Periorbital Rejuvenation Brow Lift 

Updated: Jun 26, 2018
Author: Gregory Gary Caputy, MD, PhD, FICS; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC 

Overview

Background

Periorbital rejuvenation is one of the most important areas of rejuvenation of the aging face. The eye area is important in contact between individuals, with eye-to-eye communication occurring in approximately 80% of all interactions. The orbital area conveys information on general health and impressions regarding individual health, fatigue, interest, and emotion. For many individuals with limited budgets or limited interest in facial rejuvenation, the eye area is the focus of facial rejuvenation surgery.

See the image below.

Preoperative photograph of patient prior to a brow Preoperative photograph of patient prior to a brow lift performed through the coronal approach.
Postoperative photograph demonstrating marked impr Postoperative photograph demonstrating marked improvement in the periorbital area after a brow lift performed through the coronal approach.

Periorbital rejuvenation and, in particular, eyebrow position and posture have seen a change over the past several years. Male brow position has always been accepted as lower than female position, even in youth. The brow was, essentially straight, with a slight lateral upgoing, but not so severe as to create a frown or concerned appearance when at rest with frontalis muscle relaxation. The female brow position and posture has changed significantly from the high-arched and overly elevated position of the 1950s and 1960s (or with overly exuberant brow lift surgery even today). In style today is a rather straight brow with generally lower posture than in past years but, still, with significant medial elevation and slight lateral elevation. The entire brow is much straighter than accepted for women in the past. This posture can be attained predictably with modern brow-lifting procedures, either open (preferably in order to weaken or even remove the corrugator supercilii muscles) or closed for less scarring and quicker recovery time.

Brow elevation in order to rid the lateral upper facial area of rhytides should be performed conservatively and cautiously, as an overly elevated brow does not occur in nature and gives the patient a very "operated on" appearance. Even complete paralysis of the upper, lateral orbicularis oculi muscles may overly elevate the lateral brow. Some correction of an overly elevated brow may be accomplished with opposing muscle paralysis (in this case frontalis muscle or portions of it but with the expense of loss of facial animation, to some extent). Also, relaxed brow posture should be correct and what the person desires prior to any need for paralytic agents, fillers, brow-hair manipulation, or makeup. The heavy skin of the forehead, even without a brow or a significant brow, changes to the very thin and delicate upper eyelid structures and skin rather abruptly, and that area of change should be at the correct position and in the correct postures as desired by the patient in consultation prior to surgery.

History of the Procedure

Improvement of aging facial features with cosmetics and surgery essentially parallels the developments of facial plastic surgery through time. Rejuvenation of the periorbital area, although obviously important, lagged behind that of midfacial and lower facial rejuvenation for many years. The coronal and brow lift procedures with ancillary procedures (eg, canthopexy[1] ) have been popularized mainly over the last 30 years.

Problem

The aging face has many characteristics, including gravitational (postural), animational, and textural rhytides. Generalized loss of subcutaneous volume with the interplay of sun damage and aging skin is a large topic and is not discussed at length in this article. Largely, surgical procedures help the first two problems, and resurfacing procedures help textural skin problems. Other articles address the many changes in complete facial rejuvenation (eg, nasal tip droop, earlobe lengthening, upper lip atrophy, lower lip pout). The perioral region is an important focus of attention in facial rejuvenation.

Conversely, the orbital area reflects aging in a number of ways. With time, the brow falls, tending to fall laterally more than centrally. When this occurs, a relative redundancy of upper eyelid skin is present. A disservice is done to the patient if this alone is corrected and the brow position is not corrected first. The precious skin of the upper eyelid is sacrificed, yet a large number of aging factors of the upper face are not rejuvenated with the procedure of upper eyelid blepharoplasty.

If skin resection is excessive, the resulting lagophthalmos preempts proper positioning of the brows. The brow generally descends before the face, resulting in relative excess skin lateral to the eyes. Coupled with squinting and facial animation, this results in the characteristic "crow's feet" at the lateral orbital commissures.

The inferior brow generally adheres well to the superior orbital margin, but true descent of the brows commonly occurs. Once a large amount of upper eyelid skin redundancy is present, the patient feels subjectively and objectively that the upper lids are heavy and the eyes are not opening fully. To unweight the upper eyelid region, the frontalis muscle is used, sometimes spastically. This leads to horizontal creases of the forehead termed "worry lines."

In many individuals, raising the eyebrows through frontalis action leads to overelevation of the central brow and a surprised look to the facies. The individual often is keenly aware of this and tends to try to raise the lateral brow and lower the central brow. The musculature of the forehead does not allow this directly, but the frowning or concentrated "thinking" look of the central interbrow region is caused by the interplay of corrugator supercilii muscles and procerus muscle action coupled with central brow descent. This interplay of the upper facial muscles leads to the characteristic changes observed in the upper face in all individuals.

Epidemiology

Frequency

Everyone ages, but the rate and individual nuances of needed and desired corrections vary.

Etiology

The etiology of the aging face is discussed in the Problem section. The interplay of environmental forces acting on the skin and leading to actinic and weathering changes are fundamentally different from those changes that result purely from aging. This is discussed at length in Chemical Peels.

Pathophysiology

Pathophysiology also is discussed in the Problem section. The only other relevant action involves the interplay between squinting action (mediated by the orbicularis oculi muscles) and the action of a broad smile with elevation of the entire cheek substance by the large muscles of the lateral cheek. Paralysis or surgical alteration of the lateral orbicularis muscle obviously does not greatly alter the rhytides caused by panfacial animation.

Presentation

The aging face has common characteristics. Descent of the brow and mid face causes a hollowing of the periorbital region that can be iatrogenically augmented by overly aggressive blepharoplasty procedures. Lateral canthal descent and canthal attenuation occur with time, and this can lead to ectropion, particularly laterally. This also can be worsened iatrogenically with overly aggressive skin resection during lower eyelid blepharoplasty procedures.

Components of the "tired-eye" look also require discussion. This common complaint usually is caused by lower eyelid medial problems. Three parts comprise this problem.

First, the lateral cheek descends with aging and tends to do so more in individuals with morphologically prone eyes (MPE), eyes that are morphologically prone to ectropion with lax lateral canthal ligaments, downgoing palpebral fissures, limited lateral malar prominence, and a tendency toward a sunken midfacial structure.

Second, this leads to a hollowness of the medial canthal and central upper facial area. This hollowness can be termed the nasojugal groove or, slightly differently and more central in the lower mid face, the tear-trough deformity. Some individuals are born with this area of the lateral nose and cheek depressed, leading to a tired look in the area. Atopic individuals often have this appearance, although no link between allergy and changes in the mid face is documented in the literature.

Finally, another component of aging in this area is the shadow from the central brow area if it is retruded (relatively retrodisplaced). The third component of the tired-eye look in this area is the presence of true pigment within the skin of the central lower eyelid and occasionally extending across the lower eyelid, even without the presence of true lower eyelid bags. This pigmentation has not been studied but clinically it responds to treatments used for the abolition of melanin and hemosiderin pigmentation.

Indications

The indication for facial rejuvenation surgery largely is the patient's desire. Consider the extent, anatomy, and pathology of aging of a particular patient when deciding on procedures for the patient.[2]

For example, a patient may report upper eyelid heaviness and a tired look to the eyes. A true ptosis requiring correction may be present, or, more commonly, interplay of brow descent and upper eyelid skin fullness exists. If the brows are in good position, an upper eyelid blepharoplasty may be all that is required to improve the patient's feelings about his or her appearance.[3] Conversely, a truly descended brow is not corrected with an upper eyelid blepharoplasty procedure, and the entire orbital area may have a worsened appearance after the skin is resected from the upper eyelid. Once the impetus for static contraction of the upper eyelids is gone, they descend even further than preoperatively, worsening the lateral and medial periorbital regions, which are not addressed with the upper eyelid blepharoplasty procedure.

The medial canthal area requires special consideration even though it is not well addressed by a brow lift procedure. The tear trough (Flowers) and nasojugal groove areas have been difficult areas to address with anything other than complex midface lifts. Many patients present with depressions in this area, which may or may not be overhung with lower eyelid fat. The clinician needs to differentiate whether a true groove exists in the area and determine the extent of the groove and its direction (just along the infraorbital margin or extending into an extended groove, sometimes ending in a festoon or malar bag). Pigmentation of the skin often contributes to this darkness in the area.

Relevant Anatomy

The anatomy of the periorbital region is extremely important in the area's features of aging and in the correction of those features.

Starting from the most superior area and proceeding downward on the face, the scalp, which is composed of a number of layers, is encountered first. The acronym "SCALP" (S for skin, C for subcutaneous tissue, A for loose areolar layer, L for galea aponeurotica, P for periosteum) is taught in medical school and adequately describes the layers. The presence of a large structure essentially floating on the loose areolar layer (eyebrows at the end of the long expanse of forehead) leads to the descent observed with time.

Transverse forehead rhytides largely result from frontalis muscle action. The frontalis acts broadly to elevate the brows, usually somewhat more centrally than laterally. The corrugator supercilii muscles are the depressors and central contractors of the medial brow. They insert into the medial eyebrow skin to a variable distance (up to the central brow in some individuals) and originate in the periosteum of the nasal root. They envelop the supratrochlear nerve, which supplies sensation (branch of cranial nerve V) to the central forehead area.

The supraorbital nerve is more lateral and passes through the supraorbital region either in a foramen or beneath a ledge in the central brow region. This also is a sensory nerve and a branch of cranial nerve V and supplies a slightly more lateral but larger area than the supratrochlear nerve. The procerus muscle is a small muscle at the root of the nose that serves to elevate the nasal skin and depress the brow. It inserts into the central interbrow skin and originates in the periosteum of the nasal root. The muscle can cause a transverse rhytide at the nasal root.

The contour of the eyebrow is important. Central, low brows often are not a concern for individuals once the frown lines are removed. The high arched brows produced by the coronal lifts of the past generally are not desirable today, although a relatively high lateral brow remains a component of the desirable aesthetic periorbita. Similarly, many individuals generally do not desire an exaggerated tilt to the lateral orbit compared to the medial orbit, but a slight tilt and tightness of the lower eyelid is a desirable feature in orbital rejuvenation. The overly high brow is not desirable for anyone, but it is particularly feminizing in the male patient.

The lateral canthal ligament has 3 attachments to the lateral orbital rim: superior, inferior, and posterior. Some or all of these may need to be disinserted for significant elevation of the lateral attachment of the lower eyelid. Often, a canthoplasty may be performed in which the attachment merely is tightened and slightly elevated for the desired effect. The medial canthal area generally is not addressed except in reconstructive procedures because of limited descent with aging and concern over the lacrimal apparatus in the area.

The nasojugal and tear-trough areas largely are defined by the bony margins of the lateral nose and the medial orbital region as it descends into the maxilla.

Orbicularis oculi muscles cause the eyelids to close. Lateral overactivity can lead to laugh lines in the crow's feet area of the lateral periorbital region. The importance of the pretarsal region of the lower eyelid orbicularis muscle recently has been elucidated, and it must be conserved during lower eyelid blepharoplasty.

Contraindications

Lagophthalmos with a preexisting overly elevated eyebrow or a low brow with insufficient upper eyelid skin for proper eyelid closing after brow elevation is the only contraindication to brow lift procedures. This condition usually is iatrogenic.

A high hairline previously was a contraindication to brow lift procedures. It likely remains so for coronal lifts, but hairline incisions can be made that actually lower the hairline while raising the brows. This results in a scar at the hairline, which is acceptable to many individuals who wear bangs. Often the scar can be evened by placement into and back from the hairline; this also results in a less prominent scar over less of the hairline.

Patient Education

Careful forethought must be done prior to brow lifting, as an overly elevated brow is very difficult to correct, even with recruitment of posterior scalp tissue, as there is often scarring present, which disallows brow lowering in the forehead and suprabrow areas after previous brow lifting procedures. A relaxed posture muscle should be ascertained, even if slight holding of the brow with finger pressure is needed to show the patient their nascent brow posture (some individuals almost have a spastic frontalis action with instant brow elevation with eye opening, particularly in their plastic/cosmetic surgeon's office). The exact position of the brow and the exact brow posture must be known by both the surgeon and the patient preoperatively and discussed well prior to operative marking and the normal excitement on operating day. Care should be taken to ascertain where the brow skin transitions to eyelid skin and structures without consideration of shaping done by plucking or waxing. If an overly elevated brow is the only way of clearing lateral orbital rhytides, consideration should be given to incomplete correction of this area or other means of smoothening the skin of the area. For example, carbon dioxide laser resurfacing is a marvelous adjunct to tightening the skin of this area without undue lateral brow elevation.

 

Workup

Laboratory Studies

Perform routine laboratory studies, depending on the general health of the patient, as required for routine cosmetic surgical procedures.

Imaging Studies

If superior brow fullness is a problem and the lateral orbital rim will undergo burring, some preoperative evaluation of the area's bone thickness may be considered useful.

Other Tests

Lower eyelid laxity (snap back test)

Draw the lower eyelid away from the globe using the index finger in a downward motion after placing it on the central lower eyelid skin. The lower eyelid should "snap back" quickly (1-2 s) to adhere to the globe once more. If it snaps back slowly, consider a lower eyelid tightening or canthal suspension procedure.

Visual acuity test

Routinely check visual acuity preoperatively.

Schirmer test

A tear-film test may be performed to test for true eye dryness preoperatively if dry eye symptoms are present.[4]

Exophthalmometer

If eye prominence is a problem, test true exophthalmos with an exophthalmometer. If found, consider referral to an endocrinologist or screening for hyperthyroidism.

 

Treatment

Medical Therapy

Medical therapy of the brow and periorbital area requires a short discussion. Botulinum toxin (BOTOX®) is useful in temporarily paralyzing the corrugator supercilii muscles and portions of the orbicularis oculi muscles. In individuals with little skin excess and few rhytides at rest, this is excellent therapy until the patient is ready for and requires a true brow lift procedure.

Periorbital rejuvenation using lasers is largely one of tightening the periorbital skin to some degree; it has little effect on subcutaneous fat or any long-term effect on brow posture.

Surgical Therapy

Consider many adjunctive procedures (eg, canthopexy,[1]  upper and lower eyelid blepharoplasty, laser resurfacing, midface lift) at the time of brow lift to rejuvenate the periorbital area. Periorbital rejuvenation is a vast topic; this article only discusses brow lift.

Preoperative Details

Prepare an initial analysis and surgical plan for all patients.

Assess true brow ptosis and symmetry with the patient in an upright posture with the frontalis muscle relaxed. See the images below.

Preoperative photograph demonstrating a young fema Preoperative photograph demonstrating a young female patient with marked frown lines and congested appearance of the interbrow area with marked brow ptosis.
Preoperative view of a patient with brow ptosis, m Preoperative view of a patient with brow ptosis, marked actinic skin damage, and thin upper lip.

Ascertain the amount of correction of upper eyelid skin excess with proper brow positioning and accurately predict the need for adjunctive upper eyelid blepharoplasty or skin tightening with laser.

If concurrent facelift is to be performed, also predict the amount of produced lateral orbital skin excess and the need for an excision of a lateral wedge beneath the sideburn to avoid raising the hair-bearing skin too much. This is particularly important in the female patient.

In the male patient, the height of the brow should be approximately level with the supraorbital rim. In females, personal desires more often enter into planning the shape and height of the brow.[5] Some patients desire a more exaggerated look, although currently, most desire a relatively low central brow (at the level of the orbital rim) with a relatively straight rise to a lateral margin well above the orbital rim. Computer imaging is helpful in determining the patient's wishes preoperatively.

Ascertain the extent of action of the corrugator supercilii muscle, since many patients have extensive insertions into the skin, almost to the mid brow.

The shape and positioning of the incision in a coronal lift is important. Even if the scar is a hairline in width (1-2 mm), if it is positioned laterally too far anteriorly (directly above the anterior ear, as is depicted classically), the scar is visible whenever the hair is wet or the wind blows. This is because the hair growth naturally changes direction at that point. Position the scar posterior to this, preferably near the posterior margin of the ear. This increases the technical difficulty of elevating the coronal flap but the scar is almost imperceptible.

Map the route of the incision and subsequent scar across the top of the head for each patient. In patients with temporal hair recession, the incision can progress forward to cross the hairline and then return to the top of the head. The point of maximum skin resection then occurs on the hairless skin of the forehead and the hair-bearing skin to be advanced. In addition, a partial scar at the hairline is much less perceptible than one along its entire length, even if made uneven or in the form of a W-plasty.

In select patients, the incision can be made in other places, namely within the crease of a deep transverse rhytide of the forehead (mainly in male patients) or in the suprabrow area. This latter area tends to leave prominent scars, and its use is discouraged.

The controversy of endoscopic brow lifts compared to the classic coronal lift is discussed in Future and Controversies.[6, 7] The longevity of the lift produced by the endobrow procedure and the ability to completely remove the corrugator supercilii muscle through that approach are in question. It is useful in select individuals who should have minimal scarring or minimal lift and who do not mind undergoing repeat procedures in time. In individuals for whom it is imperative that sensation of the forehead not be altered, the endobrow procedure is an excellent option.

Preoperatively, shave the hair so that the final excision of skin results in hair-bearing skin juxtaposed to hair-bearing skin. Small adjustments can be made but the author prefers to perform this procedure since it is unwise to have areas of iatrogenic short hair away from the surgical scar.

The author has found that masking tape is an excellent means of controlling the posterior hair as long as it is removed prior to the patient fully awakening at the end of the procedure.

Make ringlets with the anterior hair and elastic bands. Remove these at the end of the procedure and even the hair once again, since necrosis has occurred when ringlets have pressed on the scalp within dressings after raising the flap.

Intraoperative Details

In the author's opinion, this procedure is best performed with the patient under general anesthesia. However, a combination of local anesthesia and an oral sedative has also frequently been used.[8] After routine induction, prepping, and draping, infiltrate the supraorbital, supratrochlear, and central brow areas with local anesthetic with epinephrine. Similarly infiltrate the anterior and posterior areas around the proposed incision site.

After waiting a few minutes to allow maximum epinephrine effect, make the incision at the posterior margin of the trimmed area.

Achieve hemostasis with judicious use of electrocautery on the posterior margin and freer use anteriorly. If desired, Raney clips may be used on the anterior margin, although they rarely are necessary.

Perform the supraperiosteal dissection sharply. The authors have found that sequential retraction with hooks on rubber bands affixed to a sterilely covered ether screen set at an appropriate angle allows for excellent visibility and aids with the dissection.

Spare the nerves and extend the dissection to the level of the brow. Completely free the tight attachments of skin in the suprabrow area, especially laterally. The dissection can be continued to the mid face in individuals who require midface elevation. If this is the situation, preserve the temporal branch of the facial nerve and the frontal branch of the deep temporal artery.

Once the brow has been dissected and the supratrochlear and supraorbital nerves are exposed, resect the corrugator supercilii muscles. Loupe magnification may be used for this portion of the procedure. Preserve the supratrochlear nerve as much as possible.

After muscle resection, resect the loose areolar tissue layer from the lateral scalp. The author usually places some of this to replace the removed muscle bulk. This results in a full appearance to the interbrow area.

Redrape the scalp flap and perform the excision with elevation of the preoperatively lower eyebrow first. D'Assumpcão measuring calipers greatly help in this process.

Resect the anterior flap appropriately and use hemostasis judiciously.

Close with deep sutures of 3-0 Vicryl placed so as not to strangulate hair follicles (which results in areas of alopecia). Final closure is with staples.

Apply a mildly compressive dressing with gauze padding behind the ears and on the incision line.

Postoperative Details

Postoperative care is minimal. Remove the dressings the day after surgery.

Generally, wash the patient's hair. Instruct the patient that he or she can bathe and wash normally. Bleaching and coloring agents should not be used for at least 3 weeks following the procedure.

Remove one half of the staples (mainly lateral and at the top of the head) 7 days postsurgery, and remove the remainder after 10-14 days.

Follow-up

Contact patients the night following the procedure if they are at home, or visit them in the hospital if that level of care is warranted. Observe them the next day and then every 3-4 days thereafter until all staples are removed.

Provide follow-up care weekly for 2-3 weeks, monthly for 2-3 months, and then every 6 months until 2 years postsurgery. When this level of follow-up care is provided, the number of repeat procedures is less than 2% over many years.

Complications

The most common complication is an area of relative insensitivity and paraesthesias for a few months following the procedure. The area immediately anterior to the scar can remain insensate, but this usually is of very little concern to the patient. Areas of alopecia can be addressed by simple excision if necessary. Asymmetry likewise can be corrected with simple re-elevation of the flap and correction of the lower side. The authors have found that almost a 4-to-1 correction is necessary in most individuals for elevation of the brow from so posterior an incision.

Blood loss of greater than 10-20 mL and the incidence of hematomas are unusual when general anesthesia is used and when the posterior flap is hemostatic throughout the remainder of the procedure. Infections are rare. In the uncomplicated or sole brow lift procedure, prophylactic antibiotics are not necessary.

The complications associated with midface lifting through lower eyelid incisions have been daunting. The worst is prolonged, severe, and irreparable ectropion. More conservative skin excision has helped, as has better fixation, but any vertical lift that relies upon the lower eyelid for support will generally fail. Midface lifting performed through brow lift incisions, with or without endoscopic assistance, has a lower complication rate and is generally preferred. Fixation to the temporalis fascia is generally acknowledged as the support that differentiates the procedure from lower eyelid procedures of the mid face. Midface lifting, in general, has a more prolonged recovery than brow lifting alone; this is usually manifested by prolonged edema.

Complications of treating the tear trough and nasojugal groove have mainly involved the irritation to the area through implants (Flowers) and permanent injectable agents such as silicone or Artecoll (a main stumbling block in its Food and Drug Administration approval process). The use of injectable agents based upon hydroxyapatite or hyaluronic acid is difficult in this area because of the thinness of the skin in the area. Even submuscular placement (beneath orbicularis oculi), which is preferred, can often result in visualization of the soft tissue filling agent. Sculptra is useful in the area, but granuloma formation and subsequent irregularity in contours has been a noted problem.

Outcome and Prognosis

The outcome for almost all patients is excellent and long-lived. The incision rarely is a concern, and hairdressers and beauticians often comment that it is excellent. The procedure rarely needs to be repeated, even after 20 or more years, because elevation is performed during the procedure and loose areolar tissue is removed, stopping descent of the brow with gravity and aging. The smoothness of the central brow region is difficult to achieve with any other procedure. See the images below.

Preoperative photograph of patient prior to a brow Preoperative photograph of patient prior to a brow lift performed through the coronal approach.
Postoperative photograph demonstrating marked impr Postoperative photograph demonstrating marked improvement in the periorbital area after a brow lift performed through the coronal approach.
Preoperative photograph demonstrating a young fema Preoperative photograph demonstrating a young female patient with marked frown lines and congested appearance of the interbrow area with marked brow ptosis.
Postoperative photograph demonstrating a young fem Postoperative photograph demonstrating a young female patient who had marked frown lines and congested appearance of the interbrow area with marked brow ptosis, after only a brow lift with corrugator supercilii muscle resection performed through a posterior coronal approach.
Preoperative view of a patient with brow ptosis, m Preoperative view of a patient with brow ptosis, marked actinic skin damage, and thin upper lip.
Patient who had brow ptosis, marked actinic skin d Patient who had brow ptosis, marked actinic skin damage, and thin upper lip. Postoperative (1 wk) view after brow lift with corrugator muscle resection, full-face carbon dioxide laser resurfacing, and upper lip augmentation using autologous tissue.

Future and Controversies

Currently, the largest controversy is the move to the endoscopic approach for the lift procedure.[6] As mentioned previously, unless fixation is improved, the necessity of repeating the procedure and the inability to completely remove the corrugator supercilii muscle do not outweigh the problems with paraesthesia and anesthesia of the area and the scar. In all but a select few patients with severe baldness, the endoscopic approach offers little advantage to the open approach.

In the future, with better fixation, means to remove the loose areolar layer, and means of efficient visualization and cautery of the area of the corrugator muscle, the endoscopic approach may become the procedure of choice. A report of the use of an endoscopic handpiece on the carbon dioxide laser for help with bloodless corrugator removal has been presented, but concern exists regarding the supratrochlear nerve, which is likely damaged by this application of laser energy.[9]

Laser procedures for nonresurfacing tightening of the skin also may help with correcting skin laxity in the periorbital region. More recently, both monopolar and bipolar radiofrequency tightening of the thin skin of this area has shown promise, particularly in the "crow's feet" area. The longevity, safety, and efficacy of these procedures are not yet definitively supported by peer-reviewed literature.

Injectable agents for nasojugal groove correction are not without complication. The use of agents that completely resorb with time is preferable to the unevenness that may occur with long-term or permanent implants. Fat grafting in the area is fraught with problems of uneven contour. If a lower eyelid bag is present, the transposition, redraping, or repositioning of fat into the nasojugal groove while still attached to a stalk supplying blood to the tissue can be an excellent means of rejuvenation of this area.