Atlas of Aesthetic Eyelid and Periocular Surgery

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Author: Henry M. Spinelli | Amy Lewis | Ebby Elahi

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SAUNDERS An Imprint of Elsevier, Inc. The Curtis Center Independence Square West Philadelphia, Pennsylvania 19106

ATLAS OF AESTHETIC EYELID AND PERIOCULAR SURGERY © 2004, Elsevier Inc. All rights reserved.

ISBN 0–7216–8633–8

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier Inc. Rights Department in Philadelphia, USA: phone: (+1)215 238 7869, fax: (+1)215 238 2239, e-mail: [email protected]. You may also complete your request on-line via the Elsevier Science homepage (http://www.elsevier.com) by selecting “Customer Support” and then “Obtaining Permissions.”

Notice Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the treating physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the editor assumes any liability for any injury and/or damage to persons or property arising from this publication. The Publisher

Library of Congresss Cataloging-in-Publication Data Spinelli, Henry M. Atlas of aesthetic eyelid and periocular surgery / Henry M. Spinelli.—1st ed. p. ; cm. Includes bibliographical references. ISBN 0–7216–8633–8 1. Blepharoplasty—Atlases. 2. Eyelids—Surgery—Atlases. 3. Surgery, Plastic—Atlases. 4. Eyebrows—Surgery—Atlases. I. Title. [DNLM: 1. Blepharoplasty—methods—Atlases. 2. Cosmetic Techniques—Atlases. 3. Eye—pathology—Atlases. 4. Ophthalmologic Surgical Procedures—Atlases. 5. Reconstructive Surgical Procedures—Atlases. WW 17 S757a 2004] RD119.5.E94S657 2004 617.7’710592—dc22 2003059097

Vice President, Global Surgery: Richard Lampert Acquisitions Editor: Peter McEllhenney Design Coordinator: Steven Stave Project Manager: Tina Rebane

Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

Preface

When Elsevier approached me concerning writing a text on eyelid and periocular surgery I tried to determine which books were popular and why they maintained popularity. Given the incredibly busy schedule that most surgeons and medical practitioners maintain in every specialty, the texts that seem to be the most popular are those that are quick and easy to read and review, are well illustrated, and serve as small atlases in that they serve as “how-to-tackle” books. Books of single authorship or limited authorship appear to be the most popular because these are well-organized and cohesive texts that flow with a distinct beginning, middle, and end. In my opinion these texts are usually purposefully drafted and directed. We noted anatomy and physiology to be fundamental and everlasting in their applicability. After all, the foundation of any surgical procedure is solidly grounded in the concepts of a basic understanding of anatomy, physiology, and pathophysiology. Additionally, excellent practical drawings, illustrations, and photographs of actual procedures, when organized and crossreferenced, appear to provide the most salient teaching tool in any text. These, combined with succinctly summarized legends, enable the reader to quickly browse through a chapter, gleaning its most important aspects. A summary of each chapter, which delineates salient positive and negative points, technical aspects, and trouble spots within the concepts covered in each chapter, appears to be extremely useful in capsulating the topics covered and serves as a quick reference and refresher for the reader. With this in mind, I have compiled an atlas that combines a directed practical narrative by a single author with both illustrations, photographs, and a summary in each chapter, which I have entitled Pearls and Pitfalls. I hope I have created a text that may find itself on the shelf of every practitioner of surgery and treatment in the periocular and facial regions. These

include plastic surgeons, ophthalmologists (oculoplastic surgeons), and otolaryngologists, as well as other practitioners. I also believe that this text will be useful to the cosmetic as well as the reconstructive surgeon in its reliance on important principles and concepts. This would make the text a long-lasting addition to the library of the experienced and well-versed surgeon, as well as of the resident and student. In structuring the text I relied heavily on anatomy and physiology, as well as pathophysiology. Within the context of these basic science areas, I built on them practical options and techniques for the treatment of both functional and aesthetic problems. The single authorship and strong illustrations should make for a very directed and organized text; however, it is obviously biased toward the techniques and concepts that I find most acceptable. In the areas of eyelid, periocular, and orbital surgery, there is considerable overlap in interest by multiple specialties and there appears to be a drive on the part of some practitioners to make this region esoteric and especially complex. I have made every effort in this text to demystify this area through a fundamental understanding of anatomy, physiology, pathophysiology, and good basic clinical thinking. The “technical wizardry” is minor and within the grasp of most practitioners. The concept of identifying the pathophysiology and then how to tackle it is a much more important principle for all of us to understand and apply so that our patients may benefit. I have attempted to compile an atlas that is easy to read and reference and that unifies many of the principles and techniques I have incorporated and taught. It should enable most surgeons to feel more confident in assessing and treating patients with cosmetic and/or symptomatic periocular problems. I hope that you, the reader, will agree.

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P R E FA C E

I want to thank my family for their loving support throughout this project, my office staff for their tireless energy and enthusiasm, my mentors, my colleagues, and my residents for contributing to my thought

processes and experiences. Without any of the individuals I have mentioned, this text would not be possible. Henry M. Spinelli, MD, FACS

Bibliography

Patel BC, Anderson RL: History of oculoplastic surgery (1986–1996). Ophthalmology 103(8 Suppl):S74–95, 1996. Reifler DM: The tarsectomy operation of A.P.L. Gillet de Grandmont (1837–1984) and its periodic rediscovery. Ophthalmologica 89(1–2):153–162, 1995. Rogers BO: History of oculoplastic surgery: The contributions of plastic surgery. Aesthetic Plastic Surgery 12(3):129–152, 1988. Safian J: A late report on an early operation for “baggy eyelids.” Plastic & Reconstructive Surgery 48(4):347–348, 1971. Servat J, Mantilla M: The history of ptosis surgery. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:133–137, 1986. Silverstone P: History of surgery for involutional ectropion. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:97–123, 1986. Watts MT: The history of oculoplastic surgery. Facial Plastic Surgery 9(2):151–156, 1993. Werb A: The history and development of lacrimal surgery in England and Europe. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:233–240, 1986.

Beard C: History of ptosis surgery. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:125–131, 1986. Hughes SM: The history of lacrimal surgery. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:139–168, 1986. Katzen LB: The history of cosmetic blepharoplasty. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:89–96, 1986. Mikamo M: Mikamo’s double-eyelid operation: The advent of Japanese aesthetic surgery. Plastic & Reconstructive Surgery 99(3):664–669, 1997. Miller CC: The excision of bag-like folds of skin from the region about the eyes. By Charles C. Miller, 1906. Aesthetic Plastic Surgery 12(3):155–156, 1988. Miller CC, Miller F: Folds, bags and wrinkles of the skin about the eyes and their eradication by simple surgical methods. By Charles C. Miller and Florence Miller, 1907. Aesthetic Plastic Surgery 12(3):157–158, 1988.

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CHAPTER ONE

Anatomy A fundamental concept in viewing the eyelid is that it is composed of three distinct anatomic layers analogous to those found in the nose. These include an external coverage or skin, a middle support layer, and an internal lining (Fig. 1-1). One should view the eyelids as trilamellae squeegee-like structures supported in space across the orbital rim by medial and lateral anchors, namely, the medial and lateral canthal tendons (Fig. 1-2A). In the case of the eyelid, the three lamellae include an outside coverage of skin that is especially thin over the tarsus and preseptal areas with minimal to no subcutaneous fat. The middle, or supportive, layer includes the orbicularis muscles, with the pretarsal portion lying in front of the tarsal plate and the preorbital

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portion lying anterior to the orbital septum. The tarsal plate is a rigid cartilaginous-like structure that measures 4 to 6 mm in the lower lid and 8 to 10 mm in the upper lid. This structural layer is pierced by glands that drain or open posterior to the eyelashes or cilia line and number on average 10 in the lower lid and 20 in the upper lid. These meibomian glands and ducts are responsible for oil secretion, and when they become inspissated they may be responsible for hordeolums or styes (acute inflammation) and chalazia (chronic noncaseating granulomas) and other inflammatory processes. These are also the sites for inflammation in the postcosmetic blepharoplasty, meibomianitis, or blepharitis.

A NA T O M Y

Periosteum Skin Preaponeurotic orbital fat Whitnall's ligament Müller's muscle

Orbicularis muscle Orbital septum Levator palpebrae aponeurosis

Conjunctiva Tarsal plate

Capsulopalpebral fascia

Orbital septum

Figure 1-1 Oblique cross-section of the right orbit and adnexa beginning anteriorly with skin and ending posteriorly with conjunctiva covering the anterior sclera. The orbicularis muscle is contiguous with the frontalis, occipitalis, and superficial musculoaponeurotic system (SMAS) layer. The orbital septum is confluent with the periosteum of the skull and orbit, as well as the periorbita. The orbital septum is also fused to the levator palpebrae and, therefore, serves as a complete boundary between the anterior and deep orbit. One cannot access the preaponeurotic fat without violating the superior septum. Analogously, the inferior orbital septum is intimately linked to the periosteum and the capsulopalpebral fascial system. The main retractors of the upper and lower lids are the levator and capsulopalpebral fascia, respectively. The levator is suspended from the superior orbit by Whitnall's ligament. This structure allows the muscle to change vector forces from anterior to posterior to superior to inferior, thus serving as a pulley. The preaponeurotic and precapsulopalpebral fat is loosely but definitively linked to the respective retractors; hence, dehiscence of the levator from the tarsal plate will lead to a superior sulcus deformity. The tarsal plates are the end point for retractor insertion and provide lid stability and orientation.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY

Orbicularis muscle Whitnall's ligament

Orbital septum

Levator aponeurosis

Lower crus, lateral canthal ligament Lockwood's ligament

Arcuate expansion


A Figure 1-2 A, An anterior oblique view of the orbit viewed with selective soft tissue layers removed. Deeper structures are viewed more laterally. The orbicularis muscle is contiguous with the frontalis, occipitalis, and SMAS layers. The muscle has a medial and lateral raphe and has three divisions (preorbital, preseptal, and pretarsal) based on important underlying structures. Access to the deep orbit is blocked by the septum. The tarsal plates that give rigidity to the eyelids are engaged by their respective retractors (levator and capsulopalpebral fascia). The lateral canthal tendon is formed by two crura, which are continuous with the tarsal plates. This common canthal tendon inserts at Whitnall's tubercle 2 to 3 mm inside the orbital rim. Whitnall's tubercle serves as a common insertion point for a number of structures, which cumulatively are known as the lateral retinaculum. These include the orbital septum, canthal tendon, Lockwood's ligament, and Whitnall's ligament, along with the deep head of the orbicularis and check ligament of the lateral rectus muscles. Whitnall's ligament is the pulley that allows the levator mechanism to change vectors, and Lockwood's ligament is a sling that serves to provide globe support. Continued

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A NA T O M Y

Skin

Orbicularis muscle Levator palpabrae muscle Sup. rectus muscle

Orbital septum Müller's muscle Levator aponeurosis Tarsal plate Conjunctiva

Inferior rectus muscle

Inferior tarsal muscle Capsulopalpebral fascia Orbital septum

Inf. oblique muscle

B Figure 1-2 Continued B, On lateral view, the analogy between upper and lower eyelids is clear. The upper and lower septa merge with the periosteum externally and the periorbita internally. The levator aponeurosis merges with the septum, and the preaponeurotic fat is linked to the levator and only accessible by violating the septum. Müller's muscle is sympathomimetically innervated and is the flight/fright elevator of the upper lid, responsible for 1 to 2 mm of excursion. The capsulopalpebral fascia or lower eyelid retractor system arises off the inferior oblique and rectus muscles. Therefore, the lower eyelid "gets out of the way" when the globe is depressed, as when reading the newspaper. The conjunctiva reflects on itself, covering the undersurface of the eyelids and then onto the eyeball. This is similar to visceral and parietal layers found elsewhere in the body. The fat in the lower orbit is behind the septum but in front of the retractor system. Hence it may be termed precapsulopalpebral fat. All orbital fat is linked by septa so that traction placed on anterior extraconal fat produces a disturbance in the deep extraconal and intraconal fat. Note the coalescence of the inferior orbital septum with the capsulopalpebral fascia well below the inferior tarsal plate. This zone of coalescence is a favored access route to the important potential space. I call this the postorbicularis precapsulopalpebral fascial space, which is important in deftly executing both transconjunctival and transcutaneous blepharoplasties.

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The tarsal plate is especially important for vertical support and rigidity of the eyelid. If one were to eliminate it, an eyelid would conceivably flop or flutter like a sail on a boat in changing or slack winds. This vertical supportive task is important and fundamental in maintaining the lower eyelid position 1 or 2 mm above the corneoscleral junction or limbus. The internal lining of the eyelid is mucosa. This layer reflects off the eyeball and onto the back surface of the eyelids, including the posterior surfaces of the medial and lateral canthal tendinous structures. This reflection in itself is analogous to the visceral and parietal pericardium or pleura. The conjunctival surface provides a near frictionless surface for the lids and eyeball to move against themselves and each other. The conjunctival surface is rich in secretory cells and glands and includes mucin and goblet cells and minor salivary glands. The upper lateral fornix is especially rich in minor lacrimal glands, including the glands of Kraus and Wolfring. One should view the upper and lower lids as analogous or similar, with a few specialized differences, rather than the traditional fashion in which some anatomy and surgical texts treat the upper and lower lids as disparate anatomic and functional structures. A sagittal section through the orbit viewing the upper and lower eyelids and eyeball demonstrates how the upper and lower eyelids and periocular structures are quite similar (see Fig. 1-2B). First, there is an anterior layer of skin followed by a middle structural support layer or the tarsal plates. The tarsal plate is a little wider on the upper lid than on the lower, and both upper and lower lids enjoy a mucous membrane lining that is applied to the visceral and parietal surfaces, namely, the eyeball and posterior eyelids. The upper and lower eyelids have a cul-de-sac that is the junction between the parietal and visceral conjunctiva. Upper and lower lids are surrounded by orbicularis muscle that is contiguous with the superficial musculoaponeurotic system (SMAS), platysma, and frontalis muscles. The orbicularis functions as a sphincter, despite the possession of a medial and lateral raphe. The orbicularis muscle is traditionally divided into subdivisions depending on where it lies, and these include the pretarsal, preseptal, and preorbital areas. The orbicularis muscle is innervated by the seventh nerve and, hence, with facial nerve paralysis, the cornea and globe are typically exposed, owing to an atonic eyelid left without the protractor action of the orbicularis and with the overaction of the unopposed retractors. The retractors of the eyelids are analogous as well, with the upper lids possessing a voluntary or primary retractor, namely, the levator palpebrae superioris muscle and a secondary sympatho6

mimetically innervated muscle called Müller’s muscle. Müller’s muscle is the so-called fright/flight response muscle and is responsible for approximately 2 mm of lid elevation as occurs in sexual excitation or being chased by a ferocious dog. The levator palpebrae superioris is responsible for the remainder of lid elevation and is elective or voluntary. The levator palpebrae measures approximately 37 mm in length and is only 4 mm in width at the apex of the orbit. It gradually widens anteriorly until it fans out into an approximately 20-mm long aponeurosis that expands from 6 mm at the distal end of the levator muscle to a width of 30 mm where it inserts onto the tarsal plate. The levator muscle sends some fibers to the dermal surface of the upper lid skin, creating an upper lid fold. The exact fashion in which fibers insert onto the skin and create this lid fold has not been clearly elucidated. Surgical manipulation of the levator aponeurosis is a very powerful tool for altering upper lid height. This can be achieved by plication, advancement, or recession. A normal upper eyelid lies midway between the upper aspect of the pupillary aperture and the upper corneal scleral junction or limbus. The apex of this arch lies just medial to the pupil, and this is an important landmark in any ptosis correction. The lower lid retractors are intimately linked to the inferior extraocular muscles. The inferior rectus and inferior oblique muscles send out extensions by way of the capsulopalpebral fascia, and these insert onto the inferior edge of the tarsal plate of the lower eyelid. This is analogous to the levator aponeurosis of the upper lid. The capsulopalpebral fascia is a “voluntary” retractor of the lower eyelid and is understandably linked to the depressors of the eyeball so that in electively looking down the lower eyelid gets out of the way. The capsulopalpebral fascia is an important structure that is always divided at some level in the transconjunctival blepharoplasty or in any transconjunctival route to the orbit. Retractors of the upper and lower eyelids share a reorientation of their direction of pull within the orbit as one follows them anteriorly. The levator palpebrae superioris muscle has a significant change in direction from anterior to posterior to cephalad to caudad just as in the case of the inferior lid retractors. In the upper lid the levator aponeurosis reorients directions, and in the lower lid the capsulopalpebral fascia does the reorienting. In the case of the upper eyelid, this occurs by way of an interesting and clinically relevant mechanism. The levator palpebrae superioris muscle moves from its insertion in the apex of the orbit, from the lesser wing of the sphenoid bone, and runs in a horizontal direction anteriorly in the orbit until it changes to a vertical direction by way of a pulley system. It is this

A NA T O M Y

pulley system that converts the vector force from horizontal to vertical and allows elevation of the upper lid analogously to a garage door. This is a fascial condensation or ligamentous band stretching across the orbit that is known as Whitnall’s ligament (Fig. 1-3). Whitnall’s ligament should be visualized in all upper eyelid blepharoplasties. Its fibers connect to the trochlear medially, and laterally they extend to join the lacrimal gland stroma and fascia and actually divide the lacrimal gland into palpebral and orbital lobes (Figs. 1-4 and 1-5). It finally inserts on a key anatomic and surgical structure known as Whitnall’s tubercle, which is a bony excrescence within the orbital rim and below the zygomaticofrontal junction. This is also the

Orbital lobe of lacrimal gland

place where the lateral canthal tendon inserts and as measured on a skull lies about 6 mm below the lacrimal fossa and 2 mm within the orbit (Figs. 1-6 and 1-7). The lateral horn of the levator aponeurosis also inserts at this common anatomic focal point. This location is important in any procedure that realigns the lateral canthal tendon whether it be a periocular or craniofacial procedure. Because of the large number of anatomic insertions in this area, complications can occur when a procedure is not discrete or focused. For example, the lateral horn of the levator may be incorporated into a canthopexy procedure and lead to lateral upper lid retraction or lag on attempted closure. This results in a loss of the upper lid sweep and a peak laterally.

Whitnall's ligament

Palpebral lobe of lacrimal gland

Levator palpebrae superioris muscle

Orbital septum (partially removed) Levator aponeurosis

Superior crura Upper tarsal plate

Whitnall's tubercle Lateral canthal tendon

Medial canthal tendon

Inferior crura Lower tarsal plate

Recess of Eisler Orbital septum (partially removed)


Figure 1-3 The upper and lower eyelids are suspended in space, tethered medially and laterally by the canthal tendons; and these in turn are linked to Whitnall's and Lockwood's ligaments. The orbital and palpebral lobes of the lacrimal gland are divided by Whitnall's ligament. The orbital septum inserts at the orbital rim, except inferolaterally where it inserts beyond the rim forming Eisler's recess.

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Figure 1-4 The upper lid incision with the orbital septum incised exposes the tarsal plate just above the traction hook. The whiter levator aponeurosis above the tarsal plate merges into the redder levator muscle. The dense white condensation of fibers known as Whitnall's ligament is easily visualized lying at the junction of the preaponeurotic fat pad and the levator. The preaponeurotic fat is retracted superiorly by the forceps. Note the loose but definitive attachments the fat has to the levator. Also note the lateral third of Whitnall's ligament as it courses to insert on the internal orbital rim. Here the lacrimal gland is bisected into orbital and palpebral lobes. The light yellow orbital lobe is visualized here, sandwiched between the orbital rim posteriorly and above with Whitnall's ligament below. A small segment of the palpebral lobe is visible medially and inferior to the ligament.

Figure 1-5 A lateral oblique view of another patient whose orbital septum has been opened. The upper skin is retracted superiorly, and the lower skin and lid margin are pulled inferiorly. The tarsal plate (white) is seen just to the left of the inferior traction hook. Whitnall's ligament and its coalescence with the lateral horn of the levator lies above the forceps, and the yellow palpebral lobe of the lacrimal gland lies just below.

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A NA T O M Y

Figure 1-6 Lateral cephalic dissection exposing the superolateral orbit. Note the zygomaticofrontal junction, lacrimal fossa, and dense white Whitnall's ligament, which extends from the trochlear medially to Whitnall's tubercle laterally. The traction suture is displacing the common canthal tendon with the orbital lobe of the lacrimal gland between the blue and silver retractors. Again, note the course of Whitnall's ligament laterally as it divides the lobes of the lacrimal gland on its way to insert on the bony excrescence (tubercle) just lateral to the silver (Freer) elevator.

Superior orbital fissure Sphenoid bone Frontal bone

Figure 1-7 The eight bones of the orbit basically create two significant facial buttresses, the frontalzygomatic-maxillary and the frontalnasal-maxillary. The sphenoid articulates with the zygoma and is the major delineator between the middle cranial fossa and the orbit. The optic foramen is in the body at the sphenoid. Medially, the lacrimal fossa is visualized between the anterior and posterior lacrimal crests. These crests serve as insertions for respective elements of the medial canthal tendon. The lacrimal sac lies within the fossa, between the anterior and posterior crests. Whitnall's tubercle is seen lying 2 to 3 mm within the orbit and 6 to 8 mm below the lacrimal fossa. The position of this important tubercle is salient in performing an anatomically functional and aesthetic canthoplasty procedure.

Palatine bone

Optic canal

Ethmoid bone

Lacrimal fossa Zygomatico frontal suture Whitnall's tubercle Zygomaticofacial foramina Inferior orbital fissure Lacrimal bone Zygomatic bone Lacrimal fossa Infraorbital foramen Maxilla bone

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EXTRAOCULAR MUSCLES The so-called check ligaments serve to prevent extremes in extraocular muscle excursion with resulting snapping or uncontrolled spastic movements. The versions or movement of the eyeball is controlled by the extraocular muscles. The fascial system within the orbit supports the globe and limits ocular movement. This fascial system provides an interconnecting scaffold from one structure to the other and extends both extraconally (outside the muscle cone) and intraconally, transgressing the orbital fat. The extraocular muscles form a conical network within the orbit with the apex forming the origin of the extraocular muscles at a fibrous thickening of the periosteum known as the annulus of Zinn (Fig. 1-8A). The orbital apex delineated by the greater sphenoid wing separates the middle cranial fossa from the orbit, and it is at this juncture where a number of nerves pass between the intracranial compartment and the orbit. These include the optic, oculomotor, trochlear, and abducens nerves. The superior oblique and the levator muscles arise at the orbital apex but outside the common tendinous ring of Zinn. The functions of the extraocular muscles include not only abduction and adduction but also intorsion and extorsion. These latter functions allow the world to remain upright when one tilts one’s head toward the shoulders. Of course this is all orchestrated by the vestibulocochlear system and the brain stem. The vascular supply to the extraocular muscles is principally from the ophthalmic artery, with each muscle receiving two anterior ciliary arteries, except for the lateral rectus, which

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receives only one. The anterior ciliary arteries continue on to penetrate the sclera of the eyeball beyond the muscular insertions and thus contribute significantly to nourishing the anterior segment of the globe. Therefore, disinsertion of more than two rectus muscles from the globe can result in anterior segment necrosis. Two important muscles in anterior orbital surgery are the inferior oblique and, to a lesser extent, the superior oblique. The inferior oblique is the most anterior muscle within the orbit and is the most commonly damaged muscle in blepharoplasty or surgical approaches to the orbital rim and zygoma in fracture treatment. The inferior oblique muscle originates from the periosteum lateral to the nasolacrimal canal and then courses posteriorly and laterally within the orbit to insert on the eyeball. Therefore, one can see by the origin and insertion the mechanical results of its contraction on the globe. These are primarily elevation, secondarily abduction, and finally extorsion or rotating the eyeball clockwise as viewed from inside the skull. The superior oblique muscle that arises superomedial to the annulus of Zinn functions in depression, abduction, and intorsion. From a practical standpoint, the inferior oblique muscle should always be identified in transconjunctival blepharoplasty, as it divides the medial and central fat pads. In a transcutaneous route this is less important; however, I prefer to identify it in every approach. The superior oblique muscle divides the medial and central fat pads in the upper compartment, and, although it arises at the orbital apex, it changes direction and vector forces after looping around the trochlear in the superomedial orbit, producing a near mirror image of the vector forces created by the inferior oblique muscle (see Fig. 1-8).

A NA T O M Y

A

Most anterior portion of inferior oblique muscle

Inferior oblique muscle Check ligaments of medial rectus muscle

Superior rectus muscle

Superior oblique muscle

Check ligaments of lateral rectus muscle


Levator palpebrae superioris muscle

Superior rectus muscle

Annulus of Zinn Central fat pad

B Trochlea (pulley) Superior oblique muscle Medial fat pad

Lateral rectus muscle

Medial rectus muscle

Medial fat pad

Inferior oblique muscle

Lateral fat pad


Central fat pad

Figure 1-8 The extraocular muscles form a cone whose apex lies near the optic foramen (A). All muscles insert at the annulus of Zinn except the levator and the superior oblique. The most anterolateral rectus check ligament inserts on Whitnall's tubercle. On anterior view (B), the most anterior muscle in the orbit, the inferior oblique, can be seen dividing medial and central fat pads. The lateral fat pad can be seen draping over the orbital rim into the recess of Eisler. This may be one factor contributing to its reputation as the most frequently missed fat.

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THE MEDIAL CANTHUS The medial canthus contains a number of structures compactly arranged in a small space oriented around the lacrimal fossa. Pretarsal, preseptal, and preorbital orbicularis oculi fibers have both superficial and deep heads, and these components envelop the lacrimal sac, inserting on the anterior and posterior lacrimal crest, respectively. The medial canthal tendon extends beyond the anterior lacrimal crest to the frontal process of the maxilla and like the orbicularis oculi fibers has both anterior, posterior, and even a superior component (Fig. 1-9). The anterior and posterior components of the medial canthal tendon similarly envelop the lacrimal sac. Hence, the lacrimal system is an active pump mechanism in which orbicularis fibers inserting on fascia surrounding the lacrimal sac actively dilate and passively contract the sac, altering pressure within the middle and distal lacrimal system. These orbicularis fibers also envelop the canaliculi of the upper and lower lids, allowing this proximal aspect of the lacrimal drainage system to alter length and width with cyclical muscular contraction. The medial canthus is less likely to be addressed in standard cosmetic and periocular surgery, that is, in the absence of nasal orbital ethmoid trauma and/or elective osteotomies. However, there are instances in which the medial canthal tendinous complex needs to be

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addressed. Generally, the upper and lower puncta lie midway between the caruncle or medial lid commissure and the medial limbus (corneal scleral junction). Laxity of the medial canthal tendinous complex produces both lateral and inferior displacement of the medial commissure and canaliculi. This is especially true when concomitant lateral canthal laxity is noted and the surgeon chooses to address the lateral canthal complex with a tightening or suspension procedure. In these instances, the laxity of the medial canthal tendon allows the puncta to be displaced temporally on lateral canthal tendon tightening alone. This can have significant consequences in terms of tear drainage and patient discomfort. The surgeon must be cognizant of significant laxity in the medial canthal complex when he or she chooses to tighten or suspend the lower lid. In these cases, the medial canthal tendon may require plication or reefing before lateral canthal tightening, to obviate displacement of the lacrimal drainage system. In plication or suspension of the medial canthal tendinous complex, one must be aware of the course of the lacrimal drainage system and protect it. I recommend intubation of the lacrimal system as a prophylactic measure in many cases (Fig. 1-10). The lacrimal pump refers to the dynamic nature of the medial canthal complex, including the lacrimal sac, which sits between the anterior and posterior lacrimal crest with two thirds of it lying within the bony fossa.

A NA T O M Y Posterior limb, medial canthal tendon

Superior limb, medial canthal tendon

Figure 1-9 The medial canthal tendon envelops the lacrimal sac. It is tripartite, with anterior, posterior, and superior limbs. Like the lateral canthal tendon, its limbs are continuous with the tarsal plates. The components of this tendon along with its lateral counterpart are enveloped by deep and superficial aspects of the orbicularis muscle. This arrangement is important in maintaining a functional and active lacrimal drainage system. The upper, lower, and common canaliculi closely approximate this tendon system; and care should be taken to preserve their integrity when altering any aspect of the medial canthal tendon. This tendon may require an elective tightening procedure, especially in cases in which a lateral canthal procedure alone would produce punctal and lacrimal dystopia.

Anterior limb, medial canthal tendon

Lacrimal fossa

Anterior and posterior lacrimal crests

Figure 1-10 A medial canthal curved incision exposes the anterior component of the medial canthal tendon overlying micro forceps. The traction hooks expose the anterior lacrimal crest (medially and superiorly), and the proximal aspect of the superior component of the tendon is just visualized. Note the lower lid punctum cannulated with a probe. It normally lies lateral to the upper punctum, but here it is pushed medially by the probe. In special cases, plication of the anterior component of the medial canthal tendon is necessary to avoid overlateralization of the punctum associated with lateral eyelid tightening.

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The upper and lower canalicular systems are basically two pipes connected to the lacrimal sac, which in 90% of instances coalesce into a common canaliculus. Each system is approximately 2 mm in vertical height and 6 to 8 mm in horizontal distance before coalescing with the lacrimal sac. The lower canaliculus is slightly more lateral than the upper; and this entire system, as mentioned earlier, is enveloped by superficial and deep heads of the orbicularis muscle and respective components of the medial canthal tendon (Fig. 1-11). The lacrimal sac dilates and collapses with different phases of the blinking process and, hence, is an extremely

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active or dynamic process that does not depend on gravitational forces. The lacrimal pump is related to orbicularis muscle contraction and relaxation and therefore cycles with blinking (Fig. 1-12). Tear drainage is independent of head position; therefore, epiphora does not generally occur even while one stands on his or her head. Cosmetic or reconstructive surgical procedures in addition to trauma can disrupt fibers of the orbicularis muscle, causing anatomic and/or physiologic alterations in lacrimal drainage and creating symptoms (Figs. 1-13 and 1-14).

A NA T O M Y

Upper puncta

Tarsal plates

Common canaliculus Lacrimal sac

Ampulla Lacrimal duct

Papilla

Inferior meatus

Figure 1-11 Much of the soft tissue of the medial canthal region is composed of the lacrimal drainage system. The vertical, horizontal, and common components of the canaliculi along with the lacrimal sac are enveloped by superficial and deep heads of the orbicularis muscle (pretarsal orbicularis posterior and preseptal anterior). The tarsal plates are perforated by the upper and lower canaliculi. The lower is more lateral, and both vertical components are 2 mm in height. The horizontal components are 6 to 8 mm long and converge into a common system before the lacrimal sac (90% of the time). The lacrimal sac has an investing fascia that allows the orbicularis muscle to exert forces on it as well as the canaliculi. The lower third of the lacrimal drainage system is intraosseous (lacrimal duct). The entire system drains into the inferior nasal meatus and can be affected by turbinate lateralization or hypertrophy.

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Lacrimal gland Upper and lower canaliculi Tear film

Lacrimal sac

Lacrimal duct

Inferior turbinate

Figure 1-12 The lacrimal production and drainage systems are both active, not passive. Tears produced mostly in the upper outer quadrant of the adnexa are mixed into a trilaminar film that gets distributed by the muscular action of the eyelids. The blinking cycle is largely initiated by orbicularis muscle action. The canaliculi and lacrimal sac, surrounded by investing fascia, are cyclically altered by lid position, with alternating traction and compression creating a lacrimal pump mechanism. On opening the lids, tears produced in the upper outer fornix are distributed as the precorneal tear film. The ampullae and distal canaliculi are widely dilated to accept tears, which have collected nasally into the system. On closure, tears are squeezed across the cornea toward the canaliculi. At the same time, orbicularis action causes a foreshortening and compression of the canaliculi and a dilation of the lacrimal sac. Tears are propelled from distal to proximal in the canaliculi and concomitantly sucked into the lacrimal sac, which has negative intraluminal pressure owing to its dilation. On reopening, tears are again redistributed, the ampullae and distal canaliculi dilate, and tears are drawn in. The lacrimal sac propulsively collapses and tears are propelled through the lacrimal duct and into the nasal cavity.

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A NA T O M Y

Figure 1-13 Close-up view of the medial canthal region of a postoperative patient shown in Figure 1-14. Note the upper and lower canalicular system intubated with silicone tubes that course through the lacrimal sac and into the nose. The lower punctum is more lateral than the upper punctum.

Figure 1-14 The medial canthal incision is shown with the lacrimal sac reflected laterally out of the lacrimal fossa. Medially behind the retracted skin edge is the anterior lacrimal crest. The lower portion of the sac is fixed by the superior portion of the nasolacrimal duct that drains into the inferior meatus of the nose.

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The lateral canthal tendon should be a most familiar structure to the surgeon and is more commonly addressed than the medial canthal complex. It should be thought of as contiguous with the tarsal plates and measures approximately 2 mm in width and 6 mm in length. It is a rather thin structure that splits into an anterior and posterior leaflet, with the anterior being contiguous with the orbital rim periosteum and the posterior element inserting on the lateral orbital tubercle (Whitnall’s), approximately 3 mm behind the orbital rim. This structure lies approximately 6 mm below the lacrimal gland fossa. Superficial and deep components of the orbicularis oculi muscle (both preseptal and pretarsal) accompany the superficial and deep layers of the lateral canthal tendinous complex. The lateral horn of the levator aponeurosis, which splits the lacrimal gland into orbital and palpebral lobes, also inserts on Whitnall’s tubercle, blending with the insertion of the lateral canthal tendon. Therefore, Whitnall’s tubercle is analogous to the lacrimal fossae in that there is a convergence of support and suspensory structures that coalesce as anchor points for the eyelids, which otherwise are “floating in space” (Fig. 1-15). The

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lateral canthal tendon complex or lateral retinaculum additionally contains a coalescence of the inferior suspensory ligament of Lockwood and the check ligament of the lateral rectus muscle. It is also firmly adherent to the orbital septum and lateral orbital periosteum, which is definitively thickened in this region. From a clinical perspective one key anatomic point is that division of the lateral canthal tendon in and of itself is not sufficient to mobilize the lateral canthal tendon complex or lateral retinaculum and, hence, lower and/or upper eyelid mobility and transposition can only be achieved with division of additional structures in the lateral canthal tendon complex. Failure to address all key elements of the lateral retinaculum will result in an inability to mobilize the lateral canthus in repositioning and/or tightening procedures. Typically, this is illustrated when “lateral canthopexies” do not achieve lower eyelid or lateral canthal elevation or suspension and tightening. Topographically, the lateral canthal tendon should be inclined 10 to 15 degrees when compared with the medial canthal tendon, and it is this position that is anatomic, physiologic, and most aesthetically pleasing.

A NA T O M Y Superficial portion of orbicularis muscle

Orbital septum

Deep portion of orbicularis muscle Whitnall's ligament Tarsal plates

Lateral canthal tendon divided and inserting into Whitnall's tubercle

Orbicularis muscle (superficial portion) and orbital septum contributing to the lateral retinaculum

Figure 1-15 The anatomy of the lateral canthal region shows the integration of muscular, tendinous, and other components of the lateral retinaculum. The pretarsal orbicularis muscle follows the deep portion of the lateral canthal tendon behind the septum inserting on Whitnall's tubercle. The preseptal orbicularis muscle moves superficially with the superficial aspects of the lateral canthal tendon, just anterior to the orbital septum. Note the orbital septum dividing into anterior and posterior leaflets in continuity with the periosteum and periorbita. Whitnall's ligament, seen through the septum (insert) sends a small component superiorly and a main component to split the lacrimal gland and insert on Whitnall's tubercle.

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ORBITAL FAT Orbital fat is generally the focus of much of the cosmetic surgery in the periocular region. Whether resection, repositioning, or a combination of both is chosen for an individual patient, some fundamental anatomic points are helpful. First, all fat lies behind the orbital septum, which is contiguous with the periosteum of the bone surrounding the orbit. Here the orbital septum serves as a boundary against infection and tumor spread and basically prevents contiguous access from the anterior tissue planes to the deeper orbit where vital structures transgress bony apertures into the anterior and middle cranial fossae. In the upper lid all fat that is to be addressed is anterior to the levator aponeurosis and, hence, is termed preaponeurotic. Analogously, all postseptal fat in the lower eyelid is in the precapsulopalpebral fascial plane (see Fig. 1-2B). All fat accessed through the orbital septum is contiguous with the entire extraconal (outside the muscle cone) and intraconal (within the muscle cone) spaces (see Fig. 1-8B). Therefore, traction on fat just posterior to the orbital septum can produce forces in the posterior extraconal and even posterior intraconal and perioptic nerve region (see Fig. 1-8). The linkage of fat within the orbit by way of septa that transgress the extraocular muscle cone is the reason why there is a small but definitive risk of orbital hemorrhage and even blindness when addressing anterior orbital fat in surgical procedures. These interconnecting septa are also the reason why orbital hemorrhages do not spontaneously decompress with opening the orbital septum. Blood is generally trapped within the intraconal and extraconal spaces by this fascial network, and “indirect” decompression requires division of the inferior crus of the lateral canthal tendon and sometimes decompression of the anterior chamber of the eye, along with medical therapy such as corticosteroids, acetazolamide, and mannitol. I

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use the term indirect because the decompression is only aimed at decreasing intraocular pressure and not at evacuation of intraorbital blood.

THE LACRIMAL APPARATUS The lacrimal apparatus consists of structures that produce, distribute, and drain tears. The tear film is extremely important because it provides a wetting surface for gliding of the eyelids and eyeball structures against one another. Tears are rich in immunoglobulins and lysozymes and are the reason the eye can be exposed to ambient air without breakdown and infections. The tear film in and of itself has refractive properties and bends light with the power of approximately 0.5 diopter. Tears are basically trilaminal with an inner layer consisting of a mucoprotein that serves to decrease surface tension and allows the middle aqueous phase to spread out more uniformly over the cornea. This is produced by goblet cells within the conjunctival tarsus and limbus. The middle layer, or aqueous phase, is produced by the subconjunctival glands of Krause and Wolfring. The aqueous phase is augmented by the reflexly stimulated main lacrimal gland. Oil-producing glands such as the meibomian glands located in the upper and lower eyelids and the palpebral glands of Zeis and Moll provide an oily covering to the tears that prevent evaporative loss and provide stabilization and duration to the tear film. The reflexly stimulated lacrimal gland is divided into two portions by the lateral horn of the levator palpebrae superioris. The main orbital lobe is approximately three times the size of the palpebral lobe, and in many instances the palpebral lobe is visible with eversion of the upper lid (Fig. 1-16). Prolapse of this gland can be corrected by suspension with the use of surrounding periosteal sutures (Figs. 1-17 and 1-18).

A NA T O M Y

Lacrimal gland, orbital and palpebral lobes

Glands of Krause and Wolfring

Glands of Zeis and Moll

Conjunctival, tarsal and limbal goblet cells

Meibomian glands

Figure 1-16 Close-up view of the upper lateral adnexa and Whitnall’s ligament with the septum divided. This region of the fornix is rich in conjunctival cells specializing in the production of tear components. The upper and lower lids are perforated by tarsal meibomian glands, and each follicle has associated glandular elements (Zeis and Moll). Whitnall’s ligament can be seen extending over a medial-to-lateral course dividing the lacrimal gland into orbital and palpebral lobes and inserting at Whitnall's tubercle. More centrally, it can be seen in its primary role as a vector conversion pulley for the levator muscle.

Figure 1-17 The upper eyelid is everted, demonstrating a prolapsed lacrimal gland. Lacrimal gland prolapse must be distinguished from subconjunctival orbital fat. The latter can be resected, and the former should be suspended, except in cases of malignancy, and so on.

Figure 1-18 An upper lid incision exposing the levator aponeurosis has been disinserted from the tarsal plate. The levator is thickened secondary to thyroid infiltrative disease. The lacrimal gland and orbital and palpebral lobes are visualized in their respective positions. The orbital lobe is prolapsed from its usual cephalic location within the lacrimal fossa. The lobes of the gland are divided by the lateral horn of the levator, which has been lysed surgically in this photograph.

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The aqueous phase of tears is produced in the upper lateral fornix or cul-de-sac and then structured into three layers and distributed by means of the squeegee action of the upper and lower eyelids. These are distributed across the eye and then repeatedly pumped into and through the lacrimal system with the cyclic action of blinking. This forceful yet subtle muscular action eventually propels tears, which begin in the upper outer corner of the orbit, into the nasal cavity beneath the inferior turbinate. In the context of cosmetic surgery one can see how easily the precorneal tear film can be disturbed by, for example, changing the pattern in which the eyelids mix, distribute, and pump tears. A patient who has borderline tear production and/or quality may be sufficiently altered by surgery so that he or she may complain of dry eyes or epiphora. A change in the refractive index of the precorneal tear film may lead the patient to complain of a change in the quality of his or her vision, even when objective testing (Snellen chart) does not discern a difference from the preoperative and postoperative examinations. The blinking cycle is an important physiologic mechanism for draining tears. This mechanism is propulsive and, therefore, independent of gravity. The movement of tears into the nose is assisted by an active “lacrimal pump,” which is dependent on the superficial and deep heads of both the pretarsal and preseptal orbicularis oculi muscles as well as the lacrimal diaphragm, which is a condensation of fascia around the lacrimal sac (see Fig. 1-11). The canaliculi remain patent with the ampullae in contact with the tear lake formed in the medial canthus when the eyelids are open and the orbicularis oculi muscle is relaxed. On contracture of the orbicularis muscle, eyelid closure ensues with a milking of tears from superolateral to inferomedial over the ocular surface. Muscular contracture causes shortening of the canaliculi and closing of their ampullae. Concomitantly, the deep heads of the preseptal muscles attached to the fascia or lacrimal diaphragm dilate the

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sac and, hence, create a negative pressure within its lumen. The closing of the ampullae with shortening of the canalicular system causes propulsion of tears medially, and the negative pressure generated within the lacrimal sac causes tears to be sucked into the sac nasally on eyelid closure. As the lids reopen, the orbicularis muscle relaxes, causing collapse of the lacrimal sac and propulsion of tears into the nose beneath the inferior turbinate along with a relaxation and lengthening of the canaliculi and a redilatation of the ampullae. This cycle repeats over and over again with efficient smooth drainage of tears (see Fig. 1-12). The lacrimal sac is approximately 15 mm in height with one third of it extending above or superior to the medial canthal tendon. The nasolacrimal duct refers to the intraosseous portion, and this is approximately 12 mm in length. The duct empties into the inferior meatus of the nose approximately 15 mm from the floor (see Fig. 1-11). To commit this to memory, I prefer to divide each of these three distinct vertical segments into 15-mm lengths. The balance between tear production and evaporation is critical to patient comfort because this determines whether there is sufficient wetting of the corneal surface. Production of adequate tears is a function of both quantity and quality. That is, a patient may make a lot of tears as measured on Schirmer’s test but produce insufficient oils, which prevents evaporative loss to ambient air and, hence, may have a relatively dry eye despite adequate volumetric tear production. The homeostasis between production and evaporative loss is a critical concept in appreciating nuances in patient presentation and in deciding which procedures appropriately address aesthetic and/or reconstructive issues. For example, a patient who produces a small amount of good quality tears but has a small lid aperture that minimizes evaporative tear loss must be approached in a different way than the patient who has a large lid aperture (higher evaporative loss) with tears of a similar quantity and quality. Therefore, in choosing an appro-

A NA T O M Y

priate procedure for a patient, one must take into account the aesthetic objectives and weigh those against the need to maintain an adequate precorneal wetting surface. Some patients may require an overall reduction in lid aperture, some may not tolerate an increase in aperture and maintenance is the goal, and still others may produce enough of a quality tear film so as to tolerate a larger lid aperture, which may be an ideal cosmetic result. The concept of production and evaporation, taking quantity as well as quality into account, should be part of the surgeon’s preoperative thought process for every patient. In some cases it may only require a few seconds, and the surgeon and patient may have great latitude in choosing an optimal procedure. In others it may require a more prolonged consideration and leave the surgeon and patient with few options. Nevertheless, this preoperative process will serve to limit postoperative complications and complaints.

HOMEOSTASIS OF THE LOWER EYELID As we have discussed, the normal lower eyelid position is 1 to 2 mm over the corneoscleral junction, with the central lower eyelid being the lowest point with a gentle sweeping upward inclination toward the lateral and medial canthi. The lateral canthus is approximately 15 degrees more inclined than the medial canthus. If one views the lower eyelid as floating in space anchored between the medial and lateral canthi, there is a balance of forces maintaining this normal anatomic position. A knowledge of the forces acting on the lower eyelid and how they interact is important in understanding, treating, and providing prophylaxis against lower eyelid malposition. I like to term the forces holding the lower eyelid above the limbus and against the eye as intrinsic support. Intrinsic support is generated in part by cephalic

vector forces contributed by the tarsal plate. It is also produced by the cephalic and posterior support generated by the orbicularis muscular complex (anterior and posterior heads) and the medial and lateral canthal tendons. The tarsal plate integrates these appropriate vector forces by providing three-dimensional spatial orientation. There are physiologic forces always working on the lower eyelid whose net effect is to distract the lower lid inferiorly and anteriorly away from the globe. Generally, there is a balance or homeostasis of these forces with intrinsic support overcoming extrinsic distraction forces. Patients will be comfortable with an adequately shielded and wet cornea, provided intrinsic support is greater than extrinsic distraction forces (Fig. 1-19). There are two basic scenarios in which the normal balance of forces can be disturbed with distraction overcoming support. These are when intrinsic support is weakened by the normal senescent process or by intervention in which intrinsic support forces imparted by the canthal, tarsal, or muscular elements are surgically weakened. A second mechanism for displacement of the lower eyelid down and/or away from the globe is to increase distraction forces while maintaining intrinsic support forces intact. In this case, the lower eyelid would be displaced away from the globe by excessive distraction forces despite an intrinsic support mechanism that would otherwise be adequate. This scenario may be created by burns, contractures, or surgical intervention (e.g., excessive skin resection in a transcutaneous blepharoplasty, laser contracture, or chemical peels) (Figs. 1-20 and 1-21). Therefore, lower eyelid position is dependent on a balance of vector forces, with intrinsic support always exceeding extrinsic distraction forces in the maintenance of normal anatomic position. This normal anatomic position is critical in maintaining adequate corneal wetting, eliminating excessive evaporative loss, assisting in the physiologic squeegee and distribution effects of the lid, and maintaining an intact lacrimal pump mechanism, not to mention appropriate aesthetic appearance.

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Intrinsic Support Forces (ISF)

Extrinsic Distraction Forces (EDF)

IS

ED

IS

ED

Figure 1-19 The adnexa, and especially the lower eyelid, is held in normal anatomic position against the globe by intrinsic support provided by the tarsal plate, the canthal tendons, and the orbicularis muscle sling. These elements provide a net vector that is posterior and superior. There are forces that are acting on the lid that are in opposition to its intrinsic support. These extrinsic distraction forces provide a net vector that is inferior and anterior from the globe. The lid will maintain a functional anatomic position as long as intrinsic support is at least as strong as the extrinsic distraction forces. An unfavorable imbalance can be created by weakening the support, as in senescence, or by strengthening the distraction forces, as occurs from surgery, lasers, or trauma. This tips the scale in favor of a lid that no longer provides anatomic and functional position.

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A NA T O M Y

Figure 1-20 Normal lower eyelid position is shown with the lid at or above the lower limbus (corneoscleral junction). This is not only cosmetically pleasing but serves to maintain adequate corneal wetting by minimizing ambient evaporative loss. Note the cephalic inclination of the lateral commissure compared with the medial commissure.

A

B

Figure 1-21 The two basic mechanisms for lower eyelid malposition due to an imbalance in the normal forces, with distraction overcoming support, are demonstrated clinically. In A, a 61-year-old man demonstrates scleral show and slight ectropion on lateral view. In this case, the intrinsic support mechanisms of the lower eyelid (canthal, tarsal, muscular, etc.) have weakened so as to allow the lower eyelid to be displaced down and away from the globe by normal extrinsic forces (gravity, etc.). In B, a 64-year-old woman became symptomatic after having had eyelid and facial procedures in which excessive distraction forces were created. These forces exceeded her own intrinsic support mechanism, which was likely weak to begin with. This patient would have benefitted by having her own intrinsic support mechanism strengthened during her cosmetic procedure so as to resist both physiologic and iatrogenically induced extrinsic distraction forces. Note the scleral show, left lower lid ectropion, lateral canthal dystopia, and injection of the conjunctiva especially on the left, indicating an eyeball that is inadequately wetted and covered. The yellow-green color along the lower lid scleral junction is fluorescein dye.

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P E A R LS A N D P I T FA L LS 1. The orbital septum is confluent with the periosteum of the skull and orbit and serves as the defining structure of the deep orbit. 2. The orbital septum must be violated in order to access preaponeurotic and/or pre-capsulopalpebral fat. 3. Whitnall’s tubercle is a common insertion point for a number of structures, including the orbital septum, Lockwood’s ligament, Whitnall’s ligament, deeper aspects of the orbicularis, and check ligaments of the lateral rectus muscle. 4. The bony anatomic location of Whitnall’s tubercle (below the lacrimal fossa and several millimeters within the orbit) must be appreciated to properly execute lateral canthal suspension procedures. 5. The upper and lower eyelids and orbit are anatomically analogous and are suspended in space by the medial and lateral canthal anchors. The eyelids are laminar, like most structures in the body (external, middle, and lining). 6. In the lower eyelid, the post-orbicularis pre-capsulopalpebral space is fundamental in the execution of both transconjunctival and transcutaneous procedures. 7. The capsulopalpebral fascia is an extension off the extraocular muscles and is always divided at some level in the transconjunctival route to the orbit. 8. The levator palpebrae superioris runs horizontally from the lesser wing of the sphenoid and reorients to a vertical direction at Whitnall’s ligament. 9. Whitnall’s ligament divides the lacrimal gland laterally where it contributes to the lateral retinaculum. Medially it anchors on the trochlear. 10. The anatomic complexity at Whitnall’s tubercle can lead to complications from canthopexy procedures. For example, care must be taken to exclude the lateral horn of the levator in lateral canthal suspension procedures. 11. The fascial system of the orbit provides a scaffold that extends intra- and extraconally from anterior to posterior within the orbit. This system allows the transduction of forces from one location to another distant site within the orbit. 12. The greater wing of the sphenoid is the primary delineator of the orbit from the middle cranial fossa. Laterally it articulates with the zygoma.

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13. The extraocular muscles serve as conduits for the blood supply to the anterior eyeball. Disinsertion of more than two muscles can lead to anterior segment necrosis. 14. The inferior oblique muscle is most anterior in the orbit, followed by the superior oblique muscle. They should be visualized and protected in retroseptal dissections. Both muscles delineate the medial from the central fat compartment. 15. The medial canthus is enveloped by deep and superficial muscular and fascial extensions, which contribute to the active lacrimal pump mechanism. 16. Significant medial canthal laxity can lead to a displaced and compromised lacrimal pump when a lateral canthal tightening procedure is performed alone. This problem can be obviated with a concomitant medial canthal tightening. 17. Division of the lateral canthal tendon in and of itself is not sufficient to mobilize the lower and/or upper eyelid. 18. The lateral canthus is optimally inclined, compared with the medial canthus, from an anatomic, physiologic, and aesthetic point of view. 19. In the upper lid, all the fat that is altered (removed, repositioned, grafted) is preaponeurotic. 20. Orbital hemorrhage and possible visual loss can be produced by traction on the most anterior orbital fat. 21. Tears are trilaminar, are important for corneal integrity, and have refractive properties. 22. Eyelid integrity and the blinking cycle are important for proper tear distribution and drainage. 23. The balance between tear production and evaporative tear loss determines whether there is sufficient corneal wetting. The third element in this equation is tear quality. 24. The surgeon can alter evaporative loss by changing eyelid aperture. 25. The lower eyelid is suspended in space, and its normal anatomic position is sustained by a balance between intrinsic supportive and extrinsic distraction forces. 26. The tarsal plate provides spatial orientation and integrates components of the intrinsic support system.

A NA T O M Y

References Aiache A: The suborbicularis oculi fat pad: An anatomic and clinical study. Plast Reconstr Surg 107:1602-1604; discussion 1605-1606, 2001. Barretto RL, Mathog RH: Orbital measurement in black and white populations. Laryngoscope 109(7 pt 1):1051-1054, 1999. Berke A, Mueller S: The kinetics of lid motion and its effects on the tear film. Adv Exp Med Biol 438:417-424, 1998. Borodic G, Townsend D: Atlas of Eyelid Surgery. Philadelphia, WB Saunders, 1994. Bosniak S: Principles and Practice of Ophthalmic Plastic and Reconstructive Surgery. Philadelphia, WB Saunders, 1996, vols 1 and 2. Carter SR, Seiff SR, Grant PE, Vigneron DB: The Asian lower eyelid: A comparative anatomic study using high-resolution magnetic resonance imaging. Ophthalmic Plast Reconstr Surg 14:227-234, 1998. Cheng J, Xu FZ: Anatomic microstructure of the upper eyelid in the Oriental double eyelid. Plast Reconstr Surg 107:16651668, 2001. Craig JP, Singh I, Tomlinson A, et al: The role of tear physiology in ocular surface temperature. Eye 14(pt 4):635641, 2000. Della Rocca R, Nesi F, Lisman R: Ophthalmic Plastic and Reconstructive Surgery. St. Louis, CV Mosby, 1997, vol 1. Della Rocca RC, Bedrossian EH, Arthurs B: Ophthalmic plastic surgery: Decision Making and Techniques. New York, McGraw-Hill, 2002. Dutton J: Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia, WB Saunders, 1994. Ettl A, Koornneef L, Daxer A, Kramer J: High resolution magnetic resonance imaging of the orbital connective tissue system. Ophthalmic Plast Reconstr Surg 14:323-327, 1998. Ettl A, Kramer J, Daxer A, Koornneef L: High resolution magnetic resonance imaging of the normal extraocular musculature. Eye 11(pt 6):793-797, 1997. Ettl A, Priglinger S, Kramer J, Koornneef L: Functional anatomy of the levator palpebrae superioris muscle and its connective tissue system. Br J Ophthalmol 80:702-707, 1996. Hamra S: Composite Rhytidectomy. St. Louis, Quality Medical Publishing, 1993. Haramoto U, Kubo T, Tamatani M, Hosokawa MK: Anatomic study of the insertions of the levator aponeurosis and Muller’s muscle in Oriental eyelids. Ann Plastic Surg 47:528-533, 2001. Hwang K, Joong Kim D, Chung RS: Pretarsal fat compartment in the lower eyelid. Clin Anat 14:179-183, 2001.

Hwang K, Kim DJ, Chung RS, et al: An anatomical study of the junction of the orbital septum and the levator aponeurosis in Orientals. Br J Plast Surg 51:594-598, 1998. Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper eyelid: An anatomical study with comparison to the Caucasian eyelid. Arch Ophthalmol 117:907-912, 1999. Leone C, Grove A, Lloyd W, Wojno T: Atlas of Orbital Surgery. Philadelphia, WB Saunders, 1992. Malbouisson JM, Baccega A, Cruz AA: The geometrical basis of the eyelid contour. Ophthalmic Plast Reconstr Surg 16:427431, 2000. Matsuo K: Stretching of the Mueller muscle results in involuntary contraction in the levator muscle. Ophthalmic Plast Reconstr Surg 18:5-10, 2002. Nesi F, Lisman R, Levine M, et al: Ophthalmic Plastic and Reconstructive Surgery. St. Louis, CV Mosby, 1998. Pessa JE, Zadoo VP, Adrian EK, et al: Anatomy of a “black eye”: A newly described fascial system of the lower eyelid. Putterman A: Cosmetic Oculoplastic Surgery, 2nd ed. Philadelphia, WB Saunders, 1993. Schoenwald RD, Vidvauns S, Wurster DE, Barfknecht CF: The role of tear proteins in tear film stability in the dry eye patient and in the rabbit. Adv Exp Med Biol 438:391-400, 1998. Shinohara H, Taniguchi Y, Kominami R, et al: The lacrimal fascia redefined. Clin Anat 14:401-405, 2001. Thale A, Paulsen F, Rochels R, Tillmann B: Functional anatomy of the human efferent tear ducts: A new theory of tear outflow mechanism. Graefes Arch Clin Exp Ophthalmol 236:674-678, 1998. Tiffany JM, Pandit JC, Bron AJ: Soluble mucin and the physical properties of tears. Adv Exp Med Biol 438:229-234, 1998. Tsubota K: Tear dynamics and dry eye. Prog Retin Eye Res 17:565-596, 1998. VanDen Bosch WA, Leenders I, Mulder P: Topographic anatomy of the eyelids, and the effects of sex and age. Br J Ophthalmol 83:347-352, 1999. Wilhelmi BJ, Mowlavi A, Neumeister MW: Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. Plast Reconstr Surg 108:2137-2140: discussion 2141-2142, 2001. Wolfort FG, Vaughan TE, Wolfort SF, Nevarre DR: Retrobulbar hematoma and blepharoplasty. Plast Reconstr Surg 104:2154-2162, 1999. Yamamoto H, Morikawa K, Uchinuma E, Yamashina S: An anatomical study of the medial canthus using a threedimensional model. Aesthetic Plast Surg 25:189-193, 2001. Zide B, Jelks G: Surgical Anatomy of the Orbit. New York, Raven, 1985.

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CHAPTER TWO

Evaluation of the Patient Every patient should have a detailed history before undergoing a physical examination. In addition to eliciting a chief complaint or reason for seeking a surgical consultation from the patient, it is always helpful to have the patient describe his or her complaints while looking in a mirror. The surgeon should obtain a detailed history concerning a history of dry eyes or use of ophthalmic lubricants and artificial tears, contact lens wear and the type of lenses used, thyroid or Graves’ disease, previous refractive surgery, recurrent acute or chronic blepharitis, and other ocular or periocular conditions that are relevant. This detailed history may guide the surgeon in choosing an optimal procedure for the patient. For example, a patient with a history of dry eyes who wears contact lenses will certainly demand greater tear production and tolerate less evaporative loss than the patient who does not present with these underlying demands. A patient with Graves’ disease may have lid retraction, which can be confused with contralateral ptosis. Chronic blepharitis may be exacerbated by eyelid surgery, and prophylactic therapy including antibiotics may be warranted before embarking on eyelid surgery in these patients. Recurrent herpes zoster may serve as a contraindication to periocular laser therapy, and prophylactic antiviral agents may be indicated before embarking on surgical procedures in patients who are predisposed to these outbreaks. Refractive surgery, which has enjoyed recent popularity, predisposes some patients to dry eyes and glare, which may alter indications and choices for cosmetic procedures. The most important aspect of obtaining a good history is to tailor the surgical procedure to the individual patient. This

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will serve to diminish the risks as much as possible and maximize the cosmetic and therapeutic aspects of any procedure.

PHYSICAL EXAMINATION Gross physical examination of the patient can begin by simply viewing the patient at a comfortable distance and noting gross anatomic abnormalities and/or normalcy. For example, in viewing the general periocular region including the upper and lower eyelids, one may be looking for proper anatomic position of the upper and lower lids. The upper lid should divide the width of the upper iris in half. That is, the distance between the corneoscleral junction and the pupillary aperture should be bisected by the upper lid. The lower lid should lie above or at the corneoscleral junction, and upper and lower lids should have a smooth sweeping arch or contour. The highest point or maximal arch of the upper lid should lie at the most medial aspect of the pupillary aperture. This is especially relevant in correcting ptosis and/or lid retraction (discussed in detail later in this text). Inflammatory changes and crusting along the eyelid margins or within the eyelashes are indications of blepharitis. A clear glistening corneal surface and white scleral surface without injection is an indication of a healthy and “happy” eyeball. Conjunctiva that is glistening, flat, gossamer, and without injection or vascular engorgement is also an indication of adequate coverage, lid excursion, and adequate wetting

E VA LUA T I O N O F T H E PA T I E N T

of the ocular surface. Look for symmetric lid folds that lie at an appropriate height for the patient’s sex and racial makeup. Look carefully at the patient’s superior sulcus and note the level of concavity or convexity and its relationship to eyelid movement. Look for lid margin positional abnormalities such as ectropion or entropion and whether these change with the blinking cycle. For example, patients with involutional entropion will usually present with lax lower eyelids, scleral show, and sometimes a tendency toward ectropion until they are asked to close their eyes forcibly. Almost immediately, their lower eyelid will briskly roll inward against the globe. A “hands on” examination can be initiated once the examining surgeon has a chance to view the patient grossly. It is the attentive observational stage of the examination that allows for a focused and detailed physical review. This will enable the surgeon to make anatomic and physiologic correlates to what is observed and to make a plan for surgery in an efficient manner. It is appropriate to ascertain and document a baseline visual acuity whether using a standardized Snellen chart at a distance or a hand-held Snellen card. A visual acuity assessment is obtained of the right and left eye without correction and then with correction. It is not uncommon for patients to note or complain of visual acuity changes postoperatively, and it is, therefore, important to document presurgical visual acuity. Occasionally, more discriminating patients will note worsened or improved visual acuity after surgery, and I believe this may be caused by corneal curvature changes related to selective pressure alterations on the surface of the cornea. Astigmatism in a selective meridian can be either alleviated or induced by surgery. The patient is asked to grimace and contract the orbicularis oculi muscles so that facial nerve competence in this region can be assessed. Next, extraocular motion and pupillary function are assessed, with asymmetries being most notable. The lower eyelid is gently pulled down and distracted away from the globe and then allowed to retract back into its regular anatomic position. Delays or asymmetries in the rate or position of the lower lid snap back should be sought. A youthful and intact lower eyelid should position itself against the globe and revert to an

appropriate height within 1 second of distraction. I prefer to grade the snap back as weak, moderate, or brisk. In planning a procedure on a patient with anything but a brisk snap back, one must either increase intrinsic support factors or at least not increase extrinsic distraction forces. The level of zygomatic or malar support should be assessed by visualizing and palpating the orbital rim and malar eminence. On lateral view, one should compare the anterior projection of the eyeball and malar eminence. Patients whose malar eminence lies posterior to their cornea have poor lower lid support and are prone to malposition. In patients with lower eyelid malposition (scleral show) the lower eyelid should be digitally elevated and tightened while concomitantly visualizing the tension created on the suborbital soft tissues. The surgeon should try to assess which lamella (anterior, middle, posterior) is deficient. This will serve to assist the surgeon in planning complementary procedures to the canthopexy such as cheek or midface suspension, interposition grafts, or even skin grafts or external flaps. All patients should be assessed for the quantity of tears produced, and the surgeon should be familiar with how to assess the quality of tears in the difficult, problematic, or complex case. Baseline tear production should be assessed with the Schirmer test utilizing topical anesthesia and precut standardized No. 41 filter paper strips, which may be obtained from a number of ophthalmic pharmaceutical houses. I prefer to place the patient in a dark room while testing baseline tear production to obviate the effect that ambient light has on tear production. As in the snap back test, one may divide the Schirmer test strip results into three categories, thereby labeling the patient as a low tear producer (0 to 9 mm), moderate tear producer (10 to 20 mm), or high tear producer (21 to 30 mm). Of course, in the case of very high tear producers, one should entertain the possibility of tear drainage problems induced by nasolacrimal obstructive problems. These patients usually present with a spectrum of complaints that may range from simply epiphora to recurrent medial canthal swelling and mucopurulent discharge on the other end of the spectrum.

29


The ability to withstand evaporation or its staying power is a simplistic assessment of precorneal tear film quality. The surgeon should be familiar with a simple method of evaluating tear film quality: the tear film break-up time. Basically, fluorescein is introduced onto a topically anesthetized eye and, after the patient is allowed to blink and disperse the agent, the eyelids are then held apart and the uniform tear film is visualized over the corneal surface through a cobalt blue filter. The

30

time period between holding the patient’s eye open and the deterioration of the tear layer (tear film breakup) is an assessment of tear film break-up time and is usually over 20 seconds. Of course, given the trilaminar structure of tears, quality is a multifactorial entity and no specific conclusions concerning the cause of poor tear film quality can be drawn from this quick office test (Fig. 2-1).


20/20

< Va < 20/40 20/40 Va 20/20 sc

2. Schirmer's test

cc

1. Visual acuity via Snellen chart

4. Malar support

3. Snap back test Good

Poor

5. Tear film break up time Figure 2-1 Evaluation of the patient should include an appreciation of visual acuity (with and without correction), baseline tear production, intrinsic lid tone, lower eyelid support, and tear film quality. Of course, the specific tests performed and their interpretation should be tailored by the clinician within the context of each patient and applied on an individual basis. For example, a low Schirmer test reading alone may not be an absolute contraindication to a cosmetic procedure. Instead, it should direct the surgeon to look at other parameters (i.e., tear film quality) and then design a procedure that compensates for anatomic and/or physiologic shortcomings.

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The bottom line in evaluating the history and physical examination in each patient is to first identify the problem and second to tailor the surgical procedure according to the specific patient’s findings. There are almost no contraindications to surgery in the periocular region but rather definitive historical and physical signs that indicate an appropriate surgical procedure of choice for an individual patient. Simply put, given four or five surgical procedures that make it possible to

achieve an objective for the patient and surgeon, there is likely only one procedure of choice a surgeon may entertain once the preoperative evaluative tools have been fully utilized. This statement is more likely to be applicable to aesthetic surgery in the periocular region than aesthetic surgery in any other region, given the high functional demands imparted by the globe and associated adnexal structures (Fig. 2-2).

P E A R LS A N D P I T FA L LS 1. A detailed history and physical examination assist the surgeon in choosing an optimal procedure for the patient. 2. It is helpful for patients to point out their aesthetic concerns in a mirror for the surgeon. 3. Chronic blepharitis, Graves’ disease, herpes zoster infection, and refractive surgery are some of the conditions that may predispose to surgical complications. 4. The surgeon can ascertain a significant amount of information by simply studying the macro and micro anatomy of the eyelids and periocular region.

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5. A preoperative baseline visual acuity test and Schirmer’s test are useful in assisting the surgeon to choose the most ideal procedure and to follow and treat postoperative problems. 6. The lower lid intrinsic tone can be appreciated using a snapback test. 7. Upper lid position and excursion can assist the surgeon in determining levator function and whether and which ptosis procedure is indicated. 8. There are almost no contraindications to surgery in the periocular region, but an appropriate procedure of choice should be based on specific historical and physical signs.


A

B

Figure 2-2 A, Front view of a patient with weak intrinsic support of the lower eyelid resulting in malposition and a symptomatic dry eye syndrome. Note that despite upper eyelid ptosis he fails to maintain adequate corneal coverage and suffers excessive tear loss from ambient evaporation and poor tear film distribution. B, Lateral view demonstrates poor malar support, with the plane of the zygoma lying far posterior to the vertical plane of the lower lid tarsus. This patient also has large eyeballs (myopic) and, therefore, is more prone to having poor malar support or so-called negative vector.

References Carruthers J: Brow lifting and blepharoplasty. Dermatol Clin 19:531-533, 2001. Cheng J, Xu FZ: Anatomic microstructure of the upper eyelid in the Oriental double eyelid. Plast Reconstr Surg 107:16651668, 2001. Della Rocca R, Bedrossian E, Arthurs B: Ophthalmic plastic surgery: Decision Making and Techniques. New York, McGraw-Hill, 2002. Gallo SA, Wesley RE, Klippenstein KA, Biesman BS: Cosmetic eyelid surgery. Ophthalmol Clin North Am 13:749-764, 2000. Gorla MS, Gorla RS: Nonlinear theory of tear film rupture. J Biomech Eng 122:498-503, 2000.

Kim P, Berdoukas P, Francis IC, et al: Kinetic observational exophthalmometry: A simple clinical method of assessing the relative axial positions of the eyes. Ophthalmic Surg Lasers 32:257-259, 2001. Mulliken JB, Godwin SL, Prachanktam N, Altobelli DE: The concept of the sagittal orbital-globe relationship in craniofacial surgery. Plast Reconstr Surg 97:700-706, 1996. Olver JM, Sathia PJ, Wright M: Lower eyelid medial canthal tendon laxity grading: An interobserver study of normal subjects. Ophthalmology 102:2321-2325, 2001. Papas E: Tear break-up time: Clinical procedures and their effects. Ophthalmic Physiol Opt 19:274-275, 1999. Van Den Bosch WA, Leenders I, Mulder P: Topographic anatomy of the eyelids and the effects of sex and age. Br J Ophthalmol 83:347-352, 1999.

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CHAPTER THREE

Eyelid Malpositions Malpositions of the eyelid, specifically the lower eyelid, include ectropion (turning out of the eyelid margin), entropion (turning in of the eyelid), and retraction (scleral show) and can be grouped together despite a variety of causes. Classically, ectropion and entropion are classified as cicatricial, senile or involutional, mechanical, paralytic, or congenital. Despite these classifications, it is most useful to identify the pathophysiology in each instance and address it appropriately. Involutional or senescent eyelid malpositions are the most common. Typically, the medial and lateral canthal tendons become lax or attenuated and there is usually an inferior canthal descent, noted especially in the lateral canthus. Clinically, the approximately 15-degree lateral canthal inclination compared with the medial canthus is lost with laxity of the lateral canthal tendon. Usually with frank lower eyelid malpositions, the lateral canthal tendon is at least coplanar with the medial canthal tendon or, in more severe cases, inferiorly declined by 5 to 15 degrees. Descent of the lateral canthal tendon leads to a shortening of the intercommissure distance (the distance between the medial and lateral

34

commissures). Secondarily, the lower eyelid and the inferolateral aspect of the orbital septum develops redundancy. This results in entropion, ectropion, scleral show, or some combination of the three. Pseudoherniation of orbital fat, most notably in the lateral inferior compartment, occurs from laxity of the orbital septum (Figs. 3-1 and 3-2). Inferior lid retractor disinsertion or capsulopalpebral fascial dehiscence is associated with involutional or senescent changes. Remember the primary lower lid retractor is merely an extension of the inferior rectus and inferior oblique muscles. A loosening of the attachments of the preseptal orbicularis muscle may cause it to override the pretarsal orbicularis, converting pathophysiology appropriate for ectropion into involutional or senescent entropion. That is, on brisk blinking or forcible closure, the lax lower eyelid rolls in, causing an irritative entropion that may produce corneal ulceration, breakdown, and severe cosmetic deformities. In extreme cases, patients may be forced to tape their lower eyelids down to prevent the rolling-in process.

EYELID MALPOSITIONS LATERAL CANTHAL CHANGES WITH AGE

+10–15° 0°

A Figure 3-1 A to C, The lateral canthus is normally inclined cephalad by 10 to 15 degrees compared with the medial canthus. Attenuation with aging produces a descent of the lateral canthus so that the lateral canthus rotates (clockwise on the left and counterclockwise on the right) around the medial canthus. The end result is a lateral canthus that is coplanar or declined compared with the medial canthus. As the lateral canthus sags inferiorly, the intercommissure distance shortens (distance between medial and lateral canthus) and the lower lid and inferior lateral septum become lax. This produces scleral show, ectropion or entropion, orbital fat prominence especially laterally, and tear film distribution and drainage problems.

0°

0°

B

0° -10–15°

C

Figure 3-2 An 81-year-old patient with involutional entropion presented with lateral canthal changes associated with the aging process. Note the shortened intercanthal distance (medial to lateral), downward drift of the lateral canthus, lower lid laxity, scleral show, and “pseudoherniation” of the lower lateral fat pad. These clinical changes occur as a result of lateral canthal tendon attenuation and lengthening, with the lateral commissure moving lower and medially. Therefore, if one views the right eye, the lateral canthus is winding in a counterclockwise direction around the cornea, producing lateral septal laxity and all of the other characteristic changes.

35


ECTROPION There has been a plethora of procedures describing different procedures for the treatment of ectropion. In my view only a few are effective in addressing the underlying pathophysiology and that provide reproducibly good results. As described previously, the lower eyelid should spontaneously return back to a normal anatomic position when distracted inferiorly and away from the globe. Eyelid laxity of some degree is present when a spontaneous snap back is absent. The classically described pinch test, in which the examining surgeon can pull the lower eyelid more than 10 mm from the eyeball, may also demonstrate significant eyelid laxity. A positive pinch test is sometimes viewed as an indication for full-thickness lower eyelid shortening. This procedure may be performed transcutaneously or subcutaneously by first elevating a skin muscle flap. In either case, I do not advocate lower eyelid shortening procedures in the treatment of lower eyelid laxity. The pathophysiology of lower eyelid laxity as described previously is due to lateral and medial canthal attenuation along with attenuation of other supportive structures. Shortening the lower eyelid produces further inferomedial displacement of the lateral canthal complex and commissure along with a further diminution in the intercommissure distance. Although the lower eyelid may be tightened, the procedure in and of itself produces the exacerbation of the pathophysiologic processes that led to lower eyelid laxity in the first place. Anatomically tightening the lower eyelid by reversing the patho-

36

physiology of lower eyelid laxity is the method of choice and appropriate procedures will be described later. A cicatricial etiology for lower eyelid malposition, especially in patients seeking aesthetic surgery, is rare. Examination of a lower eyelid malposition should include a thoughtful examination and assessment of the external, middle, or internal lamellae of the lower eyelid. Cases in which there is a frank deficiency require grafting of either skin (external layer), mucosa (internal layer), or structural support tissue such as tarsal analogues (middle layer). All other cases of lower eyelid malposition can be addressed using a canthopexy with or without other procedures (Figs. 3-3 and 3-4).

CANTHOPEXY AND CANTHOPLASTY Because the mainstay of treatment in almost all cases of lower eyelid malposition includes tightening of either the inferior crus of the lateral canthal tendon or repositioning the entire lateral canthal tendon, it would be most appropriate to elaborate on several techniques that are useful in achieving this end. Technically and for clarity of communication, I will term a procedure that tightens or suspends the lateral or medial canthus, without division of one or more of its elements, a canthopexy. Once division or disinsertion is performed, then I will use the term canthoplasty.

EYELID MALPOSITIONS

Figure 3-3 A 51-year-old man presented with lower lid ectropion and secondary conjunctival hyperplasia secondary to exposure. Note the lateral canthus is coplanar with the medial canthus and the intercommissure distance is not substantially shortened, indicating relative lower lid redundancy.

Figure 3-4 In this patient ectropion was corrected with a lateral tarsal strip procedure only. Note that both low lid height and malrotation are corrected. Also note that intercommissure distance is maintained.

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THE MODIFIED LATERAL TARSAL STRIP PROCEDURE The most useful procedure in addressing lower lid malposition and laxity is probably the lateral tarsal strip or tarsal tongue procedure. Although there is a shortening of the lower eyelid in this procedure, it differs from a wedge resection in that a tarsal strip is created, and this will serve as the new inferior crus of the lateral canthal tendon. It is also imperative that the tarsal strip be inserted at Whitnall’s tubercle, the insertion point for the superior crus of the lateral canthal tendon, which is described in detail in Chapter 1. Unlike some classic descriptions of this procedure, I recommend division of the inferior crus of the lateral canthal tendon by means of a lateral canthotomy. Once the inferior crus is severed, it is most important to mobilize the lower lid. This is achieved by dividing the subcutaneous tissues, including the lower lid retractors and the orbital septum. It is only when these structures are divided that the lower eyelid can be mobilized almost to the eyebrow when placed on stretch. I believe the most significant error in failing to achieve adequate results with this procedure is by not completely mobilizing the lower lid by lysis of the lateral retinacular structures, despite all other aspects of the procedure being performed satisfactorily. Once the lower eyelid is mobilized, a tarsal strip is created by circumferentially de-epithelializing a lateral segment of the lower eyelid, which is back-cut below the tarsal plate. Approximately 3 mm of distal tarsal plate is isolated by carefully removing hair follicles superiorly, skin anteriorly, and mucous membrane posteriorly. The isolated tarsal strip will then serve as a neocanthal tendon that will be inserted into the lateral orbital rim. Proper insertion requires surgically isolating Whitnall’s tubercle. This involves lateral displacement of the lateral canthal soft tissue with digital or instrument retraction and medial retraction of the orbital soft tissue with superior dissection to the orbital rim. This serves to isolate the anterior orbital rim and then its internal aspect, at the level of Whitnall’s tubercle. This area can be readily discerned not only by its bony excrescence but also by

38

the insertion point of the superior crus of the lateral canthal tendon. The orbital rim periosteum is incised and then elevated from anterior to posterior within the orbital rim, without division or raising any flaps. I prefer to anchor the tarsal strip to the orbital rim periosteum utilizing a double-armed braided nonabsorbable 4-0 suture on a spatulated semicircular needle; however, other sutures, depending on the surgeon’s preference, are acceptable. The lateral tarsal strip is engaged with the double-armed suture, and each arm of the suture is brought through the internal orbital rim periosteum from Whitnall’s tubercle anteriorly. The path of the sutures will ride between the orbital rim periosteum and the internal orbital bony surface. If one were to visualize lower lid position without a corneal protector, the lower eyelid should ride 1.5 to 2 mm above the lower limbus once adequate positioning of the tarsal strip is achieved. The next step should involve refining the lateral commissure (commissuroplasty), and this is achieved by precisely aligning the analogous elements of the upper and lower eyelids (i.e., hair follicles or gray line) with a single small absorbable suture (i.e., 6-0 Vicryl). This can be brought through the upper and lower eyelids and tied subcutaneously just lateral to the eyelids. Mild degrees of lid rotation may be invoked with this technique, and it allows fine adjustments of the eyelids and orientation of lateral canthal elements. I have found it technically easier to pre-place the canthal suture (tarsus and periosteum) and, before tying it down, completing the commissuroplasty. Once the commissuroplasty is completed and the canthal suture tied down, the orbicularis muscle should be suspended with one or two absorbable sutures in a cephalolateral direction at the level of the lateral canthotomy. Closure of the skin can be achieved after desirable trimming, depending on the degree of redundancy and the desired results. Some skin tailoring, especially laterally, may be indicated when some form of cheek suspension is performed concomitantly. However, skin conservation should be the general rule, with secondary skin trimming always a viable option (Figs. 3-5 and 3-6). Periosteal flaps raised lateral to the orbital rim and based medially can serve as an excellent salvage canthal tendon for reconstruction and should be kept in mind should a tarsal strip be avulsed or excessively shortened (Fig. 3-7).

EYELID MALPOSITIONS CANTHAL SUSPENSION BY LATERAL TARSAL STRIP

A Lateral canthotomy Figure 3-5 The canthus may be suspended by a lateral tarsal strip procedure. There are a few steps that when properly executed allow for this to be completed quickly and simply. A, First, the lateral canthus is divided. B, The inferior crus of the lateral canthal tendon is lysed, and the lateral retinacular elements are incised (arrows) to allow complete lower eyelid mobilization. C, A transverse back cut is made in the lateral tarsal plate, and epithelium is denuded circumferentially. It is especially important to remove hair C Denude lateral tarsal strip follicles to avoid lateral distichiasis. D, The lateral orbit is exposed and periosteum is engaged with a doublearmed suture that has already been passed through the tarsal strip. It is sometimes helpful to incise the periosteum vertically so as to engage the internal orbital reflection “deeply” (2 to 3 mm) within the orbit. A small amount of lateral orbicularis muscle may be trimmed. E, The muscle is suspended laterally and cephalad with a small absorbable suture. F, Alignment of the lateral commissure is achieved with a small absorbable suture (preferably double-armed) that is passed between the upper and lower eyelids at their most lateral aspects. I prefer to complete this step before tying down my suspension suture linked to the tarsal strip. The tarsal strip procedure is well suited to the more senescent patient in whom lower lid and tarsal stretching has created relative redundancy in this structure. E Trim excess skin and/or orbicularis muscle

B

D

Division of lower crus and wide lateral lysis

Suture fixation of strip to internal periosteum of lateral orbital rim

F

Commissuroplasty

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A

B

C

D

E

F Figure 3-6 A, This patient is undergoing lateral canthotomy by spreading lids apart and transecting skin laterally from the commissure, exposing the lateral retinacular elements. A scissors may be introduced to complete the transection, or one may simply use a scalpel. B, Cantholysis is completed with scissors. All the lateral retinacular components are lysed with complete mobilization of the lower eyelid. Note how high the lid can be displaced. A back-cut is created in the mobilized lateral lid just below the tarsal plate margin. C, Beginning with skin, circumferential de-epithelialization of the tarsal strip is undertaken with scissor dissection. Care should be taken to maintain the integrity of the tarsus. D, The skin (anterior) and lashes (superior) have already been removed, with posterior de-epithelialization being completed by removing conjunctiva. E, Wide exposure to the orbital rim is gained laterally with traction, and the periosteum is scored at the lateral rim. F, An internal orbital periosteal flap is elevated medially into the orbit at the level of Whitnall’s tubercle. Continued

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EYELID MALPOSITIONS

G

H

I

J Figure 3-6 Continued G, Tarsal strip is engaged with a suture. I prefer double-armed 4-0 nonabsorbable suture on a semicircular rigid needle. H, The internal orbital rim periosteal flap is engaged and tied down. In this photograph both arms of the sutures have been passed through the periosteum at Whitnall’s tubercle and the lower lid has only been partially pulled into appropriate position. This allows visualization of de-epithelialized tarsus, orbital rim (blackened by cautery use) sutures, and the lower lid being pulled cephalad and posterior. Orbicularis muscle and skin may be repaired following this step. I, Preoperative photograph of patient with lower lid laxity, scleral show, and ectropion. J, Postoperative photograph shows good lower lid position lying above limbus and ectropion corrected. Lateral canthotomy incision is barely perceptible.

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A

B

Figure 3-7 A, Defect in the upper eyelid of a young patient after malignant melanoma was resected. The tumor was resected, and the patient was left with only one third to one half of the lateral eyelid. Note the tarsal plate evident beyond the skin margin on the lateral resected side. B, Upper eyelid canthal elements along with lateral levator extension are lysed to mobilize the lateral lid medially. Note the hook in the upper medial lid providing traction. Continued

42

EYELID MALPOSITIONS

C

D

Figure 3-7 Continued C, A periosteal flap is elevated off the lateral external orbital wall surface raised over the rim and into the internal orbital surface with a skin hook providing traction. D, The periosteal flap serves as a replacement canthal tendon and is sutured to the lateral extent of the tarsus within the remnant of upper lid that has been mobilized. A new commissure can be created, followed by muscle and skin repair.

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Another method of tightening the lower eyelid without division of the lateral canthal tendon or its inferior crus is to plicate or tuck the lateral aspect of the tarsal plate. This can be performed transcutaneously and may be performed alone or in combination with other procedures (Fig. 3-8). It is effective only in mild degrees of lower lid laxity and in youthful patients who do not have attenuation of the lateral canthal complex.

44

This subgroup of patients will tolerate increased forces across the lower lid without foreshortening the intercommissure distance and other problems associated with procedures that do not suspend the lateral canthal complex. In the face of significant horizontal lower lid laxity, the tarsal plication will produce a buckled lower eyelid that does not appropriately appose the ocular surface.

EYELID MALPOSITIONS FAT REDISTRIBUTION AND TARSAL TUCK

Depressions that may be filled with orbital fat

Figure 3-8 The transcutaneous approach to the lower eyelid affords access to the inferior crus of the lateral canthal tendon and lateral tarsus. In mild cases of lower lid laxity, plication of the inferior crus can be performed (tarsal tuck). Because the lower eyelid is not shortened, buckling is created (central insert) in the lower eyelid, which can create spatial orientation problems in the lower eyelid (e.g., ectropion, anterior displacement from the globe). Therefore, it is only applicable in very mild cases of laxity. Fat may be transposed over the orbital rim. I prefer a supraperiosteal tunnel with transcutaneous fixation sutures. The access may be transcutaneous or transconjunctival. The amount of viable filler available is limited in all pedicled fat transposition procedures and usually promises more than is deliverable. The inserts depict the subtle changes in the lower lid that may be achieved with a tarsal tuck and fat transposition.

Access incision–common canthopexy

Closeup of tarsal tuck Access incision–tarsal tuck

Fat redistribution from lateral pocket

Fat redistribution from medial pocket

Completed canthopexy

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An effective alternative approach to the inferior canthal or common canthal complex is by way of an upper lid approach. Access to the lateral canthal complex can always be achieved by way of an upper lateral eyelid incision, whether for cosmetic or reconstructive purposes. Through this route, the common canthal tendon may be suspended and anchored to the internal orbital rim periosteum in a method analogous to the tarsal strip procedure described previously. Again, cephalic and lateral pull or tension is the key to achieving satisfactory results. Using this route, I favor disinsertion of the entire lateral canthal tendon complex along with the inferolateral aspect of the lower lid retractors and orbital septum. This should allow complete mobilization of the entire lateral lid complex, including the lower eyelid. Significant degrees of elevation can be achieved without tension, and the entire complex can be anchored to the internal orbital rim at an appropriate position. This procedure enables the surgeon to effectively increase the intercommissure distance, as well as significantly alter the angle of inclination of the lateral canthus relative to the medial canthus. Should inadequate periosteum or soft tissue be present for suspension, as in secondary or tertiary procedures, then a drill hole through the orbital rim at an appropriate level will suffice. In using this approach, care must be taken to avoid entrapping the lateral horn of the levator muscle in the suspension suture because lateral upper eyelid closure problems can result in this instance. Overelevation of the lateral canthus can create an unacceptable cosmetic appearance and/or impingement on the pupillary axis by the elevated lower eyelid. When this occurs, patients complain of obstruction of their vision in down gaze, for example when reading. The upper lateral eyelid access incision may be used to approach the mid face for suspension procedures, but with slightly more difficulty than in approaching the mid face from the lower eyelid incision. I believe

46

that canthal and midface suspension is more easily and accurately achieved and the appropriate vector is more easily engendered with an upper lid approach. Because the surgeon is farther away from the structures to be addressed, he or she may be less comfortable initially. I do not recommend lower eyelid incisions combined with upper lateral eyelid incisions for approaching the canthal complex when division, lysis, and suspension are to be performed. Generally, this requires significant dissection, and the small bipedicle bridge tends to be surgically compromised, leaving the lateral canthal soft tissue elements with at least an appearance of having had a surgical procedure and sometimes with severe contraction bands that are difficult to correct. Therefore, the ideal use for the upper lateral eyelid access incision to the lateral canthal complex is one in which there is complete lateral canthal dystopia and the surgeon would like to reposition the entire complex or in the case in which a lower eyelid incision will not be used other than a transconjunctival route, thereby avoiding compromise of skin and soft tissue bridges. In all these patients, the mid face may be effectively approached through this route should the surgeon choose not to utilize a preauricular facialplasty incision to access the mid face (Fig. 3-9). The lateral canthopexy and canthoplasty can then be applied in a number of scenarios either alone or in consort with other procedures. I view canthal suspension as a procedure that should be liberally applied as a primary procedure for patients with frank lower lid laxity whether or not other procedures are being performed concomitantly. It should also be liberally applied when a patient has a tendency toward lower lid laxity, that is, he or she has normal or near-normal lower eyelid position and appearance but is undergoing a primary cosmetic or reconstructive procedure in which increased distraction forces will be applied to the lower eyelid, thereby tipping the balance of forces toward lower eyelid malposition.

EYELID MALPOSITIONS

A

Eyelid droop due to lateral canthal tendon attenuation

Line of division of lateral retinaculum for common canthoplasty

B

Common canthal tendon is retracted laterally and superiorly then anchored to periosteum

Closeup of common canthopexy

C

Effect of completed repair

Figure 3-9 A, Laxity in the lateral lid support structures is largely attributed to common canthal attenuation and stretching. These changes occur in other components of lid support, including the tarsal plate itself. A more direct anatomic approach to lateral canthal laxity and canthal dystopia is what I term the common canthoplasty. B, Here the entire common lateral canthal tendon is mobilized and fixed to periosteum in a cephalic posterior position. In distinction to other procedures that simply “pexy” or suture-fixate the tendon to periosteum or fascia, this procedure requires complete mobilization of the lateral canthus with lysis of the lateral septum and other components of the retinaculum. This allows transposition of the entire commissure en bloc into an anatomic and cosmetically pleasing position. The central insert (box) depicts how the canthus is fixed and the changes invoked by this maneuver are seen in A and B, respectively.

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Contractures in the anterior lamella of the eyelid can cause cicatricial ectropion. These conditions can be seen secondary to chemical or thermal injuries, secondary to deficiencies or devascularization after surgery or trauma, after severe outbreaks of herpes zoster, or iatrogenically after aggressive lower eyelid laser procedures. The surgeon should not be beguiled into believing that a lateral canthal procedure will suffice in correcting ectropion and/or scleral show when there is a true deficiency in any of the lamellae of the lower lid, including skin. Traction on the lower eyelid in a cephalolateral direction, while observing the lower lid and cheek, is a reasonable test to assess the extent of external lamella deficiency. Generally, if elevation of the lower

eyelid produces traction and notable movement in the cheek region, then a canthopexy alone will usually not suffice. In mild-to-moderate cases of anterior lamellar deficiency, a cheek or midface suspension, either by means of a lateral upper, lateral lower lid, or a preauricular facelift incision, may suffice. A free skin graft or transpositional flap (i.e., Trippier, Fricke) will be necessary when the external lamella deficiency exceeds the amount correctable by simply elevating the malar soft tissue. Free full-thickness skin grafts from donor sites that are as close to the lower lid as possible (i.e., upper eyelid) are quite satisfactory in the long run and look as good as transpositional upper lid flaps. Free skin grafts also avoid the distortion in the lateral canthal region that occurs with transpositional flaps. The key point in grafting the external lamellae of the lower eyelid is to re-create the defect and place the lower eyelid on cephalic traction, thereby overcorrecting the defect significantly (Fig. 3-10).

A

B

C

D

CICATRICIAL ECTROPION AND ENTROPION

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Continued

EYELID MALPOSITIONS

E

F

G

H

Figure 3-10 Continued The upper lid approach to the lateral canthal tendon and midface. A, The lateral canthal tendon is held in the forceps, and the bony orbit lies beneath the retractor. B, Note that with the lateral retinacular elements lysed, the lateral canthus and the entire lateral commissure can be transposed along an arc delineated by the lateral orbital rim. C, Viewed from the upper lid down, the dissection can be carried inferiorly to approach the mid face and any plane of preference (e.g., subperiosteal, suborbicularis) may be accessed. A suture (green) is engaged to the lateral canthal tendon, and the supraperiosteal plane over the zygoma is visualized. D, The suture engaged to the lateral canthus is then passed through the periosteum of the orbit at a desired level. Note a second amber suture is visible at the edge of the retractor and onto the skin surface. This suture passes through the malar fat pad. E, Canthal suspension suture now engaging both the tendon and the periosteum of the orbit is ready to be tied down. The midface structures have been suspended, and the entire lateral canthus and commissure will be translocated cephalad and laterally. F, Contralateral procedure on the same patient with the lateral canthus engaged by the suspension suture and all elements of the lateral retinaculum freed. Exposure to the infraorbital and midface region is demonstrated with the use of a retractor. G, Patient who had a previous blepharoplasty and now has midface ptosis and a relative deficiency of lower lid skin. She has scleral show, bowing of the lower lids laterally, especially on the right, and wide lateral commissure angles. H, The same patient as in G after a lateral common canthoplasty and midface suspension (as seen in operative views) now demonstrates obliteration of the preoperative scleral show, loss of lateral lid bowing, acuteness to the lateral commissure angles, and midface elevation.

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Cicatricial entropion usually presents as the opposite rotation of the eyelid margin as found in ectropion and is caused by foreshortening of the internal aspect or posterior lamellar eyelid structures. The etiology may include chemical burns, iatrogenic or surgical injuries, ocular pemphigoid, Stevens-Johnson syndrome, and other scarifying processes. As in ectropion, replacement of the lamella deficiency with a free graft (mucous

A

membrane or composite) is the treatment of choice. This may be combined with a lateral canthotomy and cantholysis or division of the inferior crus of the lateral canthal tendon. This allows access to the entire fornix of the lower lid. A canthopexy to further suspend the lower eyelid may be performed after grafting is complete (Figs. 3-11 and 3-12).

B

C

D

Figure 3-11 A, A 51-year-old woman presented with bilateral cicatricial ectropion from an external lamellar deficiency. She has had a number of past surgical procedures by other surgeons, including a lower lid blepharoplasty at 44 years of age (7 years before presentation) and an endoscopic browlift and lower lid blepharoplasty 4 months before presentation. Approximately 1 month before presentation she underwent a lower lid suspension procedure (type unknown) that did not correct her problem. She presents with significant signs and symptoms of corneal exposure, including corneal edema and decreased visual acuity. Note the scleral show and ectropion of the lower lid, especially on the right side. B, On close-up view of the patient’s eyes, note lateral lower lid bowing, scleral show, ectropion, and conjunctival injection, especially in the temporal quadrant of the right eye. C and D, Lateral view of the left and right eyes, respectively, demonstrating displacement of the lower lid away from the globe in two planes (vertical and horizontal) and the resulting signs of an eye that is not well covered and wet (i.e., conjunctival injection).

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EYELID MALPOSITIONS

A

B

Figure 3-12 A and B, Front and right lateral views of same patient after bilateral lower eyelid full thickness grafts obtained from the retroauricular sulci along with a canthoplasty. Note bowing in the lateral third of each lid with almost normal central lower lid position. On both views the ectropion is completely corrected. Note also there remains midface ptosis, and on the lateral view the orbital rim is visualized in relief owing to excess orbital fat resection in the past and midface ptosis. Her symptoms were relieved and her corneal edema and epithelial problems resolved with a corrective procedure. Subsequently, a midface suspension was performed to address the orbital rim and midface junction as well as to provide additional external lamella tissue for the lower lid. These postoperative photos are shown to demonstrate the potency of external lamella replacement by way of skin graft.

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INVOLUTIONAL ENTROPION The causes of senile or involutional entropion are often analogous to those of senescent ectropion, with the dominant common cause being significant horizontal eyelid laxity. There is an associated net attenuation of the inferior lid retractors along with an override of the more loosely attached preseptal orbicularis muscles over the pretarsal orbicularis muscle. In most cases there is relaxation of the medial and lateral canthal tendons along with a secondary redundancy of the lateral orbital septum with pseudoherniation of orbital fat. The dehiscence of the lower lid retractors is analogous to levator aponeurotic dehiscence in the upper lid, which will be discussed in Chapter 8. The classic presentation of patients with involutional entropion is the patient who presents in the sixth or seventh decade of life with an inturning of the lower eyelid, especially on aggressive or forced closure. This repetitive turning in of the lid can cause corneal irritation and even breakdown, leading to significant morbidity and debilitation. Although a number of procedures have been described for the correction of involutional entropion, I have found them to be either insufficient, associated with a high recurrence rate of the entropion, or overly aggressive, incurring a significant amount of unnecessary surgery. Simply stated, these solutions are either too little or too much. My recommendation for correction of involutional entropion uses a few basic techniques already described in this text. The principle is to first address the lower lid laxity and second to address the preseptal orbicularis override. This procedure can be performed quickly, reproducibly, and safely with the patient under

52

local anesthesia and with or without sedation. A lateral canthotomy and cantholysis of the inferior crus of the lateral canthal tendon is performed. The lower eyelid is mobilized with a subtarsal dissection lysing the lateral inferior lid retractors. A suborbicularis preseptal dissection is performed in the potential space between the orbicularis muscle and the orbital septum, along with a subcutaneous or preorbicularis dissection (see Figs. 1-1 and 1-2). This dissection is carried out from the lateral canthus to the medial canthus, eliminating muscular override by creating fibrosis. The canthoplasty is then completed as previously described utilizing the denuded tarsal strip (see Fig. 3-5). The lower lid retractors are allowed to spontaneously adhere to the newly elevated lid position. In my experience, this definitive and simple procedure can be nearly 100% successful with limited or no morbidity (Fig. 3-13).

SCLERAL SHOW OR LOWER LID RETRACTION In severe cases of lower lid retraction or pseudoretraction, as in mild exophthalmos or proptosis secondary to Graves’ disease, the lower lid may be elevated with a combination of canthopexy and middle and internal lamellar spacer grafts to provide rigidity and support. This is especially the case when an external lamella or skin deficiency does not exist. The atonic lower eyelid found in facial paralysis is another example of an appropriate indication for this procedure.

EYELID MALPOSITIONS

A

C

B

D

Figure 3-13 A, A 71-year-old patient presented with involutional entropion of the left lower lid. She also has chronic exotropia of her eye and ptosis of her upper lid with amblyopia. Note her left lower lid lash line is barely visible as the lid rolls in on lid closure and is exposed with upper lid retraction. Note also the contralateral right lower lid margin with lash line properly directed. This patient suffered from corneal erosion. B, Close-up view of the left lower eyelid involutional entropion. Note the distinct rolling in of the eyelid associated with lower lid laxity, orbicularis muscle override, and other factors (see text). C and D, Distant and close-up photographs of patient approximately 6 months later with left lower lid in good anatomic position with lash line everted away from the ocular surface. The underlying pathophysiology is addressed by tightening the lower eyelid with a canthoplasty, preorbicularis and postorbicularis undermining, and muscular stabilization.

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I prefer palatal mucoperiosteum as an interposition graft between the tarsal plate and lower lid retractors. A lateral canthotomy and inferior cantholysis is again performed, and the lower lid retractors are divided by way of a transmucosal approach. I prefer an insulated electrocautery to achieve this exposure. Easy access to the lower lid retractors and the inferior tarsal plate border is obtained with the lower eyelid mobilized and turned outward. The interposition graft is sutured into

A

Figure 3-14 A 61-year old woman presented with symptomatic left lower lid retraction and atonicity caused by facial nerve paralysis and multiple attempts to suspend the left face and lower lid in the past. Note lateralization of the lower lid punctum, scleral show, slight ectropion, a thinned lower eyelid compared with the normal right side caused by orbicularis atrophy, and left facial ptosis from resection of the seventh nerve on both far (A) and closeup (B) views.

B

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place apposing deeper structures (eyelid retractors) and then mucosa separately. The lower eyelid is then suspended again with a canthopexy by way of the tarsal strip or other procedure (Figs. 3-14 and 3-15). A similar interposition type graft can be employed in upper lid retraction as in Graves’ disease and is described in Chapter 8. The difference in the case of the upper lid is that the graft need not provide rigidity nor mucosa unless there is an internal lamellar deficiency.

EYELID MALPOSITIONS SPACER GRAFT FOR CONTRACTED LOWER LID

Mucoperiosteum

Lower lid retraction

A

Harvest hard palate graft

Lower border of tarsal plate

B

Conjunctiva divided and lower lid retractors disinserted

C

Graft sutured to lower edge of tarsal plate and lower lid retractors

Figure 3-15 This patient has middle internal lamella deficiencies that will not respond to canthoplasty alone or in combination with a midface support procedure. Patients with these types of deficiencies usually have had several previously failed procedures. On examination, digital elevation of the cheek and canthus fails to correct the lower lid malposition; and in these cases a spacer graft, which also provides some central vertical support, is needed. The procedure requires a transconjunctival lysis of the lower lid retractors below the tarsal plate and the interposition of a palatal mucoperiosteal graft. The lower lid retraction is severe in this figure. A, Hard palate mucoperiosteum is harvested. B, The conjunctiva and lower lid retractors are incised and recessed. C, The space between the retractors and tarsal plate is grafted with free mucoperiosteum using a fine absorbable suture (i.e., 6-0). A lateral cantholysis (not shown) is usually helpful but not necessary for access and insetting the graft and adds little time and no morbidity. In most cases in which a spacer graft is used some type of canthal suspension should be performed.

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P E A R LS A N D P I T FA L LS 1. All lower eyelid malpositions (refraction, entropion, ectropion) should be identified and then addressed by their pathophysiology. 2. Involutional lower eyelid malpositions are the most common and are associated with lateral canthal laxity. 3. Descent of the lateral canthus leads to intercommissure shortening and septal laxity. 4. Involutional entropion shares all the contributing components with involutional ectropion, but also has retractor dehiscence. 5. Lower lid shortening procedures should be avoided in the treatment of lower lid laxity. 6. Canthoplasty and canthopexy are different procedures, and each may be subdivided into one that applies to a single crus or to the common element. 7. The lower eyelid can be fully mobilized only when the lateral retinacular components (i.e., orbital septum, lid retractors) are lysed. 8. A commissuroplasty is important for proper alignment of the upper and lower eyelids when completing a tarsal strip procedure.

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9. Tarsal plication is effective only in mild lower lid laxity and, when employed in more severe cases, can lead to buckling of the lower eyelid. 10. The lateral horn of the levator may be entrapped during a lateral canthal suspension, leading to upper lid retraction or lagophthalmos. 11. Overelevation of the lateral canthus can produce an unacceptable appearance and impinge on the visual axis. 12. Lateral canthal suspension procedures alone will not correct a significant lamella deficiency of the lower eyelid. 13. One should consider midfacial suspension or even grafts in treating significant anterior lamella deficiencies. 14. The ideal treatment for involutional entropion is to tighten the lower lid and prevent orbicularis override. 15. Spacer grafts of the middle and inner lamella of the lower lid are ideal in providing central support and can be combined with canthal and midface suspension.

EYELID MALPOSITIONS

References Aldave AJ, Maus M, Rubin PA: Advances in the management of lower eyelid retraction. Facial Plast Surg 15:213-224, 1999. Caldato R, Lauande-Pimentel R. Sabrosa NA, et al: Role of reinsertion of the lower eyelid retractor on involutional entropion. Br J Ophthalmol 84:606-608, 2000. Dagum AB, Antonyshyn O, Hearn T: Medial canthopexy: An experimental and biomechanical study. Ann Plast Surg 35:262-265, 1995. Glatt HJ: Follow-up methods and the apparent success of entropion surgery. Ophthalmic Plast Reconstr Surg 15:396400, 1999. Kim JW, Kikkawa DO, Lemke BN: Donor site complications of hard palate mucosal grafting. Ophthalmic Plast Reconstr Surg 13:36-39, 1997. Lemke BN, Cook BE Jr, Lucarelli MJ: Canthus sparing ectropion repair. Ophthalmic Plast Reconstr Surg 17:161168, 2001. Lisman R, Campbell J: Tarsal suspension canthoplasty. Aesthetic Surg J 19:412-424, 1999. Matsuo K: Stretching of the Mueller muscle results in

involuntary contraction of the levator muscle. Ophthalmic Plast Reconstr Surg 18:79-83, 2002. Mommaerts MY, De Riu G: Prevention of lid retraction after lower lid blepharoplasties: An overview. J Craniomaxillofacial Surg 28:189-200, 2000. Olver JM, Barnes JA: Effective small-incision surgery for involutional lower eyelid entropion. Ophthalmology 107:1982-1988, 2000. Patel BC, Patipa M, Anderson RL, McLeish W: Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip. Plast Reconstr Surg 99:12511260, 1997. Patipa M: The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg 106:438-453; discussion 454-459, 2000. Rougraff PM, Tse DT, Johnson TE, Feuer W: Involutional entropion repair with fornix sutures and lateral tarsal strip procedure. Ophthalmic Plast Reconstr Surg 17:281-287, 2001. Yip CC, Choo CT: The correction of oriental lower lid involutional entropion using the combined procedure. Ann Acad Med Singapore 29:463-466, 2000.

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CHAPTER FOUR

Upper Lid Blepharoplasty Blepharoplasty has become one of the more common aesthetic surgical procedures performed today. Preoperative evaluation should include a number of important factors, none the least of which is the patient’s own assessment in a mirror of what he or she finds bothersome. As mentioned in Chapter 2, the preoperative evaluation should include a complete examination including a detailed history concerning dry eyes, recurrent herpes zoster or simplex infections, and thyroid disease. The physical examination should include a Schirmer test, tear film break-up time, visual acuity with and without correction, and so on. Fine examination of the lid margin for chronic blepharitis, evidence for lid retraction or laxity, and signs of associated systemic disease such as thyroid disease or other problems should be assessed. Although the surgical approaches may be the same, an appreciation of the difference between blepharochalasis and dermatochalasis, that is, the etiology for the redundant upper eyelid tissue, should be understood. I like to define blepharochalasis as redundant upper lid tissue secondary to underlying pathophysiology such as recurrent edema as found in renal failure, cardiac disease, or angioneurotic edema. Dermatochalasis is the commonly found redundancy of upper eyelid tissue secondary to

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the senescent process with or without ptotic eyebrow changes. An important concept in appreciating upper eyelid functional and cosmetic surgery is illustrated by contrasting nuances in the anatomy and pathophysiology between racial and age groups. For example, the upper eyelid crease lies 6 to 8 mm from the lid margin in the young Caucasian. The lid fold is created by extensions of the levator to the lid skin. This lid fold is significantly elevated in the deep-set eye or an eyelid in which levator dehiscence has occurred. In both instances, preaponeurotic fat is retracted or located more cephalad. In the senescent or “baggy” Caucasian upper eyelid, septal laxity and tissue relaxation allow preaponeurotic fat to prolapse anteriorly, lowering the eyelid fold and moving it closer to the lid margin. This age-related pathophysiology is analogous to the normal anatomy found in the youthful Asian upper eyelid. Here the eyelid fold is low and variably closer to the lid margin, with fullness created above it owing to prolapsed preaponeurotic fat extending to the insertion of the levator aponeurotic elements on the overriding lid skin. Therefore, the aged Occidental upper lid resembles the youthful Asian lid (Figs. 4-1 and 4-2).

UPPER LID BLEPHAROPLA S T Y

A

Occidental

B

Deep Set (levator dehiscence)

C

Baggy Eyelid

D

Asian

6 – 8 mm.

8 – 13 mm.

0 to minimum

0 to minimum

Figure 4-1 The anatomic variations in the upper eyelid displayed by different ethnic groups and the changes associated with senescence within each group allow for a convergence of anatomy. Many of these ethnic differences are erased by aging and/or attenuation of structures, allowing for what I like to call a unified upper lid concept. A, The normal youthful Occidental upper eyelid has levator extensions inserting onto the skin surface to define a lid fold that averages 6 to 8 mm above the lid margin. Note the orbital septum coalescing with the levator aponeurosis creating the fat-containing preaponeurotic space. The position of the levator-skin linkage and the anteroposterior relationship of the preaponeurotic fat determine lid fold height and degree of sulcus concavity or convexity (as shown on the right half of each anatomic depiction). B, In the deep-set eyelid or in the case of levator dehiscence from the tarsal plate, the upper lid crease is displaced superiorly. The orbital septum and preaponeurotic fat linked to the levator are displaced superiorly and posteriorly. These anatomic changes create a high lid crease, a deep superior sulcus, and, in the case of levator dehiscence, eyelid ptosis. C, In the aging or baggy eyelid, the septum becomes attenuated and stretches. The preaponeurotic fat attachments loosen, and this allows orbital fat to prolapse forward and slide over the levator into an anterior and inferior position. The net result is an inferior displacement of the levator skin attachments and a low and anterior position of the preaponeurotic fat pad. Clinically, this results in a low lid crease that is only a few millimeters from the lid margin and may not be visible owing to the overhanging lid. D, The youthful Asian eyelid anatomically resembles the baggy or senescent upper lid with a low levator skin zone of adhesion and inferior and anteriorly located preaponeurotic fat. The characteristic, but variable, low eyelid crease and convex upper eyelid and sulcus are classic.

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In the patient undergoing upper lid blepharoplasty, it is extremely important to assess eyebrow position and note the presence or absence of ptosis. The eyebrow hairline and sub-brow fat pad should be evaluated in relationship to the upper orbital rim. The surgeon may have to consider direct eyebrow elevation through the upper lid incision or an indirect approach by means of a temporal incision to be included in the facelift, an endoscopic route, or a classic coronal route when significant eyebrow ptosis is present. The surgeon who attempts to correct significant eyebrow ptosis by means of an upper lid blepharoplasty alone will meet with unsatisfactory results and usually have a dissatisfied patient. This approach usually leads to a blending of the very thin eyelid skin with the thicker eyebrow skin and sub-brow fat pad with an appearance of the eyelids being sutured directly to the eyebrows. In my experience, it is the lateral one third of the eyebrow that is most important from a cosmetic standpoint; and this has been corroborated in other studies. Redundancy in the lateral one third of the upper eyelid presents as a hooding that can only be eliminated in two ways. Either the surgeon may elevate the lateral one third of the eyebrow and then perform a more conservative blepharoplasty, or a very aggressive lateral blepharo-

60

plasty extending beyond the orbital rim is necessary in addressing this hooding. The constraint for the surgeon is that incisions that extend beyond the lateral orbital rim become proportionately more noticeable the more laterally they extend. Therefore, the surgeon must balance the extent of lateral hooding against the desire to minimize lateralization of the upper lid blepharoplasty scar. Based on each patient, the extent of lateralization necessary and other factors, the surgeon and patient may choose to add an adjuvant procedure such as a lateral browlift to the planned blepharoplasty. This becomes an easier decision when a facelift is planned, because the lateral one third of the brow can be elevated in a plane over the deep temporal fascia extending over the lateral orbital rim. This is readily accessed by way of an extension of the facelift incision into the scalp. A direct brow suspension by way of the upper lid is another satisfactory approach that requires a significant amount of dissection, which can result in more postoperative swelling and a prolonged recovery for a blepharoplasty. This latter approach is especially useful in balding men and in limiting surgery and incisions in women. These procedures are described in more detail in Chapter 10.


A

B

C

D

Figure 4-2 A to D, Clinical photographs that correspond to graphic representation as delineated in Figure 4-1. Note: A young non-Asian (A) is compared with the deep-set sulcus and preaponeurotic fat retraction associated with levator dehiscence (B), the baggy upper eyelid seen in septal laxity and fat prolapse associated with aging (C), and the Asian upper eyelid (D) with its low septal attachment and anteroinferior fat position analogous to the aging Occidental upper eyelid.

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The amount of horizontal skin laxity of the eyelids themselves, that is with the eyebrow fat pad held in an anatomic position and eliminating its contribution to skin redundancy, is another important factor that should be appreciated preoperatively. The presence or absence of lid lag or lagophthalmos should be noted and measured because asymptomatic lagophthalmos can easily be converted to the symptomatic variety with even small amounts of skin resection. Some patients may not tolerate brow suspension procedures (i.e., along with a skin resection in the upper eyelid, especially in the medial two thirds of the eyebrow). Elevation of the lateral one third of the brow is less likely to produce untoward sequelae even in patients with upper lid skin deficiencies. Therefore, the surgeon should assess “relative” dermatochalasis, that is, skin redundancy as contributed from the eyelid versus the eyebrow. Then the surgeon and patient can choose the appropriate technique based on the pathophysiology and the patient’s desires (Fig. 4-3). Because upper lid blepharoplasty basically involves removal of redundant or excessive skin of the upper eyelids along with excision of some portion of the orbicularis muscle and preaponeurotic fat with violation of the orbital septum, there are a few salient points that predicate a wellexecuted procedure. The first important anatomic location is the upper lid eyelid crease. In Occidentals, this lies 6 to 10 mm above the eyelid margin and is generally higher in females. It is important to remember that one is not bound by a particular eyelid crease height; however, the endogenous lid crease is usually the most appropriate for the patient. In Oriental or Asian eyelids the lid crease may be considerably lower than in Occidentals (see Figs. 4-1 through 4-3). Some Asian patients may request an Occidentalization or elevation of the endogenous upper eyelid fold. One may even encounter patients with asymmetric upper eyelid folds, and the surgeon should be comfortable with adjusting and repositioning eyelid folds as is discussed in Chapter 8 on the technique of supratarsal fixation. Once the upper eyelid fold is defined and marked with a surgical marking pen, the extent of upper eyelid skin excision is determined by a pinch test. The design of the upper and lower limbs of the incision lines should be curvilinear, with the medial aspect being convex superiorly and the lateral aspect being convex inferiorly. Attempts should be made to place the lateral aspect of the lower incision line within a skin crease, and this is upwardly inclined to meet the upper limb of the incision, which is extended laterally. In my mind, the importance of curving the lateral aspect of the upper incision is twofold: (1) to extend the upper eyelid 62

incision away from any potential lower eyelid incisions and, therefore, obviate a narrow skin bridge that is usually neurovascularly compromised in some fashion and (2) to curve the incision upward, allowing the lower limb to be longer than the upper limb and thereby effectively creating a Burow’s triangle resection of the potential dog-ear. An atraumatic forceps is used to pinch the skin between the delineated upper eyelid fold and the desired excision line superiorly, and I prefer to induce a small amount of upper eyelash eversion as a determinant of the proper amount of skin resection. Remember, brow positioning is important and should a brow elevation procedure be entertained, then suspension of the brow digitally before delineation of the extent of upper eyelid skin excision should be performed. Positioning the brow digitally before marking the upper eyelid allows the surgeon to address the upper eyelid first without risking overresection, independent of which procedure is chosen for brow elevation and independent of the order in which the surgeon chooses to perform the procedures (see Fig. 4-3). I find it very cumbersome to resect skin after the brow is suspended, especially in the transblepharoplasty brow elevation procedure, because this usually results in irregularities in the upper eyelid incision line. Local anesthetic with epinephrine is infiltrated and adequate time for hemostasis is allowed to elapse. Upper and lower lid eyelid incisions are made in a medial to lateral direction through skin and orbicularis muscle (Fig. 4-4). The skin muscle flap is elevated from the lateral to medial direction with digital retraction laterally. The orbital septum is tented with a forceps unroofed from lateral to medial, utilizing a sharp scissor or needle-tip cautery at the level of the upper extent of the eyelid incision. Tentative dissection by some surgeons occurs at this juncture owing to concern over creating iatrogenic damage to underlying structures at or behind the orbital septum (e.g., levator aponeurosis, tarsal plate). This can be obviated by opening the orbital septum as cephalad as possible where the levator aponeurosis lies most posteriorly away from the orbital septum and the buffer of preaponeurotic fat is interposed (Fig. 4-5). In Chapter 1, I pointed out that the levator aponeurosis and orbital septum fuse at the level of the upper tarsal plate and diverge as one moves superiorly, with the levator aponeurosis converting from an inferosuperior to an anteroposterior orientation as one moves cephalad from the tarsal plate (see figures in Chapter 1). Preaponeurotic fat (medial and central fat pads) can then be appropriately resected if desired. It is useful to use a fine hemostat with light digital pressure on the globe to tease the fat free of


Lid crease marks lower limb of incision

Lateral browlift

Upper limb of incision is defined when lashes evert

A

B

Figure 4-3 The keypoints in planning and executing the upper lid blepharoplasty are as follows: A, Determination of the endogenous lid crease or height at which to create a new lid crease (if different than the existing crease). The latter would require supratarsal fixation. The level of this crease will serve as the lower limb of the blepharoplasty incision and the height of supratarsal fixation, should that be necessary. The width or extent of skin excision is determined by pinching the lid skin between forceps using slight lash line eversion as the end point. This superior point will determine the location for the superior limb of the skin incision (left). B, Determination of the extent of lateral eyebrow ptosis and, hence, the amount of lateral upper eyelid hooding. The degree of lateral hooding will dictate the point of the lateral extension needed to treat the hooding. The greater the hooding the more lateral the extent of the incision (top, dark to lighter shades of color). In general, incisions that extend beyond the orbital rim are not well tolerated (middle). The unequal lengths of the upper and lower limbs are effectively Burow’s triangles to eliminate dog-ears and must be exaggerated as one widens the lateral skin excision. Also a brow that lacks stability may be pulled down by tension induced by a wide lateral excision. Here a balance must be made between the extent of lateral hooding and the drive to maintain incision lines within the confines of the orbital rim. Once the lateral extent of the incision becomes excessive then a lateral brow suspension should be entertained.

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septal adhesions and allow it to prolapse spontaneously. Fat may be resected by any technique; however, I find it preferable to use an insulated needle cautery. By using light inferior traction on the upper lid, one should be able to visualize the levator aponeurosis and

Whitnall’s ligament. It is easy to obtain complete access to the anterior one third of the orbit above the levator muscle using these simple technical maneuvers (see Fig. 4-5).

UPPER LID BLEPHAROPLASTY

A

Figure 4-4 In practice the upper lid blepharoplasty can be efficiently performed using a few technical manipulations consistent with the anatomy. Digital traction and light pressure by the surgeon and/or assistant allow smooth quick skin incisions. A, Slightly more pressure must be exerted on the scalpel laterally as the skin thickens around and lateral to the orbital rim. B, The skin may be elevated with the orbicularis muscle in one maneuver using an instrument on the skinmuscle section to be resected and pulling this superonasally while providing digital traction laterally. I find a needle-tipped insulated cautery to be most advantageous in this and other succeeding steps, especially in avoiding any delaying hemostasis problems. The orbital septum is then widely opened, exposing the preaponeurotic space. C, The underlying levator aponeurosis is protected by opening the septum as cephalad as possible, because the levator and septum diverge as one moves superiorly.

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Incision

Levator aponeurosis Orbital septum

Central fat pad (preaponeurotic) on levator aponeurosis

B

Skin and orbicularis muscle resection

Pressure on globe causes medial fat pad to bulge

C

Orbital septum incised

Continued


Whitnall's ligament

Levator aponeurosis

D

Figure 4-4 Continued D, The medial fat pad may require some digital pressure to expose and grasp; however, care should be taken not to overly resect fat when using digital pressure techniques. Excessive traction and manipulation of fat could cause a deep orbital hemorrhage and should, therefore, be avoided. E, Closure may then be performed and I prefer 6-0 nylon interrupted sutures laterally and 5-0 nylon intracuticular sutures medially.

Medial fat pad removed

Interrupted sutures

E

Intracuticular running stuture Closure

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A

B

C

D Figure 4-5 A, An upper lid blepharoplasty is delineated with marking ink. Slight upper lid lash line eversion delineates the extent of the skin excision. This can be ascertained by pinching the upper and lower limbs of the central aspect of the incision lines together with an instrument. B, An upper lid skin excision leaving the orbicularis muscle behind. The muscle is thin, and the underlying orbital septum is visualized in the vertical traction line lying between the upper and lower hooks. C, An incision line is made with a scalpel, and the skin flap is elevated with a cautery. I prefer to remove central orbicularis muscle beneath the skin and avoid a second step as well as hemostasis problems, leaving the orbital septum intact. D, The orbital septum is then incised at its more superior extent. The septum may be stabbed or widely incised with a needle-tip cautery. Fat will prolapse spontaneously or with light digital pressure. The medial fat (held in forceps) is whiter and lies medial to the superior oblique muscle, which can be visualized if desired. The central or preaponeurotic fat (pulled laterally by suction cannula) is darker, less fibrous, and loosely but definitively adherent to the levator aponeurosis. Continued

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E

Figure 4-5 Continued E, Contralateral upper eyelid shows preaponeurotic fat lying lateral to the superior oblique muscle and visualized more anatomically as a thin yellowish fan-shaped layer attached to the levator aponeurosis. The medial fat is separate, isolated between the medial orbit and the superior oblique muscle. After fat resection, closure may be performed as shown in Figure 4-4. F, Close-up photograph of an upper lid blepharoplasty demonstrating some important anatomic and clinical features. Here the lower forceps is indenting the levator aponeurosis and the upper forceps is retracting part of the preaponeurotic fat. Just lateral to the visualized preaponeurotic fat, the orbital septum remains intact. Note that the orbital septum must be violated to gain access to the superior orbit, the levator, and the preaponeurotic fat. Also note that the whiter medial orbital fat is spontaneously prolapsing anteriorly and the more central preaponeurotic fat is loosely attached to the underlying levator mechanism. G, The upper lid is placed on moderate traction, and the preaponeurotic fat is partially divided with a cautery and retracted nasally with forceps. Just above the skin traction hook one can see the tarsal plate with overlying orbicularis muscle (white); above that, a blue band corresponds to a levator dehiscence from the tarsal plate, and superior to that the levator aponeurosis is viewed as a white flat fan. Whitnall’s ligament is seen as a white thin band lateral to the cut end of the preaponeurotic fat. Just above Whitnall’s ligament is the blackened (cauterized) cut end of the orbital septum, and just below Whitnall’s ligament is the levator palpebrae superioris muscle, which is pale yellow and vascularized compared with the white aponeurosis distally. Modifications in the levator or at the levator tarsal junction can be easily performed with this exposure.

F

G

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The levator aponeurosis may be modified at this juncture if so desired. It may be freed from the tarsal plate and advanced as in a formal levator advancement procedure for ptosis. Alternatively, the levator may be plicated or tucked in mild degrees of ptosis (Fig. 4-6). This is described in Chapter 8. Closure is then performed, and I find the preferable method is to utilize an intracuticular suture extending from the medial canthal region to just medial to the lateral canthal region. I prefer a 5-0 nonabsorbable monofilament suture. Laterally, I prefer a 6-0 interrupted monofilament suture. Eversion of skin lateral to the canthus helps in eliminating a depressed incision line, which can be unsightly especially in women. I have seen some longer-lasting absorbable sutures produce unsightly tracts. Suture removal can be performed at 5 to 10 days as deemed appropriate by the treating surgeon. The medial aspect of the intracuticular suture that is transcutaneous tends to be prone to purulent inclusion cysts, and the surgeon may wish to trim this at the level of the skin at surgery or earlier than the scheduled complete suture removal. Supratarsal fixation refers to creating a controlled adhesion between the levator aponeurosis and the

overlying skin. An endogenous lid fold of variable height, based on ethnic origin and other factors, exists owing to extensions between the levator aponeurosis and the dermal surface of the lid (as previously described). During the blepharoplasty, the surgeon may choose to either more definitely refine the location of an existing endogenous lid crease or he or she may choose to alter its height accordingly. This can be facilitated by passing sutures from the lower margin of the skin incision through the levator aponeurosis and then through the upper margin of the skin incision. The level at which the levator aponeurosis is engaged will determine the level of the upper eyelid fold. This technique is especially useful in creating a lid fold in the patient with congenital ptosis as well as in the typical cosmetic patient. I find it to be a necessity in the Asian patient who desires not to be Occidentalized. I prefer to use three or four interrupted small absorbable sutures such as 5-0 or 6-0 Vicryl or chromic catgut sutures to achieve supertarsal fixation. Cutaneous closure may be performed as described earlier should these fixation sutures not be adequate (see Fig. 4-4).

P E A R LS A N D P I T FA L LS 1. Age and race dictate the position of the upper eyelid fold, with a convergence in anatomy occurring between the aging Caucasian and youthful Asian. 2. Eyebrow and eyelid ptosis are important factors to be noted in planning the upper lid blepharoplasty, and their presence or absence will affect the final procedure of choice. 3. Lateral eyebrow ptosis contributes to lateral upper lid hooding. The surgeon will meet with unacceptable results should he or she attempt to correct either one, using the other. 4. The endogenous or selected position for the upper lid fold is the first key step in designing an upper lid blepharoplasty. 5. When planning a brow elevation procedure, the brow should be digitally suspended prior to delineation of the extent of upper eyelid skin excision. 6. Iatrogenic injury to the levator aponeurosis can be avoided by opening the orbital septum as high as possible where the aponeurosis moves posteriorly.

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7. Careful skin eversion lateral to the canthus is important to avoid a depressed incision line. 8. Supratarsal fixation is a potent technique that may be employed in every upper lid blepharoplasty. It allows the creation of an upper lid fold based on skin fixation to the underlying levator aponeurosis. 9. The transconjunctival blepharoplasty and the transcutaneous blepharoplasty are equally effective in approaching fat but the former has some shortcomings vis-a-vis the mid face and in addressing significant skin redundancy. 10. The decision to utilize the transconjunctival versus the transcutaneous route should be predicated on the amount of skin redundancy and whether a canthal tightening procedure is indicated. 11. When fat resection is employed it should be conservative to avoid a hollowed-out appearance. 12. Skin should be redraped, with the line between the nasojugal groove and the lateral canthus kept in mind, that is, inducing a lateral cephalic vector.

UPPER LID BLEPHAROPLA S T Y LEVATOR MODIFICATIONS

Orbital septum and underlying (preaponeurotic) fat

Levator aponeurosis

or

Supratarsal fixation Levator plication

A Figure 4-6 A, Once the upper lid skin is incised or excised, the levator may be modified (shortened/lengthened) without mobilization in a number of ways. The skin edges may also be incorporated in these modifications so as to accentuate or move a lid crease. These changes may be performed alone or in combination and may be utilized freely with the standard upper lid blepharoplasty as already depicted (see Figs. 4-4 and 4-5). The orbital septum in the lower two drawings is shown to be intact to render a clear distinction in anatomic structures. Clinically, the septum may be left intact when the septum fuses with the aponeurosis above the level at which a modification will be performed; however, the septum may be liberally opened and Whitnall's ligament visualized in all cases. Continued

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B

C

D

E

Figure 4-6 Continued B, In the upper lid the skin and orbicularis muscle have been removed from the underlying orbital septum. Forceps provide traction on the septum, demonstrating its rigidity and its insertion onto the bony orbit. The preaponeurotic fat is visible superiorly beneath the septum. C, Once the septum is incised, free access is gained to the superior orbit. The upper lid is on traction, and the levator aponeurosis and more superior levator muscle is seen. D, The levator may be modified in a number of ways without complete disinsertion from the tarsal plate. Several variations include plicating the levator muscle alone, removing a strip and apposing the cut ends, or plicating and removing the excess levator above the suture line. Here a strip of levator is removed. The underlying cornea is visible through conjunctiva and Müller’s muscle. The suture is placed through the two cut ends and left loose for demonstration purposes before being tied down. E, Supratarsal fixation is a powerful tool for creating, preserving, or altering the height of the upper lid fold. I prefer to use a small absorbable suture. Here the suture is passed from the lower skin margin, through the levator aponeurosis, and then through the upper skin margin. Once tied down, the two skin edges are apposed at the desired level onto the levator aponeurosis, thereby simulating the normal mechanism for eyelid crease formation.

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References Berman M: Rejuvenation of the upper eyelid complex with autologous fat transplantation. Dermatol Surg 26:11131116, 2000. Castro E, Foster JA: Upper lid blepharoplasty. Facial Plast Surg 15:173-181, 1999. Friedland JA, Jacobsen WM, Terkonda S: Safety and efficacy of combined upper blepharoplasties and open coronal browlift: A consecutive series of 600 patients. Aesthetic Plast Surg 20:453-462, 1996. Guyuron B, Knize DM: Corrugator supercilii resection through blepharoplasty incision. Plastic Reconstr Surg 107:606-607, 2001. Lee Y, Lee E, Park WJ: Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: Do we have to make an additional scar to correct the Asian epicanthal fold? Plast Reconstr Surg 105:1872-1880, 2000.

Januszkiewicz JS, Nahai F, Zarem HA: Transconjunctival upper blepharoplasty. Plast Reconstr Surg 103:1015-1019, 1999. Kim JW, Lee JO: Asian blepharoplasty with a short-pulsed contract Nd-YAG laser: Limited-incision resectable laser double fold with internal medial and lateral functional epicanthoplasty. Aesthetic Plast Surg 22:433-438, 1998. Lee Y, Kwon S, Hwang K: Correction of sunken and/or multiply folded upper eyelid by fascia-fat graft. Plast Reconstr Surg 107:15-19, 2001. Lee Y, Lee E, Park WJ: Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: Do we have to make an additional scar to correct the Asian epicanthal fold? Plast Reconstr Surg 105:1872-1880, 2000. Ullmann Y, Levi Y, Ben-Izhak O, et al: The surgical anatomy of the fat in the upper eyelid medial compartment. Plast Reconstr Surg 99:658-661, 1997. Weber PJ, Wulc AE, Foster J: Transconjunctival upper blepharoplasty. Plast Reconstr Surg 104:2333-2334, 1999.

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CHAPTER FIVE

Lower Lid Blepharoplasty The lower lid blepharoplasty has been viewed by many, especially the less experienced, as being technically more difficult to perform than the upper lid blepharoplasty. The perception of difficulty likely lies more in the numerous decision-making processes the surgeon and patient are forced to undergo to achieve a satisfactory lower lid result. Once evaluation of the patient is complete, the surgeon has many more choices as to how to approach the lower lid blepharoplasty and less margin for error. In examining the patient, the surgeon is faced with concerns over such things as the degree of horizontal lid laxity, position of the lateral and medial canthal angles, conditions such as scleral show, entropion and ectropion, or other underlying pathologic processes. As in the case of the upper eyelid, the surgeon should obtain a thorough history. I find it is always helpful to have the patient look in a mirror and delineate, articulate, and specifically demonstrate what are his or her cosmetic concerns. Then the surgeon has a plethora of procedures available with which to address these concerns. These include whether to perform a transcutaneous or transconjunctival approach, whether to perform a canthal procedure such as a tarsal tuck or tarsal strip procedure, or even whether to reposition the entire lateral canthus (common canthoplasty). Decisions as to how to address skin and/or fat are equally numerous. The surgeon is faced with whether to address the skin and, if so, whether to perform a skin trim procedure, laser resurface the skin, or address the skin element in some other fashion. Fat can be addressed with resection, redistribution, or both. An appreciation of midface position is as important in lower lid blepharoplasty as is appreciation of brow position in upper lid blepharoplasty. Here with regard to the mid face, the surgeon has a choice as to whether he or she wishes to address it at all, whether to approach it by way of the

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lateral extent of the upper or lower lid incision, or whether to approach it by means of a preauricular facelift incision. Of course, the approach depends on the underlying pathologic process and what the patient and surgeon perceive as the underlying cosmetic and/or functional abnormality. The surgeon should be familiar and well versed and comfortable with all techniques and approaches to the lower eyelid and attempt to adjust the operation to the patient and not the other way around.

TRANSCUTANEOUS LOWER LID BLEPHAROPLASTY The transcutaneous lower lid blepharoplasty is a powerful technique for addressing lower lid cosmetic abnormalities. It allows a number of adjuvant procedures to be performed easily and more accurately than the transconjunctival route. Its disadvantages include greater technical demands, more time, more extensive dissection, and, hence, greater secondary fibrosis; and it has an inherently greater margin for error (i.e., overresection or changes in forces on the lower lid engendering scleral show and/or ectropion). It is, however, more powerful in that one can address fat alone (resect or redistribute), address skin and/or muscle separately, and approach lower lid tightening by way of a direct approach to the lateral lower lid tarsus or inferior crus of the lateral canthal tendon. Although there have been descriptions of the use of cutaneous flaps as an approach to fine skin rhytids of

LO W E R L I D B L E P H A R O P L A S T Y

the lower eyelid, I do not recommend them. These were originally described as a means of addressing fine rhytids separately from other more gross irregularities. The lower eyelid skin is extremely thin, and any attempt to raise a skin flap independently of the underlying orbicularis muscle likely leads to a poorly vascularized cutaneous segment that is prone to secondary contracture and other complications. In distinction, the myocutaneous flap is extremely hardy and, given the number of other modalities available to the surgeon today for addressing fine rhytids of the lower eyelid, the argument for a cutaneous flap independently of the muscle segment, in my opinion, is tenuous. The decision to use the transcutaneous route versus a transconjunctival route should be predicated on the amount of skin redundancy and whether a canthal tightening procedure is indicated. The transcutaneous or transconjunctival routes are equally effective in addressing fat (resection and/or redistribution). Should one wish to address the mid face (cheek suspension), then an access incision either by way of the lateral lower eyelid, lateral upper eyelid, or facelift approach is usually necessary. The transconjunctival route alone does not in

A

general provide adequate exposure to the mid face and does not allow appropriate cephalic and lateral elevation of the cheek unit. It may, however, be used to subtly elevate the medial cheek at the nasolabial junction. Midface access by way of a preauricular or lateral upper eyelid incision may force the surgeon to perform a second lower eyelid transcutaneous incision should he or she wish to achieve anything more than a canthopexy or common canthoplasty to the lower eyelid (Fig. 5-1). The lower eyelid may be delineated for blepharoplasty by drawing an incision line extending from the lateral canthus posteriorly in a natural skinfold. This is usually subtly declined inferiorly to appear more natural and avoid encroaching on the upper lid. As in the upper lid blepharoplasty, one would prefer to minimize the lateral extent of the incision line, and I choose to make a limited incision that is extended if necessary for skin and muscle redraping and/or suspension. The incision line will extend medial to the lateral canthus in a natural fold below the lower eyelid. One would prefer to leave a cuff of pretarsal orbicularis below the lash margin, which is theoretically responsible for eyelash orientation (Riolan's muscle).

B

Figure 5-1 A and B, The patient who has midface ptosis along with significant lower lid dermatochalasis that is not correctable with a canthal elevation procedure and/or laser alone is one in whom the surgeon should perform a transcutaneous lower lid blepharoplasty in conjunction with the midface suspension. Here is a patient who has facial ptosis, good lower eyelid position, significant dermatochalasis of the eyelids, and brow ptosis. The lower eyelid skin redundancy will not respond to lateral canthal elevation alone, and when the mid face is suspended, the redundancy will be exacerbated. In this case a reasonable choice would be to elevate the mid face either with a preauricular facialplasty approach or through the lateral upper eyelid. The lower eyelid may then be addressed with a transcutaneous blepharoplasty to adequately redrape the lower lid skin.

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Local anesthetic of choice (lidocaine with epinephrine) is infiltrated, and adequate time for hemostasis is allowed to elapse. An incision is made in the lateral extent of the delineated incision through skin and orbicularis muscle. A curved sharp tenotomy or Steven’s scissor is inserted in the postorbicularis/preseptal plane. This is the potential space just anterior to the orbital septum, which has been described in Chapter 1 (see Fig. 1-2). As one enters the potential space from lateral to medially, the scissor is opened gently and a true space is developed extending from the preseptal to the pretarsal suborbicularis regions. The scissor is withdrawn and a fine small sharp scissor (iris scissor) is reinserted with one limb of the scissor in the incision and the other overlying the skin of the lower lid. The marginal aspect of the incision is then made just below the lash line margin of the lid with the scissor beveled inferiorly (lower limb inferior) (Fig. 5-2). The incision should extend up to a point lateral to the medial punctum. The lower eyelid is then placed on cephalic traction with an eyelid hook, and with countertraction on the skin muscle flap the myocutaneous flap is elevated to the level of the orbital rim inferiorly. I recommend that the lower eyelid hook be placed on the conjunctival side of the lower eyelid so as to avoid corneal or eyeball injury should one choose not to use a protective eye shield or contact lens. Once the myocutaneous flap is elevated to the orbital rim, the orbital septum will be easily visualized and may be incised to address orbital fat when appropriate. I prefer to incise the orbital septum and visualize all three fat pads along with the inferior oblique muscle. The fat may then be resected, preferably with a needle cautery technique. In resecting lower lid fat, conservation is strongly recommended, because overresection usually leads to a concavity or “sickly appearance” to the lower lid and inferior orbital region. Fat redistribution techniques may be used alone or in combination with fat resection depending on which compartment is thought to be prominent or deficient. In general, in approaching resection only, only fat that spontaneously herniates with light digital pressure to the globe should be removed and the amputation point should not extend within the orbital rim. Special care should be taken to directly observe the lateral fat compartment because this is most frequently missed or inappropriately treated (see Fig. 5-2). Once fat has been addressed and the surgeon suspends the lower lid and/or mid face if appropriate, then

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the skin muscle flap is redraped and adjusted. Every attempt should be made to elevate the skin muscle flap cephalad and laterally so as to create a vector force that runs superiorly from the nasojugal groove through the lateral canthal area. This orientation is important in eliminating the line of force that links the lower eyelid directly to the malar tissue in one plane. This technique, however, may be slightly less advantageous in eliminating lower eyelid skin rhytids. The flap may be backcut at the point of insertion to the lateral canthal region, and skin may be trimmed from lateral to medial as a tapered wedge so that very little, if any, skin is resected from the level of the pupillary axis to the medial canthus. The area of skin muscle flap that lies lateral to the lateral canthus can be appropriately resected without tension with the possibility of extending the incision line temporarily depending on the amount of redundancy or dog-ear created. A separate closure of the muscular layer may be performed when a larger amount of myocutaneous resection is employed. A single absorbable suture through the orbicularis muscle that engenders cephalic lateral suspension forces can be useful in not only eliminating or reducing tension on the skin closure but also further supporting the lower lid against distraction forces. This is especially useful when one performs a formal lower lid tightening procedure whether it be a tarsal tuck, tarsal strip, or other canthopexy procedure. In fact, muscular suspension should be viewed as the simplest but least effective method of increasing lower lid support. Orbicularis repair may be achieved with a small (5-0) absorbable suture (i.e., Vicryl). Before skin closure one may consider resecting a small cuff (2 to 3 mm) of orbicularis muscle from the undersurface of the myocutaneous flap extending from the lateral canthal region medially. Although this usually creates an annoying hemostasis problem near the end of the procedure, it is useful in eliminating or avoiding orbicularis bulge inferior to the lid margin, which in many patients is noted as a preoperative cosmetic concern. Finally, skin closure is performed and I prefer to utilize a running 6-0 silk suture from medial to the lateral canthus and interrupted 6-0 nylon sutures lateral to that. Only the nylon sutures are tied down (see Fig. 5-2). This enables the silk to be easily removed early in the postoperative period, that is, 3 to 5 days.

LO W E R L I D B L E P H A R O P L A S T Y LOWER LID BLEPHAROPLASTY (TRANSCUTANEOUS)

A

B

Primary incision

Undermining in the preseptal sub-orbicularis potential space

Orbicularis muscle

C

Secondary incision

Orbital septum

Figure 5-2 As with the upper lid, the successful completion of the lower lid blepharoplasty requires a few technical steps that will simplify and speed its execution. The anatomy of the lower eyelid can be advantageous to the surgeon in properly performing these steps. A, The primary incision should be in a desired fold or potential fold at and lateral to the lateral canthus. The incision should be limited but be able to admit a small curved scissor. The scissor should be passed through the incision into the suborbicularis preseptal space. B, This plane is developed from lateral to medial while gently pushing and spreading the scissor. Once this plane is developed, the myocutaneous flap can be mobilized with ease. The scissors are withdrawn and only one limb is inserted into the preseptal postorbicularis plane, with the other over the skin surface. The scissors may be beveled toward the eyeball (less skin, more muscle). C, The second incision is completed lateral to medial with the assistance of inferior digital traction, ending just lateral to the lower lid punctum. The flap should be mobilized to the orbital rim without violating the septum. This is best achieved with a combination of digital cheek traction inferiorly and instrument elevation of the myocutaneous flap. Continued

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY Lower lid, retracted superiorly (conjunctival surface)

D

Incised orbital septum

Orbital rim

Medial fat pad

E

Remove medial and central fat pads

Central fat pad

F


Pressure on upper lid causes lateral orbital fat pad to bulge anteriorly

Lateral fat pad

Orbital rim

Figure 5-2 Continued D, The septum may then be opened either widely or with stab incisions. E, In either case the inferior oblique muscle should be visualized and protected. I usually identify the oblique muscle before resection or repositioning fat. The muscle is most anterior medially, adjacent to the medial fat pad, and this is the best place to identify it using an instrument to spread or probe while concomitantly applying light digital pressure. F, Remember overresection of fat, especially the lateral compartment, can lead to less than acceptable cosmetic results. Skin resection should be conservative and invoke lateral and cephalic vectors. Continued

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Patient looks up with mouth open for skin redraping and excision

G

Redrape skin (cephalic and lateral) and trim excess

Line of excision

H

Closure including interrupted sutures laterally and running suture medial to lateral

Figure 5-2 Continued G, This will render the most tension under the canthus and the least distraction force in the mid lower lid. I find it helpful to have the patient look up and open his or her mouth to add conservation to the skin excision step (inset). Before closure, it is sometimes helpful to resect a few millimeters of orbicularis muscle at the superior aspect of the flap. This does not affect function and avoids the annoying post-blepharoplasty bulge or roll. H, Closure is completed after hemostasis is controlled. I prefer running 6-0 silk medially and interrupted nylon laterally.

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A

C

B

D

Figure 5-3 The transcutaneous blepharoplasty can be a powerful technique yet easily executed, provided a few points are kept in mind. The only incision line I design is the lateral extent beyond the canthus. This is usually inferiorly declined and mirrors an existing skin crease. In the more youthful patient, the incision may only extend a few millimeters lateral to the canthus; and in the older patient, one may extend it much farther. A, The myocutaneous flap is developed first with an incision lateral to the lash line. Curved Stevens’ scissors are introduced, and the preseptal postorbicularis plane is developed to a point just short of the punctum. The scissors are withdrawn and one blade reintroduced and the cut made with a bevel, leaving orbicularis muscle on the lid. The myocutaneous flap is then developed to the orbital rim margin. The trick here is to provide superior lid traction with a small hook. I prefer to place this on the conjunctival side of the eyelid. Countertraction should be provided with an insulated Desmarres retractor after digital traction is first used. In this photograph one can see the developed myocutaneous flap to the inferior orbital margin. The lower lid is placed on superior traction, and the orbital septum is left intact. B, Orbital fat is visible through the thinned septum just above the orbital rim. Note orbicularis muscle left on the superior lid margin (below the superior traction hook). The mid face may be approached through this route using the inferior orbital rim as an anatomic point of dissection and fixation. The orbital septum may be incised and fat addressed. C, A lateral oblique view of the dissection shows how wide exposure can be gained with appropriate traction. The inferior lid retractors are pulled superiorly and indented by scissors. The open edge of the septum is pulled with medial orbital fat anteriorly. Just to the lower left of this retracted fat the inferior oblique muscle is visualized. D, Orbit fat may be repositioned throughout or in selected pockets and combined with resection techniques depending on the needs of a patient. In this patient the lateral fat pad was deficient and there was early midface ptosis, which the patient did not want to address. This caused a concavity in the lateral inferior lower eyelid/orbital rim junction, with the rim visible in relief. The lateral fat pad was advanced onto the orbital rim.

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Various techniques to assist the surgeon in avoiding overexcision of skin have been described, and these may be useful but not entirely dependable. The amount of skin resected and the degree of cephalic lateral suspension should be judged on the patient's history, physical examination, and appearance. That is, most of the decision making is made preoperatively. In patients who have minimal tolerance for overresection based on these parameters, one might want to evoke distraction tests, such as forcibly opening the patient's mouth and/or have the patient look up, before finally trimming the skin muscle flap (see Figs. 5-2 and 5-3).

References Alster TS, Lupton JR: An overview of cutaneous laser resurfacing. Clin Plast Surg 28:37-52, 2001. Bernardi C, Dura S, Amata PL: Treatment of orbicularis oculi muscle hypertrophy in lower lid blepharoplasty. Aesthetic Plast Surg 22:349-351, 1998. Castro E, Foster JA: Upper lid blepharoplasty. Facial Plast Surg 15:173-181, 1999.

P E A R LS A N D P I T FA L LS 1. The key anatomic plane in any of the techniques for lower lid blepharoplasty is the preaponeurotic post-orbicularis space. 2. Orbicularis muscle (i.e., orbicularis muscle at the lid margin) should be preserved when raising a skin muscle flap. 3. Orbicularis muscle suspension through the transcutaneous access route is the simplest but least effective method of increasing lower lid support.

Codner MA: Reduction of lower palpebral bulge by plicating attenuated orbital septa: A technical modification in cosmetic blepharoplasty. Plast Reconstr Surg 105:25592560, 2000. Mommaerts MY, DeRiu G: Prevention of lid retraction after lower lid blepharoplasties: An overview. J Craniomaxillofacial Surg 28:189-200, 2000. Nguyen XC: Guidelines to avoid lid retraction following lower transcutaneous blepharoplasty. Int J Cosmetic Surg Aesthetic Dermatol 2:231-233, 2000.

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CHAPTER SIX

Transconjunctival Lower Lid Blepharoplasty The ideal candidate for a transconjunctival lower lid blepharoplasty is the youthful patient who has no or only a small amount of skin redundancy but has prominent orbital fat pads that are of concern to the patient. These patients may also have depressions in the nasojugal and/or lateral orbital rim region that one may want to address with orbital fat repositioning or redraping. Patients in this category who have mild skin rhytids, pigmentary disturbances, or other irregularities may have these addressed by means of a simple skin excision at the lid margin with cephalic lateral redraping or by laser resurfacing techniques, and so on. The other category of patients in whom the transconjunctival route is most useful is the older individual who is usually thin, has minimal skin redundancy with or without fine rhytids, and does not have lower eyelid malposition and/or lower lid laxity that can be addressed with a common canthoplasty through the upper eyelid. These patients may or may not be undergoing other procedures, such as a facelift. Less time and fewer risks are involved in the transconjunctival approach to the fat pads, and again the fine rhytids may be addressed with either a marginal skin trim or a laser procedure. The surgeon should appreciate the relatively increased efficacy of the transconjunctival route in the younger individual versus the older patient. The convexity of the lower eyelid produced by herniated

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orbital fat in the younger individual is converted to a coplanar or slightly concave lower eyelid more easily than in an older individual. This is likely due to greater skin elasticity in the younger versus older patient. Therefore, when utilizing the transconjunctival route in older individuals, the surgeon should expect less effect on the skin and one should readily entertain procedures for addressing skin redundancy to achieve optimal aesthetic results (Figs. 6-1 and 6-2). These techniques for the treatment of skin rhytids or mild redundancy can include a simple rhytidectomy with orbicularis suspension without raising a cutaneous or myocutaneous flap. The technique is similar to that initially used in the full transcutaneous blepharoplasty (see Fig. 5-2). Lateral cephalic resection and suspension are the key elements in this technique. I use muscular suspension with 5-0 Vicryl and cutaneous repair with 6-0 nylon and silk. This technique can be employed in combination with a facialplasty or midface, transconjunctival, or any other procedure. I have used it frequently to supplant lower lid laser procedures, especially in those patients who are not candidates or are unwilling to undergo lower lid laser resurfacing procedures. I find this approach to be more powerful and associated with fewer complications than aggressive laser techniques.

T R A N S C O N J U N C T I VA L LO W E R L I D B L E P H A R O P L A S T Y RHYTIDECTOMY – LOWER LID

A

B

C

D

E Figure 6-1 Rhytidectomy of the lower lid may be achieved without raising a cutaneous or myocutaneous flap. A, An incision is first placed in a lateral fold or potential fold. B, The incision is completed lateral to medial, and I prefer to develop the inferior aspect of the pretarsal postorbicularis in continuity with the superior aspect of the preseptal space. C, Lateral and cephalic traction is applied to the orbicularis muscle near its raphe, and a wedge resection is performed. D, The cut edges of the muscle are approximated with sutures. E, Skin is separately addressed, again invoking the lateral and superior vectors as shown previously.

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A Figure 6-2 A, The ideal candidate for transconjunctival blepharoplasty is the youthful person without midface ptosis; and, therefore, the orbital rim is not visualized in relief. The orbital septum is convex, but there is not sufficient skin redundancy to require skin redraping. Small skin changes may be involved with a trim or laser. A 38-year-old woman presented with upper and lower lid age-related changes. Her mid face is in relatively good position, and the lower lid skin changes are subtle enough not to require a major redraping. She underwent a conservative transconjunctival blepharoplasty and erbium laser procedure of her lower lids. A standard upper lid blepharoplasty was performed Continued (preoperative view—left; postoperative view at 1 year—right).

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T R A N S C O N J U N C T I VA L LO W E R L I D B L E P H A R O P L A S T Y

B

C Figure 6-2 Continued B, A younger woman presented with herniated fat and Graves' disease. She had no appreciable midface ptosis but a prominent convexity to her lower lids with skin changes. She underwent a lower transconjunctival blepharoplasty without any skin procedures (i.e., laser, trim) and an upper lid blepharoplasty (preoperative view—left; postoperative view—right). C, This is in distinction to the case in which there is a convexity to the orbital septum but with significant rhytids and redundancy of the lower lid skin. This is usually associated with some degree of midface ptosis. Although fat may be removed or repositioned in these cases by the transconjunctival route, the skin and muscle are in need of redraping and positional reorientation (lateral cephalic vector) especially when the midface unit is suspended (preoperative view—left; postoperative view—right).

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SURGICAL TECHNIQUE The well-executed transconjunctival blepharoplasty, like the transcutaneous lower lid blepharoplasty, requires a few key steps that are predicated on anatomic points already discussed. The procedure does not require delineated surgical markings. Once the patient is appropriately sedated, topical anesthetic (tetracaine) may be instilled into the conjunctival sac. A protective contact lens may then be placed, or the surgeon may choose to use an autologous contact lens created by the elevated conjunctival flap. In the latter case, care must be taken at the initial part of the procedure to protect the cornea and eyeball during local anesthesia infiltration and the initial dissection. Local anesthetic of choice containing epinephrine may be infiltrated with a small needle (27 to 30 gauge) preferably by way of the transconjunctival route with the lower lid either everted with slight digital pressure placed on the inferior tarsus or with light traction with an instrument such as a Desmarres retractor. Once adequate time for hemostasis is allowed to elapse, the conjunctiva and lower lid retractors are grasped near the central cul-de-sac or fornix with a tooth forceps and engaged with a traction suture. I prefer to use a 5-0 fast absorbing catgut suture that will be recycled for conjunctival closure at the end of the

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procedure. The lower lid is everted with a small eyelid hook, and a transconjunctival incision is made just below the tarsal plate with the conjunctiva and lower lid placed on cephalic traction. I prefer to use a needle cautery throughout this procedure and do not use scissors or scalpels. Once the lower lid retractors are disinserted from the tarsal plate, the eyelid hook is removed and a Desmarres retractor inserted to engage the lower edge of the tarsal plate. I prefer an insulated or plastic instrument to diminish the possibility of cautery burn injuries. Traction is placed cephalad and anteriorly, and dissection is carried out in front of the orbital septum, in the preseptal postorbicularis plane, down to the orbital rim. This is exactly the plane that is developed in the transcutaneous blepharoplasty, but it is accessed differently. At this juncture, the surgeon should be able to visualize an intact orbital septum, orbital rim, and suborbital tissues, including the malar fat pad, and so on. Dissection may be carried out inferiorly either in a supraperiosteal or subperiosteal plane should the surgeon desire to execute other adjuvant procedures or effect change in other areas of the face. The orbital septum may then be incised by a wide transverse midseptal incision, or three distinct openings in the orbital septum may be created to access underlying fat compartments (Fig. 6-3). In either case, the inferior oblique muscle should be visualized


and protected, lying between the medial and central fat pads. A total transverse septal incision is preferred, especially in fat redraping, to avoid tethering or strangulation of the fat pedicle through a narrowed orbital septal opening. In fat resection, conservative resection of spontaneously herniated tissue is most appropriate, and, again, special attention should be directed toward the lateral fat compartment, which is usually under or inappropriately addressed. These are concepts that are shared with the transcutaneous route and have already been described. Hemostasis is usually spontaneous and complete when this procedure is executed appropriately. Closure requires only cutting the traction suture and allowing the conjunctival flap, which was cephalically draped over the cornea or contact lens surface, to spontaneously retract. The conjunctiva may then be apposed with a single interrupted small absorbable suture (5-0 fast absorbing catgut suture) lateral to the corneal surface (Fig. 6-4). Care should be taken to engage only the conjunctiva and not the underlying Tenon capsule, because this may lead to postoperative pyogenic granulomas. I prefer to approximate the conjunctiva because this eliminates Tenon cysts or pyogenic granulomas in my hands. The surgeon may then initiate

a skin tightening procedure such as laser or marginal skin trim. I find it advantageous to use a topical antibiotic drop containing a corticosteroid (e.g., TobraDex [dexamethasone/tobramycin/chlorobutanol] or Blephamide [prednisolone/sulfacetamide]) in the postoperative period when not contraindicated by corticosteroid-responsive glaucoma or other conditions. Low-dose corticosteroid-containing drops and ointments tend to lessen the postoperative chemosis or conjunctival edema and appear to shorten the recovery process.

P E A R LS A N D P I T FA L LS 1. A cephalic traction suture on the conjunctiva allows easy access to the post-orbicularis space. 2. The orbital septum should be visualized to the orbital rim and the inferior oblique muscle should be seen and preserved after the septum is incised. 3. Access to the lower fat pads requires disinsertion of the lower lid retractors. 4. Steroid-containing eyedrops postoperatively can be useful in lessening chemosis. 5. Topical steroids can raise intraocular pressure significantly. Lower concentrations (0.1%) of fluorinated preparations (i.e., FML) are least likely to do so.

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY TRANSCONJUNCTIVAL SURGICAL APPROACHES Retroseptal Approach Preseptal (suborbicularis) Approach

Nonconductive retractor

A

B

Conjunctiva is tented and secured with a stay suture

Conjunctiva is divided longitudinally just below tarsal plate

Nasal

Orbital septum

Inferior tarsal plate

Figure 6-3 The transconjunctival approach to the retroseptal space may be in one of two ways: preseptal or retroseptal (top). By far the most controlled and anatomically consistent is the preseptal route. In either case an insulated retractor (e.g., Desmarres) is extremely useful. The retroseptal route entails simply incising the conjunctiva and cutting through the lower lid retractors into the postseptal space (dotted lines). The preseptal route requires entry into the postorbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum. This will allow direct visualization of the septum, and each fat pad can be addressed separately in a controlled fashion. To expediently achieve this, a few simple steps are necessary. A protective lens may be used. A, A conjunctival stay suture is placed deep in the fornix and traction is applied superiorly while the lid margin is everted. This causes the inferior edge of the tarsal plate to rise toward the surgeon. B, The conjunctiva and lower lid retractors are incised just below the tarsal plate entering the postorbicularis preseptal space. This plane is developed to the orbital rim Continued with the assistance of the traction suture and a nonconductive instrument.

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Conjunctiva retracted superiorly

Nasal

C

Orbital septum opened Lateral, central and medial fat pads (left to right)

D1

E

Remove fat pads if they bulge

D2

Reposition fat pads transconjunctivally

One internal suture in conjunctiva lateral to cornea

Figure 6-3 Continued C, The orbital septum may then be widely incised or punctured and the inferior oblique muscle identified and preserved. D1 and D2, The fat pads may be addressed individually in keeping with preoperative plans with either resection, repositioning, conservation, or any combination of these techniques. In repositioning, I prefer a supraperiosteal tunnel with a temporary transcutaneous stay suture to maintain the proper location. E, A single absorbable closure suture is useful in avoiding Tenon inclusion cysts. It should be placed laterally to avoid postoperative complaints of corneal irritation.

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A

B

Figure 6-4 The surgical sequence for transconjunctival access to the retroseptal space requires appropriate traction and exposure and can be applied for fat resection, repositioning, and in medial midface exposure. The technique is also useful for bone exposure in trauma and/or elective osteotomies. When the procedure is properly executed, the preseptal postorbicularis plane may be rapidly exposed to the orbital rim and the surgeon may then perform whatever procedure is deemed necessary. A, Lid eversion with wand traction using a small hook (I prefer double to avoid traction injury to the lid margin) allows exposure of the conjunctival fornix. A traction suture is placed here (plain gut). B, Needle-tip cautery is used to dissect the preseptal postorbicularis plane down to the orbital rim. Note: the orbital septum is left intact with fat pads visualized. Continued

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D

C

E Figure 6-4 Continued C, The orbital septum may then be selectively incised and fat addressed, or the orbital rim may serve as a juncture point for midface adjustments. Here the medial fat pad is delineated by a curved hemostat. The fat pad is seen lying on the insulated retractor as it is teased anteriorly. This may be used for redraping in a fat preservation procedure. D, The inferior oblique muscle should be identified and preserved as it divides the medial from the central fat pads. E, Conjunctiva is closed with a single interrupted plain gut suture placed lateral to the cornea. Skin may be addressed with a rhytidectomy or other procedure (see Fig. 6-1).

References Eremia S, Newman N: Use of an insulated ultrafine-point electrocautery for transconjunctival blepharoplasty of the lower eyelids. Dermatol Surg 27:1052-1054, 2001. Ghabrial R, Lisman RD, Kane MA, et al: Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg 102:1219-1225, 1998. Kavouni A, Stanek JJ: Lower eyelid cysts following transconjunctival blepharoplasty. Plast Reconstr Surg 109:400401, 2002.

Seckel BR, Kovanda CJ, Cetrulo CL Jr, et al: Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: A safe and advantageous technique. Plast Reconstr Surg 106:1127-1141, 2000. Zarem HA, Resnick JI, Stuzin JM: Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg 103:1041-1045, 1999.

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CHAPTER SEVEN

Tarsal Tuck and Fat Redistribution As mentioned in Chapter 3, horizontal laxity of the lower eyelid may be addressed with plication of the lateral tarsus or the lateral canthal tendinous complex. This is best approached by means of a transcutaneous approach and is only useful in addressing milder degrees of lower lid laxity. In addition to this limitation, it can produce canthal rounding and anterior displacement of the commissure and lateral lower eyelid, unless stable fixation to orbital periosteum is achieved. Distribution of the lower lid redundancy against a fixed upper lid and canthus becomes difficult and tedious. Therefore, it is only useful in mild degrees of laxity and should be considered in the same category as any procedure that does not mobilize the lateral canthus, such as cephalic lateral orbicularis suspension or transblepharoplasty canthal suspension (canthopexy) without lysis and mobilization of the lateral retinaculum (see Fig. 3-8). Fat redistribution is a more useful adjuvant procedure in blepharoplasty. This is a powerful technique that addresses the atrophy and ptosis associated with agerelated changes or senescence along the orbital malar junction. Specifically, the malar fat pad becomes ptotic and there is an associated fat atrophy with nasojugal and orbital malar depressions (medial and lateral), resulting in prominence of the orbital rim and visualization of that structure in relief. Although there is associated pseudoherniation of orbital fat owing to septal laxity, simply resecting orbital fat only serves to further accentuate the orbital malar discrepancy instead of rejuvenating the patient's appearance. Some younger individuals present with accentuated atrophy along the orbital malar and nasojugal region without significant orbital fat prominence. These persons have early cheek ptosis and are not yet candidates for midface elevation by facialplasty or other routes, but they may be good candidates for orbital fat repositioning (Fig. 7-1).

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ORBITAL FAT REPOSITIONING TECHNIQUE Orbital fat repositioning requires atraumatic anterior translocation of postseptal orbital fat. Orbital fat is accessed by either the transcutaneous or the transconjunctival route, depending on predetermined factors. Once the orbital septum and orbital rim margin is exposed, supraperiosteal dissection is carried out over the areas for fat deposition. These areas should be delineated with a surgical marking pen while the patient is awake and standing or sitting. Once the orbital rim is exposed, limited soft tissue exposure is preferred so as not to further destabilize malar support and warrant formal suspension. Suborbicularis, subcutaneous, or supraperiosteal dissection is carried out by creating a tunnel with a small scissor or hemostat. The tunnel and pocket that is created should be limited only to the extent of fat that must be passed and the defect that one intends to fill. I prefer the plane of dissection to convert from suborbicularis to supraperiosteal at the arcus marginalis. The septal opening and tunnel should be of adequate size to obviate ischemic necrosis. The orbital fat is teased from its respective compartment (usually the medial and lateral) and by means of a transcutaneous suture engaged and fixed into position. I prefer to place the transcutaneous suture through the skin into the dissection plane where the orbital fat is dissected, engage the desired fat for repositioning, and then pass the suture back through the cutaneous surface to be loosely tied. This technique is similar to cutaneously fixing cartilage grafts, and so on, onto the dorsal nasal surface. The temporary suture is left in place approximately 1 week and then removed. Alternatively, the fat may be fixed to the orbital or malar periosteal surface;

TA R S A L T U C K A N D FA T R E D I S T R I B U T I O N

A

B Figure 7-1 A, A 39-year-old woman presented with complaints of lower lid cheek junction depressions (nasojugal, orbital malar). She also complained of lower lid darkness or pigment. She does not have significant orbital fat prominence. B, Appearance 1 year postoperatively after orbital fat repositioning over the orbital rim by way of a transconjunctival route and erbium laser treatment. Note the subtle improvement in depressions and decreased pigment to the lower eyelid. The inferior orbital rim is less visualized in relief.

however, more extensive soft tissue dissection is usually necessary and exact positioning of the fat within the area of intended filling is less optimal. Fat may be redistributed in one compartment and selectively removed in another in any combination deemed appropriate for each patient. The incisions are closed as described in

Chapter 5. Skin may be addressed with either a marginal trim or laser procedure, which is another reason for limiting the extent of subcutaneous tunneling or dissection (i.e., devascularization and compromise) (see Fig. 3-8).

References P E A R LS A N D P I T FA L LS 1. The tarsal tuck procedure is only useful in mild lid redundancy and can produce a buckled lower lid. It is, however, readily accessible as a procedure in lower lid transcutaneous blepharoplasty. 2. Orbital fat repositioning can be useful in addressing depressions along the orbit–mid face junction; however, there are volumetric limitations. 3. Various planes for fat repositioning may be chosen, but I prefer the suborbicularis to the supraperiosteal plane, converting at the arcus marginalis. 4. The septal opening and tunnel need to be large enough to obviate ischemic necrosis.

Anderson RL, Jordan DR: The tarsal tuck procedure: Avoiding eyelid retraction after lower blepharoplasty. Plast Reconstr Surg 104:284-285; discussion 286, 1999. Coleman SR: Structural fat grafts: The ideal filler? Clin Plast Surg 28:111-119, 2001. Goldberg RA: Transconjunctival orbital fat repositioning: Transposition of orbital fat pedicles into subperiosteal pocket. Plast Reconstr Surg 105:743-748; discussion 749751, 2000. Turk JB, Goldman A: SOOF lift and lateral retinacular canthoplasty. Facial Plastic Surg 17:37-48, 2001. Von Heimburg D, Pallua N: Two-year histological outcome of facial lipofilling. Ann Plast Surg 46:644-646, 2001.

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CHAPTER EIGHT

Ptosis and Upper Eyelid Retraction The evaluation and management of the patient with eyelid ptosis requires an especially careful history and repeated examinations to corroborate the extent of levator function and the degree of ptosis. One should possess facile knowledge of common conditions that may present as the ptotic eyelid and various methods for addressing them. For the purpose of simplicity and practicality, I will attempt to present the more commonly encountered entities that present as ptosis and a logical way of reliably approaching them. For the purpose of understanding this chapter and logically applying this information to patients, ptosis is defined as an abnormal drooping of the upper eyelid so that it lies below the normal anatomic position when secondary compensatory muscular action is not initiated. This may occur as a component of a syndrome or as an isolated finding secondary to a mechanical, neurogenic, or other disorder.

EVALUATION OF THE PATIENT WITH PTOSIS Eyelid ptosis, when present in syndromes, usually occurs with concomitant neurologic findings, including dysphagia, diplopia, or facial myoneuropathies, such as myasthenia gravis or other conditions. Ptosis associated with pupillary miosis or constricted pupil and anhidrosis suggests a sympathetic lesion associated with Horner’s syndrome. Ptosis associated with mydriasis or a dilated pupil along with diplopia suggests a palsy of the third cranial nerve. Ptosis associated with proptosis of the globe suggests an orbital tumor or infiltrating disease of the orbit. Multiple congenital syndromes, such as the blepharophimosis syndrome, which is asso92

ciated with bilateral ptosis, blepharophimosis, telecanthus, epicanthus inversus, and lower lid ectropion, are rare. True ptosis as an intrinsic isolated entity should be discriminated from pseudoptosis. The latter is a mechanical condition other than impairment of the upper eyelid retractor complex (levator palpebrae superioris muscle and Müller’s muscle) and can be confused with the former, especially when the patient is examined in a cursory fashion. Conditions that can mimic ptosis but that are mechanical include severe dermatochalasis with or without associated brow ptosis, hypertropia (elevation of the eyeball), blepharospasm or increased hemifacial tone, and enophthalmos, in which the affected eyeball is retrodisplaced with the upper eyelid draping over the anterior corneal surface in a lower position compared with the contralateral side. This is frequently seen in post-traumatic orbital fractures or in erosive lesions of the bony orbit that effectively increase orbital volume. Small degrees of pseudoptosis caused by orbital volume discrepancies may be addressed in a similar fashion to that of isolated true ptosis; however, the surgeon should understand that this is a “masking procedure” and with this approach the underlying pathophysiology is not specifically addressed. In severe cases of enophthalmos, procedures that alter orbital volume are indicated and are described in Chapter 11 (Fig. 8-1). Once the ptosis is determined to be an isolated intrinsic condition related to impairment of the upper eyelid retractor system, it should then be classified as to whether it is acquired or congenital. It is helpful to obtain a detailed history and view old photographs in making this determination. A history of trauma, a complicated or forceps delivery, an episode or repeated episodes of intense orbital swelling, and even cataract surgery are usually salient and indicate the cause of ptosis to be levator aponeurotic dehiscence.

P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N

Figure 8-1 The cause of ptosis of the upper eyelid is frequently ascertained by examination alone. A and B, The signs of levator dehiscence including a superior sulcus deformity, high or absent lid crease, and good levator function are typical in older individuals or those who have sustained trauma. The man shown here underwent a previous left cataract extraction. The woman has left greater than right levator dehiscence with compensatory eyebrow elevation. The etiology is likely age-related attenuation of the levator insertion. Sometimes blepharochalasis and fat herniation can mask the classic signs of levator dehiscence. C and D, Congenital ptosis usually presents as an absent lid fold and lid lag (lagophthalmos). This 18-month-old boy has moderate left congenital ptosis and no lid fold and on down gaze demonstrates lid lag. E and F, Enophthalmos may cause pseudoptosis. In this case a previous zygoma and orbital fracture has created enophthalmos, with the upper eyelid draping over the eye in a more inferior location. The computed tomographic scan demonstrates a malpositioned left zygoma and disproportionately large orbital volume compared with the contralateral right side. The lower lid on the left is pulled inferiorly by septal attachments to the malpositioned zygoma. Similarly, the left lateral canthus shows inferior dystopia. Appropriate correction of this ptosis requires osteotomies and repositioning of the zygoma. In small degrees of ptosis secondary to enophthalmos, a soft tissue masking procedure may suffice.

A

B

C

D

E

F 93


Congenital ptosis is caused by poor development of the levator palpebrae superioris muscle. The patient presents with a long-term history of ptosis associated with lid lag on down gaze caused by fibrotic replacement of levator muscle fibers. Acquired ptosis may be mechanical, myopathic, or neurogenic, but by far the most common cause of acquired ptosis is disinsertion or dehiscence of the levator aponeurosis from the tarsal plate. This may occur as a senescent or age-related change or after intense swelling, surgery for cataracts, or blunt or penetrating injuries. As in all areas of the body, gross observation and careful physical examination are paramount in diagnosing and treating the patient correctly. This can be performed quickly and accurately as time and experience are accrued. Initially, the presence or absence of ptosis should be noted on gross examination. A comparison should be made between each side concerning the upper lid position vis-à-vis the iris and pupillary aperture. Obviously, to properly make this comparison, the pupillary aperture should be the same and pupils should react similarly to light. In third nerve palsies and Horner’s syndrome this is not the case. Several gross but reliable modalities for assessing upper lid ptosis have been described. These include the corneal light reflex distance, which is defined as the distance between the corneal light reflex and the upper lid margin at its mid position. This distance usually is between 3.0 and 4.5 mm. Another useful test is to examine the position of the upper lid vis-à-vis the limbus or corneoscleral junction and the pupillary aperture. A normal upper eyelid should bisect the distance between the limbus and the pupillary aperture. The distance between the upper and lower lids or the vertical interpalpebral distance in the mid position is the least useful tool. This assessment can be influenced by lower lid position and is generally not a true measure of upper lid position. Bear in mind that proper assessment of upper lid position using these tools requires that both eyeballs are in alignment (e.g., absence of hypertropia). Ocular malalignment distorts the pupillary eyelid relationship, which is the backbone of most of these assessment tools.

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The key point is to examine the patient and appreciate gross topographic differences or surface deviations from normal before embarking on a detailed and intricate analysis. For instance, look for symmetry or absence of symmetry between the two upper eyelids and the presence and degree of prominence of the lid crease and its relationship to the eyelid margin. The upper eyelid crease is usually 7 to 9 mm above the lash line and an elevated and/or ill-defined eyelid crease usually suggests disinsertion of the levator aponeurosis. A superior sulcus deformity or asymmetry in the lid fold and sulcus usually indicates differences in the position of the preaponeurotic fat pad. This occurs because the preaponeurotic fat pad is loosely but definitively tethered to the anterior surface of the levator aponeurosis. Disinsertion of the levator aponeurosis and retraction from the tarsal plate causes the preaponeurotic fat pad to ride posteriorly within the orbital rim along with the retracted levator aponeurosis. This results in creation of a superior sulcus deformity or diminution in the upper eyelid fold. These findings are characteristic of involutional ptosis or post-traumatic levator dehiscence. The presence of lid lag or lagophthalmos may be noted by having the patient look up and down. Inability to completely cover the globe in down gaze, despite inadequate lid elevation on primary gaze, is associated with congenital ptosis. Unilateral lagophthalmos is more easily discernible than bilateral lid lag on attempted closure. The patient should demonstrate adequate orbicularis motor function by forcibly closing his or her eyes against resistance. Significant weakness in the orbicularis muscle may suggest a myopathic problem and, more importantly, these patients are very poor candidates for ptosis correction because their ptotic eyelid is protective and necessary to achieve adequate corneal coverage and wetting. Any attempt at elevation of their ptotic eyelids may produce severe lagophthalmos or an inability to completely cover their corneas. These patients can develop significant postoperative problems, and the lid lag is difficult to correct. Always have the patient perform ocular versions by looking up, down, left, and right and obliquely up and down. Changes in lid position with extraocular motion suggest


aberrant regeneration of the third cranial nerve. Chronic external ophthalmoplegia presents as limitation of extraocular muscle activity or versions. Have the patient open and close the mouth and sublux the jaw laterally looking for eyelid position. Marcus-Gunn jaw-winking phenomenon or aberrant regeneration of the facial nerve may be discriminated from isolated impairment of the upper eyelid retractor system using this method. A Schirmer test is indicated in all patients in whom a ptosis procedure is planned. A significant compromise in tear production can militate against performing a surgical lid elevation, or a ptosis procedure may have to be modified to obviate excessive evaporative tear loss. Adequate eyeball wetting is not only dependent on tear production and tear quality but also on ambient evaporative loss. The amount of evaporative tear loss will increase with ptosis correction owing to greater ambient eyeball exposure, yet tear production will remain the same. This may tip the patient over into a dry eye syndrome, with its attendant symptoms and complications. Once a diagnosis in surgically appropriate patients is identified by way of an organized screening process, then a more detailed examination of levator function should be undertaken. I will discuss this in more detail to simplify the evaluation and describe several appropriate procedures that can be logically applied.

MEASUREMENT OF LEVATOR FUNCTION Once a mechanical or isolated ptosis has been diagnosed then the most important determinant of which procedure to perform depends on two factors: (1) degree of ptosis and (2) amount of levator function. I prefer to evaluate the degree of ptosis based on it being mild, moderate, or severe. Mild ptosis is less than 2 to 3 mm, moderate ptosis is 3 to 5 mm, and ptosis of 5 mm or more is severe. An even more important factor in deciding on the best procedure is the assessment of

levator function. Levator function determines which, if any, upper eyelid retractor complex tightening procedures will work. These include levator advancement, levator tuck, levator resection, müllerectomy, and tarsal conjunctival müllerectomy (Fasanella-Servat procedures). It becomes necessary to utilize exogenous lid elevators such as the frontalis sling procedure when levator function is poor. These procedures incorporate or utilize muscles other than the primary upper eyelid retractor system to serve as upper lid elevators.

ASSESSING LEVATOR FUNCTION Levator function is the single most important determinant of the likely cause for eyelid ptosis (i.e., neuromuscular vs. involutional or senescent) and the appropriate surgical approach for its correction. Because levator function may vary temporally, based on circulating catecholamines and other factors, it is best to evaluate levator function on at least two separate occasions to corroborate the initial findings. Levator function is established by measuring excursion of the upper eyelid as it moves from down gaze to complete up gaze with the eyebrow fixed by the examiner to prevent any transmission of forces from the frontalis muscle to the upper eyelid. The patient may be asked to look straight ahead with the brow fixed so that primary lid aperture is established. The lid aperture is then measured in extreme up gaze followed by down gaze. The difference in the lid aperture between extreme up gaze and extreme down gaze with the brows fixed is a measure of levator excursion or function and is usually greater than 12 mm in the normal individual. Levator excursion or function can usually be divided into poor, fair, and good categories, with less than 5 mm being poor, 6 to 9 being fair, and 10 to 15 mm being good. Analogously, as already described, the degree of ptosis may be assessed and divided into three categories: mild (1 to 2 mm), moderate (3 to 5 mm), and severe (greater than 5 mm) (Figs. 8-2 and 8-3).

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY ASSESSING LEVATOR FUNCTION

Primary Gaze Levator aperture Degree of ptosis: mild/moderate/severe Clear ruler

Levator Excursion

Up Gaze Levator aperture

Down Gaze Levator aperture

Figure 8-2 Levator function can be assessed through the measurement of upper eyelid excursion. That combined with a measurement of the degree or extent of ptosis allows the surgeon to choose the best procedure for each patient. The degree of ptosis is best noted using a clear ruler held in front of the eyelid to be assessed. The measurement in millimeters while in primary gaze will give the aperture of the affected eye, and this may be compared with the unaffected side. The difference is the amount of ptosis, and this may be classified as mild, moderate, or severe. Grossly, one may assess the degree of ptosis by noting the position of the upper eyelid in relation to the iris and pupil. The upper lid margin is normally at the level of a line that bisects the distance between the upper aspect of the pupillary aperture and the iris. One can assess the number of millimeters the ptotic eyelid lies below that line, with mild being 1 to 2 mm, moderate 3 to 5 mm, and severe greater than 5 mm. Levator function, as measured by eyelid excursion, is then recorded by having the patient look up and then down. The difference between the apertures in extreme up gaze and down gaze indicates the extent of levator function. A significant aperture in down gaze (lagophthalmos) may be an indication of infiltrative disease (i.e., Graves’ disease) or a fibrotic process (i.e., congenital). In all measurements of aperture and levator function, the eyebrow should be immobilized by the examiner to eliminate compensatory brow contribution to upper eyelid elevation (note the examiner’s finger over brow in drawing).

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A

B

C Figure 8-3 Clinical example of levator function assessment. The lid aperture is measured in primary gaze (A). The aperture is measured in up gaze (B) and then down gaze (C). The aperture in primary gaze, in this case 12 mm, can be compared with the opposite side and is a measure of the degree of ptosis. The difference between up gaze (14 mm) and down gaze (2 mm) is a measure of levator excursion and function.

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CHOICE OF PROCEDURE The surgeon may then choose an appropriate procedure based on these two key assessments: levator excursion or function and the degree of ptosis. Any upper lid retractor tightening procedure (i.e., levator advancement, levator resection, levator tuck, müllerectomy, or a tarsal conjunctival müllerectomy [Fasanella-Servat]) are all appropriate procedures when levator function is good. Levator advancement is by far the most powerful technique for correcting larger degrees of ptosis. All other procedures have limitations and, when applied to larger degrees of ptosis, result in untoward sequelae. Therefore, posterior lamella shortening (i.e., müllerectomy, Fasanella-Servat) and other procedures are indicated only in mild degrees of ptosis. In the case of the müllerectomy procedure alone, the best candidates are those with good to excellent levator function, those with mild degrees of ptosis, and those who respond to topical instillation of phenylephrine. The FasanellaServat operation is also indicated in mild degrees of ptosis, and this operation effectively shortens the entire posterior lamella of the upper lid by resecting Müller’s muscle, superior tarsal plate, and conjunctiva. It has similar indications to the müllerectomy alone and, in my opinion, is a more powerful technique for correcting ptosis. It does, however, have greater disadvantages, including an inability to provide graduated tension on

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the lid retractors. It decreases wetting surface over the cornea and may produce corneal irritation secondary to exposed sutures. In addition, symmetric upper lid contour may be distorted by this procedure. Therefore, although I will describe the procedure for tarsal conjunctival müllerectomy (Fasanella-Servat), I recommend that all surgeons become familiar with levator aponeurosis plication or tuck, with or without resection, as well as levator advancement procedures. All of these techniques may be performed alone or in combination with various cosmetic procedures, especially upper lid blepharoplasty. The just-mentioned procedures are all indicated in patients who have an intact endogenous lid elevator mechanism. In cases in which levator function is extremely poor or absent, use of exogenous muscles, such as the frontalis muscle sling procedures, is of most benefit. Patients with congenital ptosis usually present with significant degrees of ptosis, poor to absent levator function, and significant lid lag on down gaze. These patients have a fibrotic contraction of a relatively atonic levator muscle and have the characteristic combination of significant ptosis associated with significant lid lag or corneal exposure on down gaze. As always, one should be cognizant of the patient’s ability to adequately wet their corneal surface. Elevation of the lid with ptosis correction will produce increased evaporative tear loss, and this could therefore serve to trade one symptom (ptosis) for another (dry eye syndrome). Of course, in


cases in which profound symptomatic ptosis is present in combination with borderline or frank dry eyes, obliteration or limitation of tear drainage with punctal occlusion or plugs can be considered at the time of ptosis correction. The ptosis should be undercorrected in an attempt to diminish the loss of tears by way of evaporation.

PTOSIS PROCEDURES Tarsal Conjunctival Müllerectomy (Fasanella-Servat Operation) The Fasanella-Servat procedure is a simple posterior approach to mild degrees of ptosis. It is important to achieve proper anesthesia without soft tissue distortion. Topical ophthalmic anesthetic (i.e., tetracaine) is instilled, local anesthetic is infiltrated, and adequate time for hemostasis is allowed to elapse. The upper eyelid is everted, and the tarsal plate along with the overlying conjunctiva and Müller’s muscle is engaged with a forceps. The everted tarsal plate and associated soft tissue are clamped at its most superior extent utilizing two identical curved clamps. A cuff of 3 to 4 mm of tarsal plate is left above the clamps. It is important to visualize the sweeping contour of the upper lid and

mimic this contour with clamp placement, adjusting the “heel and toe” of each clamp accordingly. Once this is accomplished, a monofilament nonabsorbable suture (i.e., 4-0 or 5-0 Prolene) is brought through the skin surface at the lateral external eyelid crease. The suture is brought into the conjunctival surface of the everted eyelid and woven from lateral to medial beneath the clamps in a horizontal mattress fashion. Once the suture is brought to the most medial extent of the clamped tarsal surface, it is brought back out through the skin surface. The soft tissue above the clamps (tarsus, conjunctiva, and Müller’s muscle) can be removed with a scissor or scalpel and the eyelid reverted. The lateral medial elements of the suture may be tied to each other loosely, and it is helpful to smooth the undersurface of the eyelid with a blunt instrument to diminish postoperative corneal irritation. No other closure is necessary, and the suture may remain in place for 1 to 2 weeks. In cases in which slight undercorrection has been achieved, it is useful to leave the suture in place for longer than 2 weeks, and the reverse is true in slight overcorrection. Early removal of the suture, frequent massage, and downward traction on the upper eyelid may also serve to improve slight overcorrection in this procedure. Because the wetting surface of the eyelid is decreased in this procedure, patients with dry eye syndrome or decreased tear production may be better served by direct levator procedures (Figs. 8-4 and 8-5).

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY TARSAL CONJUNCTIVAL MÜLLERECTOMY

Mild upper lid ptosis, 1-2 mm.

Figure 8-4 The tarsal conjunctival müllerectomy or Fasanella-Servat procedure is one of the more simple procedures that reliably corrects mild to lesser degrees of moderate ptosis (i.e., 1 to 2 mm). The procedure shortens the entire posterior lamella of the upper lid, including the tarsal plate, Müller’s muscle, and conjunctiva. A, After topical anesthetic is applied and local anesthetic is infiltrated, the upper eyelid is everted. Small curved identical clamps are used to engage the tarsal complex. A monofilament suture is passed from the skin onto the conjunctival surface and woven below the clamps from lateral to medial. It is helpful to manipulate the clamps as a unit, without disengaging the tarsal complex (toward the surgeon when passing the needle from posterior to anterior and away from the surgeon when passing in the other direction [insert]). B, The excess tissue above the suture line may then be resected with or without the clamps in place, after the suture is passed back onto the skin surface of the medial lid. C, Its suture ends are tied to each other after the eyelid is reverted. Slack should be left in the suture to prevent cheese wiring, and I like to apply a Steri-strip to prevent the suture from falling onto the eyeball when the patient ambulates. Although the procedure is straightforward from a technical standpoint, the selection of clamps (i.e., degree of curvature), clamp positioning (i.e., amount of tarsus engaged), and the clamp angulation (tip-to-heel angulation) all play an important role in determining the results achieved in the tarsal conjunctival müllerectomy.

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Cross section of suture placement

A

Running suture (full thickness) behind clamps, lateral to medial

B

C

Trim excess clamped tissue

Closure – suture tied on skin surface and covered with Steri-Strip


A

B

Figure 8-5 The proper execution of the relatively straightforward tarsal conjunctival müllerectomy (Fasanella-Servat) requires choosing the correct patient to begin with. This is one with good levator function and mild ptosis. After topical and local anesthetics are utilized, the ptotic upper lid is everted with a Desmarres retractor or other atraumatic instrument. The proximal edge of the tarsal plate now lies superior or distal. I prefer to stabilize the middle superior aspect of the tarsus with a tooth forceps (A) and then precisely place two matching curved clamps (one nasal and one temporal) across the tarsal plate, Müller’s muscle, and conjunctiva (B). The clamps, whose tips meet in the midline of the tarsus, should engender a soft sweeping curve, because this will eventually be the shape of the corrected upper eyelid. A single suture is then woven below the clamps entering and exiting the skin surface at entry and exit points, before amputations of the tissue above the clamps. The procedure is rapid and less daunting compared with levator procedures; however, great care and artful placement of the clamps is necessary to achieve a satisfactory result. Contour irregularities and overcorrections are difficult to correct. (In this patient, the upper lid was also used for a skin graft donor site.)

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Levator Tuck with or without Resection In mild to smaller degrees of moderate ptosis with good-to-excellent levator function, one may use a simple anterior approach to the levator aponeurosis that does not require extensive dissection. The redundant aponeurotic tissue is plicated or tucked. The redundant tissue above the suture line may be resected to avoid subcutaneous bulk. The procedure is carried out by performing an anterior cutaneous lid incision along the desired eyelid crease after local anesthetic with epinephrine is infiltrated and adequate time for hemostasis is allowed to elapse. Dissection is carried down to the levator aponeurosis after skin and orbicularis muscle is incised. The dissection should be carried cephalad along the levator aponeurosis, and the orbital septum should be incised, allowing visualization of the preaponeurotic fat pad. Distally, dissection is carried down to the superior border of the tarsal plate. The levator aponeurosis may be plicated at a level cephalad to the tarsal plate with an absorbable suture (i.e., 5-0 Vicryl). Generally, one chooses the medial aspect of the pupil as the apex of eyelid curvature and a plication suture is placed at this point. Two other plication sutures may be placed medially and laterally to this central suture, visualizing the anatomic sweep of the upper eyelid. Closure may be performed as in an upper lid blepharoplasty. Alternatively, the cuff of levator aponeurosis left after plication or tuck may be resected, being careful to leave the suture line intact. This is especially useful when larger cuffs are created in the treatment of larger degrees of ptosis. Larger cuffs may leave a cosmetically visible and palpable firmness to the upper lid behind, and these tend to obscure upper sulcus definition. Care should be taken to firmly and reliably plicate the underlying levator aponeurosis before resection of the overlying cuff to avoid dehiscence and postoperative ptosis. A one-to-one millimeter plication for the degree of ptosis is generally ideal. The patient may be seated upright for assessment of levator excursion and adequacy of ptosis correction before the levator aponeurosis is resected above the suture line. One must remember that the epinephrine that is infiltrated will cause some correction of ptosis by way of stimulation of Müller’s muscle (see Fig. 4-6).

Levator Advancement The levator advancement procedure is by far the most powerful technique for the correction of ptosis in 102

patients who have good-to-excellent levator function no matter how severe their ptosis. This technique may be applied in congenital ptosis when there is fair-to-good levator function. In distinction to levator plication with or without resection, this procedure involves more extensive dissection with complete mobilization of the levator aponeurosis from the tarsal plate, lysis of both the medial and lateral levator excursions (horns), and dissection carried cephalad into the orbit behind the septum. In this procedure the distal aponeurosis is resected after appropriate advancement and fixation to the superior tarsal plate. In cases of disinsertion of the levator aponeurosis or involutional ptosis (senescent ptosis) the levator aponeurosis may be freed from its other tethering points (as described earlier) and simply advanced without resection of the distal aponeurosis. In cases in which the lid crease is not well defined or deficient (i.e., involutional ptosis or congenital ptosis with adequate levator function), the lid crease may be defined at an appropriately chosen level with supratarsal fixation, which will be further delineated and has already been mentioned. I prefer the patient to be lightly sedated whenever possible to maintain his or her cooperation. Local anesthetic infiltration should be minimized to avoid soft tissue distortion and compromise of levator function. It is best that the patient become maximally cooperative once the adjustment stage of the procedure is performed. Skin resection may be performed as in an upper lid blepharoplasty, and the degree of skin excision is chosen as described in Chapter 4. Residual excess skin after the correction of ptosis can result in a prominent lid fold, distortion of eyelashes, and, in extreme cases, the creation of entropion. In cases of mild skin excess after a lid elevation procedure, a secondary skin resection can be performed later after swelling dissipates. I always try to defer significant skin resections after a ptosis correction, especially in secondary or tertiary cases, until a later date. This affords a maximal cosmetic and functional result.

Levator Advancement Technique Local anesthetic is infiltrated once the upper eyelid crease is delineated with a marking pen. Adequate time is allowed to elapse for vasoconstriction to occur. The incision is carried down through the skin and orbicularis muscle, exposing the levator aponeurosis. I prefer to perform all dissection after the initial incision with an insulated needlepoint cautery. Skin is retracted cephalad, and the dissection is carried cephalad through the orbital septum and along the levator aponeurosis. Preaponeurotic fat is exposed and left in


place unless concomitant cosmetic improvement of herniated fat and so on is desired. In levator dehiscence, preaponeurotic fat will be retracted into the orbit along with the levator to which it is loosely attached. Levator advancement will reposition this fat, and resection is not necessary in routine cases. Attention is then brought to the superior tarsal plate and with the pretarsal orbicularis and skin retracted the levator aponeurosis is dissected off the tarsal plate in a caudal to cephalic fashion. Müller’s muscle may be carried with the overlying levator aponeurosis, leaving conjunctiva behind as dissection is carried superiorly. It is preferable, but not always possible, to leave Müller’s muscle behind. A corneal protector may be placed before this surgery because conjunctiva alone may not serve as an adequate corneal protector for some surgeons. It is important to carry out the dissection as cephalad as possible so that the entire levator aponeurosis is freed and adequate advancement may be performed. The medial and lateral horns of the levator muscle are similarly severed with cautery or other dissection. Needle-point cautery is preferable because difficult bleeding can be encountered, especially laterally near the lacrimal gland during lateral horn interruption. Medial and lateral horn division is an important step, because untethered levator advancement is impossible without it. The levator aponeurosis is then advanced and reinserted into the upper one third of the tarsal plate. I prefer to use a double-armed absorbable suture such as 5-0 Vicryl. This may be temporarily tied so that the degree of advancement and correction may be assessed in the operating room, demonstrating lid position and excursion after repositioning the patient. This is achieved by removing the protective contact lens, decreasing the ambient light, and sitting the patient as upright as possible. Highintensity light will cause the patient to squint and alter the accuracy of the intraoperative assessment. Should the advancement be too little or too much, the patient may be placed in a recumbent position and the suture may be adjusted until the desired lid height is achieved. Once the appropriate degree of lid height and ptosis correction is obtained, the suture may be permanently tied down and the excess levator aponeurosis resected. A second or even third simple interrupted suture may be placed medially and laterally to fixate the distal levator aponeurosis to the tarsal plate and ensure stabilization without distortion. The key central suture should lie

along a vertical line that intersects with the nasal pupillary margin. This usually corresponds to the highest point of the lid. Should the high point on the contralateral side differ, then one may adjust the location of the key central suture during the repair of the ptotic eyelid (Fig. 8-6). An appropriate lid fold may then be accentuated with supratarsal fixation by attaching the upper and lower skin margins to the levator aponeurosis at an appropriately chosen height with several spaced absorbable sutures (i.e., 5-0 Vicryl). Skin may be closed as in the upper lid blepharoplasty procedure with intracuticular or other preferred technique as previously described in Chapter 4 (Figs. 4.4 and 8-6). Although supratarsal fixation or lid crease sutures may be applied to any upper lid procedure, I usually find it necessary only in congenital ptosis and in rare instances of involutional ptosis (see Figs. 4-6 and 8-1). In cases of congenital ptosis with fair-to-good levator function in which levator aponeurotic advancement is used, much larger degrees of levator advancement are necessary to effect a change in the degree of ptosis (Fig. 8-7). This is because of the relatively atonic levator and part of the congenital abnormality. Significant levator advancement and resection in congenital ptosis cases leads to significant degrees of lid lag, but this is invariably well tolerated in the pediatric population. The surgeon also has the significant disadvantage in the pediatric population of not having a cooperative patient in whom to adjust levator advancement and resection in a dynamic fashion at surgery. In cases of congenital ptosis, 2 to 3 mm of advancement and resection for each millimeter of ptosis is usually necessary. In distinction, much lesser degrees of advancement and resection are necessary in cases of noncongenital ptosis. I prefer to avoid relying on any formulas to determine the amount of levator advancement necessary at surgery. These formulas may serve as rough guidelines for preoperative planning but are usually not accurate enough by themselves to be relied on to determine a specific advancement. This is because of the large number of variables involved with ptosis correction, including preoperative and postoperative nuances in levator function and lid position, as well as the induced intraoperative variables, such as swelling and changes in neuromuscular activity introduced by local anesthetic and other agents (Fig. 8-8).

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY LEVATOR ADVANCEMENT

A

Figure 8-6 The levator may be advanced onto the tarsal plate in a controlled fashion for correction of significant degrees of ptosis provided the muscle has adequate function. The initial steps are those required for an upper lid blepharoplasty. A, After local anesthetic is conservatively infiltrated, a curvilinear incision is made in the upper eyelid crease or in a line where a new lid crease will be created. A suborbicularis dissection is carried out superiorly, exposing the orbital septum, which is then opened. B, The preaponeurotic space is exposed, and both fat and levator aponeurosis are visualized. C, The superior tarsal plate is exposed with inferior suborbicularis dissection. Care should be taken to avoid distal tarsal exposure, because hair follicles may be damaged. D, The levator aponeurosis is then freed from the tarsal plate and dissected superiorly.

C

Lid is incised through orbicularis muscle

B

Skin retracted exposing levator aponeurosis, cut edge of orbital septum, and preaponeurotic fat

D

Levator aponeurosis dissected cephalad

Tarsal plate Levator aponeurosis is freed from upper margin of tarsal plate

Continued

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Figure 8-6 Continued E, The medial and lateral extensions (horns) of the levator are lysed, and the levator muscle may then be freely advanced. At this point the patient may be asked to look down and then up and the free distal levator should move superiorly under the orbital rim and roof (anterior skull base). F, The levator may then be advanced onto the tarsal plate and temporarily suture-secured. The patient can sit upright with or without the help of an operating table, and the eyelid height and excursions from down gaze to up gaze can be assessed. The process can be repeated with repositioning of the temporary suture until the surgeon is satisfied. G, Permanent sutures may then be substituted and excess levator may be removed distal to the suture fixation. H, Skin closure may be performed as in a blepharoplasty, or supratarsal fixation may be used where the lid fold needs to be accentuated or its height changed (i.e., congenital ptosis). The surgeon should minimize the amount and depth of local anesthetic used because this may affect levator function and compromise intraoperative assessment. One should also remember that epinephrine can stimulate Müller’s muscle and this may “artificially” elevate the eyelid, resulting in undercorrection. However, slight undercorrection is always a better problem than overcorrection of ptosis.

E

Medial and lateral horns divided freeing superior aspect of levator aponeurosis

F

G

Advance levator aponeurosis and suture to tarsal plate

Trim excess levator aponeurosis

H

Intracuticular running suture medial to lateral

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A

B

C

D

Figure 8-7 The levator advancement procedure is a very powerful and reliable procedure that when properly employed and executed produces excellent results. I prefer to perform this procedure with sedation and minimal local anesthetic because I like to adjust the correction on the operating table by allowing the sedative to dissipate after the dissection phase of the surgery is completed. A limited upper blepharoplasty incision is all that is needed for access. The orbital septum is incised superiorly and dissection is carried cephalad anterior to the levator. Whitnall’s ligament is visualized, and for full advancement procedures dissection is carried more superiorly beneath the orbital rim and roof. Distally, the tarsal plate is exposed in a suborbicularis dissection. This dissection should remain superior to the last few millimeters of the tarsus, because very distal dissection can damage specialized orbicularis muscle and hair follicles, resulting in distichiasis and/or loss of eyelashes. The levator is then disinserted from the tarsal plate, and both medial and lateral horns are lysed. The patient may then be asked to look up and down, and the levator should freely and spontaneously excurse, retracting under the superior orbital rim. The levator is then advanced onto the tarsal plate and temporarily fixed with a suture. I prefer a 5-0 double-armed absorbable suture (i.e., Vicryl). The temporarily tied suture may then be adjusted as the patient is sat upright and lid position and function is assessed. Once the surgeon is satisfied, the suture may be permanently tied. A second more lateral suture may be placed in more significant corrections to avoid lateral lid ptosis and an unnatural lid sweep. In milder cases, the medial and lateral horns may be left intact and the levator advanced onto the tarsal plate and sutured as described in Figure 8-6. Skin closure is achieved as in the upper lid blepharoplasty. A, In the first view, Whitnall’s ligament is visualized after the orbital septum is opened. A forceps delineates the lateral extent of the ligament near the lacrimal fossa. B, The upper aspect of the tarsal plate is exposed, with forceps again pointing to the tarsus. C, A double-armed suture is passed between the tarsal plate and the free edge of the levator Continued aponeurosis. D, The suture is in place at the level of the medial pupillary margin.

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E

F

G Figure 8-7 Continued E, The suture is tied down, advancing the levator onto the tarsal plate and correcting the ptosis. F, Preoperative view. Note the left lid ptosis and compensatory left brow elevation. G, The same patient at 1 year postoperatively.

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A

B

C Figure 8-8 An 18-month-old child with left congenital ptosis had undergone previous surgery by another surgeon at 14 months of age. He presents with residual ptosis and lid lag (lagophthalmos) and asymmetric lid folds. The low fold on the congenitally ptotic side is caused by the low incision line initially used. Preoperative examination showed enough levator function to perform a ptosis repair using the levator muscle by way of an advancement procedure. Elevation of the lid fold would be necessary to achieve external lid symmetry independent of eyelid height (ptosis correction). I chose to perform a distal and proximal dissection over the tarsal plate with supratarsal fixation at the desired height along with a levator advancement procedure to address his lid fold asymmetry and eyelid ptosis, respectively. Because of his age, the procedure required general anesthesia. A, Photograph of the child before his initial surgery taken by another surgeon. Note the ptotic eyelid on the left side and absent lid fold. B, The patient at consultation with me. Note the ptosis in primary gaze. C, Despite ptosis in primary gaze there is lid lag on Continued down gaze as well as asymmetric eyelid creases which the primary surgeon created.

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D

E

F

G

H

I

Figure 8-8 Continued D, The incision line chosen is at the correct or matching height from the lash line as on the contralateral side. Wide distal and proximal undermining was performed in the suborbicularis plane. E, The levator was freed from the tarsal plate, the medial and lateral horns completely lysed, and the levator, along with loosely attached preaponeurotic fat, was advanced. Note the fibrotic and pale nature of the soft tissues. F, The levator was then reattached to the tarsal plate and excess levator aponeurosis amputated. G, Supratarsal fixation was used to create a lid fold at the appropriate height by apposing skin to levator aponeurosis on both sides of the incision. H, The skin closure was completed using the supratarsal fixation technique. I, The patient at approximately 3 months after the procedure.

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Ptosis Correction Using Exogenous Muscle Action (Frontalis Sling) Some of the more unsatisfying procedures for ptosis correction are the use of muscles outside the lid to serve as a lid elevator. These are, unfortunately, the only viable options when intrinsic levator function is not adequate. The more important of these procedures is the frontalis sling procedure, which uses a static linkage between the upper eyelid and the overlying brow. Lid elevation is achieved with contraction of the frontalis by way of eyebrow elevation. The procedure produces significant lid lag and corneal exposure, and it is important to preoperatively assess the presence or absence and degree of Bell’s phenomenon in addition to all of the other parameters that are routinely assessed in ptosis evaluation. There are a plethora of materials that have been described as appropriate in performing these sling procedures. These include Silastic tubing, Superamid and other alloplastic materials, as well as preserved fascia and autogenous fascia. Autologous tissue such as fascia lata or palmaris longus tendon tend to have the longest duration, most stable correction, and least complications associated with them. A number of configurations of the frontalis sling have been proposed and include single rhomboids, double rhomboids, and various permutations of triangles. Each of these may be satisfactory, but none of them is ideal, given the underlying conceptual and practical limitations of this procedure. The frontalis sling with a double rhomboid is performed by marking areas medially, centrally, and laterally at the superior border of the eyebrow hairs. The lower surgical incisions are delineated across the tarsal plate approximately 3 mm superior to the lash line. Local anesthetic with epinephrine is infiltrated, and

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adequate time for hemostasis is allowed to elapse. Stab incisions are made at each of these marks extending down to the periosteum in the brow region and to the tarsal plate in the lid. A long curved or straight needle (i.e., Wright) is used to pass two separate pieces of fixation material (i.e., fascia) from the medial and lateral brow incisions, respectively. Each piece of fascia or other material is passed deep to the orbicularis muscle from the brow through the pretarsal area and back to the brow area. Locking sutures such as 4-0 Vicryl may be used to reinforce the sling ties, and it is generally useful to slide the knots through the subcutaneous tunnels away from the incision lines to obviate extrusion. The undersurface of the upper eyelid should be everted before tying any knots on these slings to ascertain whether there is any exposure or conjunctival penetration, because this will lead to corneal irritation and breakdown. Fascia or other material that is exposed should be removed and repassed. This procedure is generally performed with the patient under sedation or general anesthesia and with infiltration of local anesthetic with epinephrine. These agents limit frontalis muscle action and the ability of the surgeon to assess appropriate elevator action to the sling. It is helpful to tighten the sling so that the upper lid either pulls away from the globe or reaches the superior limbus or corneoscleral junction. The upper eyelid should be set at a lower level if the patient has a poor Bell reflex or poor seventh cranial nerve or orbicularis function. The greater the patient’s inability to forcibly close his or her eyes, the closer one should set the upper lid to the visual axis. Skin closure can then be performed in layers, and a temporary tarsorrhaphy to protect the cornea in the immediate postoperative period may be used, especially when compensatory mechanisms for corneal coverage are weak or compromised (Fig. 8-9).

P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N FRONTALIS FIXATION (no levator function)

Subcutaneous placement of suspension material to create a static sling

Protective contact lens

C

B A

Figure 8-9 The frontalis sling, like all other static eyelid procedures, depends on exogenous forces to elevate the upper lid. In this case, the eyebrow is the primary provider and this, like all other static procedures, is nonanatomic with obvious pitfalls. Illustrated here is a double suspension technique in which fascia is used to connect the eyelid to the eyebrow. Three incisions are located approximately 3 mm above the lash line and three above the eyebrow (top). The upper incisions extend to the periosteum and the lower to the tarsal surface. A long curved needle (i.e., Wright) is used to pass two separate pieces of fascia from the preperiosteal to the pretarsal planes and back. Care must be taken to avoid passing the fascia through the conjunctival surface (bottom). Although a number of permutations for fascial linkage and placement exist, the technique used in this drawing requires linking the fascial strands together both with knots and a reinforcing absorbable suture (insert). The upper lid height should be set at the limbus for patients with good Bell’s and lid protractor function. For those with poorer protective mechanisms, the lid should be set at a lower level. Skin incisions can then be closed in layers, and a temporary tarsorrhaphy is sometimes necessary in those patients who are not capable of protecting their eyes initially.

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Upper Eyelid Retraction Upper eyelid retraction usually occurs as a sequela of previous trauma or surgery. Upper lid retraction results from compromise, shortening, or fibrosis of the underlying eyelid elevator system and should be distinguished from seventh cranial nerve paralysis or orbicularis muscle dysfunction in which there is adequate uncompromised “slack” in the lid elevator system but the inability to close the eye is caused by failure neurologically or mechanically to initiate or complete the closure reflex. This is a distinctly different entity from true eyelid retraction, in which there is infiltrative, post-

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traumatic, or surgical tethering of the upper eyelid at the middle lamella level. This may occur in Graves’ disease or in other infiltrative phenomena. It may also occur in the case of overcorrection of ptosis, especially with levator advancement or Fasanella-Servat procedures. In the case of a deficiency of both the middle and internal lamella (conjunctiva), a composite graft such as a mucoperiosteal palatal graft may be used as an interposition between the levator/conjunctival surface and the superior border of the tarsal plate. This is similar to the procedure described for lower lid retraction, with the exposure and dissection similar to that used in ptosis correction (Fig. 8-10).


Figure 8-10 A patient with eyelid retraction after overcorrection of acquired ptosis by another surgeon. Note the involuntary eyebrow asymmetry as the patient attempts to compensate for the condition. Another interesting and even more important compensatory mechanism is contralateral upper lid ptosis. This is caused by the concept of equal and opposite innervation to both eyelids. In the case of eyelid retraction, the brain will send less elevational drive to the retracted eyelid and, because of an inability to innervate each lid differently, the relaxation will be mirrored in the contralateral normal eyelid, resulting in relative ptosis on that side. The converse is true in primary ptosis cases, and this produces eyelid retraction on the contralateral normal side.

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A deficiency in the middle lamella either from Graves’ disease or iatrogenically after a previous ptosis procedure is more common. In these instances, I prefer autogenous deep temporal fascia as an interposition graft, although the ophthalmic literature is filled with other suggestions (e.g., banked scleral, banked fascia). In general, allografts are plagued by unpredictable longterm results. In cases of orbicularis or facial nerve compromise, simply weighing down the upper lid may serve as either a temporary or permanent solution, and this can be achieved with a pretarsal gold weight insertion. In these cases, providing additional upper lid weight is all that is needed to lower the upper lid and provide adequate corneal coverage on attempted closure. Preoperatively, with the patient awake, an appropriate weight may be taped to the outside of the eyelid to achieve the desired lid height. Basically, a minimal weight may be chosen from a trial kit that allows the upper eyelid to drape and move most appropriately. At surgery, an upper lid crease incision is made and dissection is carried down distally, raising an orbicularis myocutaneous flap. The underlying tarsal plate should be exposed and care should be taken not to carry the dissection distally to the hair follicle margin. This will result in loss of lid cilia and/or distichiasis. The appropriate gold weight is then fixed to the anterior tarsal plate, being careful not to place the weight above the superior margin of the tarsus. This is a common etiology for postoperative sulcus obliteration, lid malposition, or underutilization of the mass engendered by the gold weight. Temporary suture fixation above and below, utilizing an absorbable suture (i.e., 5.0 Vicryl), is all that is necessary, and skin closure is performed as described in Chapter 4. I have never had a malpositioned gold weight or one dislodge after an appropriate pretarsal pocket is made, and temporary immobilization is performed as described earlier. Lid retraction due to fibrosis, trauma, previous ptosis surgery, or infiltrative disease such as Graves’ disease is

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best corrected with recession of the levator and Müller’s muscle complex with placement of an interposition autogenous graft. The patient is appropriately sedated, and an upper lid crease incision is designed. Local anesthetic containing epinephrine is infiltrated, and adequate time for hemostasis is allowed to elapse. Dissection is carried down through skin and orbicularis, and with the use of an insulated needle cautery the levator aponeurosis and tarsal plate are exposed as in the description for correction of ptosis. It is necessary to free the levator and Müller muscle complex from the underlying conjunctival surface by a similar dissection as described previously. The entire complex is disinserted from the tarsus, and the medial and lateral horns of the levator aponeurosis are severed, with a dissection carried out posterior to the orbital septum. Deep temporal fascia is harvested with a small incision in the coronal plane below the palpable temporal line of the skull. An appropriate amount of deep temporal fascia can easily be harvested in minutes, and the scalp may be closed with staples or sutures as the surgeon desires. I prefer to use a few deep absorbable sutures followed by staples or a running 3-0 absorbable suture. The fascia is then interposed between the free edge of the levator aponeurosis and the superior edge of the tarsal plate and sutured into place. Approximately a 2:1 ratio of fascia to degree of retraction is necessary to appropriately lengthen the lid. Several interrupted absorbable sutures (5-0 Vicryl) on both the distal and proximal ends of the interposition graft are all that is necessary for stabilization and fixation. Skin closure is performed as described in Chapter 4, and the lid crease may be created with supratarsal fixation when appropriate (see Fig. 4-6). Temporary tarsorrhaphy or Frost sutures are especially useful in these procedures in the immediate postoperative period. These provide immobilization of the graft, adequate maintenance of length, and general patient comfort (Figs. 8-11 and 8-12).

P TO S I S A N D U P P E R E Y E L I D R E T R A C T I O N LEVATOR SPACER FOR LID RETRACTION

A

Lid is incised through orbicularis muscle

B

C

Figure 8-11 The levator muscle may be recessed instead of advanced; however, a spacer is needed when recession is above the level of the superior tarsal border. The procedure entails the same technique and maneuvers as used in levator advancement until the recession step. A, An upper lid incision is made. B, The levator aponeurosis and levator muscle are exposed transseptally. C, The tarsal plate is exposed distally in the suborbicularis plane. D, The levator is freed in a distal-to-proximal dissection. E, The medial and lateral horns of the levator are divided.

Upper margin of tarsal plate is dissected free

D

E

Skin and orbicularis muscle are retracted exposing levator aponeurosis, cut edge of orbital septum, and preaponeurotic fat

Levator aponeurosis dissected cephalad

Medial and lateral horns are divided freeing superior aspect of levator aponeurosis Continued

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Figure 8-11 Continued F, An incision is made in the coronal plane overlying the temporalis muscle. The donor site can be made inconspicuous by beveling the incision according to the direction of hair growth, approximating the temporal line superiorly and curving it well behind the anterior hair line. It is helpful to delineate the incision preoperatively by having the patient masticate and palpating the underlying anatomy of the temporalis muscle. I harvest a large section of fascia and then split or contour it according to the requirements of the recipient site or sites. Despite the sequence depicted here, I usually harvest the graft first and close the donor site before beginning the eyelid aspect of the procedure. I find this speeds the entire procedure and obviates head movement after the eyelid has been incised. G and H, The deep temporal fascial graft is then used as a spacer between the levator aponeurosis and the tarsal plate. I find it easier to first suture the graft to the tarsal plate and then contour or trim the graft and appose the levator aponeurosis to the superior edge of the graft; however, either way is acceptable. I, Finally skin is approximated and whenever possible I use a temporary tarsorrhaphy postoperatively.

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F

Deep temporal fascia (DTF) harvest

G

H

Graft sutured to tarsal plate

DTF graft sutured to free end of levator aponeurosis

I

Closure - intracuticular running suture medial to lateral


A

B

C

D

E

F

Figure 8-12 The clinical sequence for autogenous facial upper lid interposition lengthening requires only a few additional techniques beyond what has already been described for levator surgery in the case of ptosis. A, The deep temporal fascia is harvested with a small incision in the hairline below the temporal line. Closure without drains may be performed as described in the text. B, The levator is completely freed distal to the tarsal plate as well as medially and laterally. Remember the lateral horn of the levator divides the lacrimal gland. In this case, with significant previous surgery by others, there is a great deal of fibrosis and the right forceps overlies a small segment of exposed lacrimal gland. Note the thickened and whitened fibrotic tissue of the levator distracted by the left forceps. C, Fascial graft is interposed between the levator and tarsal plate. Here a lateral view shows the width of the temporal fascial graft, which is tented by the two forceps as it is being inset. D, Another patient with the facial graft already sutured to the tarsal plate and inset on the left side (nasal) to the levator after the desired length and width is created. The forceps is engaging the temporal side in preparation for the placement of a stabilizing suture. E, Same patient as seen in D preoperatively. F, Same patient postoperatively as in the previous two photographs (D, E). This is approximately 1.5 years after the lengthening procedure. Note the relative symmetry of eyelid position; however, there remains a modest superior sulcus deformity on the treated left side. Continued

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A T L A S O F A E S T H E T I C E Y E L I D A N D P E R I O C U L A R S U R G E RY Figure 8-12 Continued G, Milder forms of upper lid retraction without a soft tissue deficiency may be passively corrected by weighing down the upper eyelid with a surgically inserted gold weight. Usually these patients have an imbalance between the eyelid elevators (levator, Müller’s) and the eyelid depressors (orbicularis). This patient suffers from a left facial palsy since birth and presents with complaints and a physical examination consistent with corneal exposure from a combination of upper lid retraction, lagophthalmos on closure, and lower lid ptosis. Note his inferior scleral show and cheek ptosis compared with the contralateral right side. H, Here this patient is being assessed for an appropriate-size gold weight preoperatively. The patient’s youth and professional demands required that we achieve maximal corneal coverage but leave him as cosmetically symmetric as possible. As is always the case, the correction of lid retraction should be maximal without interfering with the pupillary axis and functional vision. I find it helpful in an office setting to try various weights that are adhered to the upper lid with a topical adhesive (i.e., Mastisol or Steri-strip). Then the patient can be evaluated through lid excursions. The weight chosen leaves him with some residual scleral, but not corneal, show. The weight should be placed beneath the pretarsal orbicularis muscle and fixed to the tarsal plate. Access is through a standard blepharoplasty incision. I, Here the patient is shown approximately 3 months postoperatively after having undergone an upper eyelid gold weight insertion, a lateral canthoplasty of the lower eyelid, and a midface suspension through the eyelid.

G

H

I

P E A R LS A N D P I T FA L LS 1. True eyelid ptosis must be discriminated from pseudoptosis before one embarks on a treatment plan. 2. Orbital volume discrepancies (enophthalmos or proptosis) can produce pseudoptosis or pseudo retraction of the eyelids. 3. A high lid fold and superior sulcus deformity suggest levator aponeurosis dehiscence. 4. Elevation of the upper eyelid will always cause higher ambient evaporative tear loss and sometimes lid lag. Preoperative evaluation should assess tolerance for these sequelae. 5. The degree of ptosis and the level of levator function are the two most important factors in determining which procedure to perform. 6. The difference in lid aperture between extreme up gaze and down gaze is a measurement of levator function. 7. Congenital ptosis consists of the triad of significant lid malposition, poor-to-absent levator function, and significant lid lag on down gaze. These characteristics are due to an atonic and fibrotic levator muscle. 8. The tarsal conjunctival müllerectomy (TCM) (Fasanella-Servat) is a posterior approach to mild ptosis. 9. In performing the TCM procedure, extreme care must be used in cross-clamping and resection so as to induce a cleansweeping, arched, and not a peaked or retracted eyelid. 10. The levator tuck is an anterior approach to mild or small degrees of moderate ptosis in the setting of good to excellent levator function. 11. The levator advancement procedure is the most powerful

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12.

13. 14.

15.

16.

17.

18. 19.

20.

technique for ptosis correction, no matter how severe the ptosis, provided levator function is good. Complete levator advancement requires adequate cephalic dissection along with lysis of the medial and lateral horns of the levator. The central suture in the advanced levator should lie at the vertical meridian of the nasal pupillary margin. A second suture laterally is helpful in avoiding too rapid a decline in the upper eyelid height as it approaches the lateral canthus. Significant levator advancement and resection can be employed in cases of congenital ptosis, provided enough levator function exists. In the absence of adequate levator function, exogenous muscle must be employed to correct the ptosis (i.e., frontalis sling). The upper eyelid should be set at a lower level than normally chosen in the presence of a poor Bell’s reflex or compromised VII cranial nerve or orbicularis function. Upper eyelid retraction must be distinguished from VII cranial nerve or orbicularis muscle dysfunction. A true deficiency in the middle lamella of the upper eyelid requires a spacer for correction, whereas a nerve or muscular compromise requires only a weighing down of the upper eyelid. The dissection for levator recession with interpositional grafting (temporalis fascia) is the same as that for levator advancement.


References Abdul-Rahim AS: Determination of resting upper eyelid position in patients with ptosis. Ann Ophthalmol 33:298299, 2001. Bartkowski SB, Zapala J, Wyszynska-Pawelec, G, Krzystkowa KM: Marcus Gunn jaw-winking phenomenon: Management and results of treatment in 19 patients. J Craniomaxillofac Surg 27:25-29, 1999. Bartley GB, Lowry JC, Hodge DO, et al: Results of levatoradvancement blepharoptosis repair using a standard protocol: Effect of epinephrine-induced eyelid position change. Trans Am Ophthalmol Soc 94:165-177, 1996. Bradley EA, Bartley GB, Chapman KL, Waller RR: Surgical correction of blepharoptosis in patients with myasthenia gravis. Ophthalmic Plast Reconstr Surg 17:103-110, 2001. Chen TH, Yang JY, Chen YR: Refined frontalis fascial sling with proper lid crease formation for blepharoptosis. Plast Reconstr Surg 99:34-40, 1997. Dinces EA, Mauriello JA Jr, Kwartler JA, Franklin M: Complications of gold weight eyelid implants for treatment of fifth and seventh nerve paralysis. Laryngoscope 107(12 pt 1):1617-1622, 1997. Harris WA, Dortzback RK: Levator tuck: A simplified blepharoptosis procedure. Ann Ophthalmol 7:873-878, 1975. Khan JA, Garden V, Faghihi M, Parvin M: Surgical method and results of levator aponeurosis transposition for Graves’ eyelid retraction. Ophthalmic Surg Lasers 33:79-82, 2002. Lim KH, Lee SY, Hwang JM: Primary levator synkinesis associated with eye movement. J Pediatr Ophthalmol Strabismus 38:179-180, 2001. Mauriello JA Jr: Modified levator aponeurotic advancement with delayed postoperative office revision. Ophthalmic Plast Reconstr Surg 14:266-270, 1998.

Mauriello JA Jr, Abdelsalam A: Modified levator aponeurotic advancement with delayed postoperative office revision. Ophthalmic Plast Reconstr Surg 14:266-270, 1998. Mercandetti M, Putterman AM, Cohen ME, et al: Internal levator advancement by Müller’s muscle-conjunctival resection: Technique and review. Arch Facial Plast Surg 3:104-110, 2001. Mulvihill A, O’Keefe M: Classification, assessment, and management of childhood ptosis. Ophthalmol Clin North Am 14:447, 2001. Saeed M, Usama U, Aziz TM: Recession of levator in the management of retracted upper lid. J Coll Physicians Surg Pakistan 10:451-453, 2000. Signorini M, Baruffaldi-Preis FW, Campiglio GL, Marsili MT: Treatment of congenital and acquired upper eyelid ptosis: Report of 131 consecutive cases. Eur J Plast Surg 23:349355, 2000. Tellioglu AT, Saray A, Ergin A: Frontalis sling operation with deep temporal fascial graft in blepharoptosis repair. Plast Reconstr Surg 109:243-248, 2002. Tezel E, Numanoglu A: Readjustment of the degree of lift following frontalis sling operation in ptosis: A new and simple method. Plast Reconstr Surg 104:587-588, 1999. Tsa CC, Li TM, La CS, Li SD: Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous frontalis suspension. Br J Plast Surg 53:473-476, 2000. Tucker SM: Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology 106:517-522, 1999. Tucker SM, Verhulst SJ: Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology 106:517-522, 1999. Woog JJ, Hartstein ME, Hoenig J: Adjustable suture technique for levator recession. Arch Ophthalmol 114:620-624, 1996.

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CHAPTER NINE

The Mid Face and Lateral Canthus ANATOMY AND PATHOPHYSIOLOGY There has been an evolution in the conceptualization and the technical approaches to the periocular region and mid face. In the past, surgeons have focused either on the periocular region within the confines of the orbital rim or on the face and brow outside the orbital rim. These two areas were traditionally treated as discrete entities. Classical thinking encouraged surgeons to address either the eyelids alone, the face alone, or the eyelids and face in combination, with the orbital rims being not only a conceptual but also a technical boundary in the amalgamation of a unified concept for addressing anatomic and technical concerns in rejuvenative surgery of the face. As alluded to earlier in this text, the lower eyelid, canthal structures, and mid face or soft tissues overlying the zygoma should be thought of as codependent anatomic and surgical regions. That is, one must consider the lateral canthus, the lower eyelid, and the cheek as three independent variables in the equation we view as the mid face. Anatomically, the lower eyelid fat pads are held posteriorly and within the orbit by the orbital septum, which effectively links the periosteum and periorbita to the inferior tarsal plate. The arcus marginalis can be viewed as a confluence of the periorbita, periosteum, and orbital septum at or near the orbital rim. The orbital malar ligament extends inferiorly and anteriorly from the arcus marginalis. The orbital malar ligament essentially links the orbital rim confluence or arcus marginalis to the overlying malar soft tissue, including skin. This is accomplished by way of its course through the preorbital orbicularis muscle and malar fat pad. In the youthful and aesthetically pleasing lower eyelid and mid face, the distance between the superior edge of the 120

lower eyelid and the junction of the cheek is only approximately 10 mm. This transition area is coplanar or even slightly concave in youth. Senescence and attenuation of the lateral canthal tendon allows the lateral canthus to drift inferiorly and medially, shortening the intercommissure distance and changing the normal lateral canthal inclination of 10 to 15 degrees compared with the medial canthal position. Analogously, the orbital malar ligament attenuates with age and the soft tissues of the cheek or mid face undergo an inferior medial ptosis. The distance from the upper margin of the lower eyelid to cheek effectively lengthens, extending well beyond the orbital rim inferiorly, as the orbital malar ligament fails. This usually occurs concomitantly with lateral canthal tendon laxity so that all three elements of the mid face equation are anatomically incorrect and connote the aged periocular look. This consists of an inferior inclination to the lateral canthus, lower lid ptosis with scleral show with or without laxity, midface ptosis, and deepening of the nasolabial fold. Further aging changes associated with soft tissue and fat atrophy produce grooving in the nasojugal region, the tear trough deformity, and depressions along the lateral orbit (Figs. 9-1 and 9-2). It is therefore important in the more youthful patient, whose only complaint may be confined to cosmetic concerns within the orbital rims, to address cosmetic concerns while keeping in mind the eventual aging changes that will occur at the orbital malar junction. We have all seen patients who have had early aggressive fat resection during blepharoplasty only to have a hollowed out or concave inferior eyelid with malar ptosis and an orbital rim viewed in relief 10 years after the original procedure. It is these more youthful patients in whom conservative resections, repositioning, and support procedures as well as fat conservation, repositioning, and augmentation procedures should be considered and implemented whenever possible and where indicated.

T H E M I D FA C E A N D L A T E R A L C A N T H U S CANTHOPEXY vs MIDFACE SUSPENSION w/CANTHOPEXY

Good cheek support

Cheek support is lacking

Figure 9-1 The mid face should be viewed as an amalgamation of the lateral canthus, lower eyelid, and cheek. These three elements should be assessed independently and collectively in deciding which procedure is best suited for the patient. The left half of the drawing depicts lower lid laxity, scleral show, and a coplanar medial-to-lateral canthal position with only slight shortening of the intercommissure distance. There is only a modest descent of the malar soft tissues, as evidenced by the relatively short distance between the lower lid margin and the cheek. This patient would be treatable with a canthopexy alone. In distinction, the patient on the right side demonstrates more significant scleral show, an inferiorly placed lateral commissure compared with the medial, a significant distance between the lower eyelid and cheek soft tissues (despite eyelid descent), and a depression between the lower eyelid and cheek, with the bony orbit rim clearly visualized in relief. This patient is not treatable by a canthal procedure alone but needs midface suspension along with a canthal procedure. Patient assessment may be simplified into an appreciation of the amount of cheek support present and then how one will support it, if necessary.

Figure 9-2 This patient demonstrates the point illustrated in the drawing in Figure 9-1. Here the aging process is exaggerated by the right facial paralysis secondary to a malignant parotid tumor resection, and this allows us to view a single patient with two distinct sides. The right side has significant midface ptosis as well as lower eyelid ptosis with significant scleral show. The left side has milder lower lid ptosis with a small amount of scleral show. Although the left side demonstrates some midface ptosis for her age, the lower eyelid position can be normalized with a canthal procedure alone with midface suspension. The contralateral right side is not correctable with a canthal procedure alone. A suspension of the mid face is necessary along with a canthal procedure. Finally, relative to Figure 8-12, this patient had a right upper eyelid gold weight inserted at the time of her parotid resection by her original surgeons. Notice the oblique, low, and superficial location of the gold weight. This can usually be avoided by defining a limited pretarsal suborbicularis pocket, positioning the weight in the midtarsus, and stabilizing it in at least two distinct points to obviate rotation in all planes.

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INDICATIONS FOR MIDFACE SUSPENSION The indications for addressing the mid face specifically are the appearance described earlier in which the lower lid to cheek distance is significantly elongated and the orbital rim is visible with a concavity between the pseudoherniated inferior and medial orbital fat and the ptotic or inferiorly displaced malar fat pad. Other associated abnormalities such as increased or deepening of the nasolabial fold, tear trough deformity, and scleral show may also be present. It is important to note that, as has been previously mentioned, scleral show or lower lid laxity in patients who have moderate or severe midface ptosis are generally not well served by canthopexy or canthoplasty alone. In fact, to reiterate an important point, the lower eyelid cannot support the cheek. Therefore, patients who present with significant midface ptosis and lower eyelid dystopia are candidates for midface suspension along with canthopexy or canthoplasty. At this juncture, clarification of canthopexy versus canthoplasty should be repeated. The canthopexy is a supportive procedure of the canthus in which the lateral canthal crura are not divided, shortened, or interrupted in any way. Generally, the common canthal tendon is fixed cephalad and laterally to provide minimal to moderate support. The canthoplasty should be defined as a canthal support procedure in which the inferior crus of the lateral canthal tendon is usually divided; tarsal elements then serve as a neocanthal tendon, should the lower lid require shortening, and

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the lateral canthus is attached to the lateral orbital rim in some fashion, as described in Chapter 3. A commissuroplasty or reconstruction of the lateral canthus is then required; however, most surgeons should not find this learning curve overly steep. There is a third canthal support procedure that does divide the lateral canthal tendon and does not require commissuroplasty. This should be called a canthopexy with disinsertion of the canthal tendon or, more appropriately, a common canthoplasty. This procedure requires mobilization of the entire lateral canthus and lateral retinaculum at the periosteal junction and reinsertion cephalad at an appropriate and desired level. Careful positioning of the suspension suture through the soft tissue avoids distortion and extrusion postoperatively. In my experience it provides the most latitude in repositioning the canthus, and, with correct dissection, the lateral canthus may be positioned as high as the eyebrow. The indication for this procedure should be the patient with severe lateral tendon laxity in whom the entire lateral canthus has drifted inferiorly and medially, presenting with lower lid laxity, scleral show, and a dystopic canthus declined (negatively inclined) by at least 15 to 20 degrees. These patients invariably demonstrate all of the anatomic elements of midface ptosis. They also are not especially well served with a lower lid canthoplasty because shortening the lower eyelid does not serve to reposition the superior crus of the lateral canthal tendon and correct the inferior drift of the upper lateral eyelid. Disinsertion of the lateral canthal tendon with canthopexy is merely a modification and an evolution of procedures familiar to surgeons with backgrounds in craniofacial procedures (Fig. 9-3).

T H E M I D FA C E A N D L A T E R A L C A N T H U S

A Figure 9-3 The common canthoplasty is illustrated in these intraoperative photographs. Unlike the common canthopexy, this procedure requires complete disinsertion of the lateral canthal tendon and lysis of the structures stabilizing the lateral canthus, namely, the lateral retinacular elements. This allows complete mobilization and repositioning of the lateral canthus. This is a very powerful technique. A, The common canthal tendon has been isolated and disinserted from its bony fixation point. The lateral retinacular elements have been lysed, and the canthus is free to be repositioned. Access is by way of an upper lid blepharoplasty incision. The forceps is holding the distal aspect of the common tendon. B, External view demonstrating how the common canthal tendon can be repositioned at any level with the forceps holding the structure. C, A suture engaging the tendon will then be fixed to periosteum at a desired level around the arc of the lateral orbit. The lateral insertion point may even be altered should one prefer to elongate the intercommissure distance.

B

C

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APPROACHES TO THE MID FACE The midface or malar soft tissues may be addressed in a number of ways, and the choice depends on the patient's age, the degree of deformity, the objectives, and the desires of the patient. One may choose a transeyelid or canthal approach in a patient who is younger (30s to 40s) and who has early senescent changes and ptosis of the mid face but is not quite ready for a full facialplasty and its associated incision lines. It may also be chosen in the older patient with significant facial aging changes whose complaints are solely focused around the periocular region. These patients are frequently symptomatic from lower lid and canthal laxity but are usually unwilling to undergo a more extensive facelift procedure. The surgeon is forced to utilize a periocular incision to suspend the mid face along with eyelid and canthal procedures, when the preauricular incision is not available as access to suspend the mid face. The approach to the mid face familiar to most cosmetic surgeons is the preauricular approach, as is typical in a facelift procedure. The facelift incision should extend somewhat into the temporal scalp either at or posterior to the hairline. This should give the surgeon adequate exposure to the deep temporal fascia, orbital rim region, and the body and arch of the zygoma. With the use of a needle-tip cautery, dissection is carried down from the outer one third of the orbit laterally at the level of the orbital rim. The dissection is carried

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superiorly as one moves laterally, mimicking the inclination of the orbital rim from medial to lateral. Dissection is carried out over the face and body of the zygoma parallel to the superior aspect of the zygomatic arch. The exposure need only be carried out laterally to the junction of the body and arch of the zygoma, and then inferior dissection is completed lysing the orbital malar ligament and exposing the suborbicularis oculi fat (SOOF) pad. The dissection is carried out superficial to the periosteum throughout the procedure, and the soft tissues can then be fixed cephalad and laterally to the underlying periosteum of the body of the zygoma and zygomatic arch. Laterally along the arch I prefer to plicate the superficial musculoaponeurotic system (SMAS) from medial to lateral approaching the ear. Following this, a canthopexy or canthoplasty may be performed, after the facialplasty flaps have been positioned. It is important for lower eyelid skin to be conserved, and any resection should engender lateral and cephalic tension. I prefer this approach whenever a facelift is part of the planned procedure or in patients who are not amenable to extended eyelid incisions or whose cosmetic concerns far outweigh their functional problems. In my experience, the facialplasty or preauricular approach is a slightly less powerful technique compared with the more direct transeyelid approach; however, it is associated with a notably lessened complication and revision rate. The appropriate lateral cephalic vector is always easier to create by a direct periocular approach to the mid face (Figs. 9-4 and 9-5).


Facelift incision

Malar fat pad

SMAS

SMAS sutured to zygomatic periosteum

SOOF and malar fat pad sutured to deep temporal fascia

Figure 9-4 The cheek may be supported in a number of ways. The facelift incision (limited or classic) may be used to gain access to the SMAS and SOOF. Patients with significant malar bulk are more important and easier to suspend. The vector invoked in the lift is the key to eliminating or softening the eyelid-to-cheek discrepancy as described earlier in the text (Chapters 1 to 3). The facialplasty or facelift approach to the mid face can be satisfactory for suspension of the soft tissue components that compose the infraorbital soft tissue structures. The correct vector must be induced by the suspension. I find this technique alone to be less powerful than the direct periocular approach. The advantage is that it avoids any extended periocular incisions and allows a total skin redraping and rejuvenation.

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A

B

Figure 9-5 In this patient a standard preauricular facialplasty incision was made and subcutaneous dissection carried to and over the orbital rim. The lateral third to half of the orbital rim and septum are palpated through this route. The SOOF and malar fat pad are sutured to either lateral zygomatic arch periosteum and/or deep temporal fascia. This approach is limited in that it does not practically allow the execution of a suture suspension in the vertical plane as in the transeyelid midface suspension (see Fig. 9-6). A, Fiberoptic retractor view of a standard facialplasty incision with a subcutaneous flap elevated. In the upper left is the deeper plane directly on the deep temporal fascia and a transition leash of more superficial structures (superficial temporal vessels, facial nerve) delineating the two planes. The malar soft tissue is just beyond and to the left of the center of the retractor. B, This is a close-up of A. The pre-orbital orbicularis muscle is reflected superiorly with the Continued flap, and the malar fat pad is directly in front of the retractor.

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C

D

Figure 9-5 Continued C, A clear monofilament suture has already been passed through the malar soft tissue pad for suspension to more stable lateral and cephalic structures. D, In distinction to malar suspension, the more lateral SMAS may be suspended by any means the surgeon feels comfortable with. I prefer suture suspension in thinner patients in whom soft tissue augmentation of the zygoma is preferred.

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The direct or periocular approach to the mid face is by means of the lateral eyelid, and this may be further subdivided into an upper or lower eyelid technique. Generally, the upper eyelid approach is preferred in patients in whom disinsertion of the lateral canthal tendon and canthopexy is planned and/or in those who do not want or need a lower eyelid skin incision. The dissection affords a more cephalic and lateral exposure of the superior lateral orbital rim, although the approach is farther from the malar soft tissues. As with all midface and canthal procedures, adequate mobilization of the soft tissues is necessary and canthopexy of the common canthal tendon requires that the surgeon

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carefully avoid lateral elements of the levator aponeurosis or lateral horn of the levator in the fixation sutures. Superior tethering of the lateral upper lid may result in incomplete lateral closure, and a peaked lateral contour can result from lateral levator entrapment in the canthopexy. As in the facialplasty approach, the dissection is carried out above the periosteum, dividing the orbital malar ligament and releasing the soft tissues. The malar fat pad is vertically and laterally elevated by way of the suspension sutures. The lateral canthus can then be tightened and/or elevated, and a conservative skin excision may be performed (Figs. 9-6 and 9-7).

T H E M I D FA C E A N D L A T E R A L C A N T H U S MODIFIED CHEEK LIFT

A

Access via upper or lower blepharoplasty incision

Orbital fat Orbital septum Orbicularis muscle Malar bag Orbitomalar ligament SOOF Malar fat pad Zygomaticus muscle SMAS Buccal fat pad

B

Extent of sub-orbicularis muscle/ malar fat pad/SMAS undermining

Single mattress suture repair

C

Cheek flap is elevated and sutured to deep temporal fascia or periosteum of lateral orbital rim

Figure 9-6 The anatomy of the soft tissue of the cheek overlying the zygoma. The arrow in red depicts the plane of dissection to the midfacial structures in the cheek in a supraperiosteal approach. A, Access may be by way of the upper lid or lower lid blepharoplasty incision. Dissection should be carried out to the malar fat pad, and it may be suspended to periosteum along the orbital rim or more laterally to the deep temporal fascia. I find the upper lid approach technically more difficult to execute but much easier to engender the appropriate cheek vector suspension. B, In both approaches a canthal support procedure is used, remembering to completely mobilize the lateral canthus with lysis of the entire lateral retinaculum. This is usually best performed before the cheek suspension is completed and access becomes limited. C, One or two mattress sutures are sufficient to suspend the cheek structures.

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A

B

C

Figure 9-7 The midfacial structures may be approached by way of the upper or lower eyelid. I prefer a lateral upper eyelid technique because this is most amenable to allowing the surgeon to access all the structures and induce the appropriate vector to the mid face elevation with the least complications and as few unsightly incisions as possible. I also find a direct vertical transcutaneous or transconjunctival midface suspension to be less effective and more prone to complications. These pure lid approaches, while not requiring a lateral extent to the incision, do not induce enough suspension in the appropriate vector. A, A close-up view of the exposure to the mid face accessed by the lateral extent of an upper blepharoplasty incision. The entire lateral retinaculum and canthal tendon have been mobilized, and a suture has been placed through the common canthal tendon. The exposure allows the inferior orbit and mid face to be accessed. B, This is the same patient as seen in the operating room (A) before surgery. She had undergone a facelift and a blepharoplasty by another surgeon in the distant past. She presents with scleral show (right greater than left) and an elongated distance between her eyelid and mid face. She complains of dry eyes, symptoms of corneal exposure, as well as the appearance of her periocular and midface region. She does not have significant generalized facial ptosis. Note the blunting of the right canthus. C, The same patient preoperatively seen with a focused view of the eyelids and midface region from the right side. Note the orbital rim viewed in relief. There is increased bowing of the right lower eyelid in its lateral one half and upper lid retraction. Continued These all account for her functional and cosmetic complaints. She preferred to maintain her upper lid position if possible.

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D

F

E

G

Figure 9-7 Continued D, The same patient after an upper lid skin trim, common canthoplasty, and midface suspension all through the upper eyelid. I used the erbium laser to resurface the lower eyelid skin. The lateral canthi have been rendered more acute and the intercommissure distance elongated. This is especially visible on the right. The eyelid-to-midface distance has been foreshortened. E, A close-up view of the same structures after surgery shows a significant improvement but some residual asymmetry in the eyelid-to-globe relationship. F, The purely vertical midface suspension is seen in this patient. Access is through a limited transcutaneous lower eyelid incision, and the structures to be suspended are held in the forceps. G, Suspension sutures are placed between the mid face deep soft tissue structures and the periosteum along the orbital rim.

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The lower lid approach to the mid face is similar to the upper lid approach; however, it cannot be used to transpose the entire lateral canthal unit cephalad as can be achieved in the upper lid approach. I find it very difficult to accomplish the correct vertical and lateral canthal position when one uses an inferior eyelid access incision. I also find the incision lines to be less well tolerated and more frequently prone to requiring revisions or modifications compared with an upper lid or facialplasty approach. Fat repositioning or conservation procedures may be used in any of these approaches, and a transconjunctival approach with a lateral canthotomy and midface suspension combined with conservative skin excision may be an ideal route of choice in some patients. Common to all approaches, the mid face must be adequately released and mobilized in every case. It must be adequately elevated in a vertical lateral plane paralleling a line between the lateral commissure of the mouth and the lateral canthus. It is important to fixate the malar tissue with long-acting sutures to nonmovable stable areas of the orbit, such as the deep temporal fascia and periosteum, invoking the appropriate vector orientation to the lift. The lower eyelid or common canthal tendon must be adequately mobilized, stabilized, and fixed to the internal orbital rim periosteum, and skin excision should be

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deferred or only conservatively performed, being mindful of the vertical lateral vector and the inherent flexibility to perform a secondary skin procedure. Skin excision, whether primary or secondary, should always employ the same vector (lateral and superior) as in the midface suspension. Midface suspension procedures combined with blepharoplasty account for a significant number of revisional procedures in most experienced hands; although these are usually small procedures, any revision in my practice is significant. In my series, the over 200 cases of transeyelid (upper and/or lower) midface elevations combined with blepharoplasty resulted in a 12% complication rate. Half of those patients (6%) required only additional skin resection or scar modifications as an outpatient office procedure. The other half (6% of complications) had more significant problems, including asymmetry of the lateral canthus or malar soft tissues, warranting more significant modifications, again as an outpatient procedure. Midface suspension by way of a facialplasty approach resulted in significantly less complications and need for revisions; however, these were generally applied as an optimal choice by the surgeon for patients with fewer ocular symptoms, greater cosmetic concerns, and those seeking more generalized rejuvenative procedures (Fig. 9-8).


A

B

C

D

Figure 9-8 Classical approaches to the mid face and periocular region can be modified by incorporating more modern, powerful, and direct approaches to the canthi, mid face, and other periocular structures. In general, I find these direct approaches very potent, but also more prone to less forgiving complications. These direct approaches also do not afford a generalized rejuvenative procedure, which in many instances is what is really indicated. A, This is a patient with generalized facial ptosis that is manifested by jowling, neck redundancy, midface ptosis, brow ptosis, and upper eyelid redundancy. She also has lower lid ptosis, scleral show, and lateral canthal dystopia. B, Postoperative view 1 year after facialplasty with internal midface and SMAS suspension, blepharoplasty, levator plication, lower lid canthoplasty, and endoscopic resection of the brow protractors. Note the significant correction in midface ptosis. There is more notable periocular correction of the canthal dystopia, lower and upper eyelid malposition, as well as the generalized facial improvement and rejuvenation. C, Full right lateral view preoperatively. D, Full Continued right lateral view 1 year postoperatively.

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F

E

G

H

Figure 9-8 Continued E, Close-up view of the periocular and midface region preoperatively demonstrating scleral show, canthal dystopia, upper lid asymmetric ptosis, and dermatochalasis. F, Close-up frontal view of the periocular region postoperatively. G, Lateral view preoperatively showing pathology in the periocular region. H, Lateral view postoperatively demonstrating improvement in the mid face and lower and upper eyelids.

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P E A R LS A N D P I T FA L LS 1. The lower eyelid and mid face are contiguous and limited both anatomically and aesthetically. Over time the distance between the lower eyelid and the cheek elongates. 2. Aging changes also occur in the lateral canthal tendon, leading to a negative canthal angle and lower eyelid and midface ptosis, with scleral show and deepening of the nasolabial fold. 3. The common canthoplasty is an ideal procedure for the patient with lower lid laxity, vertical dystopia, and medialization of the lateral canthal complex.

4. The mid face may be approached by way of the upper or lower lateral eyelid, transconjunctivally, and by way of a facialplasty route. 5. The facialplasty approach is associated with fewer complications and revisions but is more applicable to patients with fewer ocular symptoms and more generalized cosmetic concerns.

References Collawn SS, Vascconez LO, Gamboa M, et al: Subcutaneous approach for elevation of the malar fat pad through a prehairline incision. Plast Reconstr Surg 97:836-841, 1996. Finger ER: A 5-year study of the transmalar subperiosteal mid face lift with minimal skin and superficial musculoaponeurotic system dissection: A durable, natural-appearing lift with less surgery and recovery time. Plast Reconstr Surg 107:1273-1283; discussion 1284, 2001. Gunter JP, Hackney FL, Hester TR Jr, et al: A simplified transblepharoplasty subperiosteal cheek lift. Plast Reconstr Surg 103:2029-2041, 1999. Hamra ST: Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and mid facial aging: Maximizing results and minimizing complications in a 5-year experience: Discussion. Plast Reconstr Surg 105:407-408, 2000. Hamra ST: Frequent face lift sequelae: Hollow eyes and the lateral sweep: Cause and repair. Plast Reconstr Surg 102:1658-1666, 1998. Hesse RJ: The tarsal sandwich: A new technique in lateral canthoplasty. Ophthalmic Plast Reconstr Surg 16:39-41, 2000. Hester TR Jr: Evolution of lower lid support following lower lid/mid face rejuvenation: The pretarsal orbicularis lateral canthopexy. Clin Plast Surg 28:639-652, 2001. Hinderer UT: Vertical preperiosteal rejuvenation of the frame of the eyelids and mid face. Plast Reconstr Surg 104:14821499; discussion 1500-1501, 1999. Jelks GW, Glat PM, Jelks EB, Longaker MT: The inferior retinacular lateral canthoplasty: A new technique. Plast Reconstr Surg 100:1262-1270; discussion 1271-1275, 1997.

Little JW: Three-dimensional rejuvenation of the mid face: Volumetric resculpture by malar imbrication. Plast Reconstr Surg 105:267-285; discussion 286-289, 2000. Little JW: Volumetric perceptions in mid facial aging with altered priorities for rejuvenation. Plastic Reconstr Surg 106:1653-1656, 2000. McCord CD Jr, Codner MA, Hester TR: Redraping the inferior orbicularis arc. Plast Reconstr Surg 102:2471-2479, 1998. Mendelson BC: Surgery of the superficial musculoaponeurotic system: Principles of release, vectors, and fixation. Plast Reconstr Surg 107:1545-1552, 2001. Moelleken B: The superficial subciliary cheek lift, a technique for rejuvenating the infraorbital region and nasojugal groove: A clinical series of 71 patients. Plast Reconstr Surg 104:1863-1874; discussion 1875-1876, 1999. Moss CJ, Mendelson BC, Taylor GI: Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 105:1475-1490, 2000. Olver JM: Raising the suborbicularis oculi fat (SOOF): Its role in chronic facial palsy. Br J Ophthalmol 84:1401-1406, 2000. Pessa JE, Zadoo VP, Adrian EK Jr, et al: Variability of the mid facial muscles: Analysis of 50 hemifacial cadaver dissections. Plast Reconstr Surg 102:1888-1893, 1998. Turk JB, Goldman A: SOOF lift and lateral retinacular canthoplasty. Facial Plast Surg 17:37-48, 2001. Yaremchuk MJ: Subperiosteal and full-thickness skin rhytidectomy. Plast Reconstr Surg 107:1045-1058, 2001.

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CHAPTER TEN

The Eyebrow and Lacrimal Gland COSMETIC AND ANATOMIC CONSIDERATIONS OF THE BROW Patients sometimes present with complaints related to the cosmetic appearance of their upper eyelids. They may not perceive how associated eyebrow ptosis or drooping of their eyebrows accentuates their upper eyelid abnormalities. Sometimes, fullness of the lateral brow region, especially in females, is described by the patient as solely encompassing abnormalities related to upper eyelid pathology. It is up to the examining surgeon to isolate the eyelid and eyebrow abnormalities and carefully review with the patient the contribution these entities make. Patients may indeed have upper lid dermatochalasis and herniated fat, but they may also have associated sub-brow fat pad thickening and/or lateral brow ptosis that cannot be optimally repaired with a blepharoplasty alone. Suboptimal blepharoplasty will result when brow ptosis and sub-brow fat pad hypertrophy is left unaddressed. The eyebrow in most individuals is an expressive unit of the face that is functional owing to a movable superficial musculocutaneous plane that slides over a rigidly fixed bone and periosteal plane. Below the preseptal and preorbital orbicularis is a distinct fat pad that is more prominent laterally than medially. This fat pad enhances eyebrow motility and through it dense attachments secure the brow to the supraorbital ridge. This brow fat pad commonly extends inferiorly into the preorbital septal plane, especially in older individuals, and should be distinguished from the preaponeurotic fat or postseptal fat, which is commonly addressed in the blepharoplasty procedure.

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Size and position of the brow fat pad can contribute to sexual differences, and the surgeon must be cognizant of these differences not only in performing rejuvenative procedures but in avoiding masculinization of the female patient and, more commonly, feminization of the male patient. The brow is generally arched and above the level of the supraorbital rim in females. In males it is flatter and positioned at or just slightly above the supraorbital rim. The fat pad in males is more prominent than in females, producing a fuller medialto-lateral brow that is usually proportional to the increased bony supraorbital fullness found medially and centrally but is secondary to increased frontal sinus aeration. Obviously, planning a surgical procedure should take into account gender variations so as to maximize the aesthetic result. The position of the lateral one third of the eyebrow is considered the most aesthetically important region of the brow, and it is also the most commonly ptotic area, owing to a relative paucity of firm attachments of the brow fat pad to the supraorbital rim periosteum in this region. Medially, the brow is more firmly fixed to the underlying supraorbital ridge in all individuals. The frontalis muscle interdigitates with the orbicularis oculi muscle medially, and this serves as an additional support mechanism for the medial eyebrow. The surgeon should be familiar with the relevant anatomy of the supraorbital and supratrochlear neurovascular bundles as well as the course of the frontal branch of the facial nerve before performing any procedures involving positioning or debulking the eyebrow region. The patient who presents with upper lid dermatochalasis associated with brow ptosis should be examined as described previously, and the surgeon should reposition the eyebrow digitally and examine the eyelids for dermatochalasis. Female patients who have dermatochalasis with lateral brow ptosis asso-

T H E E Y E B ROW A N D LA C R I M A L G LA N D

ciated with a fullness extending from the eyebrow into the lateral eyelid are often candidates for debulking the lateral brow fat pad. Males and females who have lateral brow ptosis may undergo suspension or browpexy at the time of blepharoplasty to improve aesthetic results. The objective should be for the surgeon to create an aesthetically discrete eyelid that is distinct from the eyebrow and brow region yet smoothly and naturally blends from eyelid to sulcus to eyebrow. Ptosis and/or excessive sub-brow fat (especially in women) can blur this distinction. Therefore, the results in upper lid blepharoplasty can be enhanced by restoring the natural height and curvature of the eyebrow along with diminishing the bulk of the eyebrow. In all approaches to the browlift, especially combined with blepharoplasty, the amount of browlift desired is determined while the patient is sitting, and the amount of skin resection should be determined after the brow is digitally stabilized at the desired height. This should serve to avoid overcorrection of the brow and, more commonly, the eyelid, resulting in lagophthalmos. It is also important and helpful to clinically determine the location of the supratrochlear and supraorbital neurovascular bundles because these should be identified and preserved in any of the techniques used for brow suspension. These are reliably found approximately 11 and 22 mm, respectively, from the midline of the nasofrontal junction. One can simply palpate their respective bony notches or foramen and ascertain the course of their corresponding neurovascular bundles without the need for memorizing any numbers.

to trauma, after repeated bouts of orbital edema, or in true blepharochalasis as described in Chapter 4. The physical examination is consistent with a sharply demarcated easily reducible mass in the upper outer orbit. In cases of markedly herniated orbital fat, the prolapsed gland may not be discovered until the actual blepharoplasty is performed. The lacrimal gland is normally suspended within the lacrimal fossa by small ligaments to the frontal bone superiorly, zygoma inferiorly, and periorbita posteriorly. It is tethered by the lacrimal nerve and vessels that enter the gland from the periorbital surface. The lateral aspect of the orbital section of this gland is contiguous with preaponeurotic fat and can be visualized in many blepharoplasty procedures. In distinction, the palpebral lobe of the gland is about one fourth to one third the size of the orbital lobe and lies beneath the levator aponeurosis, within the confines of the superior lateral fornix. From a functional standpoint, it is best not to remove any sections of the gland because this may result in a dry eye syndrome. Obviously, biopsies or full glandular resections for various tumors and inflammatory processes may be necessary. Suspension of the lacrimal gland should be considered in every blepharoplasty case, along with brow positioning, browplasty, and other periocular procedures (Fig.10-1).

THE LACRIMAL GLAND

One may perform a browplasty, browpexy, eyebrow fat pad reduction, or lacrimal gland suspension in any standard blepharoplasty of the upper eyelid. A cephalic dissection can be carried out in the submuscular plane through the postorbicularis fascia, without violating periosteum, after skin, muscle, and preaponeurotic fat are appropriately resected from the upper lid. The dissection should be carried out 1.5 to 2 cm above the superior and lateral orbital rim. The easily palpable brow fat pad may be identified overlying the lateral orbital margin. I prefer to resect a desired amount of fat from medial to lateral, being cognizant of the course of the supraorbital neurovascular bundle. An approximately 1 cm vertically high (widest point) ellipse of fat is resected and tapered medially and laterally without violating periosteum. The periosteum is left intact to

Disorders of the suspensory ligaments and the orbital septum around the lacrimal gland are an additional pathologic state worth discussing at this juncture. As discussed in Chapter 1, the gland is divided into an orbital and palpebral lobe with the orbital lobe suspended within the lacrimal fossa just internal to the orbital rim. The gland can prolapse forward with relaxation of these suspensory ligaments and produce a noticeable bulge in the upper eyelid. Patients may complain of a movable soft nontender and nonpainful mass that encroaches on the upper outer eyelid. It is encountered in most states of intrinsic relaxation and associated with aging, although it may occur secondary

BROWPLASTY, BROWPEXY, AND LACRIMAL GLAND SUSPENSION

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maintain the gliding surface and as a fixation point should browpexy be necessary or desired. I prefer to use an insulated needle tip cautery for this dissection, and it is useful to optimize exposure with one or two small rakes or double-pronged retractors on the superior edge of the blepharoplasty incision line, performed as described previously in the text after the blepharoplasty and fat pad are addressed. This is an especially powerful technique in female patients with thickened brow pads who are undergoing blepharoplasty. It allows the surgeon to diminish the difference between a full and more masculine brow and the thin upper eyelid. Browpexy or suspension of the eyebrow may be performed at the time of upper lid blepharoplasty with or without browplasty or brow fat resection. In male patients, one is more likely to leave the brow fat pad intact to maintain the normal anatomic fullness in this region. In distinction, appropriate female patients may have the brow fat pad reduced at the time of browpexy. The dissection is similar to that described in browplasty, with fixation or plication of the eyebrow to the supraorbital rim periosteum. I prefer two interrupted fixation points either mimicking the straighter brow of males or the mid-arched eyebrow of females. The underlying

A

periosteum is exposed without violating it in the subbrow space to approximately 2 cm above the orbital rim or to the area for suspension as described in the browplasty approach. Each suspension suture is passed through the subcutaneous tissue of the eyebrow at the level of the inferior eyebrow hairs. These sutures are then fixed to the periosteum at the desired level of suspension and tied down. I prefer to use a 3-0 absorbable monofilament (e.g., Monocryl, PDS). It is important to place the brow fixation sutures deeply enough so as to avoid dimpling of the overlying skin and yet provide enough fixation and stability to induce a mild browlift effect that lasts but that still allows good range of motion of the overlying soft tissues. I find it helpful to evaluate the patient preoperatively by using predetermined vertical orientation lines. The brow is digitally elevated to a desired position. The distance from the inferior brow margin along these vertical meridians is measured and noted. These distances can then be used to dictate suture placement intraoperatively. I use methylene blue and 25-gauge needles to facilitate the transfer of these measurements from external brow topography to the periosteal surface (Figs. 10-2 and 10-3).

B

Figure 10-1 The lacrimal gland may prolapse and cause upper outer lid fullness that is not correctable with fat resection alone. Lacrimal gland suspension using the capsule of the gland and orbital periosteum as anchor points is a solution that can be achieved through an upper blepharoplasty incision. This is the same patient as seen in Figure 1-18. A, This patient demonstrates lateral upper lid fullness anterior and below the orbital rim. Palpation allows discrimination of the orbital fat from that of lacrimal gland prolapse. Eversion of the upper eyelid can also allow the surgeon to appreciate the prolapse of structures in this region (see Fig. 1-17). B, The lacrimal gland prolapse can be seen in Figure 1-18. Note the capsule of the gland has been violated to demonstrate the enclosed glandular structure. This should be avoided in general when suspension techniques are employed. Capsule violation, however, does not preclude a successful suspension. This photograph demonstrates how the suspension technique is employed. The forceps is pushing the gland back under the lateral orbital rim. The technique required sutures to be placed between the gland capsule and the internal orbital periosteum. I prefer a double-armed semicircular needle to allow easy execution of this procedure.

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T H E E Y E B ROW A N D LA C R I M A L G LA N D BROW SUSPENSION THROUGH UPPER LID

Supraorbital nerve

A

Medial dissection to access brow protractors (corrugator and procerus muscles)

Dissection in the suborbicularis muscle plane

Orbital rim

Figure 10-2 An alternative to the external browlift (endoscopic, temporal, or coronal) is the internal browplasty by way of an upper eyelid approach. Transpalpebral brow fat pad reduction and browlift, especially in the lateral one third, are easily executed. The same incision and access route may be applied medially to address the protractors of the brow (corrugator and procerus muscles). The medial dissection warrants preservation of the supraorbital and supratrochlear neurovascular bundles. The lateral dissection is devoid of neurovascular structures. A, The dissection plane is accessed by way of a blepharoplasty incision. Dissection is carried in the suborbicularis plane onto the periosteal surface of the orbital rim and then may be continued superiorly. B, The undersurface of the eyebrow (fat pad) may be debulked with needletip insulated cautery if indicated. C, With the use of both a cutaneous and a bony landmark as guides (lower margin eyebrow hair and orbital rim) the deep dermis is sutured to the frontal bone periosteum at the desired level of suspension. The eyelid incision may be closed in the usual fashion.

B

C

Debulking the brow fat pad

Subbrow tissue anchored to suprabrow periosteum

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A

B

C

Figure 10-3 A, An upper blepharoplasty incision is used to gain access to the supra-eyelid region by carrying the dissection cephalad over the orbital rim, leaving the periosteum intact. Note the blue marks extending from the eyebrow into the temporal hair. Preoperatively, I delineate areas of the brow and the line I would like to elevate these in with the patient sitting or standing. I also pick several reference points (i.e., inferior eyebrow hairline and a distance above the orbital rim) on the soft tissue of the brow and the underlying bone. This allows appropriate intraoperative fixation and positioning. B, A suture is then passed between the soft tissue pad at the preoperatively chosen reference point. This suture should engage soft tissue as deeply as possible without overtly passing through the skin surface. The periosteum is then engaged at the desired level above the orbital rim. In this photograph one can see a single suture already through the soft tissue and the needle, in continuity with the first pass, engaging the periosteum above the orbital rim at the preoperatively chosen level. I usually pick at least two fixation points, one in the central and one in the lateral one third of the brow. C, This patient presented with a residual or lateral brow asymmetry several years after a viral illness (Bell’s palsy). The right eyebrow is ptotic compared with the left. The eyelids are closed to eliminate Continued any impact the visual axis and eyelid position may have on intrinsic eyebrow position.

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D

E

F Figure 10-3 Continued D, Appearance of patient in C approximately 6 months after right brow suspension by an internal approach as already described. Note the right brow elevated into a symmetric or slightly overcorrected position. E, This is a patient with benign essential blepharospasm who underwent a protractor stripping (removal) and a subtle internal brow suspension through the upper eyelid. No upper eyelid skin was removed, and the degree of brow suspension was purposely small because the patient also suffers from a dry eye syndrome. F, The postoperative view shows that I undercorrected the right brow suspension, but there is a small but appreciable elevation to the brows as evidenced by less upper lid crowding.

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DIRECT TEMPORAL LIFT In patients with mild-to-moderate lateral brow ptosis who are not undergoing an upper lid blepharoplasty to access the brow fat pad, a direct lateral temporal lift can be effective either as an extension of a facialplasty or alone. An incision is made down to the deep temporal fascia depending on the surgeon's choice for a facialplasty incision (pre- or post-hairline). The incision exposes the deep temporal fascia, and anterior dissection is carried out between the superficial temporal fascia and superficial layer of the deep temporal fascia. Blunt digital dissection is all that is necessary once one completely exposes the deep temporal fascia devoid of any overlying soft tissue elements. The frontal branch of the facial nerve can be injured either with traction or dissection, and establishing the appropriate plane and utilizing minimal instrumentation is the best approach

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to obviating complications. Dissection is carried out to the junction of the lateral third of the eyebrow; and fascial attachments, as described earlier, are lysed. It is important that the entire lateral third of the eyebrow extending from the frontal bone to the frontal process of the zygoma is freed and mobilized. The brow should be freed across the frontozygomatic articulation to allow correction of lateral upper lid hooding. The flap is rotated posteriorly and cephalad, and an appropriate amount of scalp or skin is resected. Dog-ears are removed at the superior extent of the incision. These invariably occur when the flap is rotated superiorly rather than simply pulled posteriorly. Care should be taken not to create significant tension, because this results in alopecia. A layered closure with several stay sutures encompassing the deep temporal fascia assists in maintaining stability to the browlift and avoids widening of incision lines (Fig. 10-4).


A

B

Figure 10-4 The lateral one third of the eyebrow may be suspended through an incision in or just in front of the temporal hairline alone or as an extension of a facialplasty incision. The deep temporal fascia can be used as a fixation point, and this can serve to obtain a natural looking brow suspension laterally. In cases where a more medial or central brow elevation is indicated along with a facelift, I have combined the endoscopic route with this technique to address respective areas of brow ptosis. A, The staple line indicates the pretrichial incision line with the deep temporal fascia as an anchor for the lateral brow suspension. B, The incision line in continuity with facialplasty incision approximately 1 year postoperatively.

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DIRECT BROWLIFT Direct browlift by means of external skin excision above the eyebrow is well described and has a long history, especially in the ophthalmic literature. It is effective in mild-to-moderate cases of brow ptosis and quick and easy to perform. It requires an extremely accurate and precise closure of the skin to achieve even a moderately acceptable scar for most patients. There are functional brow ptosis cases in aged individuals or other mitigating conditions in which this procedure may be warranted and acceptable; however, in general, I do not recommend this approach, given the number of other procedures available and the significant risk of generating unsatisfactory incision lines. Surgeons who have considerable experience with this technique stress the need for meticulous biconcave elliptical excisions of skin that are beveled cephalad in the direction of the eyebrow hair growth and mimic an endogenous forehead crease. The dissection is always above the periosteum to preserve neurovascular integrity. A meticulous layered closure is necessary, and the final residual scar should lie just above and hugging the superior eyebrow hair follicles. Full browlifting by means of a coronal or an endoscopic approach is amply described in other texts and publications, and therefore it is not necessary to include these approaches in this discussion. For the sake of completeness, extending the medial upper eyelid dissection cephalad into the medial brow, as is done in the lateral brow for pexy or plasty procedures, can be a useful approach to the protractors of the eyebrow (corrugator supercilii and procerus

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P E A R LS A N D P I T FA L LS 1. The examining surgeon should isolate the eyelid and eyebrow and assess the relative contribution each makes to the cosmetic abnormality. 2. The lateral one-third of the brow is most prone to ptosis and is the most important aesthetic aspect contributing to a senescent appearance. 3. In performing the browlift and upper blepharoplasty in a single procedure, one must be careful to avoid overcorrection producing lagophthalmos. It is helpful fo make preoperative markings with the patient sitting and the brow stabilized in the planned superior position. 4. Lacrimal gland prolapse can present as lateral upper lid fullness, which can blend with a laterally ptotic and thickened brow pad. 5. In women, a thickened brow fat pad must be thinned during blepharoplasty. This should generally be avoided in men as it can be feminizing. 6. Direct brow lifts generally result in unacceptable scars and the procedure requires precise surgical technique to produce acceptable results. 7. The upper eyelid incision can be used to access the protractors of the eyebrow (corrugator supercilii and procerus muscles).

muscles). Each of these muscle bellies can be isolated and identified while preserving the supraorbital and supratrochlear neurovascular bundles. The muscle bellies may be divided and partially resected to assist in improving mid-forehead glabella folds and engendering a slight medial lift. This area is prone to significant ecchymosis and swelling after any muscle resection, and meticulous hemostasis in this area is helpful in avoiding some of these postoperative sequelae (Fig. 10-5).


A

B

Figure 10-5 The protractors of the eyebrow including the procerus and the corrugator supercilii can be approached through the upper eyelid. In the lateral and central brow suspension, neurovascular structures do not complicate the procedure, but in the medial brow suspension and/or protractor muscular resection, the supraorbital and supratrochlear structures should be identified and preserved. A, The neurovascular structures (supraorbital) are identified and preserved as seen above and medial to the forceps. B, A muscular protractor of the right eyebrow corrugator is isolated and is grasped in the forceps. I then remove a large portion of the muscle with a needle tip cautery with the neurovascular bundle protected. The procerus muscular complex may be similarly addressed.

References Carter SR, Choo PH: New techniques in eyebrow surgery. Ophthalmol Clin North Am 13:731-748, 2000. Dayan SH, Perkins SW, Vartanian AJ, Wiesman IM: The forehead lift: Endoscopic versus coronal approaches. Aesthet Plast Surg 25:35-39, 2001. Knize DM: Muscles that act on glabellar skin: A closer look. Plast Reconstr Surg 105:350-361, 2000. Leopizzi G: A transpalpebral approach to treatment of eyebrow ptosis. Aesthet Plast Surg 23:125-130, 1999.

Paul MD: Subperiosteal transblepharoplasty forehead lift. Aesthet Plast Surg 20:129-134, 1996. Ramirez OM: Transblepharoplasty forehead lift and upper face rejuvenation. Ann Plast Surg 37:577-584, 1996. Yeatts RP: Current concepts in brow lift surgery. Curr Opin Ophthalmol 8(5):46-50, 1997. Zarem HA, Resnick JI, Carr RM, Wootton DG: Browpexy: Lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr Surg 101:1736, 1998.

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CHAPTER ELEVEN

Cosmetic Cranio-orbital Surgery There is a subgroup of patients with cosmetic problems that are often beyond correction within the realm of soft tissue procedures alone. Bony changes must be instituted in addition to the soft tissue procedures, which have already been described. These include patients with severe enophthalmos who present with pseudoptosis and superior sulcus deformities that are beyond correction with some of the “masking” procedures, such as elevating the upper eyelid, filling the superior sulcus, or other described techniques. Patients with Graves’ disease or thyroid ophthalmopathy, either of a bilateral or more commonly unilateral form, are another group. These patients have upper eyelid and lower eyelid retraction that is intrinsic to the infiltrative disease, but the major component of their cosmetic eyelid deformity, when severe, is pseudoretraction, or retraction that is secondary to the orbital contents and eyeball being displaced anteriorly. In either case, whether there is enophthalmos or exorbitism, the intrinsic soft tissue abnormalities are outweighed by the discrepancy between orbital bony volume and orbital soft tissue volume. To address this underlying pathophysiology, the procedures of choice include and rely on altering bony volume so that it is consistent and appropriate with given orbital soft tissue volume. All surgeons who treat cosmetic and functional problems in and around the orbit and periocular tissues should be familiar with these options and have a perspective on the limitations of soft tissue surgery alone and the power and efficacy of altering the volume of the bony orbit. Of the eight bones forming the orbit, the zygoma is by far the most important bone in the craniofacial skeleton for the surgeon. It is extracranial and accessible in part by various routes, and most surgeons of various specialties are at least familiar with exposing or treating it in some fashion (e.g., fractures).

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ENOPHTHALMOS Enophthalmos most commonly presents as a posttraumatic deformity after a displaced zygoma remains malpositioned. These fractures are usually associated with displacements of the orbital floor and/or ethmoid complex. The deformity is basically caused by a new bony orbital volume that is disproportionately large for the existing orbital soft tissue volume. This volume discrepancy has been well described both narratively and pictorially. Orbital floor disruption leads to an increase in medial and inferior orbital volume, and this is associated with soft tissue contracture that leads to the deformity. The underlying pathophysiology is an inferior and lateral displacement of the zygoma, and the soft tissue abnormalities that result are specific and almost pathognomonic. They are a lateral canthal dystopia to produce an “anti-mongoloid” slant, scleral show, malar insufficiency, upper lid pseudoptosis, and enophthalmos with a superior sulcus deformity. Based on the description in Chapter 1 of the salient anatomy of the orbit and adnexal structures, the secondary soft tissue abnormalities resulting from an inferior and laterally displaced zygoma, largely due to masseter muscle pull, are self-evident. For example, because the lateral retinaculum inserts on the frontal process of the zygoma, inferior displacement of the zygoma will produce the classic anti-mongoloid slant. The inferiorly and laterally displaced zygoma also pulls on the inferior orbital septum, which produces lower lid retraction and scleral show. The retropositioned eyeball or globe allows the upper lid to drape down lower anteriorly, hence the appearance of ptosis or “pseudoptosis.” This assumes normal levator function and aponeurotic insertion on the tarsal plate. The superior sulcus deformity, globe depression, and enophthalmos are secondary to insufficient soft tissue to fill the acquired

C O S M E T I C C R A N I O - O R B I TA L S U R G E RY

new space. In earlier chapters I have described soft tissue procedures to address ptosis, scleral show, and canthal dystopia among other abnormalities; however, in the patient who presents with late post-traumatic soft tissue abnormalities after a zygoma fracture, soft tissue correction alone should be viewed as a masking or cover-up procedure and not one that addresses the underlying problem. These masking procedures may be satisfactory in mild soft tissue abnormalities or ones in which the patient is unwilling or unable to undergo underlying volume correction. In my experience, it is always preferable to reposition the zygoma with appropriate osteotomies, provide stable rigid fixation, and proceed with bone grafts of the orbital floor and/or ethmoid complex after appropriate soft tissue mobilization than to initiate soft tissue masking procedures first. In other words, soft tissue orbital surgery is almost never an appropriate substitute for orbital bone procedures when they are indicated. I like to think of it as first repairing the walls and underlying hard structures before painting, hanging curtains, and decorating. In the case of the displaced zygoma, repositioning the bone with appropriate bone grafting provides lower eyelid elevation, correction of the lateral canthal dystopia or “anti-mongoloid slant,” anterior globe positioning, and correction of the pseudoptosis and the superior sulcus deformity. This is all performed in one procedure that addresses the problem directly and appropriately. Secondary soft tissue abnormalities may be required in the future; however, they are usually small, easy to perform, and very effective. Evaluation of patients who present with late post-traumatic orbital soft tissue abnormalities, as in the displaced zygoma fracture, should have all the preoperative examination and documentation that has already been described and more. For example, visual acuity, visual fields (gross and/or formal), extraocular motility studies, sensory and motor nerve assessment, versions (passive eye movement), and forced ductions (when appropriate) should be considered. The degree of exophthalmos should be assessed when appropriate. The Hertel exophthalmometer may not be useful because it uses the lateral orbital rim (zygoma) as a reference point. Worm's eye and lateral orbital views, using the superior orbital rim or nasion as a reference point, may be more appropriate. Computed tomographic scans (coronal and axial) can be invaluable in the assessment and planning stage of treatment. Viewed simply, treatment consists of complete subperiosteal soft tissue dissection, osteotomies that basically re-create the fracture, mobilization, repositioning, and rigid fixation of the bone segments with appropriate bone grafting. These con-

cepts are not new and are largely attributable to Tessier and a few others. The zygoma and orbit should be exposed adequately. I prefer coronal, transconjunctival with lysis of the lower crus of the lateral canthal tendon, and vestibulobuccal incisions. These incisions give optimal exposure to the zygomatic arch and to articulations of the zygoma with the greater wing of the sphenoid, maxilla, and frontal bone. They provide enough exposure to adequately protect vital structures such as the globe, medial canthus, and lacrimal system. They serve to allow the surgeon to provide adequate reduction of the fractures, bone grafting of the orbit, and an optimal chance for complete correction. So-called limited exposure techniques (e.g., elimination of the coronal incision) do not provide adequate exposure, are arduous to execute, and are less likely to produce reliable and excellent correction and results. Instead, I reserve this route for patients who are bald or unwilling to accept a coronal incision. The limitations of this modified exposure technique should be reviewed with the patient in advance. I favor the transconjunctival rather than transcutaneous route to the orbital floor because the incision can be carried medially behind the lacrimal fossa, providing easy access to the ethmoid structures. Lysis of the inferior crus of the lateral canthal tendon provides additional exposure of the orbital floor for bone grafting, eliminates undue traction on the medial eyelid, which can tear through the lacrimal system, and is easily repaired with several absorbable sutures, as long as the common canthal tendon and its superior crus remain intact. In fact, foregoing a formal repair of the inferior crus usually produces excellent results, which are similar to those obtained when the inferior crus of the lateral canthal tendon is severed as part of the treatment in acute orbital hemorrhages and raised intraocular pressure. I recommend resuspension of the malar soft tissues (masseter and overlying structures) after osteotomy, mobilization, reduction, fixation, and bone grafting is completed. In my view, spontaneous reattachment of the malar soft tissues occurs “too low,” and although bone may be positioned correctly, the overlying soft tissues may remain relatively ptotic after subperiosteal stripping and cephalomedial repositioning of the zygoma. Finally, I prefer to suspend the lower eyelid cephalad by means of a temporary tarsorrhaphy (Frost suture), linking the lower eyelid to the upper eyelid and then to the eyebrow. This should remain in place for several days to 1 week postoperatively. Light perception through the eyelid is adequate for evaluation of visual function in the immediate perioperative period. However, if one prefers 147


closer monitoring, the tarsorrhaphy may be made reusable and the lids may be opened, the globe assessed, and the lids reclosed and suspended with tape. Tarsorrhaphy provides excellent corneal coverage and comfort for these patients, who inevitably have some

form of intraoperative corneal de-epithelialization during surgery. It also allows a maximal recession of the lower lid retractors, which are lysed during the transconjunctival approach to the orbital floor (Figs. 11-1 and 11-2).

ORBITAL VOLUME REDUCTION

A

Soft tissue dissection

Displaced zygoma fracture causes enophthalmos

Fractured orbital floor

B

Fracture is recreated to mobilize zygoma fragment

C

Displaced zygoma fracture

Zygoma fragment is repositioned with a bone graft bridging the gap in the zygomatic arch

Preoperative zygoma position

Figure 11-1 The orbital volume discrepancy between bone and soft tissue contained within is common after an unreduced zygoma fracture. The presenting soft tissue deformities, including enophthalmos, superior sulcus depression, lateral canthal dystopia, scleral show, and pseudoptosis, are all tempting to address with soft tissue procedures alone. A, In all but the mildest cases the surgeon should always consider repositioning the displaced bone first, before considering soft tissue “masking” procedures. The zygoma and orbit can be degloved with a coronal (hemi), vestibulobuccal, and transconjunctival incision. The inferior crus of the lateral canthal tendon can be divided, giving complete access to the orbital floor with the risk of traction tears. Every attempt should be made to remain preseptal and then subperiosteal in a continuous plane with this dissection (arrow). Although exaggerated here, the orbital floor is already healed with fibrous and/or bony union in a displaced position. B, Osteotomies are then performed using a power microsaw of personal preference (sagittal, oscillating). It is important to completely disjoin the zygoma at its frontal, maxillary, sphenoid, and arch articulations while protecting the intraorbital contents with a malleable retractor. C, The entire zygoma is then repositioned into an anatomic position under direct vision. A bony gap or significant stepoff along the arch, as well as the orbital floor, may be grafted. Recontouring the orbital floor is more salient in correction of the orbital soft tissue deformities, whereas the zygomatic arch is relevant to facial width. Significant bony orbital volume reduction is possible in this powerful procedure. Rigid fixation of the zygoma with the assistance of temporary wire fixation in one or two points (e.g., zygomaticofrontal) is helpful. Soft tissue closure of the incisions may be accomplished in the usual fashion with the inferior crus of the lateral canthal tendon approximated carefully to the common tendon with a small absorbable suture, followed by cutaneous repair. The malar soft tissue should be suspended to obviate postoperative soft tissue ptosis, and, lastly, a temporary tarsorrhaphy is performed.

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B

A

D

C

E

Figure 11-2 In patients who have enophthalmos, and a volume discrepancy exists between the intraorbital contents and the acquired orbital bony volume, an ideal procedure is to osteotomize the zygoma and reposition it to create a smaller bony orbit. This should more closely resemble the normal anatomy and be appropriate for the soft tissue contents. Sometimes a bone graft is necessary to further reduce volume, especially in the floor region, which does not reduce well after osteotomy, especially in the late post-traumatic cases. A, A 29-year-old woman suffered right facial trauma and repair approximately 2 years before presentation to me. Coronal view of her orbits on computed tomographic scan demonstrates the large orbital volume discrepancy between the treated right side and the untreated left side. Her most significant complaints are related to her appearance. B, I performed multiple osteotomies and mobilized the zygoma by way of hemicoronal, gingivobuccal, and transconjunctival eyelid incisions. Here the zygomaticosphenoid junction and arch of the zygoma are exposed for osteotomy. C, The zygomaticomaxillary and nasal buttresses are exposed by way of a gingivobuccal approach and are then osteotomized. The transconjunctival approach to the zygomaticomaxillary junction is not shown here because this approach has been seen previously in the text (Chapter 6). D, This is the patient at presentation 2 years after injury and repair by other surgeons. Note the significant enophthalmos and inferiorly displaced eye (low eye) with a superior sulcus deformity on the right. She also has a depressed malar eminence. E, This is the patient 1 year after I performed a zygoma repositioning and autogenous bone graft. Note the significant improvement in enophthalmos, superior sulcus deformity, and elevation in the globe produced by the orbital volume reduction. The malar eminence is also normalized compared with the contralateral side.

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TREATMENT OF EXOPHTHALMOS Exophthalmos or protrusion of the globe anteriorly presents as a typical set of signs and symptoms, which, like enophthalmos, are almost pathognomonic. The most common underlying condition associated with either unilateral or bilateral exophthalmos is Graves’ disease. These patients may present with a spectrum of infiltrative disorders, which may range from mild true upper lid retraction secondary to infiltrative disease involving Müller’s muscle and other structures. Alternatively, they may present with or progress to severe exophthalmos with corneal exposure and even optic nerve compression due to significant infiltration and swelling of the extraocular muscles and orbital fat posterior to the equator of the eyeball at the orbital apex. Indications for orbital decompression fall into the categories of intractable exposure or compression permanently endangering vision. These are well described (e.g., NO SPECS classification) and appropriate for various graded decompression procedures. The purpose of this discussion is not to review the literature and procedures for orbital decompression but to focus on the underlying soft tissue abnormalities that in moderate to severe cases of orbital Graves’ diseases should be addressed with selective well-executed osteotomies in conjunction with appropriate soft tissue procedures. They should not be treated with simple gross fractures into sinuses and/or soft tissue “masking procedures.” An understanding of why these osteotomies work in rearranging specific soft tissue elements allows us to integrate all the useful anatomy already covered. The procedure of choice for these unilateral cases is based on lateral orbital wall repositioning with selective decompression of the other walls of the orbit. As in the treatment of late enophthalmos, the zygoma and its bony articulation are the key anatomic structures to be addressed. In these cases, the upper segment of the zygoma (above the maxillary buttresses, lateral to the infraorbital nerve and anterolateral to the greater sphenoid wing) is osteotomized and rotated anteriorly or counterclockwise on the right side and clockwise on the left, producing a “valgus” fracture. The incisions for exposure are similar to those used in the enophthalmos procedure, including coronal, vestibulobuccal, and transconjunctival routes. The lateral retinaculum (lateral canthal tendon) should be left intact when possible because the location of the zygoma produces a

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lateralization of Whitnall's tubercle and hence traction or tightening of the tendon. This elevates the lower eyelid and defines the lateral canthus more anteriorly on the globe. A formal canthoplasty with bony fixation may be performed should disinsertion of the lateral canthal tendon occur. I sometimes electively perform a soft tissue canthopexy or tightening of the lateral canthus and thereby elevate the lower eyelid beyond what would be produced by rotating the zygoma alone. The decompression of the orbital floor and ethmoid region is well accessed by way of the transconjunctival route, again sweeping posteriorly to the lacrimal fossa. The lateral wing of the sphenoid can be resected up to the external aspect of the middle cranial fossa. Periorbita must be incised widely; however, intractable diplopia and other complications can be avoided by incising it from the ethmoid medially and around to the superior and lateral orbit. I prefer to leave the inferior periorbita intact. Gentle pressure is placed on the globe to allow herniation of orbital contents, and every attempt is made to match the contralateral side when it is normal. The arch of the zygoma may require a bone graft to maintain curvilinear facial width and appearance. A temporary tarsorrhaphy is performed and left for the first postoperative week. In cases of bilateral exophthalmos, one may consider the above procedure either in stages or concomitantly, or one may perform a subcranial Le Fort III minus the Le Fort I segment. Simply put, this is an en bloc bilateral orbital advancement above the level of the maxillary teeth (Figs. 11-3 and 11-4). P E A R LS A N D P I T FA L LS 1. Soft tissue manipulation alone is inadequate for the correction of cosmetic problems in a subgroup of patients, most of whom suffer from orbital volume/soft tissue discrepancies. 2. Soft tissue orbital surgery should almost always follow bony procedures. 3. Limited incision exposure techniques for osteotomies of the zygoma and orbit are technically demanding and are limiting to ideal positioning of osteotomized segments. 4. Although all the pathophysiology in Graves’ disease of the orbit is related to soft tissue changes, it is the “valgus” maneuver of the zygoma along with other bony osteotomies that are most effective in cosmetic and functional corrections. 5. Nonfunctional aesthetic abnormalities in Graves’ disease and other abnormalities of the orbit are sometimes best treated with osteotomies and other bone-altering procedures. 6. In orbital expansion procedures, the inferior periorbital is best left intact to obviate inferior dystopia of the eyeball.

C O S M E T I C C R A N I O - O R B I TA L S U R G E RY ORBITAL EXPANSION

A

Osteotomize zygoma and rotate nasally

Inferior displacement of lower lid with scleral show

Osteotomy line

B

Partial removal of orbital walls and periorbita incised

Rotation of zygoma tightens lateral canthal tendon and elevates lower lid

Bone graft

Figure 11-3 The patient with exophthalmos presents with a bony and soft tissue volume discrepancy opposite to that found in the case of enophthalmos. Here the bony orbit is too small for the soft tissue contained within. Soft tissue procedures alone (“masking”) are partially effective both cosmetically and functionally only in mild cases; however, they do not anatomically address the underlying pathophysiology in a global fashion. Standard intraorbital decompression procedures (without zygoma repositioning) are sometimes effective in retrodisplacing the globe and in decompression but are not effective in addressing the adnexal and canthal positional deformities and are not applicable as a single “cosmetic” procedure in the patient who has significant exophthalmos secondary to orbital thyroid disease or other processes that are “nonfunctional” in that the cornea is adequately wetted (with drops/gels/ointments) and there is no evidence for orbital apex compression. The orbit in these cases is expanded in two ways: (1) a valgus maneuver of the zygoma and (2) bone resection and incision of the periorbita with herniation of the orbital contents are performed. Exposure is gained as in the enophthalmos correction. The zygoma is osteotomized in a nonanatomic fashion in that the bone segment may be mobilized outside the normal articulations or suture lines. For example, a beveled osteotomy above the zygomaticofrontal junction and through the body of the zygoma should be carried out when indicated, and these may be tailored to conform to individual anatomy. A, Access incisions are similar to those previously described; however, care should be taken to preserve the insertion of the common lateral canthal tendon. It may be reattached to bone if necessary. The orbital walls are resected in the ethmoid, maxillary, and sphenoid region. The transconjunctival incision is useful here in that it can be carried behind the lacrimal fossa with excellent exposure of the medial orbital wall and ethmoid complex. Laterally, I resect the zygoma behind the orbital rim up to the greater wing of the sphenoid and bur down the latter, short of exposing the middle cranial fossa. Periorbita is incised laterally, superiorly, and medially but not inferiorly to avoid glove depression; and light pressure is used to accentuate herniation of orbital contents. B, The zygoma is repositioned by rotation and slight impaction and rigidly fixed, with bone grafts applied where needed (A [black arrow] and B). Contouring (bur) is helpful at the junction between the rotated and nonosteotomized bone segment to soften the step off. Closure is completed with a temporary tarsorrhaphy.

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A

B

Figure 11-4 Enophthalmos or protrusion of the globe is ideally corrected by manipulating the bony orbital confines and increasing its volume. Osteotomies through the zygoma and adjacent bone with rotational repositioning is a very powerful technique for repositioning not only the affected soft tissue structures in the deep and middle orbit but also the anterior adnexal structures. A, A 22-year-old woman presented with unilateral left orbital Graves' disease and 5 mm of proptosis without optic nerve compression and with corneal exposure that is controlled with wetting agents. She is especially bothered by her appearance and cites multiple examples of how social, school, and work interaction with others is compromised. Note upper and lower eyelid malposition. B, The lateral orbital wall is repositioned by way of osteotomies performed through the coronal and vestibulobuccal routes. The orbital floor and medial orbit is accessed by way of a transconjunctival incision that is extended behind the posterior lacrimal crest. In this photograph, the osteotomy lines are delineated in blue. The temporalis muscle is reflected only in its Continued anteriormost extent to gain access to the zygomaticosphenoid junction.

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C

D

Figure 11-4 Continued C, The zygoma is rotated and repositioned (clockwise in this case) and rigidly fixed. I prefer to rongeur the zygoma and sphenoid articulation surfaces to create the large lateral orbit gap. The orbital floor and ethmoid walls are removed, and the periorbita is opened from the ethmoid region medially through the superior and lateral region, leaving the inferior periorbita intact. A small bone graft is usually needed along the arch of the zygoma to maintain facial width and contour. D, The patient as seen in A approximately 1 year postoperatively after lateral orbit repositioning. She is asymptomatic without corneal exposure and diplopia. The proptosis is alleviated, and the lid position is satisfactory, closely matching the contralateral side. The superior sulcus on the operated side is more concave, owing to the volume redistribution caused by the surgery. I am planning a small soft tissue procedure to fill the sulcus deformity.

References Chan CH, Spalton DJ, McGurk M: Quantitative volume replacement in the correction of post-traumatic enophthalmos. Br J Oral Maxillofac Surg 38:437-440, 2000. Chen CT, Chen YR: Endoscopically assisted repair of orbital floor fractures. Plast Reconstr Surg 108:2011-2018; discussion 2019, 2001. Clavser L, Galie M, Sarti E, Dallera V: Rationale of treatment in Graves ophthalmopathy. Plast Reconstr Surg 108:18801894, 2001. Hobar PC, Burt JD, Masson JA, et al: Pericranial flap correction of superior sulcus depression in the anophthalmic orbit. J Craniofacial Surg 10:487-490, 1999.

Karacaoglu E, Tezel E, Guler MM: Rotation ligamentoplasty for the correction of epicanthus inversus. Ann Plast Surg 45:140-144, 2000. Longaker MT, Kawamoto HK Jr: Evolving thoughts on correcting posttraumatic enophthalmos. Plast Reconstr Surg 101:899-906, 1998. Van den Bosch WA, Tjon-Fo-Sang MJ, Lemij HG: Eyeball position in Graves orbitopathy and its significance for eyelid surgery. Ophthalmic Plast Reconstr Surg 14:328-335, 1998. Zabramski JM, Kiris T, Sankhla SK, et al: Orbitozygomatic craniotomy: Technical note. J Neurosurg 89:336-341, 1998.

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CHAPTER TWELVE

Laser Resurfacing in the Periocular Region Amy B. Lewis and Henry M. Spinelli

Cosmetic skin rejuvenation currently stands at an interesting juncture between the ablative resurfacing techniques developed during the 1990s and the nonablative skin rejuvenation technology of the 21st century. During the 1990s, treatment options for rhytids and atrophic scars were limited to ablative laser resurfacing that required an extended healing period as well as invited post-treatment complications. Nonetheless, ablative resurfacing is still considered to be the most effective skin resurfacing treatment, yielding the most dramatic results. With the turn of the century, medical technology has redirected its efforts to create a second treatment option for patients with mild-tomoderate rhytids or atrophic scars. This nonablative technology attempts to stimulate the skin to produce collagen without the trauma of destroying the epidermis in the process. As a result of these developments laser surgeons are now faced with the ever-more complicated task of evaluating the appropriate treatment for their patients given ever-present financial and time constraints. Compounding the dilemma is the fact that as the number and complexity of these choices increases, so do the nuances between them. We will attempt to simplify the choices to be made. A common request from patients is to improve the aging appearance around the eyes. This is often the first cosmetic region to show the effects of time and solar damage. However, it is also the most delicate and often difficult to treat with lasers. This survey of the various laser skin rejuvenation techniques that are available to laser surgeons today is intended to provide an overview of, and perhaps introduction to, this technology.

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ABLATIVE VS. NONABLATIVE LASERS When discussing laser technology, it is important to understand which lasers are used and how they affect the skin and the rejuvenative process. The two most commonly used ablative resurfacing lasers are the ultrapulsed CO2 laser and the erbium:yttrium-aluminum-garnet (YAG) laser. The CO2 laser ablates approximately 100 µm of tissue and leaves an additional 50 µm of thermally damaged tissue. The erbium:YAG laser ablates less tissue, between 20 and 40 µm, and leaves thermal damage of an additional 20 to 30 µm. However, both lasers cause sufficient enough damage to the epidermis and dermis that specific precautions, to be discussed later, should be taken by both the physician and the patient. Nonablative lasers include the modified diode, erbium:YAG, neodymium:YAG (Nd:Yag) or pulsed dye lasers calibrated to specifically induce the skin to produce collagen. However, individual laser manufacturers have differing technologic theories as to the optimal fluences needed to best induce collagen production. These theories originated in anecdotal evidence provided by physicians and patients that pulsed dye lasers treating vascular conditions produced the unexpected effect of tightening collagen. From this unanticipated side effect, laser manufacturers began investigating the rejuvenation potential of nonablative lasers. The novelty of nonablative technology has prevented any long-term studies or definitive data to be produced.

L A S E R R E S U R FA C I N G I N T H E P E R I O C U L A R R E G I O N

The first nonablative lasers premiered commercially in the United States at the American Academy of Dermatology Convention in Washington, D.C., in March 2001. Consequently, as of yet, there is no generally used or recognized nonablative laser used by most laser surgeons. Physicians are reluctant to commit themselves to particular nonablative laser technology until more concrete data are produced by laser manufacturers or physicians.

ABLATIVE LASERS Although the prospect of smoother skin free of wrinkles or scars may be enticing to the patient, the physician is obligated to speak frankly about both the logistical and the psychological impact of ablative laser resurfacing. This discussion should begin with the realistic aesthetic evaluation of how laser resurfacing can effectively treat rhytids or textural changes caused by trauma, actinic damage, biologic aging, or prior surgery. The physician should outline the amount of time that will be required for the patient to heal as well as prepare the patient for the impact of how the patient's face will look immediately after laser treatment and as it heals. The patient needs to understand that the first 10 days after treatment will require vigorous aftercare because of significant edema, erythema, some crusting, and occasional discomfort. In addition, the patient should expect at least 3 to 6 months of mild-to-moderate erythema, which can be concealed with camouflage makeup and sunglasses and, as healing progresses, simple foundation makeup. Once the physician has explained the healing time required as well as the psychological impact of an ablative laser treatment, the patient should be given adequate time to process this information. A patient will also need to consider how this procedure can be scheduled among professional, family, social, and other personal obligations. Bear in mind, that as with most cosmetic procedures, especially those requiring significant “down” time, physicians must be prepared to provide the patient with ample emotional support. Ultimately, an informed and prepared patient will return to the physician to do laser resurfacing with realistic expectations about the procedure, aftercare, and results.

Erbium:YAG vs. CO2 Laser CO2 laser resurfacing is considered the most effective form of treatment available for extensive cutaneous

photodamage, moderate-to-severe rhytids, moderate-tosevere atrophic scarring or fibrosis, and other epidermal and dermal lesions. With a wavelength of 10,600 nm, CO2 lasers emit high-energy beams that predictably vaporize 20 to 60 µm of tissue per pass and leave acceptably narrow zones of residual dermal damage. The CO2 laser’s effects are primarily photodermal, and the residual dermal necrosis modulates wound healing, thus substantially affecting the ultimate cosmetic outcome. The heat generated within tissue intraoperatively causes immediate collagen shrinkage of 15% to 25%; and during the subsequent healing period, continued collagen contraction and reorganization are evident over the ensuing 12 to 18 months. A number of companies provide CO2 laser technology. A 2- to 3-mm spot size is available for delicate areas directly under the eyes or in the immediate lateral and medial canthi. A larger scanner can be employed for the temples and larger areas to enhance the quickness of the procedure. The skin is vaporized laterally to the temples and inferiorly to the full extent of the rhytids. A common setting for the 3-mm collimated handpiece is 50 mJ/pulse at 3 to 7 W. Usually two to three passes are performed in the periorbital region and, between passes, icewater-soaked gauze is used to wipe away any debris. Eye protection for the patient can be accomplished in several ways. Many laser surgeons prefer to use water-soaked gauze pads over the eyes so that they may reposition the gauze pads appropriately as the laser moves around the area being treated. However, this requires additional comfort and skill with the procedure. Consequently, standard eye shields placed over the cornea are often a more preferred approach. The erbium:YAG laser emits a wavelength of 2940 nm, which corresponds specifically to the main absorption peak of water and consequently is absorbed 12 to 18 times more efficiently by superficial cutaneous tissue than the CO2 laser. Irradiated tissue is immediately and forcibly ejected from the surface of the skin, permitting most of the thermal energy generated to escape. Therefore, the erbium:YAG laser resurfaces skin photomechanically whereas the CO2 laser remodels skin photothermally. The erbium:YAG laser is an excellent option for the treatment of mild-to-moderate rhytids on younger patients who have less actinic damage and shallower wrinkling in the periorbital region. In addition, the erbium:YAG laser appears to create less thermal diffusion and damage and thus shortens the reepithelialization of the skin, usually 5.5 days after the erbium:YAG resurfacing, compared with 8.5 days for CO2 laser resurfacing,5 as well as the time needed for resolution of 155


the postoperative erythema and edema. Laser surgeons must remember, however, that unlike the CO2 laser the erbium:YAG laser is not an ideal hemostatic device and is associated with petechial bleeding from the dermal capillary nexus. The variability of treatment afforded by these two lasers has led laser surgeons to explore more creative applications by combining the CO2 laser and erbium:YAG laser into a single treatment protocol. For patients presenting varying levels of photodamage and lesional involvement, some laser surgeons have opted to treat less severely damaged areas with the erbium:YAG laser while reserving treatment with the CO2 laser for the more ravaged areas that would require more drastic improvement. Another interesting combined modality tries to capture the advantages offered by both the erbium:YAG and the CO2 lasers. The resurfacing protocol is superior because it achieves maximum cosmetic improvement while minimizing morbidity. In some cases we like to begin by treating the affected area with a single pass of the ultra-pulsed CO2 laser set at 300 to 500 mJ, immediately followed by two passes of the erbium:YAG laser with a 3-mm spot size. The single pass of the CO2 laser creates dermal remodeling by collagen shrinkage while minimizing collateral damage. The erbium:YAG laser is used to ablate the epidermis mechanically and overall improve texture. It also serves to lessen the thermal zone of damage dispersed by the CO2 laser. Because both the CO2 laser and the erbium:YAG laser have wavelengths that fall within the invisible infrared spectrum, the preoperative, intraoperative, and postoperative care protocols are similar for ablative resurfacing regardless of whether it is CO2 laser, erbium:YAG laser, or a combination of both used on the patient.

Pretreatment Starting 2 to 4 weeks before the procedure, patients may be started on 0.025 to 0.05% retinoic acid cream at night, hydroquinone 4% cream twice daily, and/or 5% to 10% glycolic acid lotion. However, this is still controversial, and many laser surgeons choose not to pretreat with topical agents. Sunscreens containing ultraviolet A and B blockers as well as a sun protective factor of 15 or higher should be used daily by the patient. The best sunscreen available for the patient before and after treatment is one containing mexoryl (Anthelios 60+: La Roche-Posay, Paris, France). A preoperative questionnaire is helpful for the physician to learn about the patient’s history of 156

smoking, postinflammatory hyperpigmentation or hypopigmentation, radiation therapy, scarring, herpes simplex virus (HSV) infections, and some use of isotretinoin (Accutane: Roche Laboratories, Nutley, NJ). In particular, some surgeons believe that patients with a history of isotretinoin use within the previous 1 to 2 years may not be eligible for ablative laser resurfacing. Beginning 1 day before laser resurfacing patients should be placed on preoperative antibiotics (erythromycin or dicloxacillin, 500 mg orally, two to four times a day, or azithromycin [Zithromax Z-pack]) and antiviral therapy (acyclovir or its derivatives) and continue this regimen for 7 days thereafter or until total reepithelialization is achieved.

Intraoperative Care Safety precautions must be followed when using invisible infrared laser, which can inadvertently discharge and burn areas outside the field of treatment. The operating room door must have a cautionary laser sign displayed, and all personnel must wear wavelengthspecific eye protection. Surgical drapes should be fireresistant or moistened, and oxygen delivery should be turned off when using the laser. A water-filled spray should be ready in the treatment area to extinguish any fire. Finally, the erbium:YAG laser produces a large plume of dust containing water vapor and ejected particles. This “tissue dust” may be harmful to inhale, and all personnel must wear laser facemasks that filter particles as small as 1 µm. A strong smoke evacuator is mandatory to capture the plume of dust. During treatment, the erbium:YAG laser makes a loud popping sound and the CO2 laser makes a more muted sound with each pulse. There is more airborne debris and very little gross contraction of tissue during the first pass of erbium:YAG irradiation. In contrast, there is little debris during the first pass and immediate physical contraction during the second and third passes of the CO2 laser. The erbium:YAG laser creates a focal pinpoint bleeding that increases with each pass. Generally, if only one or two cosmetic units are being resurfaced, local anesthesia with nerve blocks is used in addition to mild sedative and pain reducers such as a diazepam and meperidine cocktail. With the erbium:YAG laser, some suggest adding only topical anesthetic cream such as lidocaine (ELA-Max) or topical butacaine. However, if a full face resurfacing with the CO2 laser is planned, intravenous sedation is usually necessary. The periorbital area, however, is difficult to anesthetize with nerve blocks and is a very sensitive area


to treat. Periorbital laser treatment is often combined with another procedure, such as a blepharoplasty, that may require intravenous sedation. If done alone, the option of topical anesthesia with the aforementioned cocktail or sedation is offered to the patient. It is easier for the laser surgeon to effectively treat the periocular area if the patient is not moving or wincing. Therefore, we suggest conscious sedation for resurfacing around the eyes unless an excellent anesthetic block and adequate ocular protection are provided.

Postoperative Care The number and variety of post laser care regimens is even larger than the therapy choices available to begin with. Basically, after the laser procedure, either nonocclusive or occlusive dressings may be used. This is a controversial point in laser care at this time because each technique has distinct advantages as well as drawbacks. Occlusive dressings are applied by the surgeon immediately after the treatment and are left in place for several hours to a few days, thus requiring minimal patient involvement in wound management. This method reportedly reduces postoperative pain and modestly accelerates the initial healing process. However, occlusive dressings may prevent visual inspection of the wound and increase the risk of bacterial or yeast infection on the skin if left intact for an extended period of time. These include Second Skin (Spenco Medical Corporation, Waco, TX), Vigilon, and other hydrogel derivatives. Nonocclusive dressing involves frequent application of healing ointments such as Catrix 10 Correction Cream, Aquaphor (Beirsdorf, Inc., Norwalk, CT), Elta Renew Cream, or pure petrolatum by the patient. The patient also treats the wounds with application and soaks to decrease edema and any buildup of adherent crust. This method decreases the risk of infection and allows the surgeon to visualize the wound bed and intervene promptly if complications occur. However, postoperative pain is greater, there is significantly more crusting, and initial healing may be slightly slower. Most importantly, this method is highly dependent on strict patient compliance, and this should be taken into account by the surgeon considering postoperative care options. Whether the surgeon chooses the postoperative occlusive or nonocclusive technique is less important than keeping any uncovered area moist by the application of one of the previously mentioned ointments.

NONABLATIVE LASERS The newest generation of laser rejuvenation is still in its early stages but theoretically promises to present the opportunity for laser skin rejuvenation to an increasingly expanding array of patients. The procedure will likely cost less, requires no recovery period, and, in fact, does not even ablate the epidermis. Patients could theoretically rejuvenate their appearance without even their closest friends being aware of their going through the process. One caveat to this treatment is the “too good to be true” phenomenon, that is, there are no long-term quality studies regarding the efficacy or extent of the benefit of these lasers. As more laser surgeons collect data based on patient treatment, a more thorough clinical review of this procedure will be necessary. However, this survey of laser skin rejuvenation techniques is intended merely to familiarize the reader with the new and continually evolving technology of nonablative lasers. Generally there are three theories as to why nonablative lasers cause skin rejuvenation. Individually, one of these three theories may explain the science behind nonablative technology; however, it is more likely that these factors work together in varying capacities to create the resulting skin rejuvenation. First, photothermal heating in the dermis may produce a nonspecific dermal wound response inducing fibroblast activation and subsequent collagen remodeling. Essentially, the photothermal heating tricks the dermis into thinking that it has been injured and stimulates collagen and fibroblast production to repair itself. Second, nonablative technologies may cause displacement of elastic photodamaged dermis, which is replaced by a more normal-appearing dermal matrix. By breaking down the damaged tissue, the dermis is able to replace it with more regularly structured healthy tissue. Third, laser-induced endothelial disruption leads to cytokine activation, which may induce subsequent collagen remodeling. In other words, by injuring but not destroying the dermal microvasculature, the injured vessels release cytokines to stimulate collagen production. Heat shock protein, vascular endothelial factors, and β-fibroblastic growth factors have all been shown to be up-regulated after clinical photoendothelial interaction. Clearly, there are measurable changes that occur as a result of nonablative lasers; however, it may take another generation or two of mechanical devices to translate these changes into a broadly useful tool. As stated earlier, how and to what extent these various dermal reactions contribute to the final result of im157


proved skin texture still remains a mystery. The elusive explanation as to how nonablative skin rejuvenation works does not diminish the fact that some studies seem to indicate that it is an effective option for patients with mild rhytids and a reluctance to undergo more invasive treatments. In a study evaluating pulsed dye laser therapy for damaged skin, 9 of 10 subjects with mild-to-moderate wrinkling and 4 of 10 with moderateto-severe wrinkling showed clinical observable improvement at 6, 12, and 24 weeks after a single treatment. Histologic evaluations confirm post-treatment collagen remodeling, thickening of the stratum spinosum, and increased mucin deposition.

Candidate Selection and Treatment As with ablative resurfacing, the laser surgeon must carefully select candidates for nonablative laser skin rejuvenation. The ideal candidate is a person with pale (type I or II) skin, minimal epidermal damage, and realistic expectations about this treatment modality. An unsuitable candidate would be a person with darker skin tone (type IV to VI), moderate to severe rhytids or scars, and/or a lot of dyschromia. Although darker skin types can be treated with wavelengths used in nonablative technology, fluence parameters may change and physicians who are relatively inexperienced with this technology are advised to work first with lightskinned patients. Once a candidate is selected, obtaining baseline photographs is an essential aspect of this treatment. In contrast to ablative skin resurfacing, nonablative skin rejuvenation is a gradual change that is clinically visible only after a minimum of 60 to 90 days. As the collagen and fibroblast remodel and re-form themselves, the patient is often unaware of the subtle changes occurring in his or her skin. Consequently, laser surgeons must understand and communicate the importance of these photographs to their staff to ensure that every patient treated will have an accurate photographic record to reflect the rejuvenation process at its various stages. In addition, the surgeon should communicate clearly to the patient that nonablative treatments do not yield overnight results. Patients should be prepared for the fact that this type of dermal remodeling is progressive and slow. Similar to ablative procedure, a pretreatment patient history should be taken, especially concerning HSV, warts, and scarring. Although nonablative laser treatments rarely can reactivate prior HSV infection, it is

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advisable to prescribe HSV prophylaxis to patients with a history of HSV outbreaks. Surgeons should closely monitor variables such as skin thickness, sensitivity of the area of treatment, and hair distribution (densely bearded areas in men tend to retain more heat) when determining the appropriate level of energy applied during the treatment. Mild erythema and mild swelling are the treatment end points: there should not be blistering, scabbing, or crusting of any kind. If vesiculation occurs after the procedure, pigmentary changes and scarring are potential concerns. Otherwise, no preoperative wound care is necessary and most patients can immediately resume their regular skin care regimen. Finally, a follow-up appointment should be scheduled 3 months after the treatment to determine the clinical efficacy and to take follow-up photographs as well as to perform other treatment modalities if desired. The commercially available 1320-nm Nd:YAG laser with a cooling device is known as the “Cool Touch.” The Cool Touch I was the first laser to be introduced as a noninvasive process to stimulate the production of new collagen fibers to reduce fine lines and combat the effects of aging. Marketed in 1996, this modality boasted “results from the inside out” by selectively targeting collagen producing fibroblasts in the epidermis. The upgraded Cool Touch II is now available and is reportedly four times faster than the older system. The 1320-nm wavelength not only penetrates into the dermis with significant, and beneficial, horizontal scattering, but it also has the capacity to cause epidermal blistering. Therefore, cryogen cooling of the epidermal layers is coupled with the laser beam. This creates a dermal wounding without a risk to the epidermis. In one study, 10 patients underwent treatment with the original Cool Touch laser to evaluate clinical and histologic changes. Pretreatment biopsy specimens from all patients showed solar damage with elastosis and a thinned epidermis. Sixty percent showed improvement only 1 month after the fourth treatment, and all showed evidence of new collagen formation by 6 months after the last laser session. All participants had some degree of temporary erythema, and none showed scarring; however, the clinical results vary. Two patients showed no improvement, 2 had a significant change, and 6 showed moderate clinical rejuvenation. In this study, the handpiece was a thermal sensor to optimize the clinical effect. A similar study was performed by Menaker and colleagues on a prototype 1320-nm laser. They found improvement in only 40% of patients, and pitted scarring was seen in 30%. No thermal sensor was used in this group, and the follow-up was only 3


months long, which may account for the differing results. The dynamic cooling device can be manipulated to further control the laser irradiation and create the desired results. The cryogen spray can come before or after the laser pulse. Usually the first pass is done with the cryogen spray first, which cools the epidermis and upper papillary dermis. This allows heating of the lower papillary dermis and the upper reticular dermis. The second pass is usually done with the cryogen spray after the laser pulse. This causes the upper papillary dermis to heat up, stimulating the fibroblast, and the spray cools the epidermis before the heat wells upward. The laser pulse also is given at six pulses with a defined delay time and pulse duration for the Cool Touch II and only three passes for the Cool Touch I. There is some mild edema and erythema afterward that typically is resolved in 1 hour. The eyes are the hardest to treat because if there is extensive laxity and sagging skin a skin trim or other surgical procedure may be necessary; in less significant cases a CO2 or other ablative laser may suffice. The Smoothbeam was introduced in Paris, France, on January 5, 2001, by the Candela Company as a revolutionary new nonablative diode laser. The 1450-nm wavelength targets 100 to 450 µm below the skin surface into the epidermis and is absorbed by water 10 times greater than the 1320-nm wavelength of the Cool Touch. Both of these infrared lasers have minimal melanin absorption and rely on their water target for the rejuvenating effects. This technology was designed to emulate the injury of the CO2 lasers in the dermal layer without ablation to the epidermis. The target tissue is high up in the papillary dermis, and cooling of the skin surface is achieved with the use of their proprietary dynamic cooling device. The cryogen tetrafluoroethane is released as a prelaser spray divided into three spurts and a post-laser spray. All sprays are adjustable for pulse durations. Because the dermal elastosis and disorganization of collagen, which appears as photodamage and rhytids, lies in the epidermis, limiting the heating of this area is advantageous. The energy is absorbed where it is most needed, and the deeper tissue is spared, leading to less potential side effects. The wound healing response to this superficial thermal blast leads to deposition of new collagen by activated fibroblast. Ross and colleagues studied the effects of the prototype Smoothbeam laser on wrinkles in nine patients. Histologic evaluation from punch biopsies 2 months after treatment revealed newly deposited, wellorganized collagen fibers and an increased number of

fibroblasts. Three treatments were done to the same area at 3-week intervals. The wrinkle severity was judged before and 3 months after the third session by four independent blinded observers. The overall improvement was statistically significant (P = .004) for reduction in wrinkle severity on the treated side as compared with a control wrinkle treated with the cryogen alone. The NLite is a pulsed dye laser that operates at 585-nm wavelength. While treating vascular lesions, physicians have noticed that over time the classic pulsed dye laser, at 585 or 595 nm, allowed for some collagen improvement after several treatment sessions. In addition, the same wavelengths were used successfully to flatten the thickened collagen and scar tissue. The laser energy emitted from the NLite has a slightly different configuration than the older pulsed dye lasers. The NLite laser produces a light beam at 585 nm, with a 350-ms pulse delay that is targeted to the microvasculature in the dermal layer. This wavelength reportedly induced an 84% increase in type III collagen production after only one laser exposure in study patients.18 The interaction of the light with the blood vessels leads to mild inflammation, but not destruction, of the dermal plexus. This, in turn, causes release of natural wound healing mediators, which increase the collagenesis. In the study by Bjerring and colleagues, 30 patients were treated with the NLite laser to evaluate the clinical improvement of this nonablative procedure. In all participants, there were no untoward pigmentary changes, and three independent observers noted cosmetic improvement in all wrinkle severities. Although this laser system has significant promise for wrinkle reduction, some clinicians have been somewhat disappointed thus far in this technology. When first introduced, it was recommended that one treatment should yield appreciable results. However, most users now believe that multiple treatment sessions are required and that the results may be subtle at best. Unfortunately, there are limited scientific data to support the efficacy of the nonablative lasers. Any or all of them may prove to be effective in wrinkle reduction, but more investigation is still needed. One final note on nonablative laser resurfacing: the novelty of this technology indicates that a more thorough review of the individual nonablative lasers and their efficacy is premature at this time. The logistical operating data for each of these three most popular and other less used machines are readily available. However, objective data reporting the cosmetic results from specific lasers is pending until further studies are conducted.

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CONCLUSION Options are increasing for the patient desiring periorbital resurfacing. The ablative lasers still yield unparalleled results with collagen tightening along with surface improvement. However, the associated healing time and morbidity is not acceptable to many. In addition, the more aggressive the ablative laser (i.e., CO2 vs. erbium:YAG), the better the efficacy in improving rhytids. But with this greater efficacy comes a higher morbidity and unsatisfactory results. The advent of the nonablative series of lasers allows for many more

people to take advantage of periorbital rejuvenation without sacrificing social or professional obligations. Although the preliminary data suggest some improvements in rhytids and texture, the change is gradual and therefore may be moot. It is often only seen when comparing the pretreatment and post-treatment photographs. The treatment protocols are still in flux, and it is not known how many treatments and at what intervals will yield the best results. Significant technologic and applicational improvement will no doubt lead to an important role for nonablative lasers in the periocular and other facial regions.

References Alster TS: Controversies in laser resurfacing: Presurgical and postsurgical care. Cosm Dermatol (May):63-66, 2001. Alster TS: Cutaneous resurfacing with ER:YAG lasers. Dermatol Surg 26:73-75, 2000. Alster TS, Weinstein C: Skin resurfacing with high energy pulsed carbon dioxide lasers. In Alster TS, Apfelberg DB (eds): Cosmetic Laser Surgery. New York, Wiley-Liss, 1996, pp 9-25. Bjerring P, Clement M, Heickendorff L, et al: Selective nonablative wrinkle reduction by laser. J Cutan Laser Ther 2:915, 2000. Fitzpatrick RE, Smith SR, Sriprachya-anunt S: Depth of vaporization and the effect of pulse stacking with a highenergy, pulsed carbon dioxide laser. J Am Acad Dermatol 40:615-622, 1999. Goldberg DJ: Smoothbeam, non-ablative dermal remodeling with the 1450-nm diode laser in combination with DCD. Candela Clinical Application Notes 1(1, Feb), 2001. Goldberg DJ: Non-ablative subsurface re-modeling: Clinical and histologic evaluation of a 1320-nm Nd:YAG laser. J Cutan Laser Therapy 1:153-157, 1999. Khatri KA, Ross V, Gravelink JM, et al: Comparison of erbium:YAG and carbon dioxide resurfacing of facial rhytids. Arch Dermatol 135:391-397, 1999. Kopelman J: Erbium:YAG laser: An improved periorbital resurfacing device. Semin Ophthalmol 13:136-141, 1998. Manuskiatti W, Fitzpatrick RE, Goldman MP: Treatment of facial skin using combinations of CO2, Q-switched

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alexandrite, flashlamp-pumped pulsed dye, and Er:YAG lasers in the same treatment session. Dermatol Surg 26:114120, 2000. Menaker GM, Wrone DA, Williams RM, Moy RL: Treatment of facial rhytids with a non-ablative laser: A clinical and histological study. Dermatol Surg 25:440-444, 1999. Millman AL, Mannor GE: Histologic and clinical evaluation of combined eyelid erbium:YAG and CO2 laser resurfacing. Am J Ophthamol 127:614-616, 1999. Pollack H: NLite laser: Non-ablative wrinkle reduction. Aesthet Surg 21:371-372, 2001. Romero P, Alster TS: Skin rejuvenation with the Cool Touch 1320-nm Nd:YAG laser: The nurse's role. Dermatol Nurs 13:122-125, 2001. Ross EV, Hardaway CA: Sub-surface skin renewal by treatment with a 1450-nm diode laser in combination with dynamic cooling. Candela Clin Application Notes 1(1), 2001. Rubenstein R, Roenick HH, Stegan SJ, Hanke CW: Atypical keloids after dermabrasion of patients taking isotretinoin. J Am Acad Dermatol 15:280-285, 1982. Sadick NS: Considerations in non-ablative laser/IPL technologies for skin rejuvenation. Cosm Dermatol (May):41-44, 2001. Shim E, Yardy T, Valasquez E, et al: Short-pulse carbon dioxide resurfacing in the treatment of rhytids and scars: A clinical and histological study. Dermatol Surg 24:113-117, 1998. Zelickson BD, Kilmer SI, Bernstein E, et al: Pulsed dye laser for sun damaged skin. Lasers Surg Med 25:229-236, 1999.

CHAPTER THIRTEEN

Complications in Blepharoplasty Ebby Elahi and Henry M. Spinelli

The continuous rise in demand for blepharoplasty in the United States has predictably coincided with an increased number of early and late complications resulting from the procedure. It is imperative, therefore, that the surgeon be familiar not only with undesirable cosmetic outcomes but also with the sight-threatening complications and their management. This chapter attempts to give an overview of such complications and discusses some preventive solutions and treatment options.

VISUAL LOSS SECONDARY TO HEMORRHAGE Retrobulbar hemorrhage is one of the most commonly feared complications of blepharoplasty. The degree of visual loss can be profound should appropriate treatment be deferred. The overall incidence of retrobulbar hemorrhage is thought to be approximately 1 in 25,000 cases. Retrobulbar hemorrhage can occur during the procedure or several days after the procedure. Bleeding is believed to result from inadequate control of hemostasis during the removal of superficial orbital fat pads or secondary to disruption of deep orbital vessels from manipulation of superficial fat pads, because these pads are linked to deep orbital fat. Finally, hemorrhage can occur as a result of trauma to the vasculature during injection of local anesthetic. Patient-related factors include hypertension and certain coagulopathies, as well as the use of medication such as aspirin or vitamin E. It is important to recognize the signs of retrobulbar hemorrhage as early as possible to avoid permanent

visual compromise. On the operating table these include sudden pupillary changes, proptosis, visual loss, and/or loss of ocular motility. Patients who are discharged after routine blepharoplasty should be instructed to contact their surgeon in the event of severe pain or visual loss. For these reasons, the eyes of blepharoplasty patients should not be patched and their vision should be checked after surgery and before discharge. One of us (HMS) likes to have patients describe gross objects or count fingers, which, despite surgery and/or topical ointments, serves to screen out potential visual compromise. Should retrobulbar hemorrhage occur during the procedure, the status of the globe (including intraocular pressure) and the optic nerve should be properly assessed, preferably by an ophthalmologist. However, all surgeons should be familiar with Schiøtz tonometry and basic techniques for assessing the globe. Mild hemorrhage can be controlled by head elevation and close observation. For more severe hemorrhage a stepwise approach must be undertaken to decompress the globe. These include the lysis of one or both crura of the lateral canthal ligament. This procedure allows the globe to move forward and protects the globe and optic nerve from ischemic and/or compressive damage. In addition, the intraocular pressure can be reduced by means of topical medications (i.e., timolol 0.5%, dorzolamide 2%, or brimonidine) or systemic administration of hyperosmolar agents (mannitol). Finally, in cases of severe hematomas uncontrolled by the previously described measures, one may choose to decompress the inferior orbital wall and/or explore the retro-orbital space surgically to control the hemorrhage. The sequence for treatment in the event of orbital hemorrhage should usually be canthotomy with concomitant medical treatment: systemic corticosteroids, hyperosmolar agents, and carbonic anhydrase inhib161


itors along with topical β-adrenergic blockers. All surgeons who perform blepharoplasty should be familiar with these treatment modalities. Finally, paracentesis of the anterior chamber is very effective in decreasing intraocular pressure. However, this should be reserved for the ophthalmologist or more experienced physician.

sponding region on the macula. It is best observed between the medial and central fat pads and has a pink/purple coloration, which is easily distinguishable from the surrounding tissues. Superior oblique palsy has also been reported from damage to the trochlea during upper lid blepharoplasty. This is best avoided by careful nasal dissection, avoidance of excessive cautery in the region of the trochlea, and proper identification of the superior medial palpebral artery inferonasal to the medial fat pad.

PERFORATION OF THE GLOBE DURING ANESTHESIA DAMAGE TO THE CORNEA Perforation of the globe during anesthesia is a rare but potentially devastating complication. This is best avoided by protecting the globe with a corneal shield before injecting the anesthetic agent and by directing the needle away from the globe. Should this complication occur, however, it is important to recognize it early and intervene quickly. Ophthalmic consultation should be obtained, and the procedure should be interrupted. Some indicative signs are sudden change in vision or a change in the position or circular symmetry of the pupil.

DAMAGE TO EXTRAOCULAR MUSCLES Extraocular muscles may also be damaged during local anesthetic injection, resulting in temporary or permanent strabismus. This complication occurs more commonly with blind retrobulbar or peribulbar injections. More commonly, however, is the damage that occurs to extraocular muscles during surgical dissection. A muscle that is theoretically at the highest risk of damage in blepharoplasty is the inferior oblique muscle. Damage to the inferior oblique muscle most commonly occurs from failure to adequately identify the muscle during lower lid blepharoplasty. This muscle is the only extraocular muscle that originates anteriorly in the orbit. Its insertion is on the maxillary bone approximately one third of the way from the junction of the medial and inferior wall. It then courses posteriorly and laterally to insert on the globe near the corre162

One of the common complications during blepharoplasty is trauma to the corneal epithelium. Although the majority of “abrasions” heal spontaneously within 24 hours or less, this is a cause of significant discomfort to the patient and a potential source of infection in some. This complication commonly occurs from abrasive movements of instruments and sutures as well as traumatic insertion and removal of protective contact lenses. The best way to avoid this complication is to pay close attention to the various instruments used during the procedure and then fill the corneal protective shield with lubricants before its insertion or at least to irrigate the lens surface with balanced saline before placement. Should an abrasion occur, however, antibiotic ointment can be prescribed and the patient should be observed daily until healing occurs. It is imperative to avoid using topical anesthetic solutions to alleviate the pain because this will significantly delay healing and put the patient at risk for neurotrophic corneal ulcer.

WOUND DEHISCENCE Wound dehiscence may occur acutely immediately after the surgery or subacutely within days to weeks postoperatively. Besides inadequate closure or disruption of sutures, one of the most common causes of wound dehiscence is the formation of a hematoma. This may occur slowly as vessels recover from the effects of epinephrine used with the anesthesia, or it may occur from the lysis of the coagulum. In general, small quantities of “oozing” can be observed carefully in the

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recovery room, and the patient should be reassured about the temporary nature of the bleeding. Occasionally, however, one encounters more brisk bleeding. This occurrence is extremely rare but may need to be explored and adequately addressed in the operating room. Lower lid fat excision may be associated with “flash” hemorrhage from vessels deep in the orbit. This may present as a retrobulbar hemorrhage or a continuous serosanguineous discharge through the lower lid conjunctival incision. Sometimes it is best to loosen the conjunctival suture to allow for the expression of the fluid until hemostasis is obtained to avoid pressurizing this orbit.

EYELID MALPOSITION Eyelid malposition has been covered in detail previously (Chapter 3), but a few important points for treatment are worth repeating and elaborating on.

Lower Lid Final positioning of the lower lid relies heavily on the adequate understanding of lower lid anatomy. Externally, the lower lid must be apposed to the globe in its entire length. An imaginary line drawn from the medial canthal angle to the lateral canthal angle should subtend an angle of 10 to 15 degrees from the horizontal. Furthermore, the relation between the lower lid margin and the inferior corneal margin must be such that on primary gaze no sclera is visible (i.e., inferior scleral show). The general position of the lashes must be such that they are not in contact with the cornea (entropion), nor should the margin be rotated in such a way that palpebral conjunctiva is exposed. Overresection of skin or aggressive dissection and fat removal during transconjunctival blepharoplasty can lead to entropion or ectropion. This may be caused by the lack of external skin (ectropion) or disinsertion of the lower lid retractors (entropion). Many patients with dermatochalasis also have variable degrees of eyelid laxity, which must be addressed during the surgical intervention (e.g., canthal tightening, lateral canthal strip). These malpositions often become more apparent postoperatively after the removal of skin and fatty tissue. It is, therefore, imperative that the surgeon carefully examine the relative

position of the eyelid margin and tarsal consistency before surgery (e.g., snap back test, eyelid distraction test). Conjunctival chemosis with prolapse can be an annoying postoperative problem. It may occur secondary to significant tightening of the lower eyelid with resultant edema, or it may occur when repositioning severely and chronically malpositioned eyelids (i.e., ectropion). Ostensibly, this is caused by a stretching or expansion of the conjunctiva, which results in a redundancy when the eyelid is repositioned. Conjunctiva, like any mucous membrane, requires moisture, and desiccation is not well tolerated. Conjunctival prolapse can be positive feedback in that exposure leads to desiccation, which leads to edema, which leads to further exposure. Proper wetting with the intensive use of topical drops and ointments is usually helpful in preventing or worsening of the cycle, but one of us (HMS) finds it most useful to perform a temporary lateral tarsorrhaphy for a speedier resolution in the more severe cases.

Upper Lid Upper lid malpositions tend to be less common than those of their lower lid counterpart. The majority of upper lid malpositions occur as a result of excessive skin excision or damage to the levator complex. During the preoperative examination, particular attention must be given to eyelid closure. Any evidence of lagophthalmos must be carefully noted, because it is likely to worsen postoperatively. In deciding on the amount of skin to remove, care must be taken not to confuse excessive upper eyelid skin with brow ptosis (especially in men). After the brow is held in its desirable anatomic position, smooth forceps can be used to determine the amount of upper skin to be removed in such a way that the lashes are slightly everted. Inadequate preoperative assessment of eyelid movement and anatomy may result in postoperative lagophthalmos and corneal dryness or decompensation. Ptosis is a rare complication of blepharoplasty. It may result from damage to the levator aponeurosis muscle during the dissection or excessive stretching of an already rarified muscle during surgery. Finally, it may result from lack of recognition of preoperative ptosis in a patient with significant dermatochalasis. The takehome lesson in almost all cases of eyelid malposition after surgery is not to intervene too quickly. The patient and/or the surgeon may feel compelled to “correct the problem”; however, many difficulties spontaneously disappear or improve significantly, and often the initial 163


corrective treatment chosen is inadequate, excessive, or not appropriate in addressing the long-term problem.

LOSS OF LASHES This complication is more common in patients undergoing combined cases of blepharoplasty and ptosis repair where the anterior tarsal surface is exposed. Excessive inferior dissection (2 to 3 mm from the lid margin in the upper lid) can lead to damage of the hair follicle, with subsequent atrophy and loss of lashes in the postoperative period. For this reason, it is best to avoid distal lid dissections.

eyelids and/or orbit. Nevertheless, once the orbital septum has been violated, pathogens can easily gain access to the deep orbital structures. A common source of infection is believed to be the nasolacrimal outflow system in patients with post–lacrimal sac stenosis in whom bacteria can multiply and reflux toward the conjunctiva. Signs of orbital cellulitis include pain, redness, decreased vision, restricted ocular motility, and proptosis. Systemic antibiotics are warranted in this situation, and close management with appropriate specialists is encouraged. As a precautionary measure, proper assessment of the nasolacrimal apparatus before surgery may avoid this potentially devastating complication.

INCISIONAL SCARRING DRYNESS Postoperative complaints of dry eye occur in patients with preoperative tear insufficiency. By widening the palpebral fissure and increasing exposure to the environment, blepharoplasty can result in decompensation in the predisposed patient. Dryness may also be the sequela of cicatricial changes in the skin (pulling the lids apart) or conjunctiva. Finally, the lacrimal gland itself may be damaged during upper lid blepharoplasty, where it can mistakenly be excised as upper lid fat. This complication is best avoided by avoiding aggressive dissection laterally where the lacrimal gland is located. Usually, there is a noticeable color difference between the lacrimal gland and the upper eyelid fat. Lacrimal gland tissue in general is whiter and septated compared with the pearly smooth yellow appearance of fat. Often the symptoms of dryness can be addressed by the use of artificial tears and lubricants. However, should the symptoms persist, a referral to an ophthalmologist is warranted to evaluate the status of the corneal tear film. Possible treatment options include the use of temporary or permanent punctal plugs along with the aggressive use of topical wetting agents.

INFECTION Infection is an extremely rare complication in blepharoplasty owing to the extensive vascularity of the 164

Postoperative scarring after blepharoplasty is relatively rare and can generally be well managed with massage and topical corticosteroid application. More severe scars can be managed by intralesional corticosteroid injection or excision with radiation. The surgeon should resist any impulse to intervene early when scarring is a problem. In cases in which tension is a contributing factor, resection alone will rarely, if ever, improve on the final result and in many instances may worsen the result.

EXCESSIVE UPPER LID FAT RESECTION Although the upper lid seems more forgiving cosmetically from overzealous fat resection, the resultant “hollow” appearance should be avoided whenever possible. In certain patients with excessive skin the natural tendency may be to remove the redundant preaponeurotic fat after the skin has been removed. However, many older patients present with considerable atrophy of the orbit fat, and the presence of “rings” around the eyes only suggests laxity of the periocular aponeurotic system. Removal of excess fat from the upper lid—especially in the midportion—may result in the accentuated appearance of this superior orbital rim. The nasal fat pad, on the other hand, is more forgiving, and overresection of this fat pad rarely results in any significant cosmetic abnormality. If the surgeon believes

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some excess fat is present, he or she should sculpt the fat and periodically reposition the tissue to assess the upper lid contour. This can easily be achieved with the use of electrocautery instruments, ablative laser, or other techniques. Fat, superficial fascia, and thin dermal grafts may all serve as satisfactory late fillers.

INAPPROPRIATE LOWER LID FAT RESECTION Excessive fat resection especially from the lower lids can result in a tear trough deformity that is cosmetically displeasing. This complication can be prevented if the relationship between the globe and the orbitomaxillary junction is carefully studied before surgery. Excessive fat removal must be avoided, and, when possible, the removed fat must be repositioned on the orbital margin to soften the superficial appearance of the inferior rim. (See Chapters 4 through 6 and 9 for a detailed discussion of these techniques.)

Underresection of fat may also create superficial asymmetry and a globular appearance of the lower skin. This complication can be minimized by periodically palpating and reexamining the superficial contour of the lower lid after the removal of each fat compartment. Should the uneven appearance persist beyond the 3month postoperative period, further resection is warranted to establish appropriate lower lid contour.

CONCLUSION Blepharoplasty is a seemingly straightforward procedure; however, even the most experienced and skilled surgeon may be faced with complications. Many of the complications are avoidable through comprehensive preoperative evaluation, adequate preoperative patient education, thorough knowledge of eyelid anatomy, and meticulous surgical technique. Despite all efforts, every surgeon will eventually encounter postoperative complications and must be prepared to handle them or risk causing serious functional or cosmetic morbidity to the patient.

References Allen MV, Cohen KL, Grimson BS: Orbital cellulitis secondary to dacryocystitis following blepharoplasty. Ann Ophthalmol 17:498-499, 1985. Brown SM, Coats DK, Collins ML, Underdahl JP: Second cluster of strabismus cases after periocular anesthesia without hyaluronidase. J Cataract Refract Surg 27:18721875, 2001. DeMere M, Wood T, Austin W: Eye complications with blepharoplasty or other eyelid surgery. A national survey. Plast and Reconstr Surg 53:634-637, 1974.

Lisman RD, Campbell JP: Complications of blepharoplasty. Facial Plast Surg Clin North Am 8:303-327, 2000. Lisman RD, Hyde K, Smith B: Complications of blepharoplasty. Clin Plast Surg 15:309-335, 1988. Wesley RE, Pollard ZF, McCord CD Jr: Superior oblique paresis after blepharoplasty. Plast Reconstr Surg 66:283-286, 1980.

165

Index Note: Page numbers followed by f indicate figures.

A Ablative lasers, 154, 155-157, 160. See also Laser resurfacing. Acyclovir, prophylactic, for laser resurfacing, 156, 158 Anatomy, surgical, 2-26 pearls and pitfalls for, 26 Anesthesia. See also specific procedure. extraocular muscle injury in, 162 globe perforation during, 162 Annulus of Zinn, 10, 11f Anterior ciliary arteries, 10 Anterior lacrimal crest, 17f Antibiotics, prophylactic, for laser resurfacing, 156 Anti-mongoloid slant, in zygomatic displacement, 146 Antiviral agents, prophylactic, for laser resurfacing, 156, 158 Arcus marginalis, 120 Asians upper eyelid blepharoplasty in, 68 upper eyelid fold in, 58, 59f, 61f Atrophic scars, laser resurfacing for, 154160 Azithromycin, prophylactic, for laser resurfacing, 156

B Bleeding. See also Hemorrhage. postoperative, 162-163 Blepharochalasis, definition of, 58 Blepharophimosis syndrome, 92 Blepharoplasty. See Lower eyelid blepharoplasty; Upper eyelid blepharoplasty. Blepharospasm, vs. ptosis, 92 Blinking cycle, 16f, 22 Bone grafts, in orbital floor reconstruction, 147-148, 148f, 149f Brow fat pad, 136 debulking of, 137-138, 139f Browlift anatomic considerations in, 136 direct, 144, 145f direct temporal lift, 142, 143f pearls and pitfalls for, 144 preoperative planning for, 137 results of, 140f-141f

Browlift (Continued) with upper lid blepharoplasty, 60, 62, 63f, 137-138, 139f-141f Browplasty/browpexy, 137-138, 139f-141f anatomic considerations in, 136 pearls and pitfalls for, 144 preoperative planning for, 137 results of, 140f-141f

C Canaliculi, 15f-17f Canthal tendons, 4f, 7, 7f-9f Canthopexy common, 46, 47f for exophthalmos, 150 lateral. See Lateral canthal suspension procedures. vs. canthoplasty, 36, 122 with disinsertion of canthal tendon, 122 Canthoplasty, 46, 47f, 122 definition of, 122 lateral. See Lateral canthal suspension procedures. technique of, 123f vs. canthopexy, 36, 122 with midface suspension, 122, 123f Capsulopalpebral fascia, 3f-5f, 6 Capsulopalpebral fascial dehiscence, 34 Central fat pad, 10, 11f Check ligaments, 10, 11f, 18 Cheek as midface component, 120 soft tissue anatomy of, 129f Cheek suspension, for cicatricial ectropion/entropion, 48 Cheimosis, conjunctival, postoperative, 163 Chronic external ophthalmoplegia, 95 Cicatricial ectropion, 36 repair of, 48, 48f, 49f Cicatricial entropion, 36 repair of, 50, 50f, 51f CO2 laser, 154-156. See also Laser resurfacing. Commissuroplasty, 122 Common canaliculus, 14, 15f Common canthal tendon, 4f, 9f Common canthopexy, 46, 47f. See also Canthopexy. Common canthoplasty, 46, 47f, 122 definition of, 122 technique of, 123f

Common canthoplasty (Continued) vs. canthopexy, 36, 122 with midface suspension, 122, 123f Complications, operative, 161-165. See also Operative complications. Congenital ptosis, 92-94, 93f. See also Eyelid ptosis. levator advancement for, 102-103, 104f109f Conjunctiva, 3f, 5f, 6 examination of, 28 Conjunctival cheimosis, postoperative, 163 Conjunctival goblet cells, 20, 21f Conjunctival prolapse, postoperative, 163 Cool Touch laser, 158. See also Laser resurfacing. Corneal injury, intraoperative, 162 Corneal light reflex distance, 94 Corneal shield, 162 Cranio-orbital surgery, 146-153 for enophthalmos, 146-148, 148f, 149f, 150 for exophthalmos, 150, 151f-153f patient selection for, 146 Cryogen spray, for nonablative lasers, 158159 Cutaneous flaps, in lower lid blepharoplasty, 72-73

D Deep temporal fascia graft, for upper lid retraction, 114, 116f, 117f Dehiscence of capsulopalpebral fascia, 34 of levator aponeurosis, ptosis and, 92, 94 wound, 162-163 Dermatochalasis definition of, 58 eyebrow ptosis and, 136-137 postoperative eyelid malposition and, 163-164 preoperative evaluation of, 62 vs. ptosis, 92 Dicloxacillin, prophylactic, for laser resurfacing, 156 Direct browlift, 144, 145f Direct temporal lift, 142, 143f pearls and pitfalls for, 144 Dressings, for laser resurfacing, 157

167

INDEX

Dry eye after ptosis repair, 95 eyelid ptosis and, 98-99

E Ectropion, 36. See also Eyelid malposition. cicatricial, 36 repair of, 48, 48f, 49f classification of, 34 lower eyelid shortening for, 36 pathophysiology of, 34 repair of, 36-46, 37f, 39f-43f, 45f, 47f. See also Lateral canthal suspension procedures. En bloc orbital advancement, for exophthalmos, 150, 152f, 153f Enophthalmos causes of, 146 vs. ptosis, 92, 93f correction of, 147-148, 148f, 149f, 150 Entropion. See also Eyelid malposition. cicatricial, 36 repair of, 50, 50f, 51f classification of, 34 involutional, 29, 34, 35f repair of, 52, 53f pathophysiology of, 34 Erbium:YAG lasers. See also Laser resurfacing. ablative, 154-156 nonablative, 154-155, 157-160 Erythromycin, prophylactic, for laser resurfacing, 156 Ethmoid bone, 9f Exophthalmos, 150, 151f-153f Extraocular muscles, 10, 11f check ligaments of, 10, 11f intraoperative injury of, 162 Eyebrow. See also under Brow. aesthetic considerations for, 136-137 anatomy of, 136 evaluation of, 136-137 gender differences in, 136 mobility of, 136 Eyebrow fat pad, 136 debulking of, 137-138, 139f Eyebrow position, in upper lid blepharoplasty, 60, 62, 63f Eyebrow ptosis/hooding, 60, 136 browlift for. See also Browlift. direct, 144, 145f with upper lid blepharoplasty, 63f, 68, 70f, 136, 137-138, 139f-141f dermatochalasis and, 136-137 direct temporal lift for, 142, 143f Eyebrow suspension anatomic considerations in, 136 in upper lid blepharoplasty, 60, 62, 63f, 137-138, 139f-141f pearls and pitfalls for, 144 preoperative planning for, 137 results of, 140f-141f Eyelashes, loss of, 164 Eyelid. See also Lower eyelid; Upper eyelid. anatomy of, 2-26. See also specific structures. gross examination of, 28-29

168

Eyelid (Continued) layers of, 2, 3f-5f pulley system of, 6-7, 11f reorienting mechanisms in, 6 retractors of, 6 Eyelid aperture, measurement of, 95, 97f Eyelid fold, position of in blepharoplasty, 62, 63f, 68, 70f normal, 94 racial differences in, 58, 59f, 61f supertarsal fixation and, 62, 63f, 68, 70f Eyelid laxity pinch test for, 29, 36 snap back test for, 29, 36 Eyelid malposition lower lid, 33f, 34-56, 121. See also Ectropion; Entropion; Lower eyelid retraction; Scleral show. cicatricial, 36, 48-50, 48f-51f evaluation of, 29, 33f, 36 full-thickness lower eyelid shortening for, 36 involutional, 29, 34, 35f repair of, 52, 53f lateral canthal inclination and, 34, 35f modified lateral tarsal strip procedure for, 38, 39f-43f myopia and, 33f pathophysiology of, 34 postoperative, 163-165 tarsal tuck for, 44, 45f, 90-91, 91f with midface ptosis, 120, 121f, 122 midface suspension for, 122-135. See also Midface suspension. upper lid. See Upper eyelid ptosis; Upper eyelid retraction. Eyelid ptosis, 92-111 causes of, 92 choice of procedure for, 98-99 congenital, 92-94, 93f levator advancement for, 102-103, 104f-109f contralateral, 113f dry eye and, 98-99 evaluation of, 92-95, 93f frontalis sling procedure for indications for, 98 technique of, 110, 111f grading of, 95 in zygomatic fractures, 146-147 involutional, 29, 34, 35f, 94 levator advancement for, 102-109 eyelid retraction after, 112 indications for, 98 results of, 107f-109f technique of, 102-103, 104f-107f, 109f levator function evaluation for, 95, 96f, 97f levator tuck for indications for, 98 technique of, 102 myopathic, 94-95 pearls and pitfalls for, 118 physical examination in, 94-95, 96f, 97f postoperative, 163-164 tarsal conjunctival müllerectomy for indications for, 98

Eyelid ptosis (Continued) technique of, 99, 100f, 101f tear production and, 95 vs. pseudoptosis, 92, 93f Eyelid retraction. See Lower eyelid retraction; Upper eyelid retraction.

F Facelift incision, in midface suspension, 124, 125f, 127f Facial nerve, aberrant regeneration of, 95 Fasanella-Servat operation eyelid retraction after, 112 indications for, 98 technique of, 99, 100f, 101f Fat eyebrow, 136 debulking of, 137-138, 139f orbital. See Orbital fat. Fat redistribution, 44, 45f, 90-91, 91f Flaps cutaneous vs. myocutaneous, in lower lid blepharoplasty, 72-73 periosteal, in lateral tarsal strip procedure, 38, 42f-43f Fractures, zygomatic, enophthalmos and, 146-147, 148f, 149f, 150 Frontal bone, 9f Frontalis sling procedure indications for, 98 technique of, 110, 111f Frost suture, in enophthalmos repair, 147148

G Globe, perforation of, 162 Glycolic acid lotion, for laser resurfacing patients, 156 Goblet cells, 20, 21f Gold weight insertion, for upper lid retraction, 114, 118f Graft bone, in orbital defect repair, 147-148, 148f, 149f interposition for lower lid retraction, 54, 55f for upper lid retraction, 114, 116f, 117f skin, for cicatricial ectropion, 48, 49f Graves‘ disease exophthalmos in, 146, 150, 151f-153f upper lid retraction in, 112. See also Upper eyelid retraction.

H Hemorrhage. See also Bleeding. orbital, 20 retrobulbar, visual loss and, 161-162 Herpes simplex virus, prophylaxis for, for laser resurfacing, 156, 158 History taking, 28 Hooding, eyebrow. See Eyebrow ptosis. Hydroquinone 4% cream, for laser resurfacing patients, 156

INDEX

I Infection, wound, 164 Inferior lid retractor disinsertion, 34 Inferior oblique muscle, 6, 10, 11f Inferior orbital fissure, 9f Inferior rectus muscle, 6, 10, 11f Inferior turbinate, 16f Infraorbital foramen, 9f Intercommissure distance, shortening of, 35f Interposition graft for lower lid retraction, 54, 55f for upper lid retraction, 114, 116f, 117f Intraoperative complications, 161-165. See also Operative complications. Involutional entropion, 29, 34, 35f repair of, 52, 53f Involutional ptosis, 29, 34, 35f, 94. See also Eyelid ptosis.

L Lacrimal apparatus, 20, 21f tear production in, 20-23. See also Tear(s). Lacrimal bone, 9f Lacrimal drainage system, 12, 13f, 14, 15f, 16f Lacrimal duct, 15f, 16f Lacrimal fossa, 9f Lacrimal gland, 8f, 9f, 16f anatomy of, 20, 21f, 137 intraoperative injury of, 164 prolapse of, 20, 21f, 137, 138f Lacrimal gland suspension, 137, 138f Lacrimal pump, 20, 22 Lacrimal puncta, 15f, 17f displacement of, 12, 13f Lacrimal sac, 12, 13f, 14, 15f-17f Lagophthalmos after ptosis correction, 94 preoperative evaluation of, 62 ptosis and, 94 Laser(s) ablative, 154, 155-156 cooling devices for, 158, 159 nonablative, 154, 158-159 safety precautions for, 156 Laser resurfacing, 154-160 ablative, 154-157, 160 CO2 vs. erbium:YAG laser for, 155-156 intraoperative care in, 156-157 postoperative care in, 157 pretreatment in, 156 nonablative, 154-155, 157-160 candidate selection for, 158 dermal reaction in, 157-158 lasers for, 158-159 technique of, 158-159 Lashes, loss of, 164 Lateral canthal complex transcutaneous approach to, 44, 45f upper eyelid approach to, 46, 47f, 48, 49f Lateral canthal suspension procedures common canthoplasty, 46, 47f, 122, 123f for cicatricial ectropion/entropion, 48-50, 48f-51f

Lateral canthal suspension procedures (Continued) for ectropion, 36-46, 37f, 39f-43f, 45f, 47f for exophthalmos, 150 for involutional entropion, 52, 53f for scleral show, 52-54, 54f, 55f indications for, 46 interposition grafts in, 54, 55f pearls and pitfalls for, 56 tarsal strip, 37f, 38, 39f-43f, 44, 45f transcutaneous approach in, 44, 45f upper eyelid approach in, 46, 47f with midface suspension, 48-50, 49f-51f, 122-135 Lateral canthal tendon, 4f, 7, 7f-9f, 18, 19f laxity of, 34, 35f, 120 tightening of. See also Lateral canthal suspension procedures. lacrimal puncta displacement and, 12, 13f Lateral canthus as midface component, 120 inclination of, 23, 34, 35f Lateral fat pad, 11f. See also Orbital fat. Lateral rectus muscle, 10, 11f Lateral retinaculum, 4f, 18, 19f Lateral tarsal strip procedure results of, 37f technique of, 38, 39f-43f Le Fort III procedure, for exophthalmos, 150, 152f, 153f Levator advancement, 102-109 eyelid retraction after, 112 indications for, 98 results of, 107f-109f technique of, 102-103, 104f-107f, 109f Levator aponeurosis, 3f-5f, 6, 7 dehiscence of, ptosis and, 92, 94 lateral horn of, insertion of, 7, 8f, 18, 19f supertarsal fixation of, 68, 70f Levator palpebrae superioris muscle, 6-7, 7f, 10, 11f functional evaluation of, 95, 96f, 97f Levator recession, for upper lid retraction, 114, 115f-117f Levator tuck for ptosis indications for, 98 technique of, 102 in upper lid blepharoplasty, 68, 70f Lid aperture, measurement of, 95, 97f Lid lag after ptosis correction, 94 preoperative evaluation of, 62 ptosis and, 94 Limbal goblet cells, 20, 21f Lockwood‘s ligament, 4f, 7f, 18 Lower canaliculi, 15f-17f Lower eyelid as midface component, 120 displacement of, 23, 25f extrinsic distraction forces on, 23, 24f, 25f gross examination of, 28-29 homeostasis of, 23, 24f, 25f intrinsic support for, 23, 24f, 25f normal position of, 6, 23, 24f, 25f, 28 relationship of to upper eyelid, 5f, 6

Lower eyelid (Continued) rhytidectomy in, 80, 81f snap back test for, 29, 36 transconjunctival approach to, 84-85, 86f transcutaneous approach to, 45f, 73-74, 75f Lower eyelid blepharoplasty, 72-89 complications of, 161-165. See also Operative complications. midface position and, 72 preoperative evaluation for, 72 transconjunctival, 80-89 advantages and disadvantages of, 73 indications for, 73, 80, 82f, 83f pearls and pitfalls for, 85 results of, 82f, 83f technique of, 84-85, 86f-89f vs. transcutaneous approach, 72-73 transcutaneous, 72-78 advantages and disadvantages of, 72 cutaneous vs. myocutaneous flaps in, 72-73 indications for, 73 pearls and pitfalls for, 78 preoperative planning in, 72, 78 technique of, 73-74, 75f-77f, 79f vs. transconjunctival approach, 72-73 with midface suspension, 132, 133f, 134f Lower eyelid laxity. See also Eyelid malposition. modified lateral tarsal strip procedure for, 38, 39f-43f pinch test for, 36 snap back test for, 29, 36 tarsal tuck for, 44, 45f, 90-91, 91f Lower eyelid ptosis. See Eyelid malposition. Lower eyelid retraction, 33f, 34, 52-54, 54f, 55f. See also Eyelid malposition. evaluation of, 29, 33f in Graves‘ disease, 146, 150, 151f-153f in zygomatic fractures, 146-147 pathophysiology of, 34 repair of, 52-54, 54f, 55f Lower eyelid shortening, full-thickness, for lid laxity, 36 Lower eyelid–upper eyelid relationship, 5f, 6

M Malar eminence, position of, evaluation of, 29, 31f, 33f Malar support evaluation of, 29, 31f inadequate, 33f Marcus-Gunn jaw-winking phenomenon, 95 Maxilla bone, 9f Medial canthal tendon, 12, 13f insertions of, 9f Medial canthus anatomy of, 12-14, 13f, 15f-17f, 18, 19f inclination of, 35f Medial fat pad, 10, 11f. See also Orbital fat. Medial rectus muscle, 10, 11f Meibomian glands, 2, 20 Mid face age-related changes in, 120, 121f anatomy and physiology of, 120, 121f components of, 120

169

INDEX

Midface ptosis, 120, 121f repair of. See Midface suspension. Midface suspension canthal approach in, 124 complications of, 132 direct (periocular) approach in, 128, 129f131f facelift incision in, 124, 125f, 127f facialplasty (preauricular) approach in, 124, 125f, 127f, 132 for cicatricial ectropion/entropion, 48, 49f general technical aspects of, 132 indications for, 122 lower lid approach in, 132 pearls and pitfalls for, 135 results of, 131f, 133f, 134f transeyelid approach in, 124 with blepharoplasty, 132, 133f, 134f with common canthoplasty, 122, 123f Modified lateral tarsal strip procedure results of, 37f technique of, 37, 39f-43f Müller‘s muscle, 3f, 5f, 6 Muscles. See Extraocular muscles and specific muscles. Myocutaneous flaps, in lower lid blepharoplasty, 73 Myopathic ptosis, 94-95 Myopia inadequate malar support and, 33f negative vector and, 33f

N Nasolacrimal duct, 17f, 22 Negative vector, myopia and, 33f Neodymium:YAG lasers, 154-155, 157-160. See also Laser resurfacing. cooling devices for, 158, 159 types of, 158-159 Nlite laser, 159. See also Laser resurfacing. Nonablative lasers, 154-155, 157-160. See also Laser resurfacing.

O Oculomotor nerve, aberrant regeneration of, 94-95 Operative anatomy, 2-26. See also specific structures. pearls and pitfalls for, 26 Operative complications, 161-165 corneal injury, 162 dry eye, 164 extraocular muscle injury, 162 eyelid malposition, 163-164 globe perforation, 162 hemorrhage-related visual loss, 161-162 incisional scarring, 164 infection, 164 insufficient/excessive fat resection, 164-165 loss of lashes, 164 wound dehiscence, 162-163 Operative procedure, selection of, 32 Ophthalmic artery, 10 Orbicularis oculi muscle, 2, 3f, 4f, 6, 12, 18, 19f

170

Orbicularis oculi muscle (Continued) evaluation of, 94 innervation of, 6 Orbital advancement, en bloc, for exophthalmos, 150, 152f, 153f Orbital bones, 9f Orbital decompression, for exophthalmos, 150, 151f-153f Orbital fat, 3f, 5f, 8f, 10, 11f excessive resection of, 164-165 malposition of, ptosis and, 94 pseudoherniation of, 34, 35f repositioning of, 44, 45f, 90-91, 91f underesection of, 165 vs. brow fat pad, 136 Orbital fissures, 9f Orbital floor defects, in zygomatic fractures, 146-147, 148f, 149f repair of, 147-148, 148f, 149f, 150 Orbital hemorrhage, 20 Orbital malar ligament anatomy of, 120 laxity of, 120 Orbital septum, 3f-5f, 8f, 11f, 18, 19f, 20, 120 insertion of, 7f orbital fat and, 20 Orbital volume discrepancy in enophthalmos, 146-148, 148f, 149f in exophthalmos, 150, 151f-153f Orbital wall repositioning, for exophthalmos, 150, 151f-153f Osteotomy, zygomatic for enophthalmos, 147-148, 148f, 149f, 150 for exophthalmos, 150, 151f-153f

P Palatal mucoperiosteum graft, in lower lid retraction, 54, 55f Palatine bone, 9f Palpebral glands of Zeis and Moll, 20, 21f Patient evaluation, 28-33 history in, 28 pearls and pitfalls for, 32 physical examination in, 28-30 Patient history, 28 Periosteal flaps, in lateral tarsal strip procedure, 38, 42f-43f Photodamage, laser resurfacing for, 154-160 Physical examination, 28-30 pearls and pitfalls for, 32 Pinch test, 36 Platysma muscle, 3f, 6 Postorbicularis precapsulopalpebral fascial space, 5f Preaponeurotic orbital fat, 3f, 5f, 8f, 20. See also Orbital fat. malposition of, ptosis and, 94 vs. brow fat pad, 136 Precapsulopalpebral fat, 5f, 20 Preoperative evaluation. See Patient evaluation. Preorbital orbicularis oculi muscle, 12 Preseptal orbicularis oculi muscle, 12, 18, 19f

Pretarsal gold weight insertion, for upper lid retraction, 114, 118f Pretarsal orbicularis oculi muscle, 12 Pseudoptosis, 92 in zygomatic displacement, 146-147 Ptosis eyebrow, 60, 136 browlift for, 63f, 68, 70f, 136, 137138, 139f-141f, 144, 145f. See also Browlift. dermatochalasis and, 136-137 direct temporal lift for, 142, 143f upper lid blepharoplasty and, 63f, 68, 70f lower lid. See Eyelid malposition. midface, 120, 121f repair of. See Midface suspension. overcorrection of, eyelid retraction and, 112-118, 113f. See also Upper eyelid retraction. upper lid, 92-111. See also Eyelid ptosis. Pulsed dye lasers, 154-155, 157-160. See also Laser resurfacing.

R Retinoic acid cream, for laser resurfacing patients, 156 Retrobulbar hemorrhage, visual loss and, 161162 Rhytidectomy, lower lid, 80, 81f Rhytids, laser resurfacing for, 154-160. See also Laser resurfacing.

S Scars incisional, 164 laser resurfacing for, 154-160. See also Laser resurfacing. Schirmer test, 29, 31f in ptosis, 95 Scleral show, 33f, 34. See also Eyelid malposition. evaluation of, 29, 33f pathophysiology of, 34 repair of, 52-54, 54f, 55f with midface ptosis, 120, 121f Senile entropion, 29, 34, 35f repair of, 52, 53f Skin flaps, in lower lid blepharoplasty, 72-73 Skin grafts, for cicatricial ectropion, 48, 49f SMAS muscle, 3f, 6 Smoothbeam laser, 159. See also Laser resurfacing. Snap back test, 29, 36 Snellen test, 29, 31f Spacer graft, in lower lid retraction, 54, 55f Sphenoid bone, 9f Subconjunctival glands of Krause and Wolfring, 20, 21f Sun damage, laser resurfacing for, 154-160. See also Laser resurfacing. Sunscreens, for laser resurfacing patients, 156 Superior oblique muscle, 10, 11f Superior orbital fissure, 9f

INDEX

Superior rectus muscle, 10, 11f Superior sulcus deformity, 94 Supertarsal fixation, 68, 70f Supraorbital neurovascular bundle, location of, 137 Supratrochlear neurovascular bundle, location of, 137 Surgical anatomy, 2-26. See also specific structures. pearls and pitfalls for, 26 Surgical complications, 161-165. See also Operative complications. Surgical procedure, selection of, 32

T Tarsal conjunctival müllerectomy eyelid retraction after, 112 indications for, 98 technique of, 99, 100f, 101f Tarsal goblet cells, 20, 21f Tarsal plate, 2, 3f, 6, 8f in lower eyelid support, 23 lateral canthal tendon and, 18, 19f Tarsal tuck with fat repositioning, 44, 45f, 9091, 91f Tarsorrhaphy, temporary in enophthalmos repair, 147-148 in exophthalmos repair, 150 Tear film, 16f, 20 evaluation of, 30, 31f inadeqaute after ptosis repair, 95 in ptosis, 98-99 refractive properties of, 20, 22 Tear trough deformity, iatrogenic, 165 Tear(s). See also under Lacrimal. aqueous phase of, 20, 22 blinking cycle and, 16f, 22 constituents of, 20 distribution of, 22 drainage of, 12, 13f, 14, 15f, 16f, 22 evaporation of, 22 ptosis repair and, 98-99 homeostasis of, 22-23 layers of, 20 production of, 14, 16f, 20, 21f Schirmer test for, 29, 31f, 95 quality of, evaluation of, 29-30 Tetrafluoroethane spray, for nonablative lasers, 158-159 Thyroid ophthalmopathy exophthalmos in, 146, 150, 151f-153f

Thyroid ophthalmopathy (Continued) upper lid retraction in, 112. See also Upper eyelid retraction. Transconjunctival lower lid blepharoplasty, 80-89 indications for, 80, 82f, 83f pearls and pitfalls for, 85, 86f-89f results of, 82f, 83f technique of, 84-85, 86f-89f Transcutaneous lower lid blepharoplasty, 7278 advantages and disadvantages of, 72 cutaneous vs. myocutaneous flaps in, 72-73 indications for, 73 pearls and pitfalls for, 78 preoperative planning in, 72, 78 technique of, 73-74, 75f-77f, 79f

U Upper canaliculi, 15f-17f Upper eyelid age-related differences in, 58, 59f, 61f baggy, 58, 59f, 61f deep-set, 58, 59f gross examination of, 28-29 maximal arch of, 28 normal position of, 6, 28, 94 normal variations in, 58, 59f racial differences in, 58, 59f, 61f relationship of to lower eyelid, 5f, 6 superior sulcus deformity of, 94 Upper eyelid approach, to lateral canthal tendon and midface, 46, 47f, 48, 49f Upper eyelid blepharoplasty, 58-70 brow fat pad debulking in, 137-138, 139f browplasty/browpexy in, 137-138, 139f141f complications of, 161-165 eyebrow position in, 60, 62, 63f eyebrow ptosis and, 63f, 68, 70f in Asians, 68 lacrimal gland suspension in, 137, 138f lid crease position in, 62, 63f, 68, 70f pearls and pitfalls for, 68 preoperative evaluation for, 58-62 preoperative planning in, 62, 63f, 66f technique of, 62-68, 64f-67f, 69f, 70f Upper eyelid excursion, measurement of, 95, 96f, 97f Upper eyelid fold, position of in blepharoplasty, 62, 63f, 68, 70f

Upper eyelid fold, position of (Continued) normal, 94 racial differences in, 58, 59f, 61f supertarsal fixation and, 62, 63f, 68, 70f Upper eyelid ptosis, 92-111. See also Eyelid ptosis. Upper eyelid retraction, 112-118 after ptosis surgery, 112 contralateral, 113f in Graves‘ disease, 112, 146, 150, 151f-153f interposition graft for, 114, 115f-117f postoperative, 163-164 weight insertion for, 114, 118f Upper eyelid–lower eyelid relationship, 5f, 6

V Visual acuity testing, 29, 31f Visual loss, due to retrobulbar hemorrhage, 161-162

W Weight insertion, for upper lid retraction, 114, 118f Whitnall‘s ligament, 3f, 4f, 7, 7f-9f, 19f, 21f Whitnall‘s tubercle, 4f, 7, 9f, 18, 19f Wound care, after laser resurfacing, 157 Wound dehiscence, 162-163 Wound infection, 164 Wrinkles laser resurfacing for, 154-160. See also Laser resurfacing. lower lid rhytidectomy for, 80, 81f

X Xerophthalmia after ptosis repair, 95 eyelid ptosis and, 98-99 postoperative, 164

Z Zygomatic bone, 9f Zygomatic fracture, enophthalmos and, 146147, 148f, 149f, 150 Zygomatic osteotomy for enophthalmos, 146-148, 148f, 149f for exophthalmos, 150, 151f-153f Zygomaticofacial foramen, 9f Zygomaticofrontal suture, 9f

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Atlas of Aesthetic Eyelid and Periocular Surgery

Manual of Aesthetic Surgery

Diagnostic Atlas of Common Eyelid Diseases

Manual of Aesthetic Surgery 2

Manual of Aesthetic Surgery 2

Atlas of Abdominoplasty (Techniques in Aesthetic Plastic Surgery)

Reconstructive Aesthetic Implant Surgery

Atlas of lacrimal surgery

Atlas of Otologic Surgery

Atlas of Hand Surgery

Atlas of Surgery

Atlas of Hand Surgery

Diagnostic Atlas of Common Eyelid Diseases

Innovations in Plastic and Aesthetic Surgery

Text Atlas of Penile Surgery

Innovations in Plastic and Aesthetic Surgery

Aesthetic Surgery of the Abdominal Wall

Aesthetic Surgery of the Abdominal Wall

Atlas of Oculoplastic and Orbital Surgery

Aesthetic Surgery of the Abdominal Wall

Manual of Aesthetic Surgery, Second Edition

Oculoplastic Surgery Atlas

Color Atlas of Dental Medicine - Aesthetic Dentistry

Atlas of Aesthetic Eyelid and Periocular Surgery

Manual of Aesthetic Surgery

Diagnostic Atlas of Common Eyelid Diseases

Manual of Aesthetic Surgery 2

Manual of Aesthetic Surgery 2

Atlas of Abdominoplasty (Techniques in Aesthetic Plastic Surgery)

Reconstructive Aesthetic Implant Surgery

Atlas of lacrimal surgery

Atlas of Otologic Surgery

Atlas of Hand Surgery

Atlas of Surgery

Atlas of Hand Surgery

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