识别所有与泪沟畸形手术矫正相关的已描述的临床回顾性或前瞻性、比较性或简单队列研究外，还分别在PubMed数据库中对这6个术语进行了搜索。对检索到的临床研究的参考文献进行了额外筛选，以识别任何遗漏的报告。
初始搜索共识别出435篇出版物。排除所有不相关的研究后，选择了44篇论文进行综述。通过筛选相关参考文献又识别出6项研究。
几乎所有作者都认同在增加容量的同时松解泪沟保留韧带的必要性。报告了经结膜和经皮肤切口。大多数人建议将突出的眶脂肪重新定位以增加容量，主要是置于骨膜下或骨膜前间隙。其他报告的选择包括带蒂颊脂垫移位、分段脂肪移植和微小碎粒移植。已经描述了重新定位的脂肪瓣的内部和外部固定方法。尽管缺乏确凿的客观证据，但据报道，这些技术中的一些在为选定患者正确选择适应症并正确实施时，会产生令人满意且持久的效果。不幸的是，很难确定哪种最合适的技术能普遍产生最令人愉悦和协调的面部轮廓，而不会产生不自然的肿胀外观。外科医生仍需确定一种安全的手术方法，该方法不会损害下眼睑功能，并以最少的并发症和最短的恢复时间实现最令人满意的美学效果。
证据水平III：本刊要求作者为每篇文章指定一个证据水平。有关这些循证医学评级的完整描述，请参阅目录或在线作者指南www.springer.com/00266 。
