Transconjunctival fat repositioning is the gold standard for the
correction of tear trough deformity. For fixation of fat pedicle, the internal
fixation (IF) and externalized percutaneous suture (EPS) techniques are used, which
have their own advantages and disadvantages. The present study aimed to introduce a
new IF technique using a devised needle (EZ-Tcon) and to compare its outcomes with
those of the conventional EPS technique.
Methods
Patients with primary tear trough deformity who underwent
transconjunctival fat repositioning were reviewed and categorized into two cohorts
according to the fixation technique: cohort 1 consisted of patients treated using the
conventional EPS technique and cohort 2 consisted of those in whom the new IF
technique using EZ-Tcon was adopted. Post-operative complications and aesthetic
outcomes were assessed using a four-scale grading system.
Results
A total of 545 patients, 211 from cohort 1 and 344 from cohort 2 were
evaluated with a median follow-up of 70 days. Compared to cohort 1, cohort 2 showed
significantly lower rates of long-standing conspicuous scars on lower eyelid,
re-operation and overall complications. In the analysis of aesthetic outcomes, 88.9
percent of cohort 2 showed grade 0 (no deformity) or I (mild deformity)
post-operatively. The rate of excellent outcomes (improvements of ≥ two grades) was
significantly higher in cohort 2 than in cohort 1 (p-value < 0.001).
Conclusion
Our technique using EZ-Tcon could possess advantages of the conventional
IF and EPS techniques, showing lower complication rates and aesthetically
satisfactory outcomes, and could be a safe and reliable method of transconjunctival
fat repositioning.
Level of Evidence IV
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.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Introduction
Tear trough deformity represents a set of conditions showing a prominent
nasojugal groove with the medial periorbital hollow that extends obliquely from the
medial canthus. It can be caused by a bulge of the orbital fat through the attenuating
orbital retaining ligament and sagging of the orbicularis oculi muscle as well as
through reduction of the volume of facial fat compartments [1, 2].
Diverse treatment modalities have been attempted for its correction [3], for the purpose of seeking an ideal method that
can provide long-lasting aesthetically pleasing outcomes with minimal violation of the
normal anatomy. Among them, transconjunctival repositioning of the orbital fat along the
infraorbital rim, first introduced by Loeb [4] and further modified by many surgeons including Goldberg
[5], has been popularly used, and it is
considered as the gold standard for correction of tear trough deformity [5‐7].
With an effort to achieve optimal outcomes, there has been a debate on the
technical specifications of transconjunctival fat repositioning, which include
dissection plane (subperiosteal vs. supraperiosteal) for pocket preparation
[8] and methods of fat repositioning
(redraping of pedicled fat versus repositioning with septal reset) [9]. Selection of fixation methods for transposed fat
pedicles has been one of the main issues. Traditionally, two methods have been commonly
used for fixation of transposed fat: externalized percutaneous suture (EPS) technique
and internal fixation (IF) technique. Each technique has its own advantages and
disadvantages. The main advantage of the EPS technique is technical ease, which allows
the use of a shorter incision and enables fixation of fat into the optimally lowermost
position in the pocket without difficulty. Further, it can be performed in the
supraperiosteal or subperiosteal planes. However, this method is limited by a relatively
higher chance of relapse owing to less secure fixation. Besides, post-operative
discomfort related with pull-out suture is one of the main drawbacks of this method,
which requires additional visits to the outpatient clinic for suture removal and can
often result in local inflammation or dermatitis. Meanwhile, the IF technique can
provide secure and rigid fixation, leading to a relatively lower rate of relapse
theoretically, and does not cause problems related to fixation of sutures. However, this
method can be technically demanding owing to a narrow operation field, needing a
relatively steep learning curve, and often require a longer incision. Its use can be
limited in the subperiosteal plane only for firm anchoring. In addition, there could be
a chance of fixation at a less optimum position, especially for a novice, which can
result in unfavourable results (Fig. 1).
Fig. 1
Fixation position of transposed fat pedicles. Orbital
fat can be secured at the lowermost end of the dissected space with the
externalized percutaneous suture technique (a) and internal fixation technique by EZ-Tcon (b), whereas fixation may be conducted at a more
cephalic position with the conventional internal fixation technique owing to
limited working space (c)
×
Anzeige
In 2017, the author introduced a new internal fixation technique using a
devised needle, termed as “Chang’s needle”, for transconjunctival fat repositioning
[10]. EZ-Tcon (HandBioMed Corp, Korea)
is the commercial name of Chang’s needle attached with 4–0, 5–0 and 6–0 absorbable
thread (polyglycolic acid or polyglycolide-co-caprolactone) (Fig. 2). This technique was suggested to have the strengths of
both IF and EPS techniques theoretically, including technical ease, rigid fixation,
elimination of additional visit for removal of pull-out suture and reliable and
aesthetically pleasing outcome with a low relapse rate. However, whether these
theoretical strengths of this method could lead to practical benefits and efficacy in
the clinical settings remains unclear. Therefore, the present study aimed to compare the
clinical outcomes of our new IF method for transconjunctival fat repositioning with
those of the conventional EPS method.
Fig. 2
Picture of EZ-Tcon. EZ-Tcon is composed of Chang’s
needle and absorbable thread connected with it. Chang’s needle is 28 mm in
length, 3/8 circle, and bidirectional type. The skin side end is sharp round
or cutting style for easy skin penetration, whereas the conjunctival side
end is blunt round style to reduce the chance of blood vessels and eyeball
injury. There is a laser mark from the thread attachment point for easy
prediction of thread’s position from skin side to facilitate prevention of
skin dimpling caused by unintentional exposure of
thread
×
Patients and Methods
Study Population
Patients who presented with a primary tear trough deformity and were
treated with transconjunctival fat repositioning by a single surgeon at the Wannabe
Plastic Surgical Clinic between January 2010 and May 2019 were retrospectively
reviewed. The patients were excluded if they visited for revision operation after
they had undergone a previous operation at other clinics, or had been lost to
follow-up within one month after the operation.
The patients were categorized into two cohorts according to the
fixation method of transposed fat. Cohort 1 consisted of patients who were treated
with the conventional EPS technique, between January 2010 and July 2016. This cohort
served as the control in the following analysis. Cohort 2 included patients who were
treated with the new IF technique using the devised needle EZ-Tcon from August 2016
to May 2019.
Surgical Procedure
All operations were conducted under local anaesthesia. In the control
group (Cohort 1), the conventional EPS technique was used. Transconjunctival incision
was made using electrocautery 3–4 mm above the fornix, approximately 12 mm in length.
Dissection was performed along the orbital septum until the arcus marginalis was
reached. Then, supraperiosteal dissection was performed 10–12 mm in vertical length
from the arcus marginalis, freeing the tear trough ligament and palpebromalar
ligaments from the underlying tissue. After exposing the orbital fat pad, fat pedicle
was prepared by careful dissection of the surrounding fibrous tissues. The prepared
orbital fat was transposed into the supraperiosteal pocket and fixed with
externalized loops of 5–0 absorbable sutures (See video, Supplemental Digital content
1). The pull-out threads were removed after five to six days post-operatively
[2, 9]. (See video, Supplemental Digital content 2).
Anzeige
The new IF technique used in Cohort 2 was conducted as previously
reported (Fig. 3) [10]. In brief, supraperiosteal pocket dissection
and fat pedicle preparation were performed in the same way as in the conventional EPS
technique described above. The skin end of 5–0 EZ-Tcon was penetrated through the
prepared fat pedicle and passed from the lowermost point of the dissected space to
the skin, until the laser marking on it was seen from the skin side or until its
conjunctival end is not visible from the conjunctival side. Then, the needle was
passed back into the dissected space to approximately 2–3 mm from the previous entry
point of the needle, which traps some portion of the thread at the premaxillary soft
tissue. Then, inner fixation was completed by tie (See video, Supplemental Digital
content 3). Fixation was performed at three points, which could be adjusted to two or
four points individually according to the distribution pattern of orbital fat
(Fig. 4). A single 6–0 absorbable suture
was placed at the centre of wound. A light dressing was usually applied using
hydrocolloid to absorb slight oozing from the needle puncture site and to reduce
post-operative swelling; the dressing was removed by the patients themselves the next
day.
Fig. 3
The internal fixation technique using EZ-Tcon. The
devised needle is placed at the fat pedicle (above, left). EZ-Tcon is
passed from the distal end of the dissected space to the skin with paying
attention to not pulling it beyond the laser mark (above, right). After
checking the laser mark, the needle is passed back into the
supraperiosteal dissected space, which is 2-3 mm from the original
puncture point (below, left). As a result, part of the absorbable thread
is trapped in the premaxillary soft tissue, and the transposed orbital
fat can be fixed to the lowermost dissected space by placing several
knots
Fig. 4
Fixation style of orbital fat pedicles. Two-point
fixation for medial and central fat pedicle, respectively, which could
cause contour irregularity (a).
Three-point fixation enables even distribution of medial and central
orbital fat (b). When the volume of
central fat exceeds that of medial fat, medialization of the 2nd fixation
point can be performed, which provides wider coverage by the central fat
pedicle and eventually more even volumetric distribution (c). Reverse case of C (d). In a case of long tear trough line in Grade II or III
in modified Barton’s grading system, additional suture in the midpoint of
central fat is useful for lowermost fixation over the full length(e). If there is only lateral
depression (Grade 1L in the modified Barton’s
grading system), the two points fixation of central fat pedicle would be
sufficient for coverage (f)
×
×
For middle-aged patients with excessive skin laxity and wrinkles on the
lower eyelid, lateral partial incision blepharoplasty was conducted in both groups,
which consisted of excision of redundant skin and suspension of the orbicularis oculi
muscle.
Outcome Measure
The primary outcomes were rates of post-operative complications and
aesthetic results. Post-operative complications included hematoma, infection,
granuloma, long-lasting (> 4 weeks) conspicuous scars on the lower eyelid,
ectropion, retraction, diplopia, chronic chemosis over two weeks post-operatively,
and reoperation. The long-lasting conspicuous scars were defined as scar conditions
visible after four weeks, which due to needle penetration or placement of sutures.
Cases with reoperation were defined as those undergoing take-back to the operating
room due to the development of complications, including haematoma or
infection.
Aesthetic outcomes were assessed using a four-scale grading system,
ranging from 0 to III, as shown in Table 1.
This was modified based on Barton’s grading system [11] by adding a new IL grade that was
characterized by the mild, subtle presence of a lateral line or shadow and the
absence of a medial line. The patient photographs taken by professional photographers
at pre-operative and final post-operative visits were used for the evaluation. Two
plastic surgeons who were not involved in the operations participated in the
evaluation of the aesthetic outcomes, with the final decision based on discussions in
case of any disagreements. They were blinded to which surgical group the patients
belonged to. In addition to the distribution of pre-operative and post-operative
grades, the rates of cases showing excellent results and improvement/no improvements
were also evaluated. Excellent outcomes were defined as improvements of ≥ two grades
at the final follow-up photograph compared to the pre-operative appearance. Cases
with no improvement were defined as those showing the same grade post-operatively and
pre-operatively.
Table 1
Modified Barton’s grading
system
Grade
Anatomic
analysis
0
The absence of medial or
lateral lines demarcating the arcus marginalis or the orbital rim,
and a smooth youthful contour without a transition zone at the
orbit–cheek junction
IM
Mild, subtle presence of a
medial line or shadow; smooth lateral transition of lid–cheek
junction
IL
Mild, subtle presence of a
lateral line or shadow; The absence of a medial
line
II
Moderate prominence of a
visible demarcation of the lid–cheek junction extending from medial
to lateral
III
Severe demarcation of the
orbit–cheek junction with an obvious step between the orbit and the
cheek
Grade IL is newly added to the
original grading system
Statistical Analysis
The patient demographics, complication profiles and aesthetic outcomes
were compared between the two cohorts. Pearson’s Chi-square test or Fisher’s exact
test was used for analysis of the categorical variables, and the Student’s t-test or Mann–Whitney test for that of continuous
variables. To identify independent predictors for the development of complications
and excellent outcomes, univariable and multivariable logistic regression analyses
were conducted by calculating odds ratio (OR) and 95% confidence intervals (CIs). A
p-value of less than 0.05 was considered statistically significant. All statistical
analyses were conducted using IBM SPSS 20.0 (IBM Corp., Armonk, NY.).
Results
A total of 1,119 patients with tear trough deformity who underwent
transconjunctival fat repositioning were identified at the initial search. After the
application of the above selection criteria, 545 patients who were followed up for at
least post-operative one month were included in the final analysis. The mean age was
34.2 years. There were 59 male and 486 female patients. The median follow-up period of
the overall study population was 70 days.
Of 545 patients, 211 were included in cohort 1 and 334 were included in
cohort 2. The patients in cohort 2 tended to be younger and included more male patients
compared to those in cohort 1, which showed no statistically significant differences
(Table 2). The rate of performing lateral
partial incision blepharoplasty was significantly higher in cohort 2 (30.5% vs. 22.7%).
Regarding the pre-operative grade of tear trough deformity, the two groups had similar
distribution (p-value = 0.364), showing patients with
grade II and III in approximately 95 percent in both.
Table 2
Patient demographics and pre-operative grade of tear
trough deformity in two cohorts
Overall
Cohort 1 (n = 211)
Cohort 2 (n = 334)
p-value
Demographics
Age
(mean ± SD)
34.2
(± 11.8)
35.2
(± 10.9)
33.6
(± 12.4)
0.113
Sex
0.053
Male
59
16 (7.6%)
43 (12.9%)
Female
486
195
(92.4%)
291
(87.1%)
Follow-up period (days),
median
70
58
73
0.002
Pre-op grade of tear trough
deformity
0.364
0
1
0
0
I
20
11 (5.2%)
10 (3.0%)
IM
14
8 (3.8%)
6 (1.8%)
IL
7
3 (1.4%)
4 (1.2%)
II
294
115
(54.5%)
179
(53.6%)
III
230
85 (40.3%)
145
(43.4%)
Post-operative Complications
Table 3 lists the complication
profiles of the two groups. Post-operative complications developed in 29 patients
(5.3%) during the follow-up period. None of them developed ectropion, retraction and
chronic chemosis. Reoperation was conducted in eight patients owing to complications
including haematoma (n = 7) and infection
(n = 1). All patients with haematoma underwent
reoperation for removal regardless of its extent to prevent fibrosis and retraction.
Of two patients with infection, one in cohort 1 underwent take-back and underwent
drainage of pus and irrigation with antibiotic solutions through the conjunctival
wound. Another patient in cohort 2 was managed with conservative treatment including
intravenous antibiotics (Fig. 5). Two
patients in cohort 2 complained of palpable granuloma of approximately 2–3 mm in
diameter, which was treated with diluted triamcinolone injection. Transient diplopia,
which developed in one case (cohort 1), was spontaneously resolved within one-month
post-operatively. The rate of overall complications was significantly lower in cohort
2 than in cohort 1. Especially, cohort 2 had significantly lower rates of conspicuous
scars and reoperation than cohort 1. The rates of other complications including
infection did not differ between the cohorts. Multivariable analysis demonstrated
that the type of fixation method had a significant influence on the development of
overall complications, showing that cohort 2 had significantly lower rates of
complications than cohort 1 after adjusting for other variables (OR; 0.102, 95% CI;
0.038–0.280, p-value < 0.001). Other variables
including sex, age and lateral partial incision blepharoplasty were not influence
significantly.
Table 3
Comparison of complication profiles between cohort
1 and cohort 2
Complication
profiles
Overall
Cohort
1
Cohort
2
p-value
Overall
complications
29
24
(11.4%)
5
(1.5%)
< 0.001
Haematoma
7
5
(2.3%)
2
(0.6%)
0.074
Infection
2
1
(0.3%)
1
(0.3%)
0.743
Granuloma
2
0
2
(0.6%)
0.260
Conspicuous scars on lower
eyelid
17
17
(8.1%)
0
< 0.001
Diplopia
1
1
(0.3%)
0
0.208
Reoperation
8
6
(2.8%)
2
(0.6%)
0.034
Fig. 5
Development of local infection following a
transconjunctival fat repositioning with internal fixation technique
using EZ-Tcon. Pre-operative appearance (Above). Occurrence of focal
redness, swelling and tenderness on her right lower eyelid at
post-operative 5 days (Middle). The lesion was resolved with conservative
managements using intravenous antibiotics administration for three days
(Below)
×
Anzeige
Aesthetic Outcomes
In the evaluation of post-operative aesthetic outcomes, 514 (94.3%) out
of 545 patients showed improvements. Specifically, a majority of patients showed
grade 0 (33.8%) and grade I (49.4%) deformity post-operatively. Only 31 patients
(5.7%) showed no improvement. The rate of no improvement was significantly lower in
cohort 2 than in cohort 1 (3.3% vs. 9.5%, p-value = 0.002). Excellent outcomes with improvement of ≥ 2 grades were
observed in 266 patients (48.8%) overall. Cohort 2 showed significantly higher rate
of excellent outcomes than cohort 1 (Table 4).
Table 4
Comparison of post-operative aesthetic outcomes
between two cohorts
Overall
Cohort
1
Cohort
2
p-value
Post-op grade of tear trough
deformity
< 0.001
0
184
(33.8%)
35
(16.6%)
149
(44.6%)
I
269
(49.4%)
121
(57.3%)
148
(44.3%)
II
86
(15.8%)
50
(23.7%)
36
(10.8%)
III
6
(1.1%)
5
(2.4%)
1
(0.3%)
Aesthetic
outcomes
0.002
Improvement
514
(94.3%)
191
(90.5%)
323
(96.7%)
No
improvement
31
(5.7%)
20
(9.5%)
11
(3.3%)
Excellent
outcomes
266
(48.8%)
70
(33.2%)
196
(58.7%)
< 0.001
Multivariable analysis showed that the fixation method was an
independent predictor for excellent outcomes, showing that cohort 2 had significantly
higher odds for achieving excellent outcomes than cohort 1 (OR; 3.365, 95% CI;
2.232–5.073, p-value < 0.001). The patient sex
and pre-operative aesthetic grade also significantly influenced the outcome (Table
5).
Table 5
Multivariable analyses for independent predictors
of achieving excellent outcomes
Variables
Adjusted p-value
OR (95%
CI)
Sex
Male
Ref
Female
0.044
1.927 (1.018 –
3.648)
Age
0.344
1.013 (0.987 –
1.039)
Lateral partial incision
blepharoplasty
0.404
1.335 (0.677 –
2.634)
Fixation
method
EPS (cohort
1)
Ref
IF (cohort
2)
< 0.001
3.365 (2.232 –
5.073)
Pre-operative
grade
Grade II versus
I
0.334
1.692 (0.581 –
4.925)
Grade III versus
I
< 0.001
7.803 (2.641 –
23.054)
Representative cases are shown in Figs. 6 (Cohort 1), 7 and
8 (Cohort 2).
Fig. 6
Case 1. A 41-year-old woman visited our clinic for
correction of a tear trough deformity of grade IM
(Above). She underwent the transconjunctival fat repositioning using the
externalized percutaneous suture technique with lateral partial incision
blepharoplasty (Cohort 1). Appearance at post-operative eight years,
showing excellent long-term outcomes without recurrence (Grade 0)
(Below)
Fig. 7
Case 2. A 35-year-old man presented a tear trough
deformity of Modified-Barton grade IL (lateral
mild groove without medial depression) (Above). He was treated with
transconjunctival fat repositioning with internal fixation technique
using EZ-Tcon (Cohort 2). Appearance at post-operative 3 months
(Below)
Fig. 8
Case 3. A 44-year-old woman had tear trough
deformity of modified Barton Grade II and mild skin laxity (Above). She
underwent transconjunctival fat repositioning using EZ-Tcon and lateral
partial incision blepharoplasty (Cohort 2). Tear trough deformity was
improved to grade 0 with preservation of the pretarsal roll which can
make her look younger and healthier (Below)
×
×
×
Discussion
The presents study described in detail a new IF technique using the
devised needle EZ-Tcon for correction of tear trough deformity and evaluated its
clinical outcomes with a considerable number of cases. Besides, a comprehensive
head-to-head comparison of the outcomes between the new IF technique and popularly used
conventional EPS technique was conducted not only in terms of complications, but also in
aesthetic outcomes.
Anzeige
We found that cohort 2 showed a significantly lower rate of post-operative
complications than cohort 1. In particular, the rate of long-lasting conspicuous scars
on the lower eyelid had the greatest difference showing 8.1 percent in cohort 1 and 0
percent in cohort 2. The presence of sutures for five or six days could cause local
inflammation around the stitches especially in cases with oily and acneiform skin, which
can lead to long-lasting stitch mark (Fig. 9).
Further, prolonged taping of the skin for fixing threads can cause skin complications or
contact dermatitis to sensitive skin. This could distress patients and eventually reduce
the overall satisfaction. With our new IF technique, this skin problem and long-lasting
scars, one of the common complaints related to the EPS technique, can be avoided as
shown here. In addition, this allows for earlier recovery to social life and daily
living, as application of taping for longer period is not necessary.
Fig. 9
After removal of thread and taping in cases using the
EPS technique, skin inflammation and dermatitis around the site of
thread/needle penetration are observed (Left), which could last after
post-operative 5 weeks (Right)
×
In the current study, significantly better aesthetic outcomes were
observed in patients in cohort 2 comparted to those of cohort 1. Specifically, cohort 2
showed significantly fewer cases with no improvement and significantly more with
excellent outcomes than cohort 1. Theoretically, to achieve aesthetically optimal
results, two factors are required to be met: transferring the orbital fat pedicle into
the proper position and fixating it rigidly to avoid reverting to the original position
after a long time. Regarding the former, the fat pedicle should be transferred and fixed
to the lowermost portion of the prepared pocket. However, with the conventional IF
technique, placing fixation sutures at the lowermost position is technically demanding
owing to the narrow transconjunctival incision; therefore, fixating at a less optimum
position often occurs, especially for a novice surgeon, which can result in suboptimal
outcomes. To avoid this adverse result, lengthening of transconjunctival incision can
often be conducted, which could cause more frequent chronic chemosis and patient
discomfort after operation. However, with our new IF technique using EZ-Tcon, these
limitations of the conventional method can be easily overcome. All procedures of the IF
technique were conducted through transconjunctival incision of approximately 12 mm in
length, without lengthening the incision. Moreover, no patients showed chronic chemosis
post-operatively. Excellent aesthetic outcomes with approximately 90 per cent of
patients from cohort 2 showing grade 0 or I post-operatively further support the
technical feasibility of our procedure for fixation lowermost position of the fat
pedicle. It can be assumed that this technique using EZ-Tcon can allow for more facile
internal fixation of transposed fat into the lowermost position with short incision,
which can lead to achieving optimal outcomes and reducing morbidity compared to those
obtained using the conventional IF technique.
Durability of fixation of transferred fat is another critical factor to
determine final aesthetic outcomes, as mentioned above. The EPS technique is popular
owing to technical ease and reliability for fixation of the fat pedicle into an optimal
position, which can satisfy the first condition, fixation to proper position.
Considering that there would be no difference between cohort 1 and 2 in the point of
lowermost placement of fat pedicle during the operations, with both techniques enabling
fixation in the proper position. Then, it could be assumed that significant differences
in aesthetic outcomes between the two cohorts might be associated with higher rate of
recurrence in cohort 1, which may result from lesser durability of fixation. A potential
risk of recurrence after removal of pulled out thread has been suggested as one of the
main drawbacks of the conventional EPS technique, which could be related to insufficient
adhesion with adjacent tissue, excessive tension on fat pedicles and accidental external
force, such as rubbing of the operative sites during sleeping. Instead, our IF technique
allows for rigid and durable fixation of fat pedicle, which could lead to excellent
outcomes, suggesting low recurrence, in cohort 2.
Another advantage of this technique over the conventional IF technique is
that it provides options to choose between the supraperiosteal and subperiosteal planes.
It is known that fat repositioning through the supraperiosteal plane could be relatively
faster and easier. Dissection along the supraperiosteal plane could release the
orbicularis oculi muscle attachment to the periosteum below arcus marginalis more
effectively than subperiosteal dissection, which can allow for improved and more natural
effacement of the nasojugal groove. Although it could have higher risks of bleeding and
haematoma, it can be avoided using suitable retraction of the orbicularis oculi muscle
and sharp electrocautery dissection close to the periosteum. However, despite these
potential strengths of supraperiosteal dissection, the conventional IF technique cannot
be performed in this plane as there is no anatomic structure to anchor the transferred
fat pedicle. It is likely that with the devised needle, easy and secure fixation can be
achieved with supraperiosteal dissection besides subperiosteal dissection.
Anzeige
Several limitations of the present study need to be mentioned. Owing to
the retrospective study design, effects of other variables that can affect the outcomes,
such as comorbidities and medications, could not be assessed. However, our study
population consisted of relatively young patients with a mean age of 34 years, who were
healthy, which could reduce the risk of confounding effects of those variables.
Different time periods between the two cohorts could raise a concern of potential
learning curve effect. The relatively inferior outcomes in cases of cohort 1 might be
attributable to less skillfulness because they were treated in the former part of the
study period. However, the primary surgeons had considerable experience of
transconjunctival fat repositioning for tear trough deformity correction before this
study and had become sufficiently competent and experienced to perform such procedures,
which might have reduced the confounding effect related to learning curve. The patients
of private plastic clinics are usually reluctant to visit frequently after operation and
tend to be lost to follow-up in early post-operative period. Although we included only
patients with follow-up longer than one month and a median follow-up period of the study
population was over two months, this would not be sufficient for evaluating long-term
efficacy of this procedure. Further well-designed long-term studies would be definitely
required to draw more solid conclusions.
Conclusions
Our results suggest that the new IF technique using EZ-Tcon could have
advantages of the conventional IF and EPS techniques, including secure fixation, low
relapse rate, elimination of need for thread removal, early recovery, straightforward
procedure, short conjunctival incision and optimally lowermost positioning of transposed
fat, as summarized in Table 6. This technique
could be a safe and reliable method of transconjunctival fat repositioning for the
correction of tear trough deformity, with low complication rates and aesthetically
satisfactory outcomes.
Table 6
Summary of comparison of three fixation
techniques
Advantages
Conventional
IF
EPS
IF with
EZ-Tcon
Stability
V
V
Technical
easiness
V
V
Short
incision
V
V
Ideal
positioning
V
V
Patients
convenience
V
V
No conspicuous skin
scar
V
V
Compliance with Ethical Standards
Conflict of interest
The first author is the inventor of a devised needle (EZ-Tcon)
mentioned in the manuscript and has obtained a U.S. patent on January 7, 2020 (Patent
No.: US10,524,781B2). He has a financial interest with the manufacturer and supplier
(HansBioMed) of the product. The other authors declare that they have no conflicts of
interest to disclose.
Ethical Approval
This study obtained an approval of institutional review board of the
authors’ institution.
Informed Consent
All participants gave their informed consent in writing prior to
inclusion in the present study.
Open AccessThis article is licensed under a
Creative Commons Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons licence, and indicate if changes were made. The images or other
third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is
not included in the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder. To view a copy of this licence,
visit
http://creativecommons.org/licenses/by/4.0/.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Mit der Zeitschrift Die Chirurgie erhalten Sie zusätzlich Online-Zugriff auf weitere 43 chirurgische Fachzeitschriften, CME-Fortbildungen, Webinare, Vorbereitungskursen zur Facharztprüfung und die digitale Enzyklopädie e.Medpedia.
Selbstverschuldete Fehler oder unerwartete Komplikationen machen jungen Chirurginnen und Operateuren mit Migrationshintergrund offenbar besonders zu schaffen. Benötigt werden routinemäßige Programme zum Umgang mit Zwischenfällen im OP.
Offenbar muss es nicht immer die bariatrische Chirurgie sein, wenn es darum geht, durch deutlichen Gewichtsverlust auch das Krebsrisiko günstig zu beeinflussen. Eine große Kohortenanalyse zur Behandlung mit GLP-1-Agonisten wurde dazu auf der ASCO-Tagung vorgestellt.
In der Notaufnahme wird die Chance, Opfer von häuslicher Gewalt zu identifizieren, von Orthopäden und Orthopädinnen offenbar zu wenig genutzt. Darauf deuten die Ergebnisse einer Fragebogenstudie an der Sahlgrenska-Universität in Schweden hin.
Darüber reden und aus Fehlern lernen, sollte das Motto in der Medizin lauten. Und zwar nicht nur im Sinne der Patientensicherheit. Eine negative Fehlerkultur kann auch die Behandelnden ernsthaft krank machen, warnt Prof. Dr. Reinhard Strametz. Ein Plädoyer und ein Leitfaden für den offenen Umgang mit kritischen Ereignissen in Medizin und Pflege.
Update Chirurgie
Bestellen Sie unseren Fach-Newsletterund bleiben Sie gut informiert.
Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.
Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?
Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.
