New Technique of Internal Fixation in Transconjuctival Fat Repositioning by using Chang's Needle

Dr. Chang devised a new needle (Chang's Needle) for easy internal fixation in transconjunctival fat repositioning.

 

Fig. 1. Design of Chang’s needle

 

 

Fig. 1. Design of Chang’s needle

There are two common methods of fixation of transposed fat pedicle using transconjunctival fat repositioning: one is the internal fixation method (IFM) and the other is the externalized percutaneous suture method (EPSM). IFM is more ideal because it provides more secure fixation, has a lower risk of relapse, and is convenient for patients because there is no suture removal. However, EPSM is more widely used because placing anchoring sutures in the subperiosteal or supraperiosteal space is a difficult task due to the narrow operation field of the transconjunctival approach. The orbital fat pedicle should be fixed at the distal end of the subperiosteal or supraperiosteal pocket for optimal positioning, which is more easily accomplished via EPSM. In an effort to combine the advantages of IFM and EPSM, we devised a new needle (Chang’s needle).

Fig. 2. Illustration of internal fixation of transposed fat pedicles using Chang’s needle. (Above) Chang’s needle is placed at the fat pedicle and then passed from the distal end of the dissected space to the skin while being careful not to pull it beyond the laser mark. (Center) After checking that the conjunctival side of the needle cannot be seen, the needle is passed back into the supraperiosteal dissected space, which is 2-3 mm from the original puncture point. (Below) Part of the absorbable suture is trapped in the flap, and transposed orbital fat can thus be fixed to the lowermost dissected space by placing several knots.

 

Fig. 3. Fixation position of transposed fat pedicles. Orbital fat can be secured at the caudal end of the dissected space via the externalized percutaneous suture method (above), and internal fixation method by using Chang’s needle (middle), whereas fixation may occur at a more cephalic position than intended due to the narrow space available for needle anchoring in the conventional internal fixation method (below).

Two methods of fixation of transposed fat pedicle are commonly used in transconjunctival fat repositioning, the internal fixation method (IFM) and EPSM. Although IFM is more ideal, ESPM is more widely used because it is less technically challenging.

 

EPSM has several advantages in addition to its ease. First, it requires a shorter incision than IFM, in which a longer incision is needed to secure space for needle holder handling in suture fixation. Second, fixation of transposed fat to the optimal position is possible. Orbital fat can be moved and secured at the caudal end of the dissected space by EPSM, whereas fixation may occur at a more cephalic position than intended in IFM due to the narrow space available for needle anchoring. Third, in ESPM, there are no limitations regarding the dissection plane, whereas IFM is limited to the supraperiosteal plane because the orbicularis oculi muscle and suborbicularis oculi fat are insufficiently firm for anchoring. Sullivan and Youn, who successfully performed IFM via a transconjunctival approach, typically used subperiosteal dissection. 

 

IFM has advantages over EPSM, the most important of which is the low risk of relapse. Externalized sutures are secured over a cotton or bolster or just fixed in place using Steri-Strips and removed 3 to 6 days after surgery. During those days, adhesion between transposed fat and the new supraperiosteal or subperiosteal pocket is expected. However, relapse can occur if there is tension remaining on the fat pedicles due to insufficient release, or unintentional mechanical forces like rubbing on the tear trough area. Sullivan did not observe movement of fat in their long-term results, and attributed this durability to internal fixation. Youn mentioned that long-term maintenance of buried sutures was a prerequisite to more experienced surgeons for stability of the repositioned fat.

 From the perspective of patients, IFM is much more comfortable and preferable to EPSM. For 3 to 6 days after ESPM, patients have trouble washing their face because of bolster or taping on their cheek. Furthermore, social activity may be limited by esthetic issues. Patients must return to the clinic to have sutures removed. Some patients suffer from skin trouble or scarring related to the placement of stitches.

With Chang’s needle, easy internal fixation of transposed fat to an optimal position is possible without the fear of recurrence, and with greater comfort and convenience for patients. 

Cheol Ho Chang, M.D.
Wannabe Plastic Surgery Clinic, Seoul, Korea
tougeon@hanmail.net