Fat Pearl Grafting
Fat pearl grafting
Fat pearl grafting is a technique that can help patients who have hollow upper or lower eyelids. This is most commonly used for the management of patients who have undergone an excessive removal of fat during the course of cosmetic eyelid surgery (blepharoplasty) undertaken by plastic surgeons elsewhere, but it can also be used for patients who have hollowing as an hereditary problem, as a result of aging, as a consequence of previous trauma, or due to disorders such as Rhomberg’s hemifacial atrophy. It can also be combined with microfat grafting to the temple and cheeks.
Fat pearl grafting
Fat for fat pearl grafting is taken via an incision which is typically made around the lower half of the umbilicus (the tummy button). Other donor sites can be used if preferred. The fat is then divided into very small “pearls” (seen in the photograph) and transplanted into the eyelid, usually via a skin crease incision in the upper eyelid and via a transconjunctival incision (on the inside of the eyelid) in the lower eyelid. The overall results of this surgery are good and long lasting. The results are not, however, as good in smokers. Patients are advised to discontinue smoking for a few months prior to this surgery. This surgery is usually undertaken under “twilight anaesthesia” on a day case basis. The lack of patient photographs for this procedure reflects the fact that patients undergoing this surgery do not want their photographs to be viewed by others and their wishes are entirely respected.
Fat pearl grafting
In order to minimize the risk of bruising it is advisable to discontinue the use of Aspirin, Anadin or any anti-inflammatory medicines e.g. Indomethacin, Ibuprofen, Diclofenac, Voltarol, for 2 weeks before treatment provided it is medically safe to do so (please discuss this with your GP or physician if in doubt about this). It is quite in order to take Paracetamol and Codeine before this treatment.
You will visit the clinic to have a preoperative consultation with your surgeon. This usually lasts approximately 45 minutes. You will be asked to complete a healthcare questionnaire in advance, providing information about:
- Your specific concerns and aims
- Your current and past general health
- Any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery
- Any past dermatology history e.g. cold sores, eczema, rosacea, skin cancer
- Any history of a dry eye problem
- Any contact lens wear
- Any previous non-surgical aesthetic treatments e.g. Botox/Azzalure injections, dermal fillers injections, the use of IPL or laser treatments
- Any allergies
- Any medications you take (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements)
- Any history of smoking
It is very helpful if you have old photographs which you can bring along to the consultation. If you are happy to email us digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.
- Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your cosmetic procedure can be planned as carefully as possible. The information is treated confidentially. If you are unsure of the names of any medications, bring them with you.
- Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope).
- The rest of your face is then examined. The general state of your skin is assessed and photographs of your face and eyelids are taken before surgery so that the results of treatment can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
- All our patients are provided with a detailed report following a consultation. This summarizes the consultation, the recommendations and also the preoperative and postoperative requirements.
- You will have your blood pressure checked by the nurses. You may also be required to have a physical examination of your heart and lungs by the anesthetist to make sure it is safe for you to have a general anesthetic if this is required in your case. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), a chest x-ray, or a blood cell count. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing is usually necessary, however, if you are in good health and younger than age 55.
- The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use. They can also advise you about additional non-surgical treatments and long term skin care which may enhance and help to maintain the results of surgery. If you have any specific skin problems, we may refer you to our clinic dermatologist for help and advice.
- You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
- If you can, try to stop smoking at least six to eight weeks prior to surgery. Smoking has an adverse effect on healing and damages your eyelid skin and supporting tissues and your eyes (it can result in premature cataract formation and age related macular degeneration with a loss of central vision).
- Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) are examined as well as the eyelids themselves.
- The rest of your face is then examined. The general state of your skin is assessed and photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
- All our patients are provided with a detailed report following a consultation. This summarises the consultation, the recommendations and also the preoperative and postoperative requirements.
- We much prefer that our patients return to see us in clinic before proceeding with their surgery so that we can have the opportunity to answer any queries and so that a consent form for surgery is completed in advance and not on the day of surgery. If a patient is travelling a long distance however, this second consultation can be omitted and instead queries can be addressed by email and a copy of the consent form sent in advance so that this can be checked by you.
What are the possible complications of fat pearl grafting?
Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.
Most complications of eyelid surgery are amenable to successful treatment.
Complications from cosmetic eyelid surgery include:
- Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons – ointment put in the eyes immediately after the operation, local anaesthetic used in the operation, swelling of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctiva (this may mimic a severe hay fever reaction) is referred to as “chemosis” and in some patients can take a few weeks to resolve. If blurring persists for longer than 48 hours, it is important to inform your surgeon.
- Watery eyes – this is quite common for the first few days after the operation due to some irritation of the eyes and a temporary weakness of reflex blinking of the eyelids.
- Dry eyes may persist for two to three weeks or sometimes longer. You will need to lubricate your eyes every 1-2 hours using artificial tears during the day (e.g. Hyabak drops, Hylotears, Viscotears, Systane drops) and an ointment at night (Lacrilube). These should be prescribed for you. You will gradually reduce the frequency until you can dispense with them altogether. It is very rare for patients to have to continue with them long-term but this is possible. This is why it is important to exclude a dry eye problem before proceeding with this type of surgery.
- Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a bandage contact lens needs to be used.
- Bleeding. A collection of blood around the eyelids or behind the eyeball, is called a haematoma. A sudden haematoma behind the eyeball can cause loss of eyesight if not managed appropriately and without delay. This is the most serious potential complication of this surgery but is extremely rare. An oculoplastic surgeon is trained to prevent and to manage such a problem. A haematoma usually needs to be drained in the operating theatre.
- Damage to the muscles that move the eyeball (e.g. the inferior oblique muscle from the use of cautery to seal a bleeding blood vessel adjacent to the muscle) causing double vision is an extremely rare problem and this usually resolves by itself with time. In the very unlikely event that double vision were to persist, a referral to another ophthalmic surgeon with expertise in the management of eye movement disorders and possible further surgical intervention would be required.
- A ptosis (the upper eyelid does not open because of stretching of the muscle or tendon that controls it). Another operation may be necessary to repair this. An oculoplastic surgeon undertakes ptosis surgery routinely.
- Exposure of the cornea, the clear sensitive surface of the eye. When blinking the eyelids do not cover the eyeball completely. This often occurs for a short time after the operation and is treated routinely with artificial tear drops. If too much skin is removed from the upper eyelids, the eyelid closure can be compromised long term. This may require further surgery to correct it. For this reason, great care is taken to mark the skin to be removed before surgery is commenced. Such a problem is very unusual in the hands of an oculoplastic surgeon.
- Acute glaucoma – this is raised pressure within the eye, which results in pain in the eye, haloes around lights or severe blurring of vision, a headache above the eye, and vomiting. A patient at risk of such a postoperative problem would be identified by an oculoplastic surgeon. An oculoplastic surgeon is trained to diagnose and treat such a problem.
- Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.
- A higher lower lid position. Rarely, the lower eyelids may remain slightly high following a lower lid transconjunctival approach if the eyelid retractors are not sutured (stitched) or if excessive swelling causes cheese-wiring of the sutures. The eyelid may not move downwards properly when looking down, requiring a chin down posture to compensate for this.
- Under or over-correction of the grafting. This may necessitate further surgery.
- Atrophy of the transplanted fat. This is rare but is the reason why the procedure is not advised in smokers who have a poor microvasculature. The procedure can be repeated if necessary.
- Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this. A cosmetically unacceptable asymmetry e.g. of the upper lid skin crease, fullness of the eyelids, lower lid position is always possible and further surgery may be required to address this.
- Scarring. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.
- Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds. These usually resolve with time but occasionally steroid injections are required. Rarely, lumpiness can occur in fat that is repositioned over the inferior orbital margin. This usually responds to postoperative massage.
- Granuloma. A pink fleshy lump can occur as a stitch reaction on the inside of the lower eyelid following a transconjunctival blepharoplasty. This often resolves with the use of a course of postoperative steroid eye drops but occasionally the granuloma needs to be removed surgically in the clinic or operating theatre.
- Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
What happens after fat pearl grafting?
After surgery, the eyes are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.
You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are dissolvable but are usually removed in clinic after 2 weeks. The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using protective sunglasses. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended. (The aesthetics nurses at the clinic Face & Eye can demonstrate this to you). It is important to devote a lot of time to your aftercare for the first 2 weeks and some patients find this somewhat labour intensive.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required. You should be aware that swelling and bruising can sometimes create quite an initial psychological impact for some people and you should prepare yourself and your relatives for this.
The scars gradually fade to fine white marks within a few months. Those in the upper eyelid are hidden within the skin crease.
You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops. These will be prescribed for you e.g. Xailin gel (or Theoloz Duo drops, Hyabak drops or Hylotears), and Xailin Night ointment (or Lacrilube or Vitapos ointment at bedtime).
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.
Chemosis, a swelling of the conjunctiva, the membrane covering the white of the eyes, often occurs following this surgery, particularly with the transconjunctival approach. This usually takes 1-2 weeks to resolve but can take longer in some patients. Artificial tears must be used every 1-2 hours during the day until this has gone.
Contact lenses should not be worn for a few weeks following this type of surgery.
A period of postoperative massage is often advised following lower eyelid surgery. You will be shown how to do this. It is usually undertaken after applying some Xailin ointment to the eyelid skin. The massage helps to reduce swelling. It is usually undertaken for 3 minutes 3 times a day in an upward and side to side direction.
Conscious sedation, also known as “twilight anaesthesia”, is a type of anaesthesia which is preferred by many patients for most of our surgical procedures. It is a very comfortable and gentle type of anaesthesia which is far less invasive than the typical general anaesthesia but at the same time highly effective. It is also of advantage for very nervous or anxious patients undergoing quite minor procedures. Typically patients sleep most of the way through their procedure and have no or very little recollection of it at all. You are looked after throughout the procedure by a specialist consultant anaesthetist who has many years of experience of this type of anaesthesia, so that your surgeon can concentrate fully on your operation.
Shortly before moving to the operating room, a small tube (cannula) is placed into a vein in the back of your hand by the consultant anaesthetist and the anaesthetic drugs are given through that. These are Midazolam (a short acting type of Valium) and Propofol, a drug which is also used for general anaesthesia but, for conscious sedation, much lower doses are used. With conscious sedation there is no breathing tube or breathing machine, just a gentle flow of oxygen given through a plastic tube within a soft sponge protector inserted into one of your nostrils. Once the sedation has been commenced a local anaesthetic solution (a mixture of Marcaine and Lignocaine) is injected into the operative area to ensure a painless procedure. Typical side effects of general anaesthesia including a sore throat and nausea are avoided. Waking up takes only a few minutes at the completion of the surgery and is usually free of any “grogginess.” This type of anaesthesia has been used safely and successfully for our surgical procedures for over 15 years.
Below is a video of a patient describing her experience of “twilight anaesthesia and explaining why she would opt for this again if given the choice. She underwent a bilateral upper lid blepharoplasty and an endobrow lift at the clinic.