Putterman's Cosmetic Oculoplastic Surgery, 4th Edition

An imprint of Elsevier Inc. First published 1982 Second edition 1993 Third edition 1999 © 2008, Elsevier Inc. All rights reserved. Illustrations for Chapters 3, 7, 11–14, 16, 17 and 18 adapted from drawings by Lisa Birmingham, Adrienne Boutwell and Linda Warren, University of Illinois at Chicago. Cover photo © Management Artists Syndication No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Publishers. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899, USA: phone: (+1) 215 239 3804; fax: (+1) 215 239 3805; or, e-mail: healthpermissions@elsevier. com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Support and contact’ and then ‘Copyright and Permission’. ISBN: 978-0-7216-0254-7 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Medical knowledge is constantly changing. 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 practitioner, 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 or contributors assume any liability for any injury and/or damage to persons or property arising from this publication. The Publisher

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Foreword The eyes are the windows to the soul, and are our primary focus in interpersonal contact. As surgical rejuvenation of the aging face has evolved, perhaps no form of facial enhancement has been given so much attention as periorbital rejuvenation. Blepharoplasty techniques have progressed from fairly simple procedures involving predominantly skin and fat resection to complex techniques which are anatomic in their approach, focusing on aesthetic shaping of both the upper and lower eyelid. To this end, the fourth edition of Putterman’s Cosmetic Oculoplastic Surgery, edited by Dr Steven Fagien, represents a comprehensive analysis of not only periorbital surgical techniques, but also emphasizes the aesthetic precision required to obtain consistent results with these procedures. Why a fourth edition? The answer obviously is progress. Since the third edition was published in 1999, great strides have been made in oculoplastic surgery and cosmetic blepharoplasty in terms of a more thorough understanding of periorbital anatomy, as well as in a greater appreciation of how the soft tissues of the periorbitum age. These foundations now provide surgeons with the ability to perform not just simple cosmetic enhancement but rather to reconstruct the anatomic changes which occur in aging, producing more natural results for our patients. The procedures illustrated in the text demonstrate methods to individualize shaping of the upper and lower eyelid (while preventing lid malposition), blending the lid–cheek junction, volume enhancement of the aging upper eyelid, as well as creating balance between the forehead, brow, eyelid and upper cheek. With this increased array of surgical options comes the need for increasing technical expertise, as well as developing a more sophisticated aesthetic analysis, all of which are so well discussed in this current edition.

Perhaps no area of cosmetic surgery lends itself to a multidisciplinary approach more than periorbital rejuvenation. Evolving from the functional aspects of orbital reconstruction, in conjunction with the aesthetic concepts well-founded both in plastic surgery as well as oculoplastic surgery, a synthesis of both specialties is required to optimize results in eyelid surgery. This theme is clearly noted throughout Dr Fagien’s current edition, with chapters on periorbital anatomy and aging, as well as eyelid aesthetic analysis written by both oculoplastic and plastic surgeons. This text is further augmented by collaborations by oculoplastic and dermatologic colleagues illustrating an array of non-surgical procedures for facial rejuvenation as well as methods of improving the appearance of lower lid skin through chemical peeling and laser resurfacing. In my opinion, the strengths of the current edition lie in this multi-specialty approach, providing readers with a wide spectrum of methods to optimize precision and increase consistency in their surgical results. In summary, I would like to congratulate Dr Fagien for not only undertaking, but completing this important compendium of knowledge which comprises the fourth edition of Putterman’s Cosmetic Oculoplastic Surgery. To update an already classic textbook is a major endeavor, but, in my opinion, Dr Fagien has made this textbook not only more current, but has also taken it to a new level of quality. With the plethora of procedures available in cosmetic blepharoplasty, it is refreshing to finally have a resource that brings all of this knowledge together in a single text. My congratulations to Dr Fagien and to all of the contributors of the fourth edition for their worthwhile efforts to educate surgeons focusing on cosmetic oculoplastic surgery. James M. Stuzin, MD Miami, Florida

Preface First, it is a true honor and privilege to have been asked by my mentor and friend, Allen Putterman, to continue his scriptural legacy with the opportunity to become the editor of Cosmetic Oculoplastic Surgery, beginning with this fourth edition. At first, I accepted the invitation with serious trepidation as I was unsure of what I could add to this highly acclaimed text book that has earned the distinction of being one of the world’s best reference texts on aesthetic periorbital procedures and techniques from the very start and has continued to improve through three editions. I initially agreed to this task simply out of true admiration, appreciation, and gratitude to my teacher, Allen – I realize that without him, I would never have embarked on my career journey that I still, to this day, consider as an enormous gift and am eternally thankful for. When it became more obvious to me that this fourth edition was clearly in the works and that I would be taking the helm, I wanted to make it something that continued in the tradition of this book yet could stand on its own and not simply be a revision of prior work. Additionally, I wanted to get back to the roots of oculoplastic surgery (even a re-simplification of the title) that related much to my philosophical beliefs that we, as oculoplastic surgeons, have an enormous advantage in the understanding of eyelid and periorbital anatomy, physiology, surgery, and the recognition and treatment of complications that may occur, and that this is where we should focus our educational contributions. As well, my exposure to many individuals outside of our relatively small sub-specialty has helped me realize the large contributions by our colleagues in the other aesthetic specialties, not only periorbital surgery, but also current concepts of periorbital aging and applied practical anatomy, and the non-surgical treatments for aesthetic enhancement of the aging face. Inasmuch, I have recruited and am truly thankful and appreciative for the contributions in this text by our plastic surgery and dermatology colleagues who are also well known in their respective fields and beyond, and add greater depth to the project. In this fourth addition, you will find that several of the chapters on the classic procedures have been updated by their noted authors to keep current with the history and improvements of these various periorbital surgical techniques. New and never previously published chapters have been added, one on updated concepts of periorbital and facial aging as well

as another chapter dedicated to current revelations of detailed applied anatomy that not only reflect a better understanding of the static and functional anatomy but are more relevant to the latest aesthetic periorbital surgical techniques. New chapters demonstrating alternative approaches to upper and lower blepharoplasty have also been added to revisions of existing chapters to illustrate options and add a larger perspective to surgeons depending on the presenting situation and the desired outcome. The attempt was not to include every option for each topic, yet provide the reader with the rationale and current approach by the individual contributors. Another new chapter is dedicated to the use of alloplasts for periorbital aesthetic enhancement that demonstrates that at times there is not an adequate soft tissue solution to a wide variety of patient presentations and desires. A chapter dedicated to decisionmaking in cosmetic eyelid plastic surgery has also been added that reveals a multitude of pearls that hopefully will assist the novice surgeon to be aware of common pitfalls that are often quite avoidable. And finally, two chapters on injectable agents for facial aesthetic enhancement (one on botulinum toxins and the other discussing a variety of soft tissue augmentation agents) have been completely overhauled with the enormous contributions by the my valued colleagues and coauthors, adding an international perspective that highlights how this component of our aesthetic practices has essentially exploded with the many options, improved agents and techniques now available. The book has been also graced by a world-class editorial and art staff that has assisted in the format, development, and design for which I am extremely proud of and honored to have worked with. Another exciting and highly welcomed addition is the inclusion of a DVD that highlights many of the surgical procedures and techniques discussed in the book to give the reader a greater perspective of the OR and clinical experience that will add to your ease in acquiring the skills necessary for the decision making and precision surgical/procedural delivery. Frankly, many (especially outside the medical field) have asked, ‘why contribute so much valued time and energy to this book’? There are few (if any) businesses that so freely and selflessly offer to their colleagues (sometimes viewed as competitors) such a display of collective experiences that do not directly benefit the educators. The answer is always quite simple – to

Preface xii

improve patient care and outcomes for all surgeons. This is what my mentor has done through forty years of training residents and fellows and this is what I shall do. It has been my attempt to continue with my love and appreciation of the aesthetic surgery education process with this display of a consortium of world renowned experts that I have organized into this comprehensive offering. If I may speak for them, I believe

they also share in this philosophy. It is my sincere hope that you enjoy the fourth addition of this classic text and that it adds to your understanding and performance of aesthetic periorbital surgery so that you gain the proficiency to deliver highly satisfactory results for your patients. Steven Fagien

List of Contributors Richard L. Anderson, MD FACS

Steven Fagien, MD FACS

Medical Director Center for Facial Appearances Salt Lake City, UT USA

Aesthetic Eyelid Plastic Surgery Private Practice Boca Raton, FL USA

Sterling Baker, MD

Robert A. Goldberg, MD FACS

Drs Baker and Holloman: Oculoplastic & Cosmetic Surgeons Assistant Clinical Professor, Department of Ophthalmology Adjunct Clinical Professor, Department of Dermatology College of Medicine University of Oklahoma Oklahoma City, OK USA

Professor of Ophthalmology; Chief, Orbital and Ophthalmic Plastic Surgery Division Jules Stein Eye Institute David Geffen School of Medicine at UCLA Los Angeles, CA USA

John R. Burroughs, MD Medical Director Eye and Facial Appearances Colorado Springs, CO USA

Alastair Carruthers, FRCPC Clinical Professor Department of Dermatology and Skin Science University of British Columbia Vancouver, BC Canada

Paul A. Harris, BSc MD FRCS(plast) Consultant Plastic Surgeon The Royal Marsden Hospital London, UK

Jonathan A. Hoenig, MD LA Plastic Surgery Beverly Hills, CA USA

Erin L. Holloman, MD Drs Baker and Holloman: Oculoplastic & Cosmetic Surgeons Oklahoma City, OK USA

Jean Carruthers, MD FRCS(c) FRC(Ophth), FASOPRS

Jeffrey E. Janis, MD

Clinical Professor Department of Ophthalmology and Visual Sciences University of British Columbia Vancouver, BC Canada

Assistant Professor Department of Plastic Surgery University of Texas Southwestern Medical Center Chief of Plastic Surgery, Parkland Health and Hospital System Co-Director, Plastic Surgery Residency Program Dallas, TX USA

William Pai-Dei Chen, MD FACS Clinical Professor of Ophthalmology UCLA School of Medicine Los Angeles, CA Senior Surgical Attending Eye Plastic Surgery Service Harbor-UCLA Medical Center Torrance, CA USA

Lawrence B. Katzen, MD Voluntary Assistant Professor Bascom Palmer Eye Institute University of Miami School of Medicine Miami, FL USA

List of Contributors xiv

Val Lambros, MD

Allen M. Putterman, MD

Clinical Instructor in Surgery University of California, Irvine Newport Beach, CA USA

Professor of Opthalmology Director of Oculoplastic Surgery University of Illinois College of Medicine in Chicago Chairman, Department of Ophthalmology Michael Reese Hospital and Medical Center Chicago, IL USA

William M. McLeish, MD Assistant Professor of Plastic Surgery & Ophthalmology Mayo Clinic Scottsdale, AZ USA

Rod J. Rohrich, MD

President International Society of Aesthetic Plastic Surgery Toorak, VIC Australia

Professor and Chairman Crystal Charity Ball Distinguished Chair in Plastic Surgery Betty and Warren Woodward Chair in Plastic and Reconstructive Surgery Department of Plastic Surgery UT Southwestern Medical Center Dallas, TX USA

David M. Morrow, MD FAAD FAACS

Norman Shorr, MD

Medical Director The Morrow Institute Rancho Mirage, CA USA

Private Practice Beverly Hills, CA USA

Jason K. Potter, MD DDS

Medical Director Plastic Surgery Institute of Southern California Thousand Oaks, CA USA

Bryan C. Mendelson, FRCSE FRACS FACS

Head and Neck Surgical Associates Portland, OR USA

Edward O. Terino, MD FACS

Dedication I dedicate this book to all of my teachers over the many years who had faith in me and offered their selfless commitment to education . . . and of course, to each of the four beautiful girls in my life – Debra, Samantha, Alyssa, and Kayla – that continue to also make each day a learning experience and a blessing to wake up to.

CHAPTER 1

The History of Cosmetic Oculoplastic Surgery Lawrence B. Katzen and Steven Fagien Whether regarding cosmetic oculoplastic surgery or life in general, a knowledge of the history that brought us to the present provides many advantages, most of which relate to warnings of potential unfortunate events, or encountering concepts that have been already discovered. If one knows the history, one can benefit from the experiences of others, and even endeavor to improve upon existing methods. Far too often, I read about or watch surgeons display their ‘discoveries’ only to be disappointed that they were unaware of, or do not acknowledge, those before them who, even many years previously, had authored the same results. So many of the procedures discussed today in the literature, at meetings, and in this text have roots far back in time. In this chapter, I have added to the comprehensive writings of Larry Katzen, who traced back some of the pinnacle historical discoveries of periorbital surgery. For instance, in his research, he found that the first recorded resection of excessive upper eyelid skin was performed over 2000 years ago. Many other procedures performed today such as resection of orbital fat, and the formation of the upper eyelid crease also have a long history, as do the appreciation and value of reviewing preoperative photographs, and cultural-specific attitudes towards cosmetic surgery. In this chapter, we will present some of the historical discoveries and developments of cosmetic oculoplastic surgery that have brought us to the present. Before the technicalities of cosmetic surgery are presented, we provide a background that further contributes to our appreciation of what has gone into the development and advances of modern cosmetic eyelid and facial surgery, and demonstrate that many of our current techniques are merely modifications of those developed long ago. This chapter has been updated to include the many new advances in cosmetic eyelid plastic surgery and aesthetic facial rejuvenation over the last 20 years. Not surprisingly, some procedures and techniques have been improvements of existing methods that had fallen out of favor, but have been reintroduced as promises of more recent developments have not lived up to expectations. These include the origins and evolution of some of the more recent technological advances, including laser surgery and skin resurfacing, extended and more sophisticated periorbital and midfacial procedures, the latest devices for improved soft tissue fixation, botulinum toxin, and an update on the advances in injectable agents for facial soft tissue augmentation. Steven Fagien

Chapter 4

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The History of Cosmetic Oculoplastic Surgery

Ancient medicine Gather a fold of lid skin between a couple of fingers, or raise it up with a hook, and lay the fold between two small wooden bars or rods as long as the lid and as broad as a lancet. Bind their ends very tight together. The skin between these small pieces of wood, deprived of nutrient, dies in about ten days, the enclosed skin falls off, leaving no scar. The Tadhkirat of Ali ibn Isa of Baghdad

Cosmetic eyelid surgery today has the benefit of 2000 years of development and refinement of surgical techniques and instruments. Ali ibn Isa (AD 940–1010) described the procedure just quoted more than 1000 years ago (Fig. 1-1), at a time when his medical treatment for ‘oedema of the lids’ was ‘letting blood from the head, and treating the eye with a preparation of celandine, sandlewood, and endives. . . .’1 Aulus Cornelius Celsus, a Roman encyclopedist and philosopher in the first century, was probably the first to comment on the excision of skin of the upper eyelids when he described the treatment of ‘relaxed eyelid’ in his De re Medica (AD 25–35).2 De re Medica was not

Figure 1-1 Early technique of excision of excess skin of the upper eyelid.

published until 1478, following its rediscovery by Pope Nicholas V. Even before Celsus, the Hindus were known to have referred to cosmetic and reconstructive surgery about the face. The accepted form of corporal punishment in India 2000 years ago was amputation of the nose. The surgeons of this time became so skilled in reattaching this appendage that officials began to throw the amputated nose into the fire to ensure their goal of disfigurement. It is interesting that the skilled surgeons who were able to reattach the nose successfully were actually members of the lowly tile makers’ caste.3

Modern cosmetic eyelid surgery Blepharoplasty (Greek blepharon, meaning eyelid, and plastos, meaning formed) was originally used by von Graefe4 in 1818 to describe a case of eyelid reconstruction that he had performed in 1809. This meaning prevailed for the next 150 years. In the 1913 American Encyclopedia of Ophthalmology,5 blepharoplasty is defined as the reformation, replacement, readjustment, or transplantation of any of the eyelid tissues. In contemporary usage, blepharoplasty refers to the excision of excessive eyelid skin, with or without the excision of orbital fat, for either functional or cosmetic indications. The cosmetic indications have been recognized by physicians only since the turn of the 20th century, but are now the most common reasons for such surgery on the eyelids. This change followed the development of improved operative techniques, better surgical results, and control of sepsis as well as changing social mores. It is difficult to determine whether the ‘relaxed eyelid’ described by Celsus was a true ptosis or an excess skin fold. In any event, by the late 1700s, reports began to appear in Germany6 specifically identifying the excess fold of the upper eyelid. Beer’s 1817 text is credited with providing the medical literature with the first illustration of this eyelid deformity.7 Many different authors from the first half of the 19th century began advocating excision of this excess skin, including Mackenzie,8 Alibert,9 Graf,10 and Dupuytren.11 The first ‘accurate’ description of ‘herniated orbital fat,’ written in 1844 by Sichel,12 did not create a wave of surgical excisions because surgery at that time was performed only for functional reasons. The case of Fetthernien reported in 1899 by Schmidt-Rimpler,13 which described herniated orbital fat, was clouded by the later report by Elschnig,14 who called the same patient’s condition a lipoma. Near the turn of the 19th century, Ernest Fuchs15 attempted to decipher the confusing terminology that had developed in the literature. ‘Ptosis adiposa,’ the

Modern cosmetic eyelid surgery misnomer used by Sichel, and ‘ptosis atonica,’ used by Hotz,16 had been introduced earlier in the 19th century. Sichel12 had claimed that the excess upper lid fold was filled with fat, which caused it to hang down over the lid margin. Hotz believed that the skin was normally attached to the top of the tarsus, and that the loss of this attachment created an excessive upper lid skin fold with a pseudoptosis. It was Fuchs who recognized the importance of the weakening of the fascial bands connecting the skin and orbicularis with the tendons of the levator in the development of the excess skin fold. In his 1892 text, Fuchs15 wrote: So also the ptosis adiposa of Sichel, which consists in the fact that the covering fold of the upper lid is of unusual size, so as to hang down over the free border of the lid in the region of the palpebral fissure, does not belong under the head of ptosis proper. It was formerly assumed that this enlargement was caused by an excessive accumulation of fat in the covering fold, for which reason the name of ptosis adiposa was given to it. Its true cause, however, depends upon the fact that the bands of fascia connecting the skin with the tendon of the levator . . . and with the upper margin of the orbit are not rigid enough; consequently the skin is not properly drawn up when the lid is raised, but hangs down in the form of a flabby pouch (Hotz). Except for the disfigurement it causes ptosis adiposa entails no disagreeable symptoms. It can be removed by simple ablation of the excess of skin, but it is better, although also more tedious, to attach the skin to the upper border of the tarsus by Hotz’s operation, and thus prevent its drooping.

And so Fuchs was the first to recognize the cosmetic value of reformation and elevation of the eyelid crease. Fuchs17 is also credited with originating the often misused term blepharochalasis in 1896. Sometimes used to describe the changes associated with herniated orbital fat, this term should be reserved for those cases of thickened and indurated eyelids, most often found in younger women, and associated with recurrent episodes of idiopathic edema.18,19 The term dermatochalasis was introduced 56 years later by Fox20 to describe the apparent excess eyelid skin associated with aging. In the early 1900s, the historical focus on cosmetic eyelid surgery shifted to the United States, where Conrad Miller,21 in 1907, produced Cosmetic Surgery: The Correction of Featural Imperfections, the first published book on cosmetic surgery. This edition, which covered many aspects of plastic surgery, contained the first photograph in medical history to illustrate the lower eyelid incision for removing a crescent of excess skin. It is interesting to note Miller’s surgical

technique. In his discussion of the lower eyelid incision, Miller stated that ‘just sufficient skin is left along the margin of the lid to permit the stitches being passed in closing. The line of union is brought in this way under the shadow of the lashes, and is entirely invisible.’ On excision of the fold above the eye, Miller wrote that ‘the fold above the eye after infiltration is picked and trimmed away. The line of closure here is at the upper extremity of the lid so that the slight line of the union is hidden in the fold between the lid and the brow when the eye is open, and only shows slightly when the eye is closed.’ Miller’s enlarged text,22 which followed in 1924, provided diagrams of incision sites for upper and lower eyelid blepharoplasty that are remarkably similar to those commonly used today (Fig. 1-2). Frederick Kolle,23 in a 1911 text on plastic and cosmetic surgery, wrote about wrinkled eyelids in a chapter on blepharoplasty. He probably was the first to recognize and note the safety and value of marking the skin preoperatively to determine the amount of excess skin to excise. Adabert Bettman24–26 added to the contributions by Miller and Kolle in his publications in the 1920s, in which he described precautions, specifically related to surgery about the eyelids, to be taken in minimizing postoperative scarring. He emphasized gentle treatment of the tissues, exact apposition of wound edges, elimination of tension on all wound edges, and timely suture removal. These, of course, are concepts that are still important today. The first work in English devoted solely to oculoplastic surgery was written by Edmund Spaeth.27 Newer Methods of Ophthalmic Plastic Surgery, published in 1925, deals entirely with eyelid reconstruction and does not mention cosmetic surgery. By the late 1920s, still no mention had been made in the United States of the excision of herniated orbital fat for cosmetic reasons. Although advances and progress in medicine (including antibiotics, finer suture materials, improved technology, and better control of sepsis) allowed for the beginnings of the public desire for and acceptance of cosmetic surgery, it was still frowned on by the majority of physicians. In the same decade in Europe, Julian Bourguet28 was also developing new techniques in cosmetic eyelid surgery. In 1924, he was probably the first to describe transconjunctival resection of the pockets of herniated orbital fat. In the following year, he published probably the first before and after photographs of patients who had undergone cosmetic lower eyelid surgery (Fig. 1-3).29 In 1929, Bourguet30 described the two separate fat compartments of the upper lid and advocated their removal. Many surgeons followed his lead, including Claoué31 and Passot.32 Passot32,33 is also credited as

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The History of Cosmetic Oculoplastic Surgery

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Figure 1-2 A, An upper eyelid incision. B, An upper eyelid closure. C, A triangular resection modification to lower eyelid incision to prevent ectropion. D, A lower eyelid closure. From Miller CC: Cosmetic Surgery: The Correction of Featural Imperfections. Philadelphia, FA Davis, 1924. With permission.

Figure 1-3 Earliest photographs illustrating preoperative (A) and postoperative (B) appearances of lower eyelid blepharoplasty. From Bourguet J: Chirurgie esthétique de la face: Les nez concaves, les rides et les ‘poches’ sous les yeux. Arch Franco-Belges Chir 1925; 28:293. With permission.

being the first to name the supraciliary brow incision for the correction of brow ptosis. It is also quite interesting that Passot expressed his objections to the secrecy of techniques practiced by some of his contemporaries: ‘By keeping their methods secret, they allow a certain suspicion to exist about their procedures.’34,35 These ‘suspicions’ for many procedures can be related to the present. At the same time, one of the first female surgeons to appear in the history of cosmetic surgery was perfect-

ing her techniques in Paris.36,37 Suzanne Noel’s 1926 book on cosmetic eyelid surgery38 was the earliest to include numerous preoperative and postoperative photographs.36 Noel also initiated the emphasis, for the benefit of other surgeons, on the advantages and the importance of looking at these photographs and showing them to one’s patients. She was also the first to be photographed performing a blepharoplasty. Thanks to the contributions of Noel and others and to the development of photography as an art and science,

Modern cosmetic eyelid surgery photographic documentation is now an integral part of the practice of the cosmetic oculoplastic surgeon. In addition, Noel must certainly be credited for recognizing the importance of the psychological implications of cosmetic surgery for both the patient and the patient’s family. She distinguished between the attitudes of American and European men: ‘American men are anxious to encourage their wives to have such an operation. . . . [S]uch is not the case with the European male; as a result, French women have the operation performed and do not talk about it.’ In the first two decades of the 1900s, a surgical technique widely used in Europe for elevation of the eyebrow was commonly known as the ‘temporal lift.’ Its benefits remained controversial. Bourguet,39 in 1921, was the first to condemn this type of surgery. In 1926, Hunt40 described a coronal skin resection to achieve a forehead lift. Joseph,41 in 1931, described hairline and forehead crease incisions to raise the brows. The coronal brow lift, as described by Hunt, lost favor because the results with the methods performed in a matter similarly ascribed by him were thought to be too transient. A number of authors then recognized the importance of manipulating the frontalis and other muscle activity to achieve better results with the forehead lift.35,42–45 The importance of attenuating the action of the procerus and corrugator muscles was recognized by Salvadore Castanares in 1964.46 Since the 1930s, additional individual contributions have been made to cosmetic eyelid surgery. An offering in 1951 by Castanares47 of a detailed description of the fat compartments of the upper and lower orbit and their relationship to the eyelids cannot be overlooked. It was also Castanares48–50 who recognized the importance of the orbicularis muscle (including its hypertrophy and excision, when indicated) as part of the overall evaluation and technique in cosmetic blepharoplasty.48–50 Furnas51–53 later elaborated on the origin of eyelid and cheek contour abnormalities (including festoons) in his landmark chapter in Clinics of Plastic Surgery edited by Flowers. In 1954, Sayoc54 reported on the use of the Hotz trichiasis procedure for the cosmetic alteration of the Asian upper eyelid crease/fold complex. Pang’s 1961 report on the Far Eastern method of the surgical formation of the upper lid fold55 was the first to advocate the technique of supratarsal fixation, although this term was reintroduced 13 years later by Jack Sheen.56 Khou Boo-Chai’s 1963 report57 was the initial description of eyelid crease elevation with upper eyelid blepharoplasty, but he advocated dermal fixation to the tarsal plate and referred only to the Asian eyelid. Significant contributions to cosmetic eyelid surgery in the 1970s focused on the levator aponeurosis and crease-fold complex.58 In 1974, Sheen56 recognized the

low eyelid crease as the cause of apparent failure in many Caucasian patients undergoing upper lid blepharoplasty. He advocated orbicularis fixation to the levator aponeurosis 16 mm above the lid margin; 3 years later, iatrogenic postoperative ptosis prompted him to lower it to 12 mm.59 At that time, observing postoperative lid retraction, he inadvertently discovered a way to strengthen the levator aponeurosis by tucking it. The next year, Dryden and Leibsohn60 reported on intentional levator advancement for simultaneous blepharoplasty and repair of ptosis. The current thinking for the next 20 years for a high-definition and enhanced upper eyelid ‘invagination’ with blepharoplasty were in part due to contributions from Flowers61,62 and Siegel.63,64 Putterman and Urist65 recognized the role of the crease-fold complex in upper eyelid asymmetry associated with ptosis, trauma, and other eyelid abnormalities. Sheen66 also advocated tarsal fixation in the lower eyelid to achieve a ‘youthful’ appearance. In the last 25 years, there have been significant additional contributions to the development of cosmetic oculoplastic surgery. With the increased frequency of operations, there has been a growing awareness of potential complications. The importance of the preoperative evaluation has been emphasized as essential to minimizing complications; this also has resulted in the development of adjunctive surgical procedures. With a perceived improved understanding of orbital and periorbital anatomy and failure of existing methods relating to upper blepharoplasty, a focus was directed to the preoperative evaluation of the (upper) blepharoplasty patient that should detect the presence of a prolapsed lacrimal gland. This trend also reflected the age of the most common presenting patient for upper blepharoplasty at that time; currently this may have less relevance. In 1978, Smith and Petrelli67 described the surgical repair of a prolapsed lacrimal gland. Specific adjunctive dacryoadenopexy in upper eyelid blepharoplasty was described in 1983 by Smith and Lisman.68 This technique has been used far more frequently in geriatric blepharoplasty, but illustrates well (in an albeit macroscopic way), some of the involutional changes that relate to attenuation of the retaining ligaments that can be ascribed to many of the aspects of facial aging. Because of an escalating concern regarding complications from cosmetic periorbital surgery, in 1975 Putterman69 recommended that the eyes not be patched after cosmetic blepharoplasty so that a potential sightthreatening retrobulbar hemorrhage could be more easily identified. Putterman and Urist70 also demonstrated that baggy eyelids can occur as a true hernia resulting from detachment of the septum from capsulopalpebral fascia and levator aponeurosis.

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Chapter 8

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The History of Cosmetic Oculoplastic Surgery In the 1970s, reports first appeared in the plastic surgery literature describing and confirming the existence of the dry eye syndrome after blepharoplasty.71–73 In 1976, Tenzel74 recommended that each patient be given a Schirmer tear test to evaluate basic tear secretion before cosmetic blepharoplasty. These tests however have been used and abused, and consistency has been lacking. However, they are still widely performed today.75 He recommended that function take precedence over cosmesis in patients with decreased tear function. His observations have however dictated the necessity of caution in patients with compromised ocular lubrication and a greater awareness that dry eye syndrome can be a real and devastating problem after surgery. The decade of the 1980s witnessed the development of a better understanding of the causes of dry eye symptoms and procedures that could aid in the reduction of these occurrences.76 The recognition in 1972 of lower eyelid laxity as a cause of postblepharoplasty lower eyelid malposition has also significantly reduced the incidence of this complication.77 Tenzel74 recommended combined horizontal shortening and lower eyelid blepharoplasty when lower eyelid laxity is recognized preoperatively. In 1979, Webster and colleagues78 described a temporary lateral canthal suspension suture in cases of minimal to moderate horizontal eyelid laxity. In 1982, Putterman79 edited the first textbook dedicated to cosmetic oculoplastic surgery. In it, he described and illustrated the use of Byron Smith’s modification of the Kuhnt–Szymanowski procedure for tightening the lower eyelid at the time of cosmetic blepharoplasty. This involved a full-thickness resection at the eyelid margin. Katzen and Tenzel80 were the first to recommend that horizontal shortening be performed at the lateral canthus at the time of cosmetic lower eyelid blepharoplasty, thus eliminating the need for eyelid margin sutures. Horizontal shortening procedures such as the lateral tarsal strip, remained the most popular of procedures for treating horizontal laxity for the next 20 years.81 The ‘tear trough’, although seemingly a recent phenomenon, written about extensively in not only the medical literature but fashion magazines to the lay public, represents a periorbital region of continued frustration. Raul Loeb in the 1970s wrote about his perception of the cause82 and even described the treatment, including his version of fat transposition and transplantation, which probably was not as well appreciated until his concepts were published in English several years later.83,84 Historical developments in the 1980s have sometimes seemed less significant. Blepharopigmentation, for example, was a trend introduced more by industry and in the lay press than in the scientific literature. Blepharopigmentation, or as it is commonly called ‘tat-

tooed eyeliner’ was introduced to ophthalmologists by Giora G. Angres.85 It was initially developed for aphakic and presbyopic patients and by handicapped persons who were unable to accurately apply their own eyeliner. Although it waned in popularity, it has since been used as an adjunct to cosmetic blepharoplasty,86 as well as eyebrow enhancement87 for cosmesis and in patients with alopecia. The consumer demand for the cosmetic procedure was predicted to be great by the equipment manufacturers but never really developed. The procedure has still remained reasonably popular, more so in the Asian and Hispanic communities, who were first to accept delivery by non-physicians. It is now widely offered in spas and by cosmetologists and less often by surgeons. In 1980, Orkan Stasior88,89 described posterior eyebrow fixation, a technique for brow elevation through a blepharoplasty incision. Since then, similar techniques were independently developed and described in the literature as a response for the obvious need for brow elevation and or stabilization in the appropriate patient.90 In 1982, trichloroacetic acid (TCA) exfoliation was first described in the ophthalmic literature by Allan Lorincz91 as a ‘superficial chemical cautery for circumscribed eyelid skin lesions.’ Ten years earlier, Wolport and colleagues92 had described a chemical peel with trichloroacetic acid for fine wrinkles of aging skin. This technique has been gaining popularity as a ‘light chemical peel’ to reduce the fine wrinkle lines in the periorbital area. The efficacy and duration of chemical peels used today (mostly TCA, but other agents are also used) relate to a host of factors including concentration and method of application.

Recent advances in cosmetic eyelid and facial surgery Some of the more recent advances, despite an improved understanding of periorbital aging, have not prevailed, but were attempts to simplify surgery and/or reduce complications. In 1985, Bosniak and Sachs93 described lipolytic diathermy as a technique for fat pad ‘sculpting’ in cosmetic blepharoplasty. The attempt here was to reduce the volume and appearance of the eyelid fat by thermal melting without the need for an eyelid incision. The procedure did not catch on with any great success, but it paved the way for other methods and agents that would reduce the volume of fat that was perceived as a cause of periorbital aging. Putterman94 described scalpel-YAG laser blepharoplasty in 1990 which was early in the ‘laser era.’ The hope of a more precise and advantageous ‘laser’ solution to cold steel

Recent advances in cosmetic eyelid and facial surgery for incisions has not come to fruition. Rapid-absorbing gut sutures were also introduced for skin closure around the same time. The attempt to replace the painstaking chore of removing sutures has been more satisfactorily solved by using capable clinical assistants, rather than materials that were at times inflammatory, caused wound irregularities, and were less dependable. Baker and associates95 first described carbon dioxide (CO2) laser blepharoplasty in 1984. This technique involved skin and fat excision using continuous energy laser output, which was the only power mode available at the time. The work of Baylis and colleagues96 and their multiple courses, exhibits, and presentations were responsible for popularizing and reintroducing the oculoplastic community to the benefits of transconjunctival blepharoplasty. David97 was the first, in 1988, to describe the use of the CO2 laser for transconjunctival lower eyelid fat excision. The potential of nonincisional surgery that could potentially address some of the issues not dealt with by traditional surgery led to the expansion of applications of laser energy, and for the next ten years remained a major focus. These developments were fueled in part by industry greed and the knowledge of the explosive growth of cosmetic surgery, and the possibility that these procedures could expand into non-surgical practice. Many were convinced that laser technology would soon replace the need for any significant surgical intervention in the majority of patients. Despite the fact that this has not occurred, the insights gained have been invaluable.

Laser resurfacing Many of the oculoplastic surgical advances in the last 10 years have been technology-dependent. Refinements in our understanding and delivery of laser energy, combined with development of new lasers, have had a dramatically favorable impact on the art of cosmetic oculoplastic surgery. For the first time in the short history of the multiple subspecialties offering cosmetic procedures, there has been an interdisciplinary exchange of knowledge as each specialist offered a valued vantage-point that has contributed to improved patient results and satisfaction. This has been well illustrated by the introduction and refinement of laser technology and resurfacing procedures. The use of the CO2 laser for surface vaporization began in 1987 as a treatment modality for localized cutaneous tumors and more diffuse dermal disease. The incidental finding of cosmetic benefit led to the initial report of cosmetic facial resurfacing in 1989.98 The initial use of a computer-assisted scanning device to achieve uniform and smooth depth vaporization was reported in 1987 by Brauner and Schifman.99 The

technique was not initially successful, because of inadequate energy levels and a gaussian laser beam distribution. At about the same time, dermatologists began understanding the importance of laser tissue interaction and the theoretical thermal relaxation time of skin.100–102 Hobbs and colleagues103 described the use of superpulsed laser and high-irradiation, short-duration pulses (1 ms) to minimize thermal damage. In 1989, David and Lask104 demonstrated histologic evidence of the cosmetic benefit that was being observed clinically. They showed reduction in atypical keratocytes and solar elastosis with a histologically normal epithelium 4 weeks after laser resurfacing. In the early 1990s, the medical laser industry responded by producing a variety of superpulsed, ultrapulsed, and scanning lasers with and without computer-generated pattern delivery systems. In 1994, Weinstein105 was the first to describe laser resurfacing of periocular wrinkles in the literature. At the 1994 American Academy of Ophthalmology annual meeting, many oculoplastic surgeons were skeptical as they viewed Sterling Baker’s videos, live surgery, and postoperative patients. Since that time, cosmetic laser resurfacing has enjoyed immense popularity and is now widely accepted by the medical community and the public as a valued option for facial skin aesthetic improvement. It has been a significant advance in improving the appearance of periocular rhytids (‘crow’s feet’) that are not solved with incisional surgery. Hibst and Kaufman106–108 worked with and recommended the erbium : YAG laser for cosmetic resurfacing. The erbium laser’s shorter pulsed time, higher pulsed power, and increased laser light absorption in tissue water may make it more efficacious for surface ablation. Further clinical experience has shown that hybrid lasers which combine the advantages of both the thermal components of CO2 lasers and the ablative effects of the erbium laser (such as the Sciton System) have reduced recovery time and complications, while improving patient outcomes.

Extended blepharoplasty: a return to incisional surgery In the 1990s, we also entered the age of the lateral canthus and the appreciation of this anatomic region for stabilization of the lower eyelid during blepharoplasty. As procedures such as the lateral tarsal strip were still the most popular, the previous history should have been a clue to potential future problems. Cantholytic canthoplasty was used primarily for the treatment and correction of lower eyelid malposition and ectropion, both involutional and iatrogenic.84,109 Despite its

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The History of Cosmetic Oculoplastic Surgery usefulness for the treatment of these misadventures, problems related to its use in primary blepharoplasty were soon to follow. Canthal asymmetry, misalignment, and most of all eventual shortening of the horizontal palpebral aperture, all made these procedures suboptimal (except in certain circumstances) for the average patient who presented for cosmetic lower blepharoplasty. Flowers, Jelks, and McCord’s contributions in the advancement of routine canthopexy/ plasty have been enormous.110–113 May and colleagues114 in 1990 described sculpting and resection of the retro-orbicularis oculi fat as a solution to the perceived heaviness and fullness of the infra-brow region in selected patients. In 1995, Aiche and Ramirez115 also described the excision of the suborbicularis oculi fat. Knize116 and Guyuron and colleagues117 described resection and/or interruption of the corrugator supercilii and procerus muscles through eyelid incisions; this process has only recently gained popularity. Owsley118 initially described a cheek lift by elevating the malar fat pad to reduce prominent nasolabial folds. This was performed through a preauricular incision. May and associates119 described malar augmentation and a cheek lift through a subciliary incision. That same year, McCord and colleagues120 described a subperiosteal malar cheek lift combined with lower eyelid blepharoplasty that is still currently used. The aim was to discover a solution to midfacial descent, and improve the deflationary changes of the lower periorbita by elevating the stronger tissue of the midface into the atrophic lower periorbita. A continuum of techniques has been developed, combined with simpler and more effective suture suspension methods for the lateral canthus. These address the descent of the orbicularis oculi and associated retaining ligaments for lower periorbital rejuvenation, resulting in fewer complications.121 Midfacial suspension has also been well-described through distant incisions (i.e. away from the eyelid; posterior hairline via the endoscope) and the process continues to evolve.122 A major focus has also been on fixation and suspension devices that continue to emerge. Barbed suture technology is evolving, whereby soft tissue can be more reliably suspended by sutures that can better grasp the affected regions with a greater drag coefficient (compared with simple braided or monofilament sutures). Absorbable plastic devices such as the CoApt systems offer the potential for better bone attachment during the healing (scarring) period to give longer lasting results.123,124

Botulinum toxin A Purified botulinum toxin type A was initially developed as an alternative to the surgical treatment of

strabismus. In the early 1970s, many ophthalmologists participated in the Food and Drug Administration (FDA) approved study of the efficacy of botulinum toxin A in the treatment of benign essential blepharospasm and hemifacial spasm. Noting the coordinated beneficial effects on periocular wrinkles and glabellar frown lines first reported by Carruthers and Carruthers,125 surgeons began using botulinum toxin A for cosmetic purposes in the early 1990s. In 1994 others also reported on their experiences with the cosmetic use of botulinum. That same year, Keen and Blitzer126 performed a double-blind study confirming the efficacy of botulinum toxin A for the treatment of hyperkinetic facial lines. Facial aesthetic enhancement by botulinum toxin type A injection is currently the most commonly performed cosmetic procedure. The perceived simplicity, unfortunately, has resulted in its use by non-physicians, as well as practitioners of every specialty outside those that traditionally perform cosmetic procedures (e.g. emergency room physicians, family practice physicians, anesthesiologists, obstetricians, dentists, nurses . . . and the list keeps growing). In our society today, a rapid demand has grown for procedures that are minimally invasive, safe, and effective. The popularity of botulinum continues to escalate, as results can be achieved with even novice injectors with no ‘down time’ in a non-clinical setting.127

Soft tissue augmentation Another fascinating perspective that illustrates some of the history of ophthalmic surgery in facial rejuvenation relates to facial soft tissue augmentation by injection. In 1990, Charles Kelman, the famous ophthalmologist/pioneer and inventor of phaco-emulsification, personally witnessed some concerns over the use of bovine collagen (mostly relating to severe allergic reactions) while appreciating the benefits of collagen as a soft tissue augmentation agent for the improvement of facial wrinkles. As the agents Zyderm and Zyplast were the only agents available in the US at that time, Kelman and biochemist Dale P. DeVore began their quest to produce a safe, injectable autologous collagen that evolved into the current products such as Dermalogen.128,129 Besides collagen, hyaluronic acid (Restylane, Juvéderm, etc.) also has its origins in ophthalmology. As a routine component of successful intra-ocular surgery, hyaluronic acid proved its safety, efficacy, and biocompatibility. Modifications of the molecule (such as cross-linking) has aided in persistence and residence time. Intra-ocular surgery, performed on millions of patients, has also broadened the experience of biocompatible implants with an unprecedented safety profile. Intra-ocular lenses use a poly-

References methylmethacrylate (PMMA) component as the optical haptic, and polypropylene for fixation and stabilizing. After many implantations, these substances have proved to have no inflammatory response. Permanent fillers such as Artefill (polymethylmethacrylate beads in a collagen dispersion) have been developed as a result of years of experience.130,131 Other materials such as polypropylene sutures that are now used commonly for both canthal suspension procedures as well as barbed suture technology, have also been ratified by years of in-vivo compatibility testing.132

The future of cosmetic eyelid and facial surgery

6. 7. 8. 9.

10. 11.

12. 13. 14.

We look forward to new techniques and refinements in existing techniques to further reduce the already low complication rate associated with cosmetic oculoplastic surgery. Advances in laser delivery systems continue to evolve, and may further improve the appearance of skin with our surgical results that continue to be a limiting factor. Current interest in wound healing via stem-cell research133 may solve some of the current issues with postoperative scarring. Future developments will also focus on prevention through the use of antiaging therapies to slow or reverse solar damage, maintain and improve skin elasticity, and other methods that reduce the myriad of components of facial aging. There is also the potential for many of the newer injectable agents for selective chemodenervation and soft tissue augmentation that will be longer lasting, and will use components that prevent not only the normal biologic biodegradation of the implant, but the native soft tissue as well. The knowledge of our history in this field, a better understanding of the periorbital aging process, and improved techniques, products, and devices will ultimately improve the resources of surgeons for better and longer lasting patient outcomes.

15. 16. 17. 18. 19. 20. 21.

22.

23. 24. 25. 26. 27. 28.

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59. Sheen JH: A change in the technique of supratarsal fixation in upper blepharoplasty. Plast Reconstr Surg 1977; 59:831–834. 60. Dryden R, Leibsohn J: The levator aponeurosis in blepharoplasty. Ophthalmology 1978; 85:718–725. 61. Flowers RS: Upper blepharoplasty by eyelid invagination; anchor blepharoplasty. Clin Plast Surg 1993; 20:193–207. 62. Flowers RS: Cosmetic blepharoplasty – state of the art. In Advances in Plast and Reconstr Surg, vol 8. Chicago, Mosby-Yearbook, 1992. 63. Siegel RJ: Essential anatomy for contemporary upper lid blepharoplasty. Clin Plast Surg 1993; 20:209–212. 64. Siegel RJ: Contemporary upper lid blepharoplasty. Tissue invagination. Clin Plast Surg 1993; 20:239–246. 65. Putterman AM, Urist MJ: Reconstruction of the upper eyelid crease and fold. Arch Ophthalmol 1976; 94:1941–1954. 66. Sheen JH: Tarsal fixation in lower blepharoplasty. Plast Reconstr Surg 1978; 62:24–31. 67. Smith B, Petrelli R: Surgical repair of prolapsed lacrimal glands. Arch Ophthalmol 1978; 96:113–114. 68. Smith B, Lisman R: Dacryoadenopexy as a recognized factor in upper lid blepharoplasty. Plast Reconstr Surg 1983; 771:629. 69. Putterman AM: Temporary blindness after cosmetic blepharoplasty. Am J Ophthalmol 1975; 80:1081–1083. 70. Putterman AM, Urist M: Baggy eyelids: A true hernia. Ann Ophthalmol 1973; 5:1029–1032. 71. Graham WP, Messner KH, Miller SH: Keratoconjunctivitis sicca symptoms appearing after blepharoplasty. Plast Reconstr Surg 1976; 57:57–61. 72. Rees TD: Dry eye complications after blepharoplasty. Plast Reconstr Surg 1975; 56:375–380. 73. Scholtz RC, Swartz S: ‘Dry eye’ following blepharoplasty. Plast Reconstr Surg 1974; 54:644–647. 74. Tenzel RR: Cosmetic blepharoplasty. In Soll DB (ed): Management of Complications in Ophthalmic Plastic Surgery, pp 119–131. Birmingham, Ala, Aesculapius, 1976. 75. Fagien S: The follow-up on ‘The value of tear film breakup and Schirmer’s tests in preoperative blepharoplasty’ by McKinney P, Byun M. Plast Reconst Surg [Discussion] 1999; 104:1. 76. Fagien S: Reducing the incidence of dry eye symptoms after blepharoplasty. Aesthetic Surg J 2004; 24:464. 77. Edgerton M: Causes and prevention of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 1972; 49:367–373. 78. Webster RC, Davidson TM, Reardon EJ, Smith RC: Suspending sutures in blepharoplasty. Arch Otolaryngol 1979; 105:601–604. 79. Putterman AM: Cosmetic Oculoplastic Surgery, pp 187– 208. New York, Grune & Stratton, 1982. 80. Katzen LB, Tenzel RR: Canthal laxity and eyelid malpositions. Adv Ophthalmol Plast Reconstr Surg 1983; 2:229–243. 81. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol 1979; 97:2192. 82. Loeb R: Correction of eyelid depressions with free fat grafts. Cir Est 1978; 3:68 [in Spanish]. 83. Loeb R: Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 1981; 8:4.

References 84. Loeb R: Nasojugal groove leveling with fat tissue. Clin Plast Surg 20:393–401. 85. Angres GG: Angres permalidliner method: A new surgical procedure. Ann Ophthalmol 1984; 16:145–148. 86. Angres GG: The Angres permalidliner method to enhance the result of cosmetic blepharoplasty. Ann Ophthalmol 1985; 17:176–177. 87. Angres GG: Blepharopigmentation and eyebrow enhancement techniques for maximum cosmetic results. Ann Ophthalmol 1985; 17:605–611. 88. Stasior OG: Posterior eyebrow fixation. Presented at the 1980 Scientific Symposium of the American Society of Ophthalmic Plastic and Reconstructive Surgery, Chicago. 89. Stasior OG, Lemke BN: The posterior eyebrow fixation. Adv Ophthalmic Plast Reconstr Surg 1983; 2:193–197. 90. McCord CD, Doxanas MT: Browplasty and browpexy: An adjunct to blepharoplasty. Plast Reconstr Surg 1990; 86:248–254. 91. Lorincz A: Chemexfoliation. In Putterman AM (ed): Cosmetic Oculoplastic Surgery, p 246. New York, Grune & Stratton, 1982. 92. Wolport FG, Dalton WE, Hoopes JT: Chemical peel with trichloroacetic acid. Br J Plast Surg 1972; 25:333–334. 93. Bosniak SL, Sachs ME: Lipolytic diathermy. Orbit 1985; 44:157. 94. Putterman AM: Scalpel neodymium : YAG laser and oculoplastic surgery. Am J Ophthalmol 1990; 109:581–584. 95. Baker S, Muenzler W, Small R, Leonard J: Carbon dioxide laser blepharoplasty. Ophthalmology 1984; 91:238–244. 96. Baylis HI, Long JA, Groth MF: Transconjunctival lower eyelid blepharoplasty, techniques and complications. Ophthalmology 1989; 96:1027–1032. 97. David LM: The laser approach to blepharoplasty. J Dermatol Surg Oncol 1988; 14(7):741–746. 98. Spadoni D, Cain CL: Facial resurfacing using the carbon dioxide laser. Am Operating Room Nurses J 1989; 50:1007, 1009–1013. 99. Brauner G, Schifman A: Laser surgery in children. J Dermatol Surg Oncol 1987; 13:178–186. 100. Anderson RR, Parrish JA: Selective photothermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220:524–527. 101. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD: Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Arch Dermatol 1996; 132; 395–402. 102. Alster TS, Garg S: Treatment of facial rhytides with a high-energy pulsed carbon dioxide laser. Plast Reconstr Surg 1996; 98: 791–794. 103. Hobbs ER, Balin PT, Wheeland RG, et al: Superpulsed lasers: Minimizing thermal damage with short duration, high irradiance pulsed. J Dermatol Surg Oncol 1987; 13:955–964. 104. David LM, Lask GP, Glassberg E, et al: Laser abrasion for cosmetic and medical treatment of facial actinic damage. Cutis 1989; 43(6):583–587. 105. Weinstein C: Ultrapulse carbon dioxide laser removal of periocular wrinkles in association with laser blepharoplasty. J Clin Laser Med Surg 1994; 12(4):205. 106. Hibst R, Kaufman R: Effects of laser parameters on pulsed erbium : YAG laser skin ablation. Laser Med Sci 1991; 6:391–397.

107. Kaufman R, Hibst R: Pulsed 2.94 µm erbium : YAG laser skin ablation: Experimental results and first clinical application. Clin Exp Dermatol 1990; 15:389–393. 108. Kaufman R, Hibst R: Pulsed erbium : YAG laser ablation in cutaneous surgery. Lasers Surg Med 1996; 19:324–330. 109. Shorr N, Fallor MK: ‘Madame Butterfly’ procedure combined with cheek and lateral canthal suspension procedure for post blepharoplasty ‘round eye’ and lower eyelid retraction. Ophthal Plast Reconstr Surg 1985;1:229. 110. Flowers RS: Canthopexy as a routine blepharoplasty component. Clin Plast Surg 1993; 20:351–366. 111. Jelks GW, Jelks EB: Repair of lower lid deformities. Clin Plast Surg 1993; 20:417–426. 112. Glat PM, Jelks GW, Jelks EB, Longaker M: Evolution of the lateral canthoplasty. Techniques and indications. Plast Reconstr Surg 1997; 100:1396. 113. Fagien, S: Lower eyelid rejuvenation via transconjunctival blepharoplasty and lateral retinacular suspension: A simplified suture canthopexy and algorithm for treatment of the anterior lower eyelid lamella. Operat Tech Plast Reconstr Surg 1998; 5:121–128. 114. May JW, Feason J, Zingarelli P: Retroorbicularis oculus fat (ROOF) resection in aesthetic blepharoplasty: A 6year study in 63 patients. Plast Reconstr Surg 1990; 86:682–689. 115. Aiche AE, Ramirez OH: The suborbicularis oculi fat pads: An anatomic and clinical study. Plast Reconstr Surg 1995; 95:37–42. 116. Knize DM: Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast Reconstr Surg 1995; 95:52–60. 117. Guyuron B, Michelow BJ, Thomas T: Corrugator supercilii muscle resection through blepharoplasty incision. Plast Reconstr Surg 1995; 95:691–696. 118. Owsley J: Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg 1993; 91:463–476. 119. May JW, Zenn MR, Zingarelli P, et al: Subciliary malar augmentation and cheek advancement: A 6-year study in 22 patients undergoing blepharoplasty. Plast Reconstr Surg 1995; 96:1553–1559. 120. Hester TR Jr, Codner MA, McCord CD Jr: Subperiosteal malar cheek lift with lower lid blepharoplasty. In McCord CD Jr (ed): Eyelid surgery: Principles and Techniques, pp 210–215. New York, Lippincott-Raven, 1995. 121. Fagien S: Algorithm for canthoplasty. The lateral retinacular suspension. A simplified suture canthopexy. Plast Reconstr Surg 1999; 103:2042. 122. Ramirez, O: Endoscopic techniques in facial rejuvenation. An overview. Part 1. Aesthetic Plastic Surg 1993; 91: 463–476. 123. Stuzin JM: Endoscopic forehead rejuvenation. I. Limitations, flaws, and rewards. Discussion. Plast Reconstr Surg 2006; 117:1134–1136. 124. Berkowitz RL, Apfelberg DB, Simeon S: Midface lift technique with use of biodegradable device for tissue elevation and fixation. Aesth Surg J 2005; 25:376–382. 125. Carruthers JDA, Carruthers. JA. Treatment of glabellar frown lines with C. botulinum – an exotoxin. J Dermatol Surg Oncol 1992; 18:17.

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The History of Cosmetic Oculoplastic Surgery 126. Keen M, Blitzer A, Aviv J, et al: Botulinum toxin A for hyperkinetic facial lines: Results of a double-blind, placebo-controlled study. Plast Reconstr Surg 1994; 94(1):94–99. 127. Carruthers J, Fagien S, Matarasso SL: Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 2004; 114: (Suppl.):1S. 128. DeVore DP, Fagien S, Kelman CD, Casson P: Autologous injectable dermal collagen. In Bosniak S (ed): Principles and Practice of Ophthalmic Plastic and Reconstructive Surgery, pp 670–675. London, W.B. Saunders, 1993. 129. Fagien S: Facial soft tissue augmentation with injectable autologous and allogeneic human tissue collagen matrix (Autologen and Dermalogen). Plast Reconst Surg 2000; 105:362.

130. Cohen SR, Holmes RE: Artecoll: A long-lasting injectable wrinkle filler material. Report of a controlled, randomized, multicenter clinical trial of 251 patients. Plast Reconstr Surg [Discussion] 2004; 114:960. 131. Fagien S, Born TM: Artecoll: A long-lasting injectable wrinkle filler material: report of a controlled, randomized, multicenter clinical trial of 251 patients by Cohen SR and Holmes RE. Plast Reconstr Surg [Discussion] 2004; 114:977. 132. DeLorenzi CL: Barbed sutures: Rationale and technique. Aesthetic Surg J 2006; 26; 223–229. 133. Longaker M: Stem cell based regenerative therapy; implications for aesthetic surgery in the next decade. Presented at the 40th Annual Baker–Gordon–Stuzin Meeting, Miami, Florida, February 3, 2006.

uded on DVD

CHAPTER 2

Current Observations of Periorbital Aging: A Prelude to Improved Surgical Results Val Lambros and Steven Fagien Surgical approaches for the cosmetic improvement of the aging periorbita continue to evolve. A combination of factors have added to improved methods that relate to a higher level of understanding of facial aging that has been supported by information gained from the both histologic and gross anatomy dissections as well as observations made through imaging and photography. A large distraction has been a wide variety of personal perception of what occurs with facial aging combined with a surgical interpretation that did not always reflect the most accurate analysis or what would approach the rejuvenated state. Even simply evaluating ‘old’ photographs, although useful, can be deceptive, whereas the illusion of the components of facial aging are actually not supported by reality. Through morph-like techniques pioneered by Lambros1 whereby current and dated posturally matched images are superimposed that more accurately detect the changes in the various facial regions, we now have a better understanding of the truth of facial changes with age that have revealed surprising discoveries. As these findings relate to the periorbita, we have also found it useful to compare the same eyes and periorbital regions as they age, and report on what lessons can be learned from watching this progression. Val Lambros and Steven Fagien

Introduction Although there is abundant variation in the aging patterns of the billions of human periorbita (eyes) on the planet, there are also commonalities that influence the way the eye region is perceived. An old Asian is as easily recognized as is an old Caucasian and for similar reasons.2 We have found it more useful to examine the aging face and periorbital region in a linear fashion rather than to look at populations for several reasons. Firstly, population studies are valuable for looking at particular eye regions at a particular point in time, but comparisons are necessarily on different eyes and statistical differences are the usual method of analysis. Tables and charts of measurements are customary in anthropologic studies, but not so in surgery which relies on more direct visual comparisons.3 Secondly and more importantly, seen at a single point in time, the aging face and periorbital region are frequently deceptive. Because finger elevation

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Current Observations of Periorbital Aging: A Prelude to Improved Surgical Results may make a part look better, the perfectly reasonable but not necessarily true assumption may be that the part has fallen. It is also easy to underestimate tissue thinning and deflation because their contribution to an aged appearance are not always immediately obvious, and altering these variables is not in the common surgical repertoire. For several years we have conducted linear comparisons in individuals by means of highly matched old and recent photographs, which are sized and aligned on stable points. The image pairs are then studied by overlaying the images on the computer and transitioning from one to the other. The eye is very sensitive to motion presented this way, and differences in position and shape are easy to see and compare (see Chapter 2, DVD). Briefly the technique is as follows: As has become customary during consultations, patients are asked to bring in old photographs of themselves. Friends and relatives are also easy targets because of the availability of old pictures. New pictures are then taken and every effort is made to match the orientation of these old photos. This is the most tedious part of the process as it takes many exposures to get within the several degrees necessary to make the technique valid and it takes some time to sort through them on the computer. Straight anterior–posterior (with the head level in primary position) [APs] are the easiest to match; obliques are more difficult and laterals are the most difficult to match because of the lack of reference points. If not taken on a digital camera, the old and recent prints are digitized and compared in an imaging program, in this study, Adobe Photoshop. The layers function of Photoshop digitally stacks one image on top of the other and is indispensable in accurately matching multiple images. By toggling the upper image on and off, any offset relative to the lower image is quickly visible. In the antero-posterior view, the alignment and sizing points are the medial canthal tendon’s insertion into the nasal side-wall, the interpupillary distance, the base of the columella and other confirmatory points. The two saved images, the old and the recent are then converted into a gif animation using Adobe Image Ready, or other gif animation programs. GIF Construction Set Professional (www.alchemymindworkshop.com) was extensively used in this series. The gif animation automates the process of fading from one aligned and sized image to the other for careful inspection (see Chapter 2, DVD). As the images are never perfectly aligned, some practice is needed to look at them. If the relative motion is small, within a degree or so, and in an easily understood direction, for example side to side or up and down, the eye compensates for the motion and the

images make sense (Animation 1, see DVD). If there is a combination of motions, then the progression is not as intuitive and there is less gained by studying position changes, though shape comparisons may be made. Low-contrast tissue borders on the face are more easily appreciated from a distance rather than close-up and hence these images are best studied from a modest distance. This method of analysis was not intended to be quantitative, though measurements can be taken. Rather it is a method to visually compare changes in size position and shape of structures. A rule of thumb is that the diameter of the iris is approximately 101/2–111/2 mm. More recently we have used a 3-D camera (Canfield scientific) to acquire the entire surface of the face. These images can then be used to match to other 3-D images or to match against 2-D images. Measurements may be taken in any axis with this kind of system and comparing old and recent 3-D images is the logical future of this kind of research. None of these images are used in this article. At current count the number of patients in the series is 135. The overwhelming majority of the patients studied were Caucasian and most were of normal (range) weight. Typically a patient in her 50s or 60s brings a photo from her teens or 20s, though intervals of ten to 60 years were obtained. In this series the average time between photos was 24.85 years. Behavioral issues can modify the pictures and the conclusions that may be drawn from them. Smiling pictures are not included in this study as a smile distorts the cheeks and may compress the lower lid. It is very common for people to elevate the brows slightly when being photographed. By and large this does not, in most, significantly affect the position of the upper lids and lower face, though it does affect conclusions that may be drawn about brow position. We observed in these images several commonly known phenomena and several that were new to us. It is widely accepted that, under normal conditions, the globe itself does not shrink with time.4,5 However one of the common signs of aging is that the eyes appear to become smaller. Although, historically, there has been speculation on why this occurs, we found this visual finding to be related to the actual size of the eyelid aperture, both horizontal and vertical, though we believe that horizontal shortening is perceptually more powerful. In this we are in agreement with other authors.6,7 Medialization of the lateral canthal tendon, an extremely common finding, is combined with a frequent, albeit mild degree, of lid ptosis (1–2 mm) to create the illusion of the smaller eye (Figs 2-1 and 2-2; Animations 1, 2, 9, 11, see DVD). The presence of agerelated enophthalmos may also be contributory and

Introduction would explain by itself many of the findings but cannot be directly observed in this study. The brow position is difficult to assess, as mentioned, because of the tendency of people to hold their brows up. Because we are unaware of any nonmuscular phenomenon that will elevate the brows with time (except possibly a compensatory response for those individuals that develop blepharoptosis), we made the assumption that brow elevation was behavioral in these individuals and these patients were excluded from our brow position analysis. In most patients whose brows remained in the same position (46/135), the forehead did not look as if it was contracting, making it difficult to know if brow position was unaltered because of minor frontalis function or because the brow truly did not descend. We suspect the latter, though we cannot prove it to date. Twenty patients had brow descent. As a clinical aside we would note that the brows do not descend as much as they are elevated with a brow lift (Fig. 2-2). The area of the superior orbital rim and upper lid commonly lose soft tissue volume (Animations 2, 4–6, see DVD). This occurs typically at the medial third of the upper lid and the entire brow extending onto the temple. This finding may be related to the population studied, and is by no means universal but was consistent enough to be remarkable. In many of these

patients the changes in subcutaneous volume were accompanied by dermal changes which were sometimes profound (Fig. 2-1). In many patients dermal changes of periorbital skin overwhelm deeper shape changes. Of great interest is the change in shape of the upper lid arc and consequently the shape of the lid aperture. Again this finding is not universal but is widespread. In the young person, the upper lid arc can have a distinct medial peak, giving the eyelid aperture a characteristic almond shape (with the apex laterally) (Fig. 2-1A). This is not to be confused with the so-called almond shape of the eyelid seen in Asians (Fig. 2-3). With time the peak of the upper lid moves laterally (Fig. 2-1B), giving the upper lid arc a more elliptical shape and reducing its medial (peak) elevation (Animations 4 & 5, see DVD). Although this phenomenon is most obvious in the age span from childhood to adolescence, one can also trace it over longer periods of time. The upper lid arc shift may be partially responsible for the smaller eye seen in older patients, as it makes the medial scleral triangle smaller. The causes of this finding are probably multifactorial and complex. The levator aponeurosis is known to stretch medially more than laterally with time.8 In addition retrusion of the globe into the orbit (from volume loss and shifts) may also play a part. Certainly the area needs more study.

Figure 2-1 A, 36 years old. B, 54 years old. Careful inspection of these two images reveals that there is minimal ptosis of the brows. The medial upper lid has deflated somewhat. There is an oblique line of moles near the left lower lid–cheek junction which has not changed position. The lid–cheek junction is unchanged. In passing, we note that upper lid surgery would not restore the look of the younger picture. A

B

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Figure 2-2 A & B, The earlier image was taken in 1989; the older in 2004. She had a brow lift prior to the early photograph but no lid surgery. Note that the eyes appear smaller. The position of the lid–cheek junction is unchanged and the moles in the lower lids have not moved. One can see the loss of skin thickness.

A

B

Figure 2-3 The epicanthal fold imparts an ‘almond’ shape to the eye. However, the upper lid arc is not almond-shaped but fusiform. The arc of the upper lid margin can change with age.

We somewhat arbitrarily define the lid–cheek junction (LCJ) as the pigmented border of the thin lid skin with the thicker, less pigmented cheek skin at the midpupillary line. The most significant finding of this longitudinal study is the positional stability of the lid– cheek junction. In 93 of the 135 patients, the lid–cheek junction could be well seen in both the old and recent photographs. In five of the 93 (5.3%) the lid–cheek junction was seen to descend. This finding was unanticipated, as another of the common visual conceptions of aging is that the lid–cheek junction and the dark circles appear to enlarge with time (Fig. 2-4; Anima-

tions 1, 7–11, see DVD). What appears to happen is also likely complex whereas the border of the lid–cheek junction remains stable, but the thinning skin allows the underlying musculature to show through and at the same time the enlarging lower lid shadow delineates the border even more. The attenuation of the retaining ligaments (see Chapter 5) combined with subtle loss of regional suborbicularis oculi fat (SOOF) may also add to the deflationary effects. In other words, the lid–cheek junction and the dark circles seem to grow by increasing contrast not by descent. From about the midpupillary line in different subjects

Introduction

Figure 2-4 A, Taken at the age of 52. B, Taken at 62. He tilts upward very slightly in the older picture. Within the lower lid some compression of lid landmarks can be seen, common in sun-damaged skin, but the lid–cheek junction remains stable. Visible on both the right and left malar area are crosses made by orbicularis wrinkles. These landmarks stay stable over the time that the face has clinically acquired a great deal of laxity. The skin quality can be seen to deteriorate.

A

B

one can see different patterns of soft-tissue borders comprised of pigmentation and thinner skin and malar mounds. These are not well characterized though often put into the category of ‘nasojugal folds.’ In fact the findings of positional stability seem to pertain to all pigmented borders around the lower lid and upper midface as well as to the LCJ. In addition moles, wrinkles and other markers on the upper midface and malar region are similarly stable over time, leading one to the conclusion that gravitational soft tissue descent is not a major aging consequence in aging of these areas. As mentioned, this lower lid and upper midface area is also known to overlie a major distribution of retaining ligaments9,10 (see Chapter 5) and the support offered by these ligaments may be more likely to allow for deflationary effects and less for overall geographic tissue motion (descent). The regional dynamic motion, and the limitations due to retaining ligaments, is likely a primary culprit of many of the visual changes of the face including, but not limited to, focal fat loss and shifting, dermal lines and depressions, etc. Attenuation of mobility (i.e. with botulinum toxin) in selected regions, although still speculative at this point, may also in some way influence facial/periorbital aging (see Chapter 24, Botox).

An additional finding which is difficult to see but consistent, is the appearance of the caruncle and its relation to the globe. In many aging patients the caruncle seems to extend onto the medial globe and the medial upper lid seems to go from being tented smoothly over the globe to a ‘break point’ as the lid indents very slightly inferiorly before contacting the globe (Animations 4–6 [left eye], see DVD). This sign, though subtle, is frequent and is consistent with a number of mechanisms. We tentatively ascribe it to progressive enophthalmos. In addition the superior lacrimal papilla seems to enlarge with age. Traditional surgery is excellent for removing and redraping skin muscle and fat in the upper lid and brow and establishing definition of soft tissue against bone. A defined upper eyelid and brow has little fat, considerable lid show and provides ample area for make-up. These effects are surgically easy to achieve and results can be dramatic. While many patients and surgeons believe that an extremely defined eye is the most desirable result, definition is not necessarily a desirable change in the aging patient, as young periorbita tend to exhibit fullness and hollow ones are associated with age. In other words, though not immediately visible with surgical swelling, the newness of the look creating more definition sometimes further ages the

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Current Observations of Periorbital Aging: A Prelude to Improved Surgical Results appearance of the periorbita. Though beyond the scope of this article it appears that there is a paradigm change in what looks acceptable. The same amount of fat in an older eye typically looks worse than the same amount in the young. Many older lids are operated on for what is essentially minimally changed anatomy from youth. And finally why would one ‘hollow out’ the upper lid of a young person who has a normal amount of fat? A greater understanding of the true anatomic changes that cause these involutional occurrences of the orbital region has shed light on methods that are both safer and more aesthetically effective (see Chapter 5). The best surgical results seem to be those that impart rejuvenation yet are largely undetectable. Unfortunately many methods impart dramatic changes in facial appearance. A careful observation of the true visual changes of several aspects of facial/periorbital aging has also challenged traditional and current concepts of aging and the varied surgical approaches, and also offers a greater perspective on what direction we should be heading for to achieve the most aesthetic and natural results. However, it is true that many patients have fixed ideas about how they should look after periorbital surgery, and their thoughts should be taken into account in the final treatment plan. These collective observations are a contradistinction of traditional concepts of periorbital and facial aging; however in many ways they will enhance our understanding of the changes we see and the solutions for reversal. We have said that these are as yet just several notations of an extremely complicated process for which some components are difficult to measure on a short-term photographic basis. Finally, as surgeons we like to think that our methods rejuvenate patients, although the reality is that most (at best) create the illusion of youth. Finally, to this end, we believe that

the word ‘rejuvenation’ is more of a marketing term than truth. It is rare that the cosmetic surgery replaces the true youthful composition and, in many cases, it is best that it doesn’t. When people look better than they did, they are commonly perceived as being younger than they are. We think that the highest goal of cosmetic surgery is to weave a complex illusion that improves the face, without relying on doctrines or fixed principles to do so.

References 1. Lambros VS: The illusion of facial aging. About Face: Advanced Interactive Symposium in Cosmetic Surgery. The St. Regis Hotel; Aspen, Colorado; July 17, 2000. 2. Gonzales-Ulloa M, Flores ES: Senility of the face: Basic study to understand its causes and effects. Plast Reconstr Surg 1965; 36:239. 3. Farkas LG: Anthropometry of the Head and Face. New York, Raven Press, 1994. 4. Duke-Elder S, Wybar KC: The anatomy of the visual system. In Duke-Elder S (ed): System of Ophthalmology, vol II. St. Louis, C.V. Mosby, 1961. 5. Whitnall SE: The Anatomy of the Human Orbit and Accessory Organs of Vision. London, Oxford University Press, 1932. 6. Van den Bosch W et al: Topographic anatomy of the eyelids, and the effect of sex and age. Br J Ophthalmol 1999; 83:347–352. 7. Hill J: Analysis of senile changes in the palpebral fissure. Trans Ophthal Soc UK 1975; 95:49. 8. Shore JW, McCord CD: Involutional changes in blepharoptosis. Ophthalmology 1984; 98:21–27. 9. Muzaffar AR, Mendelson BC, Adams WP Jr: Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110:873. 10. Stuzin JM, Fagien S, Lambros VS: Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Surgical anatomy of the midcheek and malar mounds by Mendelson BC, Muzaffar AR, Adams WP. Plast Reconstr Surg [Discussion] 2002; 110:905.

CHAPTER 3

Evaluation of the Cosmetic Oculoplastic Surgery Patient Allen M. Putterman The preoperative evaluation of the candidate for cosmetic oculoplastic surgery is extremely important and cannot be overemphasized. In addition to helping determine the specific procedures required by the patient, evaluation aids in selecting candidates for surgery. Moreover, the initial visit provides a setting in which to prepare patients for surgery and to inform them about its possible complications, thereby ensuring a smoother postoperative course. In this chapter are the steps I follow in evaluating patients who desire cosmetic oculoplastic surgery: (1) examination of abnormalities of the forehead, eyebrows, eyelids, cheeks, face, and skin condition; (2) ocular assessment; (3) tear secretion measurements; and (4) photographs. Most important, the preoperative examination provides an opportunity for the surgeon to determine what the patient hopes to gain from this operation and to tell the patient what can be realistically accomplished. Allen M. Putterman

Evaluation of the patient who may be interested in cosmetic surgery is very important. The surgeon can decide which patients should or should not have surgery and can choose the appropriate procedures. A thorough evaluation also can help avoid postoperative complications and unhappiness. One of the most important aspects of evaluation is to establish what patients find objectionable in their appearance and what they expect surgery to accomplish. I usually determine this by handing patients a mirror and asking them to hold it at eye level as they point out their objectionable features (Fig. 3-1). Frequently, patients emphasize their most minor blemishes and dismiss the major defects noted by the surgeon. The surgeon should therefore make sure that the patient has realistic expectations.

History In taking a medical history, the surgeon questions the patient about illnesses, medications, allergies, and edema. Emphasis is on ruling out thyroid disease, heart failure, hypertension, bleeding tendencies, and unusual edema. For example, patients with thyroid disease may look as if they need cosmetic surgery, but the treatment needed is frequently medical, not surgical. Also, patients with thyroid disease must be followed up for at least 6 months until their eyelid retraction measurements and amounts of eyelid edema and her-

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Figure 3-1 Cosmetic oculoplastic surgery patients view themselves in a mirror and point out to the surgeon what changes they would like in their appearance. This may differ greatly from what the surgeon sees as the patients’ problems.

niated fat are stable before surgery can be considered. Patients should also be questioned about intake of aspirin or anti-inflammatory medications, such as ibuprofen, vitamin E, anticoagulants and herbal remedies. These drugs must be discontinued for several weeks pre-operatively to avoid the possibility of complications of bleeding during and after surgery. The surgeon should also try to find out why the patient wants surgery now. In this way, the surgeon can differentiate patients who have realistic, mature reasons for requesting surgery from those who do not. The examination includes an evaluation of the forehead, eyebrows, upper and lower eyelids, cheeks, face, and skin condition. I encourage all surgeons to step back and view the patient’s entire face first before they focus on specific structures. The purpose of this examination is to determine which cosmetic problems are correctable so that they can be compared with the patient’s expectations.

Forehead and eyebrow examination In examining the forehead and eyebrows, the cosmetic surgeon is looking mainly for brow ptosis (drooping), which causes excessive upper eyelid folds. The surgeon also looks for asymmetric brow ptosis or ptosis of

parts of the brow (e.g. nasal or temporal). In patients with apparent dermatochalasis (excess skin) of the upper eyelid that is actually due to a brow ptosis, excising upper eyelid skin without elevating the eyebrow only minimally improves appearance. Additionally, forehead wrinkles and frown lines caused by overactive corrugator, procerus and frontalis muscles are examined. Measuring the distance from the central upper eyelid margin to the central inferior brow edge (brow upper lid, BUL) with the patient gazing in primary position can help identify patients with brow ptosis. If this measurement is much less than 10 mm, especially in women, surgical elevation of the brow may be desirable. Another useful measurement is the distance from the central inferior part of the eyebrow to the inferior corneal limbus (brow inferior limbus, BIL) as the patient gazes in primary position. The measurement is commonly about 22 mm. If this measurement is much less than that amount, especially in women, elevation of the brow is also suggested. Also, this measurement is frequently more reliable than that of the brow to upper eyelid, which varies with upper eyelid ptosis or retraction. The amount of brow ptosis can be determined in several ways. The first is to line the zero mark of a millimeter ruler with the central superior brow edge (Fig. 3-2). The brow is then elevated to a cosmetically acceptable level with the examiner’s finger, and the amount of excursion of the brow is noted on the ruler where the superior central brow edge meets the ruler. This measurement is repeated over the temporal and nasal aspects of the brow about 10 mm from the brow ends, and similar measurements are made over the opposite brow. The same measurement can be made by first placing the brow in a cosmetically acceptable position with the examiner’s finger, lining the 20-mm mark of the ruler with the superior central brow edge, and then releasing the brow and noting how many millimeters the brow drops as it assumes its ptotic position. Still another method of measuring brow ptosis or asymmetry is to use the ocular asymmetry measuring device (Bausch & Lomb Storz® Instruments),1 an instrument that Chalfin and I devised. It consists of a headband, a ruler, and a T-shaped crosspiece. When the band is placed around the patient’s forehead, it fixes the ruler vertically over the midforehead. The crosspiece line intersects the medial canthus and levels the crosspiece. The crosspiece is then aligned with the central superior brow, and the location where the indicator is positioned on the ruler is noted (Fig. 3-3). The brow is elevated with the examiner’s finger to a cosmetically acceptable level. The crosspiece is then elevated to the new superior central brow position, and the excursion of the indicator on the ruler is noted. The

Examination of the upper eyelid 23 Figure 3-2 Measurement of the amount of eyebrow ptosis. A, The zero (0) mark of a millimeter ruler is aligned adjacent to the top of the central ptotic brow. B, The surgeon lifts the ptotic brow to the desired postoperative position, and the amount of excursion of the central superior brow is noted by the level of the brow adjacent to the ruler. In this case, the brow has been elevated 7.5 mm.

measurement of asymmetry, as the indicator is fixed to the crosspiece and they move as one unit. Measuring the amount of brow ptosis aids in determining the amount of skin that must be removed to elevate the brow surgically. (The ocular asymmetry measuring device is also useful in measuring asymmetric canthi and eye positions.)

Examination of the upper eyelid The upper eyelid is evaluated for excessive skin, herniated orbital fat, abnormal eyelid creases, ptosis, retraction, and prolapse of the lacrimal gland.

Eyelid skin-fat examination

Figure 3-3 Ocular asymmetry measuring device for determining the amount of brow ptosis. In asymmetric brow ptosis, the measuring rod is set at the central superior aspect of the more ptotic brow, and the point of indicator on the ruler is noted. The measuring rod is then elevated to a similar position on the more normal brow, and the millimeters of excursion of the indicator determine the amount of brow ptosis.

measurements are repeated temporally and nasally and on the opposite brow. The ocular asymmetry measuring device is especially useful in unilateral brow ptosis. In these cases, the crosspiece is raised to the highest position on the arch of the lower eyebrow, and the position of the indicator on the millimeter ruler is noted. The crosspiece is then raised to the corresponding point on the opposite eyebrow, and the position of the indicator is again noted. The excursion of the indicator is a direct

The amount of excessive skin and whether the skin is more redundant over part of the upper eyelid are determined. The surgeon finds herniated orbital fat by noting fullness in the upper eyelid, especially nasally and, at times, centrally. Lifting the lid fold by elevating the brow and simultaneously pushing on the eye through the lower eyelid can increase the fat herniation in the suspected areas and verify that the fullness is due to fat, not edema. Fat generally flows forward during this maneuver, whereas edema of the eyelids remains unchanged. Preoperative determination of excessive skin and herniated orbital fat establishes candidates who would benefit by the excision of these tissues.

Eyelid crease examination The examiner can find the upper eyelid crease by lifting the eyebrow and asking the patient to look downward first, then slightly upward, and then downward again. The distance from the central upper eyelid margin to the central crease as the patient looks down and as the eyelid fold is elevated with the examiner’s finger deter-

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MCD

Figure 3-4 The margin crease distance (MCD) is a measurement of the distance from the lid crease to the lid margin over the central upper eyelid on down gaze.

mines the margin crease distance (MCD) measurement described by Urist and me (Fig. 3-4). Normally, this is 9–11 mm. If the distance is much less, reconstruction of the eyelid crease and excision of the skin fat should be considered (see Chapter 7). If the MCD is much greater than normal, a disinsertion of the levator aponeurosis should be suspected. As the levator aponeurosis recesses into the orbit, it frequently elevates the eyelid crease upward. The surgeon must discuss reconstruction of an upper eyelid crease with the patient preoperatively. Although most patients find a high upper eyelid crease to be cosmetically appealing, some, especially Asians, may strongly dislike its appearance. It is therefore advantageous to be able to demonstrate to patients preoperatively how they will look with crease reconstruction and to predetermine the desired level at which to reconstruct the upper eyelid crease. To predetermine the position at which to reconstruct an upper eyelid crease, the surgeon will need a curved instrument for compression of the upper eyelid skin. I formerly used an unwound, slightly curved paper clip and pressed it at various positions of the upper eyelid. Many of my patients reacted negatively to the use of a paper clip to determine the eyelid crease, saying how crude an instrument it was. This negative reaction led to my development of a more sophisticated instrument, the upper eyelid creaser (Bausch & Lomb Storz® Instruments).2

This creaser consists of a 4-cm, curved, thin metal wire attached to a handle (Fig. 3-5). The wire has a curvature similar to the normal upper eyelid crease, but it is flexible and can be bent by the examiner if the curve needs to be flattened or extended. The examiner holds the handle and presses the wire into the upper eyelid at various positions until the surgeon and patient agree on a desirable level at which the reconstruction is to be performed (Fig. 3-6). A measurement is made between the upper eyelid margin and the chosen position and is used intraoperatively to determine the position for reconstructing the crease. The eyelid creaser is also useful in demonstrating to patients the need for forehead and brow elevation. Reducing the upper eyelid fold with the creaser will show patients the residual skin under their brows and if they find that unacceptable they are usually more willing to undergo a forehead and brow lift with an upper blepharoplasty.

Evaluation of blepharoptosis Ptosis of the upper eyelid is determined by measuring the palpebral fissure width and margin reflex distance1 (MRD1) described by Urist and me.3 Palpebral fissure width is the distance from the central lower eyelid to the central upper eyelid margins and is measured with the patient’s eyes in the primary position of gaze (Fig. 3-7). Normally, this width is about 10 mm. If it is significantly less, a ptosis should be suspected and treated. The MRD1 is a quantitative measurement of ptosis and is determined as follows. With the eyes of the examiner and patient at the same level, an eye muscle light held between the examiner’s eyes is directed at the patient. The MRD1 is the number of millimeters from the light reflex on the patient’s cornea to the central upper eyelid margin with the patient’s eyes in the primary position of gaze; this is recorded in positive numbers (Fig. 3-8).3 If the ptotic eyelid covers the corneal reflex, the eyelid is raised until the reflex is seen. The number of millimeters that the eyelid must be raised is recorded as the MRD1 in negative numbers. The MRD1 is a more accurate measurement of the amount of ptosis than the palpebral fissure width because the latter can be altered by abnormalities of the lower eyelid, including lower eyelid retraction. The normal MRD1 is 4–4.5 mm. A smaller measurement usually means ptosis of the upper eyelid. The palpebral fissure width on down gaze is another important measurement of blepharoptosis. The examiner uses his or her finger to fixate the patient’s brow on the side being examined while raising the brow and upper eyelid on the opposite side. The patient is instructed to look to the extreme downward position

Examination of the lower eyelid

Figure 3-5 The upper eyelid creaser (Bausch & Lomb Storz® Instruments) consists of a handle and a thin, slightly curved metal extension.

Figure 3-6 A patient with upper eyelid dermatochalasis (excess skin) and poorly defined upper eyelid creases. The upper eyelid creaser is used to compress the upper eyelid skin to determine the desired position at which to reconstruct an upper eyelid crease.

of gaze while the distance between the upper and lower eyelids is measured. Normally, this distance is 2 mm or more. If the distance is 1.5 mm or less, patients frequently have difficulty reading because of the upper eyelid ptosis unless they raise their eyebrows, which is usually difficult to sustain. Olson and I4 showed that approximately one-third of patients with acquired ptosis of the upper eyelids have a zero palpebral fissure width on downgaze and are essentially blind unless they raise their eyebrows and thus their eyelids.

Fissure width

Evaluation of upper eyelid retraction Upper eyelid retraction occurs in some patients with thyroid ophthalmopathy. The retraction is determined by measurement of the palpebral fissure width in the primary position of gaze or by the MRD1 (see previous paragraph). The measurements are helpful in the treatment of upper eyelid retraction (see Chapter 13).

Figure 3-7 The palpebral fissure width is measured over the central eyelid with the patient gazing in the primary position. This is a measurement from the central lower to the central upper eyelid, and the difference between the normal and ptotic lids determines the amount of eyelid ptosis.

Evaluation of prolapsed lacrimal gland

Examination of the lower eyelid

Fullness of the upper eyelid in the temporal region should alert the surgeon to a possible prolapsed lacrimal gland because there is no significant orbital fat in the temporal upper eyelid. Pulling the upper eyelid fold upward by elevating the brow with the surgeon’s finger helps to identify this abnormality. If prolapse exists, it is treated by repositioning the lacrimal gland into the lacrimal fossa at the time of the blepharoplasty.

The lower eyelid is evaluated for excessive skin, herniated orbital fat, retraction, inferior hollowing, and laxity.

Lower eyelid skin-fat examination The excessive skin in the lower eyelid is considered as the patient looks upward. This position places the skin

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4mm

2mm

Figure 3-8 The margin reflex distance-1 (MRD1) is useful for determining the amount of ptosis. This is the distance from the light reflex on the patient’s cornea to the central upper eyelid as the patient gazes in the primary position. The difference in MRD1 between the normal and the ptotic lid determines the amount of ptosis.

on the stretch needed to look upward, and any extra skin with the eyelid in this position usually can be sacrificed without fear of producing a cicatricial ectropion postoperatively. If the amount of excessive skin is determined with the patient looking straight ahead or downward and if the excessive skin in these positions is excised, the patient might have an ectropion on up gaze. Herniated orbital fat in the lower eyelid is judged by determining fullness in the medial, central, and temporal areas of the eyelids when the patient looks upward. To differentiate fat from edema, the examiner applies pressure to the eye through the upper eyelid. Increased fullness in the lower eyelid correlates with fat herniation; no change in fullness is seen if edema is present. Also, the examiner must consider hypertrophy of the orbicularis muscle, which can be emphasized by having the patient smile. Smiling also demonstrates lower eyelid wrinkles that might be treated with botox, skin flap plications, laser resurfacing, or chemical peels (see Chapters 21 and 22). Nasojugal depressions or inferior orbital rim hollowing should be examined as they might require orbital fat repositioning or cheek lifts (see Chapter 17).

Evaluation of lower eyelid retraction Lower eyelid retraction occurs in some patients with thyroid ophthalmopathy. The amount of retraction is measured by the distance from the inferior limbus to the lower eyelid temporally, centrally, and nasally. Normally, the lower eyelid is at the level of the inferior limbus. This measurement is helpful in determining the size of the grafts used to treat lower eyelid retraction (see Chapter 18). Another measurement is the margin reflex distance2 (MRD2) (Fig. 3-9).5 The MRD2 is the distance from

a corneal light reflex to the lower eyelid as the examiner and patient’s eyes line up at the same level and the examiner shines a muscle light at the patient’s eyes. This distance normally is about 5.5 mm but increases with lower eyelid retraction. The MRD2 also is helpful in determining the size of the grafts used to treat lower eyelid retraction (see Chapter 18).

Evaluation of lower eyelid laxity Laxity of the lower eyelid is evaluated when the surgeon pulls the lower eyelid downward and observes how quickly it snaps back to the eye (Fig. 3-10). Pinching full-thickness eyelid tissues together also helps in the evaluation of a redundant eyelid. In cases of marked horizontal lower eyelid laxity, redundant eyelid, or a slowness in the eyelid to snap back after eversion, the surgeon should consider a lower eyelid horizontal shortening/full-thickness temporal eyelid resection, lateral canthal tendon tightening or tarsal strip procedure in order to avoid a postoperative ectropion after resection of skin and fat (see Chapters 15 and 17). The examiner measures laxity of the lateral canthal tendon by pulling the lateral canthus nasally (Fig. 3-11). Normally, the lateral canthus moves only minimally with this maneuver; however, if the lateral canthus can easily be pulled to or beyond the lateral limbus of the eye, attenuation of the lateral canthal tendon must be suspected. Similarly, medial canthal tendon attenuation is diagnosed by the ease in pulling the medial canthus temporally. In either case, the surgeon should consider a lateral or medial canthal tendon tuck procedure, combined with a cosmetic blepharoplasty, in order to avoid a postoperative lower lid ectropion (see Chapters 15 and 17).

Skin evaluation 27

5 mm

8 mm

Figure 3-9 The margin reflex distance-2 (MRD2) is useful for measuring the amount of lower eyelid retracton. This is the distance from a corneal light reflex to the lower eyelid as the examiner and the patient’s eye line up with each other and the examiner shines a muscle light at the patient’s eyes.

Figure 3-10 A, The amount of horizontal laxity of the lower eyelid is determined by pulling the lower eyelid downward. B, Lack of elevation of the lower lid from the everted position on releasing the surgeon’s finger indicates that the lower lid is horizontally lax and that an ectropion is likely to complicate lower eyelid cosmetic surgery.

A

B

Examination of the cheek and face

Orbital rim

Figure 3-11 Lateral canthal tendon laxity is measured by the ease with which the lateral canthus can be pulled nasally when the lower lid is drawn in this direction. This signifies the need for a lateral canthal tuck.

The cheek and face should be examined. Cheek bags and cheek depressions occur with thyroid ophthalmopathy and aging; nasolabial fold depressions also occur. Inferior orbital rim hollowing and cheek flattening are also associated with cheek mid face ptosis. These problems can be improved with a cheek or midface lift through a lower blepharoplasty approach (see Chapter 17). Sagging of the face, jowels and neck also occurs with aging and is treated with a facelift and liposuction.

Skin evaluation The condition of the skin should be evaluated. Wrinkled skin of the eyelids, lip area, and face are frequently due to aging and sun exposure. Chemical peels and laser resurfacing are methods that can be used to improve skin texture (see Chapters 21 and 22).

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Determination of visual acuity Visual acuity is determined with the patient wearing glasses or contact lenses. If the acuity is less than 20/20, a refraction is performed to determine the best vision. If visual acuity cannot be improved to 20/20, a thorough eye examination should be performed to find the cause. If patients have poor vision postoperatively, they may believe the operation to be the cause. If the postoperative visual acuity is the same as that recorded preoperatively, the operation undoubtedly is not at fault.

Ocular motility testing The examiner can test ocular motility by having the patient follow a muscle light to the cardinal positions of gaze. A cover–uncover test rules out tropia (deviation) and phoria (movement). Phorias can become tropias, and diplopia (double vision) can occur spontaneously as a result of injury to the inferior or superior oblique tendons during a blepharoplasty.

Evaluation of basic tear secretion A basic tear secretion test is performed to rule out hyposecretion of the basic tear secretors. Several drops of proparacaine topical anesthetic are applied to each eye and the lower cul-de-sac. The lower cul-de-sac and lower lid palpebral conjunctiva are blotted with a tissue paper. A Schirmer strip (SMP Division, Cooper Laboratories, San German, Puerto Rico) is bent at its notch, 5 mm from one end, and the strip is placed over the temporal palpebral conjunctiva of the lower eyelid (Fig. 3-12). The patient is instructed to look upward, and the lights are dimmed. After 5 minutes, the strip is removed and a measurement is made from the notch to the end of wetting. (Theoretically, it is possible to do this test for 1 minute, rather than 5 minutes, and to multiply the amount of wetting in 1 minute by 3 to obtain an appraisal of the 5-minute level.) Normally, this measurement should be between 10 and 15 mm of wetting in 5 minutes. If it is significantly less, hyposecretion of the basic tear secretors should be suspected. The basic tear secretors consist of the conjunctival goblet cells, the meibomian oil glands, and the accessory lacrimal glands of Krause and Wolfring, and they are believed to keep the eyes moist during normal conditions. If basic tear secretion is insufficient, symptoms of ocular irritation may develop or increase following a cosmetic blepharoplasty. In these cases, tightening the

Figure 3-12 A basic tear secretion test identifies patients with potentially dry eyes. Schirmer strips are placed over the temporal lower eyelids as the patient looks upward, and the amount of wetting on the strip is measured.

eyelid skin by excessive skin resection might lead to lagophthalmos (difficulty in completely closing the eyelids). Whereas a patient with normal tear-secreting eyes might tolerate this condition, a patient with dry eyes may not. This may be the ultimate condition that causes the asymptomatic patient to become symptomatic. If the basic tear secretion test result is low, it is important to ensure that the patient is not taking a diuretic or antihistamine because these drugs can cause a falsely low reading. If so, these drugs should be discontinued and the test repeated. In a patient with low basic tear secretion, a cosmetic blepharoplasty might be contraindicated; if such a procedure is done, only a very conservative skin excision should be performed. In any case, patients must be fully aware that they have this problem and that after the blepharoplasty they may have to use artificial tears or a lubricating ophthalmic ointment for the rest of their lives. Some surgeons believe that the cause of the ocular irritation in this situation is excision of too much upper eyelid skin. In my experience, however, the more common cause is lower eyelid retraction or ectropion secondary to excessive resection of lower eyelid skin. Repair of blepharoptosis with the possibility of secondary lagophthalmos may also be contraindicated in patients with dry eyes.

Evaluation of visual fields Peripheral visual fields are evaluated if a loss of peripheral vision is suspected. The purpose is to document any loss of peripheral vision from upper eyelid derma-

Evaluation of the cornea tochalasis or brow ptosis that causes the upper eyelid skin fold to overhang the upper eyelid margin. This skin fold acts as an ‘awning’ that usually leads to a loss of vision in the superior or superotemporal periphery. Visual fields are also helpful in establishing the amount of peripheral vision loss in patients with blepharoptosis. Documentation of these problems can be helpful to patients in obtaining insurance benefits for surgery. Many insurance companies will pay for surgical excision of excessive upper eyelid skin or brow or upper eyelid elevation that results in a legitimate improvement in vision. Many companies, however, want proof in the form of peripheral visual field examination results and preoperative photographs. They also usually want the visual field done with and without the brow and lid being elevated with tape. Many different perimeters can determine peripheral visual field loss. Many insurance companies require the use of automated equipment, such as the Goldman and Humphrey perimeters, with tests performed both with the upper eyelid taped upward and untaped (Fig. 3-13). Currently, I use the A-Mark perimeter, an arc that is moved to various positions as a light is shifted from the extreme peripheral visual field toward central areas and the patient notes when he or she first sees the light. In my experience, this

method provides a satisfactory documentation of visual field loss.

Assessment by photography Photographs are taken of every candidate for cosmetic oculoplastic surgery. Preoperative photographs have several advantages: 1. They provide a visual record for preoperative assessment of the patient’s cosmetic problems. 2. New aspects of the patient’s problems that were not appreciated at the initial examination become apparent on photographs. 3. They give the surgeon an opportunity to demonstrate to the patient the improvement in appearance postoperatively. It is amazing how easily patients forget how they appeared preoperatively when they are examined several months after surgery. Seeing their preoperative photographs gives them a renewed appreciation of their operation, which is beneficial to both the patient and surgeon. Usually, I take photographs of both eyes and eyelids in primary and in up and down positions of gaze, as well as the left and right side oblique view. I also take full-face photographs in primary, left and right side oblique views. Photographs are taken preoperatively and 2–4 months postoperatively.

Evaluation of the cornea

Figure 3-13 Peripheral visual fields are performed in patients with upper eyelid ptosis and upper eyelid skin folds that hang over the upper eyelid margin. Loss of superotemporal vision is common in patients with marked upper eyelid dermatochalasis, and diffuse loss of superior vision is common in ptosis.

Candidates are routinely tested for Bell’s phenomenon and corneal staining. Corneal sensation is tested in selected patients whose corneas stain. The examiner tests for Bell’s phenomenon by having the patient tightly close the eyelids. The examiner then pries the eyelids open slightly and notes the position of the cornea and iris. Normally, the eye will elevate. If not, the patient may have a potential for ocular irritation after tightening the eyelids, and the surgery should be conservative or not performed at all. Certainly, patients should be warned of this possibility preoperatively because they may have to use artificial tears or ocular ointment for the rest of their lives. Corneal sensation is tested while the patient gazes slightly upward. The examiner pulls up a wisp of cotton from a cotton applicator and touches the peripheral cornea with it. No response or a minimal response is abnormal, and surgery is contraindicated because of the possibility of postoperative corneal problems. Fluorescein applied to the inferior cul-de-sac allows the examiner to study the cornea for staining under the cobalt blue light of the slit lamp. Marked keratopathy

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Evaluation of the Cosmetic Oculoplastic Surgery Patient can be expected to increase after cosmetic eyelid surgery. Affected patients should not have surgery unless the keratopathy is minimal; even if it is minimal, the skin and fat should be resected very conservatively and the patient should be warned preoperatively of the possibility of postoperative ocular irritation and longterm need for ocular lubricants. The same is true for patients with blepharoptosis.

Consultation After the examination is complete, it is important to explain the findings to the patient. While the patient holds a mirror directly in front of his or her face, I point out the abnormalities. I demonstrate ptotic brows and a wrinkled forehead, low or duplicated upper eyelid creases, excessive skin, herniated fat, skin discoloration and wrinkles, upper eyelid ptosis, orbicularis muscle hypertrophy, cheek bags and ptosis, nasojugal or inferior orbit rim hollowing and nasolabial folds. Then I demonstrate sites for surgical incisions and postoperative scars. I correlate the patient’s complaints with what I have found and discuss what can and cannot be accomplished surgically. After bringing the patient into a consultation room, I discuss operating procedures and potential complications. I explain to the patient who has a ptotic eyebrow that unless the brow is elevated, I can only minimally eliminate the excessive upper eyelid skin folds. Additionally, I emphasize that there will be a brow scar after a direct brow lift, which can be covered with cosmetics. I explain complications of upper eyelid surgery, such as cysts, ptosis, and asymmetry, and make an effort to put these complications into perspective. I tell the patient that upper eyelid cysts are common in the incision line postoperatively but that, to date, no patient of mine has had upper eyelid ptosis. For surgery of the lower eyelid, I explain the possibility of ectropion postoperatively. I emphasize the potential for hair loss and sensory or motor dysfunction with forehead elevation, skin dimples with internal brow and cheek lifts, and redness and skin pigmentation with chemical peels and laser resurfacing. If the patient has a tendency for dry eyes, I discuss this problem and the possible need for artificial tears and ocular ointments after surgery. For cheek-midface lifts, I also emphasize possible facial asymmetry and numbness. With facelifts, I discuss asymmetry, scars, suture extrusion, and sensory and motor paresis.

If there is a need to resect herniated orbital fat, I inform patients that I prefer them to stay for 2 to 3 hours postoperatively in the surgical facility. With this type of surgery, it is possible to produce a hemorrhage, which can migrate to the retrobulbar position and cause blindness.6 The chance of this occurring, however, is rare, and I have not had a case of permanent blindness resulting from cosmetic surgery. If patients stay in the recovery area for several hours, they can be watched carefully for this complication; if a hemorrhage does occur, it can be detected quickly and treated. For any surgery whose costs are not covered by insurance, I request that all surgical fees be paid in full 2 weeks preoperatively. This eliminates payment problems later. Insurance companies will not pay for the operation if it is purely cosmetic. Also, if patients are dissatisfied, they cannot withhold or reduce the surgeon’s fees. The 2-week interval is enough time for checks to clear through bank processing and discourages patients from changing the date of surgery. This prepayment does not apply to blepharoptosis or eyelid retraction surgical procedures that are medically necessary and paid for by insurance companies. A second consultation and examination are performed at the surgical center immediately before the operation. This meeting allows the surgeon to view the patient and reappraise the surgical approach. It also lets the surgeon review with the patient what the operation should accomplish, the hospital’s procedures, and potential complications. The patient may also use this time to ask questions, which can lessen fears of surgery and decrease any chance of misunderstanding.

References 1. Putterman AM, Chalfin J: Ocular asymmetry measuring device. Ophthalmology 1979; 86:1203–1208. 2. Putterman AM: Eyelid creaser. Arch Ophthalmol 1990; 108:1518. 3. Putterman AM, Urist MJ: Müller muscle-conjunctival resection. Arch Ophthalmol 1975; 94:619–623. 4. Olson JJ, Putterman AM: Loss of vertical palpebral fissure height on downgaze in acquired blepharoptosis. Arch Ophthalmol 1995; 113:1293–1297. 5. Putterman AM: Basic oculoplastic surgery. In Peyman GA, Sanders DR, Goldberg MF (eds): Principles and Practice of Ophthalmology, pp 2248–2250. Philadelphia, WB Saunders, 1980. 6. Putterman AM: Temporary blindness after cosmetic blepharoplasty. Am J Ophthalmol 1975; 80:1081–1083.

CHAPTER 4

A Comprehensive Evaluation of the Cosmetic Oculoplastic Surgery Patient Beyond Formal Measurements. Decision Making and Tips to Enhance Patient Satisfaction and Outcomes Steven Fagien The accurate evaluation of the patient who presents for consideration of aesthetic improvement of the periorbita is as important as any of the other components that lead to a successful outcome. Often an unfavorable result can be traced back to a less than precise evaluation of the situation at hand that would include failure to observe some of the salient findings that were neither protected or improved. Frequently patients present with a general dissatisfaction of the aging appearance of the periorbita, but are not quite exactly sure what are the particulars that bother them, the options for improvement, or the potential risks with the multitude of approaches. As in all aspects of medicine, an accurate history, physical examination, and thorough discussion with the patient will lend itself to better treatment planning. This combined with precise surgical execution, will nearly always result in a happier patient. More often, even subtle findings or clues that lend themselves to particular maneuvers that will optimize the overall result can be seen before (or are seen retrospectively) by careful evaluation of the patient and review of preoperative photographs. In this chapter, I will discuss some of the important aspects of this process, including choices and decision making that must be considered in every patient evaluation for the individual who presents for periorbital cosmetic surgery. Steven Fagien

History The patient’s purpose for their consultation and general history is commonly first obtained by a nurse, medical assistant, or resident/fellow in training. At times this is obtained only and directly by the surgeon him/ herself. If the initial history is taken by someone other than the operating surgeon, it behooves the surgeon to review the obtained data and often supplement the historical information with data that will improve and clarify the overall patient status. This starts, as with all medical evaluations, with a chief complaint. Sometimes the chief complaint is disregarded

Chapter 32

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A Comprehensive Evaluation of the Cosmetic Oculoplastic Surgery Patient: Beyond Formal Measurements only to be discovered after surgery when the patient states that although there is obvious improvement of the overall presenting condition, the main purpose for this patient proceeding with surgery was to improve a situation that was clearly stated in the chief complaint and possibly forgotten, ignored or not adequately addressed in the final analysis. Obviously, once the patient makes this statement, their expectations are that this will be addressed, despite the elaboration and performance of other procedures that might globally improve the appearance of the periorbita and face. These additional procedures are usually recommended after either an expanded description of the chief complaint, or by questions asked directly by the medical assistant or physician which further clarify the situation and are then a prelude to a more meaningful discussion of this and the potential options for their remedy. Patients will often elaborate on situations that are either difficult or impossible to treat, however, their concerns should be addressed and appropriate actions taken either by a discussion of the impracticality, impossibility, or unreasonability of their requests and/ or a detailed explanation of the proposed treatment and more reasonable expectations. At times, I will request a relative of the patient to accompany them during a follow-up consultation regarding their requests and desires, if I detect a lack of adequate understanding of the procedures proposed. Typically what follows the chief complaint during the history taking portion of the consultation is a list of prior surgical and dermatologic encounters and possibly a description and elaboration of prior consultations and recommendations as well. At this time it is helpful to question the patient on his or her satisfaction with prior recommendations and/or treatments which will sometimes be a hint of the likelihood of their satisfaction with your surgical efforts. It is not uncommon for patients to either forget or choose to not mention prior experiences for a variety of reasons. Patients who deny prior surgery or treatments where the examination indicates otherwise can pose other problems (discussed later). Patients will often vary from refusal to mention the names of prior treating or consulted physicians or (to the contrary) insistence on your knowing who the prior surgeons were (whether they were happy with the recommendation and treatments or not) and careful attention should be noted to the sentiment regarding these discussions. The dates of prior procedures should be documented, as these may indicate a behavioral pattern of the patient, as well as appropriate timing of future treatment. Past medical history and prior non-plastic surgical procedure experiences should also be documented in the history. This should

also include claims of unfavorable results as well as potential anesthetic problems that can enlighten the surgeon and future anesthetists/anesthesiologists to problems which might be avoided. General medical conditions should be carefully documented and if not offered freely, questioned directly, especially in lieu of information that has already been obtained. Other information including medications, allergies and possible drug reactions should be documented. Present and past usage of medications should be listed and dosages of medications should also be noted, as well as the frequency and duration of taking these medications. Self-administered medications without prior physician recommendation as well as refusal to take medications despite physician’s recommendations should also be documented. This may also suggest to you what medications the patient may refuse to take after surgery, together with their overall compliance with postoperative instructions despite your recommendations. Patients must also be questioned on particular medications that have been recommended to them to administer before surgery or (specifically) dental procedures. Often this will reveal other possibly pertinent information about their general medical condition (mitral valve prolapse, orthoarticular prostheses, recurrent herpes simplex, etc.) that may have been omitted. Their usage for their upcoming periorbital surgery can then be assessed. History of allergies to medications as well as other known substances (including latex, injectable anesthetics, etc.) should be discussed. For instance, patients will often state that they are ‘allergic to lidocaine’ and when on further elaboration they claim that asymptomatic palpitations were noted during a dental procedure, for example. Often they will consider this an allergy or contraindication to use, when in fact under controlled and monitored anesthesia this may not be the case. If they claim an allergy to a particular drug, they should also describe (if they can recall) exactly what type of ‘reaction’ occurred during the usage of this medication or drug. Commonly patients will state other (non-allergic) symptoms including ‘upset stomach,’ nausea, lethargy or sleeplessness, all of which are obviously not necessarily true allergic responses. Patients should be directly questioned on the use of any anti-inflammatory medication or any drugs which could potentially increase bleeding time; this medication will probably be discontinued for at least one to two weeks prior to surgery. A list of medications that could alter bleeding times may be given to them for a review and reminder. They should also be questioned regarding personal experiences with bruising or bleeding which may help counsel patients on

General upper facial assessment what they can expect regarding their appearance immediately after surgery. Finally, a history of dry eye symptoms, use of artificial tears and other topical emollients for the eye surface, as well as the use of contact lenses should be elicited that may give you more information than can be obtained by didactic measurements.1,2 For instance, if a patient states that they have intermittent dry eye symptoms of irritation, pain, light sensitivity, and decreased vision, an elaboration of these questions may reveal that the patient infrequently uses tear supplements and by increasing their usage of the topical agents dramatically reduces and even eliminates symptoms. These patients must be approached (i.e. for surgical candidacy) with great caution and the procedures may be modified to reduce the chance of increased ocular exposure symptoms. Similarly, if the patient states that their dry eyes are ‘terrible’ but also denies the use of tear supplements, or that they are able to tolerate contact lenses for days and weeks at a time without symptoms of dryness or irritation, they can do very well after surgery with regard to the concerns of potentially worsening dry eye symptoms. To the contrary, if a patient denies a history of dry eye symptoms but after further questioning reveals a complete intolerance to the use of contact lenses (due to pain and discomfort), can’t tolerate a fan or air-conditioning (i.e. in a car or plane) blowing near them due to enhanced ocular foreign body sensation, they may pose significant risk when proceeding with any eyelid surgery. Finally, women that are nearing menopause, immediately pre-, or postmenopause, should be warned that their incidence of dry eye symptoms can be worsened even when surgery is performed very well. As this is a common age for women to have cosmetic blepharoplasty, their increased symptomatology is often blamed on the surgery. Appropriate preoperative counseling lets them know that their worsening of symptoms may be expected and fortunately, is temporary in most situations. Finally, those individuals who have had keratorefractive surgery (i.e. LASIK and related procedures), clearly exhibit a greater risk and incidence of dry eye symptomatology after surgery, and this should be discussed beforehand, so that the choice to proceed with cosmetic blepharoplasty, understanding the risks, becomes theirs. After an accurate history followed by a discussion regarding much of the data obtained, an accurate physical examination is then performed. Any data obtained during the history or examination that suggests an instability or concern regarding the patient’s general medical condition indicates that, prior to surgery, a preoperative clearance by their primary care physician or specialist may be warranted. Often these physicians

can aid in medical care that might be required after surgery, for whatever reason, and are more likely to be helpful if they had been made fully aware of the upcoming surgery and contributed in the preparation of this mutual patient. Also, if there is any concern regarding the ocular status before proceeding with surgery, it might be prudent to have the patient consult his/her personal eye care professional for guidance prior to surgery. This can be helpful if the patient develops even temporary symptomatology after surgery, whereby eye care is perceived as a shared effort that is seen in a more favorable light.

The physical examination The first part of the physical examination begins during the history taking process. I commonly will simply observe a patient while they are speaking, and simultaneously evaluate them for animation and effects that may relate to either their complaints or possibly recommendations and treatment options. Asymmetries are commonly noted, especially with regard to the position of the eyebrow(s), as well as the size of the horizontal and vertical palpebral apertures (Fig. 4-1). At times during this discussion, even subtle facial weakness or dyskinesis can be identified which must be considered while entertaining surgical options, as well as documentation of its presence as it may only become obvious to the patient after surgery. A prelude to the patient’s personality can also at times be detected by their habits and mannerisms. Those who are shy or even untruthful will not as frequently maintain eye contact. Those who continuously question or even argue every statement or recommendation negatively, may cause trouble after surgery even if it is performed at or near perfection. Those patients who have been unhappy with all prior experiences and speak unfavorably about many or all prior treating physicians are also likely to be dissatisfied with your efforts. So the history portion of the consultation is not simply performed to obtain routine historical data, but the treating surgeon should be keenly observant of facial expression as well as personality and mannerism traits of the individual which will lead to the best possible treatment recommendations, that might include no treatment at all.

General upper facial assessment Once the general assessment and more casual observation (during the history-taking portion) of the patient’s situation has been obtained, a more detailed evaluation should follow, including more formal measurements

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Figure 4-1 (Left) This patient presented for periorbital rejuvenation surgery. She was unhappy with the aging appearance which she described as hanging skin of the upper eyelids on her right side more than her left, and the lower eyelid dark circles. (Right) After upper and lower blepharoplasty with particular attention to her presurgical crease and fold asymmetry. A brow lift was not performed, but differential surgery was performed on her upper eyelids. Canthal surgery was also performed with her lower blepharoplasty and was carried out so as not to exaggerate her pre-existing canthal asymmetry.

Figure 4-2 This patient presented several years after having undergone upper and lower blepharoplasty and facelift elsewhere. She noted significant facial asymmetry, especially in photographs, but was not aware of the cause. The evaluation detected brow asymmetry that was in part due to her upper eyelid ptosis, left greater than right with a compensatory elevation of her left eyebrow.

and notations (see Chapter 3) of the eyebrow position and asymmetry. There should be careful evaluation of forehead and periorbital lines and furrows, which will often indicate chronic and habitual animation (Figs 4-2 to 4-5). I do not believe that formal or precise brow measurements will dictate whether or not to perform brow surgery (Fig. 4-6); however it will serve as a basis for discussion of the possible options. For instance, I will often request to review old photographs of the patient to determine their opinion on their brow position in the past and present, and then will discuss the reality of actual brow descent. Photographs are generally helpful for many aspects of periorbital surgery (see Chapter 2), especially in lieu of asymmetry and general aesthetic appearance and ultimately the goal for our rejuvenative efforts (Fig. 4-7). Nonetheless, useful didactic measurements including the vertical and hori-

zontal palpebral fissures, margin to reflex distance (MRD1) and lower lid position with regard to shape, retraction, canthal position and lower eyelid laxity should be determined (see Chapter 3). I have not found reliance on snap-back or lower eyelid distraction maneuvers particularly useful as a screening tool for the necessity (or not) for canthpexy/plasty, especially in lieu of my philosophy that most lower lid surgical procedures (except in the very young) require routine, varying degrees of canthal support5 (see Chapter 15). These maneuvers, however, may simply confirm the necessity for lower eyelid/canthal re-enforcement procedures, and vectors for commissure support or repositioning (Fig. 4-8). They may also serve as an illustration (to the patient) of the need for particular ancillary procedures at the surgical setting. Although I have not found absolute brow position to be a qualifier for the suggestion of browplasty, this observation as well as the amount of brow laxity can often be helpful in determining whether further brow descent will be likely after upper blepharoplasty alone.3,4 The brow shape and contour should also be considered (see Chapter 6). An assessment of relative globe prominence should be made, especially in lieu of lid position anomalies or asymmetries. Globe prominence is not always related to orbital pathology (such as thyroid exophthalmos or other orbital processes including lesions/tumors and old fractures) and may be due to a host of situations including (but not limited to), maxillary hypoplasia (Fig. 4-9), axial myopia (Fig. 4-10), or prior surgery (Fig. 4-11). Formal measurements including Hertel exophthalmometry are usually not required, but may be used for confirmation of the general assessment. The globe prominence will significantly impact both the selected surgical procedures and the modification of ancillary steps (including

Figure 4-3 (Left) This 35-year-old female presented for periorbital rejuvenation. She was aware of a significant difference and asymmetry in the appearance of her eyes. She strongly preferred the appearance of her right (‘larger’) eye. The evaluation detected a significant difference in the horizontal and vertical palpebral apertures and increased orbicularis oculi muscle tone of the left lower eyelid. (Right) After lower blepharoplasty, including orbicularis muscle trimming of the left lower eyelid and differential canthal refixation.

Figure 4-4 This patient presented for upper blepharoplasty. She had undergone lower blepharoplasty several years prior and always noticed a difference in her ‘eye size.’ The higher lid fold on her left side was in part due to a mild relative left upper eyelid ptosis and compensatory elevation of the left eyebrow. If the patient is not interested in upper eyelid ptosis repair, an upper blepharoplasty must be performed differentially to improve the symmetry of the upper eyelid folds.

Figure 4-5 (Left) This patient presented for periorbital rejuvenation and felt that a surgical procedure might improve her situation. She was unhappy with the periorbital lines and felt she had ‘small eyes.’ The evaluation revealed mostly lateral canthal and lower eyelid dynamic lines with hyperkinetic lower eyelid orbicularis oculi. (Right) After Botox treatments to the lateral canthus and lower eyelids. It was explained to her that her situation was not well suited for surgery.

Figure 4-6 (Left) This patient presented for upper periorbital rejuvenation. She had consulted with many surgeons who felt that she would need a brow lift that she was not interested in having. (Right) After volume enhancing upper blepharoplasty without a brow lift.

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Figure 4-7 (Left) Patient in her early 20s. Note the position of the eyebrow and upper eyelid fold in youth. Also note the smooth convex contours of her lower eyelids and mild lateral canthal dystopia left greater than right. (Right) Same patient in her 60s. Note the deflationary changes of the upper eyelids and brow and the convexity of the cephalad components of the lower eyelid that resides above the deflationary changes at the lower eyelid/cheek junction. Surgical remedies should consider the appearance of youth.

Figure 4-8 Lower eyelid and canthal surgery must be titrated and is dependent on several factors including the anterior projection of the globe relative to the lower orbital rim/maxillary component (left), the distance of the lateral commissure to the lateral orbital rim (top right), and the vertical displacement of the lateral commissure (bottom right).

Figure 4-9 (Left) This young male presented for correction of lower eyelid bags. The evaluation was significant for lower eyelid bags contributed to by maxillary hypoplasia. (Right) After lower blepharoplasty with lateral retinacular suspension, canthoplasty was performed in a way that protected against lower eyelid malposition while maintaining normal lower eyelid shape.

Examination of the upper eyelid 37

Figure 4-10 (Left) This patient presented for upper and lower blepharoplasty. Note the anterior globe projection that in his situation was due to high axial myopia. (Right) After upper and lower blepharoplasty with lateral retinacular and orbicularis muscle suspension.

Figure 4-11 (Left) This patient presented with unhappiness with the appearance of her eyelids after undergoing upper and lower blepharoplasty/cheek-lift elsewhere without canthopexy/plasty. (Right) After lower eyelid reconstructive surgery that included transconjunctival lower eyelid retractor release, placement of acellular dermal matrix grafts to the lower eyelids and lateral retinacular suspension canthoplasty.

canthopexy/plasty) to avoid common pitfalls and achieve optimal results.

Examination of the upper eyelid Typically several notations of the upper eyelid are important in giving a clear picture of the situation regarding the upper periorbita. Often patients complain of ‘hooding’ at the lateral aspect of the upper eyelid when this can be related to ptosis of the lateral eyebrow, simple volumetric diminishment, skin elastosis, and the appearance or illusion (see Chapter 2) of brow descent and excessive skin, or (more commonly) a combination of these factors. I then determine/ approximate the relative amount of apparent skin

‘excess’, especially when evaluating prior to surgery which may also define placement of the upper eyelid crease. The upper eyelid should be evaluated for lid position (as it relates to the pupil) by measuring the margin reflex distance (MRD) to detect even mild upper lid ptosis or eyelid retraction, position and irregularities of the eyelid crease, and herniation of central and medial orbital fat (Fig. 4-12). Lateral upper eyelid soft tissue ‘herniation’ may indicate a ptosis, malposition, and (even more rarely) pathology of the lacrimal gland. The native eyelid crease can be determined by raising the eyebrow digitally and observing the patient’s natural crease in down gaze. I usually pay less attention, however, to the native eyelid crease, since I more often try to surgically redefine the upper eyelid crease and fold according to where

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Figure 4-12 (Left) This patient presented for periorbital rejuvenation. The evaluation revealed upper and lower eyelid aging and a mild left upper eyelid ptosis that she noticed only when ‘tired.’ (Right) After upper and lower blepharoplasty with treatment of left upper eyelid ptosis.

Figure 4-13 (Left) This patient presented for periorbital rejuvenation along with photos of her youth. She particularly was concerned with ‘changing’ the appearance of her eyes, especially the low upper eyelid folds that had been present life-long. (Right) After upper and lower blepharoplasty. The design of the upper eyelid crease was purposefully low.

I (and the patient) believe aesthetically the crease should be placed or repositioned in any particular individual for the optimal rejuvenative result (Figs 4-13 and 4-14). I have found that the eyelid margin to fold measurement (MFD) and the patient’s predicted brow animation (do they continuously animate/raise brows during the interview etc.) also to be a more important determination of where to place the upper eyelid incision to reduce visibility of the incision (Fig. 4-15) and how much skin excision will be performed in any particular region of the upper eyelid. The MFD is the distance between the eyelid–lash/margin to the first skin fold (see Chapter 3). This is almost always a smaller measurement laterally consistent with lateral brow ptosis and volumetric changes, and a greater measurement medially, often just beneath the supraorbital notch (Fig. 4-15). I find the MFD helpful to assist in deciding on the best placement for the eyelid crease, as well as determination of how much skin will be removed in any particular area along the upper eyelid to produce the desired aesthetic effect in re-creating the upper eyelid fold (Fig. 4-16). While evaluating for blepharoptosis, one should consider the margin reflex distance (Fig. 4-17) as well

as the palpebral fissure measurement in downgaze (see Chapter 3). Even mild degrees of acquired blepharoptosis will show diminishment of the palpebral fissure in downgaze on the affected side whereas congenital ptosis shows a wider (vertical) palpebral fissure in downgaze is seen in the more ptotic upper eyelid. An assessment of the levator function should also be made which may in part determine the longevity of ptosis, including congenital ptosis situations which were previously unnoticed. Determination of eyelash fullness and position (especially lash ptosis) should be made as patients will often observe this after surgery when it had not been previously noted, even though present prior to the surgical procedure. Laxity of the pretarsal skin that manifests as horizontal striae should also be noted, as again once the eyelid fold is elevated this may become more apparent after surgery. Notations of prior surgery (even if not offered in the history) should be made. This is important not only in determining prior surgical procedures but in assessing where the new eyelid incision would be placed, whether preferred or mandated in an attempt to remove the old scar and avoid the possibility of leaving two!

Examination of the lower eyelid 39

Figure 4-14 (Left) This patient presented for periorbital rejuvenation but desired a higher more defined upper eyelid crease, a more ‘almond shape’ to her lower eyelids, and restoration of the ‘bulge’ (as she called it) of her lower eyelids that was ever so present in youth. (Right) After upper and lower blepharoplasty with elevation of the upper eyelid crease and lateral retinacular and orbicularis oculi muscle suspension.

A

B Figure 4-15 (Left) This patient presented for upper and lower blepharoplasty. Note the high upper eyelid folds and chronic forehead elevation. (Right) After upper and lower blepharoplasty with a high design of the upper eyelid crease and incision so as not to be visible.

Figure 4-16 (Left) This patient presented for upper and lower blepharoplasty and was particularly bothered by the lower upper eyelid skin fold on the right and the relative increased visibility of the upper eyelid on the medial aspect of her left upper eyelid. (Right) After upper and lower blepharoplasty with differential skin removal and manipulation of the upper eyelid crease to approach symmetry.

Most important, the patient’s desires and expectations should be reviewed and compared with your findings. Ultimately, the outcome and satisfaction depends on delivering what the patient expects. Sensitivity to their wishes and achieving results that are rejuvenative without alteration and distortion (particularly in ethnic morphology, i.e. Asian eyelid etc.) will more often lead to a successful result.

Examination of the lower eyelid More commonly, patients who present for lower blepharoplasty will complain of either puffiness or ‘bags’ of the lower eyelids, ‘excess skin,’ and lower eyelid and lateral canthal lines. During this time, I will warn them of the unlikelihood of significant improvement of dynamic lines that are usually at best

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Figure 4-17 (Left) This patient had undergone prior upper and lower blepharoplasty elsewhere and felt that her eyes were now dramatically asymmetric. The examination showed significant upper eyelid ptosis right greater than left. (Right) After secondary upper and lower blepharoplasty with upper lid ptosis repair.

Figure 4-18 In primary position, the lower eyelid position and fat pad herniation should be acknowledged and documented.

minimally or moderately affected by surgery. I usually start with assessing the appearance of herniated lower periorbital fat and grade this in a somewhat arbitrary fashion to assess where the greater and lesser amounts of ‘bags’ are present (Fig. 4-18). I do this on several occasions including immediately preoperatively as a ‘check and balance’ to be sure that the amount of surgery performed (intraoperative assessment) is consistent with the noted ‘herniation’ of the lower eyelids. This is most easily performed and exaggerated for better illustration by having the patient look in upgaze (Fig. 4-19), to the superior temporal field of the contralateral eye which will then more readily illustrate a sometimes elusive lateral fat pad. Having the patient smile (animation) may also completely conceal the lower eyelid fat, and relaxation is often necessary to elicit a more true determination quantitatively in any lower periorbital area, as well as cautioning the abundant removal of fat that might exaggerate lower eyelid ‘hollows’ after surgery (Fig. 4-20). Animation is also important in determining the amount of rhytid formation that relates to this. At

Figure 4-19 The changes, visibility, and location of the lower periorbital fat herniation at times can best be detected while the patient looks in upgaze.

Figure 4-20 The patient should also be evaluated (and photographed) when smiling to detect the changes that occur with animation. Note the reduction in the appearance of lower eyelid fat visibility as well as the increased appearance of lower eyelid and canthal rhytids and orbicularis muscle thickening. This must be considered when performing lower blepharoplasty.

Examination of the lower eyelid times it is a major component, however, whereas the static rhytids are less apparent which may be the only component that can be adequately improved upon by several surgical options. The amount of lower eyelid retraction, lower eyelid position, and canthal position (both vertical and displacement distance from the lateral orbital rim) should be determined (Fig. 4-21). As previously mentioned, although I find a ‘snap-back’ test and ‘distraction’ test in the lower eyelid less necessary for determining the need for canthal support (as it is routinely performed), some degree of lower eyelid laxity determination must be made which will indicate the amount and direction of canthal reinforcement. It will also indicate the tolerability of the lower eyelid to soft tissue distraction and excision, and how much will be required or permitted. As a general rule, the relatively enophthalmic eye may exhibit a significant degree of lower eyelid laxity, but supra-placement of the canthal suspension might cause a longer than tolerated (or permanent) over-correction (Fig. 4-22), while the exopthalmic eye that exhibits only a mild-moderate degree of lower eyelid laxity, might require significant

supra-placement to avoid postoperative lower eyelid retraction or ectropion (Fig. 4-23). Evaluation of lower eyelid and lower periorbital subcutaneous veins should be noted and discussed if necessary, as well as the skin thickness, type, and quality. The quantification of lower eyelid skin redundancy as well as skin and orbicularis muscle laxity and descent should be made and will influence the approach. Marked skin ‘excess’ may require a greater degree of skin dissection and/or excision. Your orbicularis muscle evaluation may suggest trimming of hyperdynamic orbicularis muscle which will require enhanced canthal support (Fig. 4-24) or increased muscle suspension in situations of significant muscle laxity and ptosis (Fig. 4-25). The assessment of ‘malar bags’ and the presence of midface and cheek descent should be made as well. Often, patients are expecting blepharoplasty surgery to improve (or eradicate) this when only midfacial or full lower facial rejuvenative surgical procedures will improve this situation. Marked malar edema may indicate a metabolic problem, including thyroid disease that should be discussed and explored as well.

Figure 4-21 (Left) This patient presented for upper and lower blepharoplasty. Note several findings including the asymmetry of the upper eyelid folds and fat herniation as well as the pre-existing lower eyelid malposition associated with maxillary hypoplasia. (Right) After upper and lower blepharoplasty with differential surgery performed right versus left to reduce (and not exaggerate) the asymmetry and to stabilize the lower eyelid and canthal position.

Figure 4-22 (Left) This patient with ‘deep set’ eyes presented for upper and lower blepharoplasty and felt, in part, that her eyes were ‘getting smaller.’ Note also the prominence of the lateral orbital rim, thinness of skin and subtle asymmetric lower eyelid and canthal position, and enophthalmic appearance of her eyes. (Right) After upper and lower blepharoplasty with lateral retinacular suspension canthoplasty, with careful attention to canthal positioning and avoidance of supra-placement that would make the eyes appear ‘smaller.’

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Figure 4-23 (Left) This patient presented for upper and lower blepharoplasty. The examination revealed dramatically hooded upper eyelids and only a mild to moderate degree of eyebrow ptosis, lower eyelid retraction, and canthal dystopia. (Right) After upper blepharoplasty with volume-enhancing orbicularis preservation without browplasty, and lower eyelid blepharoplasty with lateral retinacular suspension canthoplasty with supra-placement to improve lower eyelid and canthal position.

Figure 4-24 (Left) This patient presented for periorbital rejuvenation after undergoing prior blepharoplasty elsewhere and was unhappy with the result. Her dissatisfaction included what she felt was a hollowing appearance, especially to her right upper eyelid as she always had ‘full’ upper eyelids in youth and persistent/recurrent puffiness of the lower eyelids, an exaggerated ‘bulge’ to the left lower eyelid at the lid margin, and an overall shape change to the eyelids. She refused a brow lift. (Right) After upper blepharoplasty and lowering the upper eyelid crease, orbicularis muscle trimming to the left lower eyelid, orbicularis muscle and lateral retinacular suspension (canthoplasty) to enhance symmetry and the appearance of improved volume.

Figure 4-25 (Left) This patient in her mid-70s presented for periorbital rejuvenation. Note the dramatic and asymmetric deflationary volume loss and shifts with canthal dystopia that gives her an older and sad appearance. (Right) After upper and lower blepharoplasty with orbicularis muscle and lateral retinacular canthal suspension.

Lacrimal secretory evaluation

Assessment of asymmetry and how to best manage this It is well known that most faces are not entirely symmetric (Fig. 4-1). The notion that the establishment of symmetry is necessary to achieve optimal results is also an historical and philosophical fallacy. Some of the most attractive people demonstrate marked facial asymmetry. Interestingly, asymmetries are well tolerated and often unnoticed in youth and much less tolerated and more obvious with age. More often, patients are unaware of their facial asymmetry but might be more keenly observant of this after surgery due, in part, to their obsession with the mirror. During the evaluation of the patient, I will usually determine this and discuss this with the patient during the treatment planning. Although not perceived by the patient, the asymmetry is sometimes a large component of their displeasure with facial aging. The assessment of asymmetry must extend far beyond the simple evaluation for blepharoptosis to achieve maximum benefit through the surgical encounter. For instance, relative or asymmetric brow ptosis may be discussed (Fig. 4-1). At times, the brow position is influenced by the upper eyelid (especially in those who reflexively elevate their ipsilateral eyebrow in response to blepharoptosis) and the upper lid ptosis is only apparent when that brow is digitally depressed by the examiner to determine the true upper eyelid position (Fig. 4-2). A patient with brow asymmetry for any reason, may also sense a greater relative amount of ‘excessive’ skin on the brow ptotic side and if this relates to brow ptosis, this should be discussed to explain the rationale for the treatment and how it relates to the chosen procedures. The side with brow ptosis is also usually the small side of the face. This must be considered, especially if the patient is having lower eyelid, mid-, or lower facial surgery. Canthal dystopia and lower eyelid position asymmetry (even in the surgically naïve patient) is also common and also more often unnoticed by the patient (see Fig. 4-1). The ‘big eye–small eye’ phenomenon (see Fig. 4-3) is also far more common than previously appreciated6 and aesthetic remedies may or may not be selected to address this. The ‘big eye’ is also usually on the large side of the face. When I detect this I ask patients what they see when they look at pictures of themselves (often this is exactly what brought them into your consulting room, but they simply have not realized this or simply can not verbalize their exact reasons for unhappiness with their appearance). Surgical and non-surgical7 maneuvers may be performed to lessen the asymmetry in the patient who is desirous of this approach. Caution must be used however with any attempt to alter the natural asymmetry in selected patients. Although an

independent observer (and surgeon) might consider the subjective improvement in doing so, at times the patient feels as if they appear ‘out of balance’ much like looking at a photograph of oneself (in the days when we actually used film!) where the negative had been reversed for the printing. There is no question that this is the patient (in the photo) but the relative asymmetries that they have been accustomed to their whole life have now been altered. In general, I find the evaluation of periorbital asymmetry most useful to determine how I might titrate procedures to optimize results by either maintaining the asymmetry, or improving symmetry so that the asymmetric appearance does not become more obvious after surgery (Fig. 4-25).

Lacrimal secretory evaluation I have not found any of the lacrimal secretory tests, including basic tear secretion with Schirmer’s tests, helpful in determining whether the patients will fare favorably after surgery performed by myself or elsewhere. Contrary to traditional teachings,1,2 I do not routinely include these tests in my practice. As we all know, patients who do very well after surgery performed with the highest of precision and care may have lacrimal secretory tests (including the Schirmer’s test) that indicate severe dryness, whereas patients who have demonstrated completely normal secretory tests and who have experienced untoward results after surgery can be dramatically symptomatic. In lieu of this, I rely heavily on an accurate history more than formal secretory function tests. The patient’s tear function is discussed (during the history and recommendations portion of the consultation and subsequent preoperative evaluations) with regard to their requirement for the use of artificial tears prior to surgery, their tolerance of contact lenses, the general symptoms with reading etc., which I find are a much greater aid in determining whether surgery is likely to impact on lacrimal function and symptomatology related to exposure. Again, female patients, especially middle-aged (nearing menopause), may be at particular risk for tipping the balance from being entirely asymptomatic to mild to moderately (and even severely) symptomatic after eyelid surgery (due to reduced lacrimal secretion that is hormonally mediated) as are those individuals who have had refractive surgery and must be reminded and warned of this. At times this particular subset of patients are actually of greater risk then the more elderly who have either adapted or compensated for the (preoperative) onset of dry eye symptoms. The possibility of intolerability to future contact lens use (especially in secondary blepharoplasty patients) should also be discussed, although I have found this less of a problem in my practice. The

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A Comprehensive Evaluation of the Cosmetic Oculoplastic Surgery Patient: Beyond Formal Measurements questions and issues regarding potential dryness after surgery, however, should be discussed with every patient so that should these symptoms occur (which are typically transient) the patient is less alarmed and realizes that the effects are usually temporary. Finally, aesthetic blepharoplasty rarely improves dry eye symptoms and patients should be made aware (especially premenopausal women) that the likely possibility of temporary and the rare incidence of worsening of dry eye symptoms exist even when surgery is satisfactory from an aesthetic standpoint.

Visual field testing At times when patients are undergoing cosmetic blepharoplasty combined with true blepharoptosis repair (see Chapters 10 and 11), visual field tests can be obtained either by the treating surgeon or the patient’s ophthalmologist to determine if the lid malposition causes any significant visual deficit. This can be documented and submitted either by or for the patient (in a rare situation) for the consideration of insurance benefits. Either automated (Humphrey, Octopus etc.) or manual (Goldmann) field test can be obtained and similar information can be derived. Typically the tests are performed with the patient in their natural position (with upper lid malposition) and then the test is repeated with the lid taped into its normal position to determine a certain degree of visual field improvement. This continues to be a bit of a ‘gray area’ and is highly dependent upon the skill of the technician performing these tests and influenced by the will of the patient. An insightful and experienced evaluation of the results of these tests relative to the eyelid measurements can often determine the integrity of these findings.

Assessment by photography Accurate and comprehensive photography is essential for a variety or reasons, including preoperative counseling, preoperative study by the physician, documentation of the present situation including pre-existing pathology (i.e. asymmetry), as well as being a rewarding gift to the patient following surgery so that they can fully appreciate their improvement. The patient’s periorbital appearance should be photographed in

primary position (Fig. 4-9) as well as oblique periorbital views (Fig. 4-10) to reveal to both the treating surgeon and patient the balance prior to and achieved after surgery. It is helpful to illustrate the patients relaxed and animated (especially when their complaints include dynamic facial lines that are less effected/ improved by surgery) (Figs 4-18 and 4-20). For valid comparison, it is optimal (although not always possible) to have the patient photographed without cosmetic (make-up) application in both the pre- and postoperative photos. In situations where cosmetics have been applied (and the patient prefers not to remove them) during the preoperative photographic assessment, the ‘after’ photos are more easily compared with the cosmetic application; however the validity of the details of improvement that relate to the surgical efforts may be diminished.

Conclusion In summary, as physicians, it is our obligation to ourselves and to our patients to elicit as much meaningful information prior to surgery to optimize our surgical results, meet or exceed patient expectations, and to establish the appropriate relationship for long-term success. More often, what separates an average or satisfactory result from an outstanding one is in the detail.

References 1. Fagien S: The follow-up on ‘The value of tear film breakup and Schirmer’s tests in preoperative blepharoplasty’ by McKinney P, Byun M. Plast Reconst Surg [Discussion] 1999; 104:1. 2. Fagien S: Reducing the incidence of dry eye symptoms after blepharoplasty. Aesthetic Surg J 2004; 24:464. 3. Fagien S: Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper periorbita. Plast Reconstr Surg 2002; 110:278. 4. Fagien S: Eyebrow analysis after blepharoplasty in patients with brow ptosis. Ophthal Plast Reconstr Surg 1992; 8:210. 5. Fagien S: Algorithm for canthoplasty. The lateral retinacular suspension: a simplified suture canthopexy. Plast Reconst Surg 1999; 103:2042. 6. Fagien S: Temporary management of upper lid ptosis, lid malposition, and eyelid fissure asymmetry with botulinum toxin. Plast Reconstr Surg 2004; 114:1892. 7. Fagien S: Botulinum toxin type A for facial aesthetic enhancement: role in facial shaping. Plastic Reconstr Surg 2003; 112 (Suppl.):6S.

CHAPTER 5

Eyelid and Midcheek Anatomy Paul A. Harris and Bryan C. Mendelson

Eyelid The eyelids are complex dynamic structures that protect the globes while providing a sufficient and appropriately located aperture for vision regardless of the location of the pupil. In higher species, the lids have also assumed a role in facial expression. These functions can only be achieved by the balanced interaction of many individual anatomical structures. It is fundamental in eyelid surgery to appreciate the two distinct surgical lamellae of the lids. The superficial and deep lamellae are fused in the pretarsal area. However, they are separate in the preseptal area and this separation allows mobility of the anterior lamella, the cheek part of the lid separate from the deep lamella, the orbital part of the lid. Paul A. Harris and Bryan C. Mendelson

Eyelid anatomy Surface anatomy and skin The appearance of the ‘eye’ is largely determined by the shape of the palpebral fissure and its position relative to the globe. This aperture between the upper and lower eyelid margins measures 28–30 mm horizontally and 10–12 mm vertically. The upper lid covers up to 2 mm of the upper cornea, with the lower lid typically crossing at the level of the lower corneoscleral limbus. The point of maximum lid margin concavity differs in the two lids: in the upper lid it is medial to the pupil and in the lower it is lateral (Fig. 5-1). The skin of the eyelid is the thinnest in the body, being less than 1 mm thick, with sparse underlying subcutaneous fat. This relative absence of a padding fat layer predisposes to the characteristic fine wrinkles that appear with age in the mobile preseptal skin. The skin is also prone to stretching and further thinning by the repetitive forces resulting from too much eyelid rubbing or excess tension following surgical over-resection. The lid margins are 2 mm wide, with the posterior margin being sharp and applied to the globe. The anterior margin is rounded and holds the eyelashes. The grey line, visible along the middle of each lid margin and formed by the gap between the pretarsal tissue and the underlying tarsal plate, marks the junction of the skin and conjunctiva. The Meibomian glands that contribute to the tear film, reside within the substance of the

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Figure 5-1 Eyelid surface anatomy.

Preseptal skin Pretarsal skin crease Pretarsal skin

tarsal plate giving rise to openings just behind the grey line. The apocrine sweat glands of Moll and the specialized sebaceous glands of Zeis are found just anterior to the grey line in association with the lash follicles. Eccrine sweat glands and conventional sebaceous glands are found throughout the eyelid skin, although the sebaceous glands are more numerous on the medial half, contributing to the skin’s smoother and oilier texture medially. The skin crease of the upper eyelid typically overlies the superior border of the tarsus and is referred to as the supratarsal skin crease. Fascial bands from the underlying pretarsal extension of the levator palpebrae pass through the orbicularis oculi muscle and insert into the pretarsal dermis, maximal near the lash line passing up to the level of the crease (Fig. 5-2). The preseptal skin superior to the crease is comparatively non-adherent and mobile with a degree of laxity to allow movement of the lid. This relatively lax skin hangs over the supratarsal crease to create the supratarsal fold. In the oriental eyelid, the supratarsal skin crease is less well-defined and lower set on the upper lid due to the low insertion of the levator aponeurosis closer to the lashes. In the lower eyelid, fibrous bands from the capsulopalpebral fascia also pass through the orbicularis muscle and insert into the skin to create the infratarsal skin crease. This extends as an oblique line 5 mm from the lid margin medially and 7 mm laterally, that is less well defined than its counterpart in the upper lid and becomes less visible as aging progresses.

Orbicularis oculi The orbicularis oculi is the sphincter of the eyelid consisting of two distinct parts: the pars palpebarum and

Superior rectus muscle

Whitnall’s ligament

Preseptal orbicularis Septum orbitale Levator aponeurosis Muller’s muscle Superior tarsus Pretarsal orbicularis

Inferior septum orbitale Lockwood’s ligament Fat Inferior oblique muscle

Capsulopalpebral fascia Inferior rectus muscle

Figure 5-2 Sagittal section of the eyelids.

the pars orbitalis (Fig. 5-3). The pars palpebarum overlies the aperture of the orbit within the eyelids and is further subdivided into pretarsal and preseptal parts. The pretarsal part is supported by its close adherence to the tarsal plates and the preseptal part is more mobile overlying the orbital septum in both upper and lower lids. Both the pretarsal and preseptal parts have

Eyelid anatomy 47

Corrugator

Procerus

Capsulopalpebral fascia Septum orbitale Orbicularis retaining ligament Orbicularis oculi Sub-orbicularis oculi fat (SOOF) Pars palpebarum Pars orbitalis

Prezygomatic space Preperiosteal fat

Figure 5-3 Orbicularis oculi.

Figure 5-4 Schematic representation of the orbicularis retaining ligament.

superficial and deep components medially that are connected to the orbital wall at the medial canthus in a complex anatomical arrangement that is linked to the drainage of the lacrimal sac. Laterally, the muscle fibers do not have a direct bony attachment, but are stabilized to the orbital rim by a ligamentous connection at the lateral canthus. The pars orbitalis is more extensive and less compacted than conventionally described. Superiorly it overlies the lower forehead, lower frontalis and corrugator supercilii muscles, giving off a slip of muscle to form the depressor supercilii. Inferiorly the sheet of orbicularis lies flat across the cheek with a variable descent towards the upper lip. Classical anatomists have labeled this part the muscularis malaris, reflecting its extensive midfacial distribution. It is now considered to be part of the superficial musculoaponeurotic (SMAS) layer (see midcheek section below). At the junction of the lower lid with the cheek, the orbicularis oculi muscle is attached to the orbital rim at the junction of the pars palpebarum above and the pars orbitalis below. This is a direct muscle attachment medially, from the anterior lacrimal crest to approximately the level of the medial limbus. This tight attachment is largely responsible for the appearance of the nasojugal groove. Lateral to this point, the attachment is continued indirectly through a fibrous connection known as the orbicularis retaining ligament, as far as the lateral canthal region1 (Fig. 5-4). This ligament spans from the periosteum just outside the orbital rim to the fascia on the under-surface of the orbicularis. It

can be considered to be a specific part of the ‘periorbital septum’2 and has also been described as the ‘orbitomalar ligament’.3 The location of the attachment to the orbicularis correlates with the position of the palpebromalar groove, which appears on the surface of the overlying skin with aging. In the lateral canthal region, the orbicularis retaining ligament expands and merges with a dense fibrous condensation between the superficial and deep fascia lateral to the lateral commissure known as the lateral orbital thickening.1 The microanatomy of the orbicularis reflects its unique function. The myofibers are the smallest of all skeletal muscles and there are distinct microarchitectural differences within the muscle itself. The finest and shortest fibers are in the pretarsal region, progressively increasing in size away from the lid margin. Individual fibers do not extend the full length of the lid and not all myofibers attach to the canthal ligaments. Rather, there is an overlapping arrangement of short myofibers with the pretarsal fibers averaging one-third of the lid length and the preseptal half the lid length, although considerable variation exists.4 Of importance for Botox use is the location of the neuromuscular junctions, which are concentrated at the canthal ends, more laterally. Each fiber has a single innervation and similar to the extraocular muscles, the motor units are small consistent with fine motor control. The dominant fiber type (90%) are fast twitch, fatigueable with low vascularity that are suited to brief, rapid blink movements.5

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Eyelid support The complexity of eyelid anatomy reflects the competing functional demands of providing support for the lid margins while allowing mobility of the lids. Primary eyelid support is provided through the bony attachment of the canthi with a secondary level of support from the orbicularis muscle and its fascial attachments. The medial canthus is medial to the globe with a rigid fixation to the orbital wall. By contrast, the lateral commissure overlies the lateral part of the globe and is mobile, having up to 6 mm of vertical movement and 2 mm of lateral movement.6 These anatomical landmarks are determined by the medial and lateral palpebral ligaments, which provide the ligamentous support for the tarsal plates. The palpebral ligaments are commonly referred to as the medial and lateral canthal tendons on account of the pretarsal orbicularis fibers that contribute to their superficial surfaces. In addition, the orbicularis muscle and more particularly the fascia on its deep surface forms a continuous fibrous network of support through the orbicularis attachment to the tarsal plates and canthal tendons, and to the lateral orbital rim via the firm fibrous attachment provided by the orbicularis retaining ligament and the lateral orbital thickening.

Medial canthus The medial canthus involves the integration of the pretarsal and preseptal orbicularis oculi, the septum

Deep insertion of pretarsal orbicularis muscle

Lacrimal sac

orbitale, the medial end of Lockwood’s ligament, the medial horn of the levator aponeurosis and the check ligament of the medial rectus muscle. The precise anatomical arrangement of the various components is debated, but in practice they are not individually identified at operation. These structures attach to the medial orbital wall via the medial canthal tendon, which is intimately associated with the lacrimal sac. The pretarsal orbicularis muscle inserts medially by a superficial head and a deep head (Fig. 5-5). The superficial head from each lid blends with the fibrous continuation of the tarsal plates to form the anterior part of the medial canthal tendon. The deep head from each lid is also known as the pars lacrimalis, or Horner’s muscle. Its fibers begin at the medial end of the tarsal plates and insert into the posterior lacrimal crest just behind the lacrimal sac. The preseptal muscle also inserts medially by a superficial and deep head. The superficial head from each lid inserts into the upper and lower borders of the medial canthal tendon. The deep heads insert into the fascia overlying the lacrimal sac and the medial orbital wall above and below Horner’s muscle. Closing the eyelids leads to traction on the deep heads which pulls the lacrimal sac fascia laterally, producing a negative internal pressure.7 The medial canthal tendon inserts into the frontal process of the maxilla in a tripartite manner: anterior and posterior horizontal elements and a vertical element (Fig. 5-6). The anterior horizontal insertion point is onto the anterior lacrimal crest, level with the upper part of the lacrimal sac. The posterior part leaves

Superficial insertion of preseptal orbicularis muscle

Fibromuscular part of medial canthal tendon

Deep insertion of preseptal orbicularis muscle

Figure 5-5 Medial canthus.

Superficial insertion of pretarsal orbicularis muscle

Eyelid anatomy 49 Lateral orbital thickening Lateral canthal tendon

Orbicularis fascia

Temporoparietal fascia

Tarsal plates Posterior limb, medial canthal tendon Superior limb, medial canthal tendon Anterior limb, medial canthal tendon Lacrimal fossa Anterior and posterior lacrimal crests

Orbicularis retaining ligament

Figure 5-6 Medial canthus tendon insertion.

the deep surface just before the anterior lacrimal crest and inserts into the posterior lacrimal crest behind the sac. The tendon has a definite inferior margin but the superior border blends with the periosteum having vertically orientated fibers that insert into an ill-defined portion of the medial orbital rim at or close to the nasofrontal suture. This vertical component of the medial canthal tendon is thought to be responsible for suspension and fixation of the medial canthus, while the horizontal components are relatively weak and contribute little to medial canthal stability.8

Lateral canthus Despite varied anatomical descriptions and nomenclature, the lateral canthus should be considered in terms of a deep skeletal attachment via the lateral canthal tendon and a superficial fibrous attachment via the lateral canthal raphe and lateral orbital thickening. The deep attachment serves to stabilize the tarsal plates whereas the superficial attachment functions to stabilize the orbicularis over the orbital rim.6 The lateral canthal tendon is less well defined than the medial side and has less orbicularis muscle connection. It takes the form of a Y-shaped fibrous condensation measuring 6 mm in transverse length and up to 10 mm in vertical height. It extends from the upper and lower tarsal plates and is reinforced by significant attachments from the lateral horn of the levator aponeurosis and the check ligament of the lateral rectus muscle as well as from Lockwood’s ligament. This confluence of structures (the lateral retinaculum) attaches to the lateral orbital wall at Whitnall’s tubercle, which is located just inside the orbital rim and

Figure 5-7 Lateral canthus (view from inferiorly). Modified from Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110:873–884.

approximately 10 mm below the zygomaticofrontal suture.9 Whitnall’s (superior transverse) ligament is part of the levator aponeurosis and is not part of the lateral canthus. Superficially, the preseptal orbicularis fibers of the upper and lower lid interdigitate to form the lateral canthal raphe. The raphe, although often referred to in eyelid texts, has not been clearly described and is difficult to identify as a discrete anatomical structure. It is connected on its deep surface to the underlying septum orbitale and merges laterally with a significant confluence of fibrous tissue known as the lateral orbital thickening1 (Fig. 5-7). This thickening is a condensation of fascia passing over the orbital rim, lateral and superficial to the lateral canthal tendon. It has also been termed the ‘superficial leaf of the lateral canthal tendon’10 and the ‘precanthal web’.11 It is a triangular fibrous adhesion connecting the orbicularis fascia on the under-surface of the muscle to the underlying deep fascia, which in this region is made up of thickened lateral orbital rim periosteum and adjacent deep temporal fascia. The lateral orbital thickening is continuous with the orbicularis retaining ligament inferomedially and must be released surgically if a canthoplasty is to be effective. The lateral canthus is positioned approximately 2 mm higher than the medial canthus. Despite previous assumptions, this is the same for both sexes and does not change with increasing age.12 Inherent variations of the intercanthal angle do, however, have a significant impact on facial aesthetics in normal people and descent of the lateral commissure secondarily to lateral canthal tendon laxity produces an apparent change in

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Eyelid and Midcheek Anatomy: Eyelid and Midcheek the lateral canthus position, which predisposes to a premature aging appearance.

Tarsus and septum orbitale The tarsal plates are crescentic-shaped, dense condensations of connective tissue that maintain the structural integrity of the eyelids while accommodating the contour of the globe. The upper tarsus is approximately 29 mm long and extends from the lateral commissure to the punctum medially. It is 10 mm wide in the central eyelid, narrowing medially and laterally. The lower tarsus is a similar length to that of the upper but is only 4–5 mm wide at its center. The septum orbitale, or orbital septum, consists of a thin fibroelastic membrane of varying consistency that is notably non-distensible adjacent to the inferolateral orbital rim. It extends from the bony margin towards the tarsus and represents the continuation of the orbital periosteum. At the junction where the periosteum and septum fuse along the orbital rim is a dense white fibrous band termed the arcus marginalis (Fig. 5-8). The arcus marginalis is clearly evident inferomedially where the rim has a sharp edge, whereas it is less defined on the rounded inferolateral rim. In the upper eyelid, the septum attaches to the levator aponeurosis, generally 2–5 mm above the superior edge of the tarsal plate.13 However, this septallevator attachment can vary from the level of the superior tarsal border to almost 10 mm above. Below this level there is a blending of the connective tissue lamellae from both the septum and the levator aponeurosis called the pretarsal extension of the levator or the conjoined fascia.14 This fascia continues inferiorly to attach to the lower third of the anterior surface of the

tarsal plate and sends fibrous slips forward to invest fascicles of the pretarsal orbicularis. In the lower lid, the septum similarly attaches to the capsulopalpebral fascia (which is the equivalent of the levator aponeurosis of the upper lid) below the inferior edge of the tarsus. This line of fusion between the two structures occurs in an oblique direction approximately 5 mm from the tarsal plate medially and 10 mm from the plate laterally. It is usually visible on operative dissection as a thickened white line in the septum that expands out laterally as it attaches to the inferolateral orbital rim by a triangular fascial band known as the arcuate expansion (Fig. 5-8). The lower lid septum can therefore be considered as being divided into an upper part, reinforced by the capsulopalpebral fascia on its deep surface, and a lower unsupported part.15 Orbital fat distension and bulging of this relatively weak lower septum orbitale results in the characteristic lower lid fat bags of aging. The septum attaches medially to the spine at the lower end of the anterior lacrimal crest, called the lacrimal tubercle. It then extends from the lower eyelid to the upper eyelid medially by passing behind the attachments of the medial orbicularis at the posterior lacrimal crest. Superomedially the arcus marginalis forms the inferior portion of the supraorbital groove and laterally it blends with the lateral canthal raphe.16

Eyelid fat The fat of the eyelid consists of preseptal (extraorbital) and postseptal (intraorbital) components. The preseptal fat occurs mainly outside the orbital rim on the lower lateral brow and upper malar areas. Superiorly, this fat is positioned deep to orbicularis

Upper orbital septum (reinforced with capsulopalpebral fascia)

Capsulopalpebral fascia Lower orbital septum (transparent, unreinforced)

Arcuate expansion

Arcus marginalis

Figure 5-8 Septum orbitale and capsulopalpebral fascia of the lower lid. Modified from Mendelson BC. Fat preservation technique of lower-lid blepharoplasty. Aesth Surg J 2001; 21:450–459.

Eyelid anatomy and frontalis, extending over the brow onto the surface of the adjacent septum orbitale of the upper lid. This ‘brow fat pad of Charpy’ has more recently been termed the retro-orbicularis oculi fat (ROOF)17 and the lid part as the preseptal fat pad. It can be up to 6 mm thick as it passes over the rim, tapering as it descends toward the lid margin to terminate where the fibers of the septum orbitale fuse with the fascia on the undersurface of orbicularis just millimeters above the supratarsal crease. Aesthetically, the ROOF provides fullness and projection for the brow and the preseptal component contributes to the supratarsal fold fullness. The equivalent layer inferiorly is the sub-orbicularis oculi fat (SOOF), which differs in being thinner and it usually does not cross the orbital margin into the lid. The SOOF is discussed in the midcheek anatomy section. The postseptal fat is conventionally divided into compartments: two (medial and central fat pads) in the upper lid and three (medial, central and lateral fat pads) in the lower lid (Fig. 5-9). These compartments are made up of fat extensions from the adipose body of the orbit except for the upper lid central fat pad, which is separate preaponeurotic fat. The two types of fat differ in their color and consistency, however all the fat is linked by interconnecting septa that transgress the intrinsic muscle cone. Hence traction on fat just posterior to the septum orbitale can produce forces in the posterior extraconal and even intraconal and perioptic nerve region. The adipose body of the orbit is pale yellow and fills the orbital cavity, reaching the septum orbitale anteriorly. It has a central portion included in the cone of intrinsic muscle around the optic nerve (intraconal) and extensions coming out of the cone to reach the orbital walls through the orifices between the muscles

Levator palpebrae superioris muscle

Central fat pad

(extraconal). As this fat reaches the septum orbitale it is divided into compartments by structures within the anterior orbit. Thus inferomedially the fat passes either side of the inferior oblique muscle to appear as the medial and central compartments of the lower lid. Inferolaterally the arcuate expansion of the capsulopalpebral fascia separates the central from the lateral compartment. In the upper lid, the fat of the adipose body only reaches the septum orbitale superomedially, where it extends forward as the medial fat pad. The preaponeurotic fat, which is the central fat pad encountered in blepharoplasty, appears to be a different type of fat and perhaps separate from the adipose body of the orbit. It is deep yellow in color and is the most cephalad fat compartment. It is located under the orbital roof and lies on the levator aponeurosis, in contact with the septum orbitale. It is usually limited medially by a fibrous septum containing the reflected tendon of the superior oblique muscle, separating it from the medial compartment. With aging changes, a medial herniation of the central fat pad occasionally develops and comes to overlie the true medial fat pad. Judicious adjustment of this fat extension may be required during upper lid blepharoplasty. A lateral extension of the preaponeurotic fat is always present behind the lacrimal gland, and in many older patients it protrudes anteriorly beyond the inferior border of the lacrimal gland becoming clinically apparent.18 The individual appearance of upper lid fullness is determined by the summation of the volume and precise location of both the preaponeurotic fat and the preseptal fat. Eisler’s fat pad is a small pocket of fat situated between the orbital septum anteriorly and the lateral canthal tendon posteriorly. It is inferior to the lateral

Superior rectus muscle

Figure 5-9 Postseptal fat.

Trochlea (pulley) Superior oblique muscle Medial fat pad Medial rectus muscle Medial lower fat pad Inferior oblique muscle

Lateral rectus muscle

Lateral fat pad

Inferior rectus muscle

Central fat pad

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Eyelid and Midcheek Anatomy: Eyelid and Midcheek extension of the preaponeurotic fat and is not encountered during standard blepharoplasty. It is however useful as a landmark for Whitnall’s tubercle during canthoplasty.

Eyelid retractors The upper eyelid is responsible for 90% of eyelid opening. This action is mediated by the levator palpebrae superioris and Müller’s muscle. The levator palpebrae originates from the lesser wing of the sphenoid and extends anteriorly along the superior orbit. At 15–20 mm above the tarsal plate, the levator forms a condensation of fascia known as the superior transverse or Whitnall’s ligament (Figs 5-2 & 5-10). It extends from the lacrimal gland fossa laterally to the trochlea medially and is thought to act as a fulcrum to translate a horizontal into a vertical vector. It also has a suspensory role in the orbit and may function as a check ligament for the levator muscle to limit its excursion. Anterior to Whitnall’s ligament, the levator divides into an anterior aponeurotic layer and a posterior muscular layer. The aponeurosis passes over the tarsal plate to attach to the lower 7–8 mm of its anterior surface. It also sends fibers through orbicularis to the skin in the pretarsal zone. The attachment of the levator to the skin in this region determines the height and quality of the superior tarsal crease and therefore also impacts on the shape of the supratarsal fold. The anterior prolongation of the lateral edge of the levator aponeurosis forms a lateral horn which divides the lacrimal gland into the palpebral and orbital lobes and contributes to the lateral canthal retinaculum. A medial horn inserts into the lacrimal crest as part of the medial canthal mechanism. The total length of the levator is approximately 40–45 mm, with a 10–15 mm aponeurotic extension and a total excursion of 10–15 mm. Posteriorly Müller’s muscle attaches 10 mm away from its origin to the upper border of the tarsal plate. Müller’s muscle consists of smooth muscle under sympathetic control. It is normally responsible for 2–3 mm of lid lift; however, with sympathetic stimulation an additional 1–2 mm of lift above baseline is possible. When sympathetic tone is lost in Horner’s syndrome, 2–3 mm of ptosis may be seen. In contrast to Müller’s muscle, the levator is a striated muscle innervated by the oculomotor nerve. The lower eyelid retractors are the homolog of those of the upper eyelid. The inferior rectus muscle has a capsulopalpebral head which is the peripheral extension of the inferior rectus muscle. This muscle splits around the inferior oblique muscle to rejoin anteriorly as Lockwood’s ligament and then fuses with the septum orbitale and the tarsal plate (Figs 5-2 & 5-8). Like the levator, it is thought that the capsulopalpebral

fascia sends anterior projections to the skin that penetrate through the orbicularis muscle to define the transverse crease of the lower lid. Just posterior to the capsulopalpebral fascia is the inferior tarsal or Müller’s muscle which, like its counterpart in the upper lid, is made up of smooth muscle fibers under sympathetic control.

Conjunctiva The palpebral conjunctiva can be divided into marginal, tarsal and orbital parts. The marginal part joins the skin at the eyelid margin. The tarsal conjunctiva is firmly adherent to the tarsus, and the orbital conjunctiva lies adjacent to the superior and inferior Müller’s muscles.

Lacrimal system Under normal circumstances there is a constant production of a tear film for corneal protection. The entire volume of this tear production by basic secretors evaporates from the surface of the cornea. Three sets of glands comprise the basic secretors. The conjunctival, tarsal, and limbal mucin-secreting goblet cells are responsible for producing a mucoprotein layer that forms the innermost layer of the precorneal tear film. This layer allows the overlying layers to spread more uniformly over the cornea. The second group of basic secretors consists of accessory lacrimal glands lying within the subconjunctival tissues. They are responsible for producing an intermediate aqueous layer. The outermost layer of the precorneal tear film is produced by the Meibomian glands located within the tarsal plate, and the glands of Zeis and Moll at the root of the eyelashes. This layer stabilizes the film and helps reduce evaporation. The main lacrimal gland is a reflex secretor, which respond to sudden changes in physical and emotional environment. The lacrimal gland is divided into an orbital and palpebral lobe by the lateral horn of the levator (Fig. 5-10). The larger orbital lobe is prone to prolapse against the overlying septum orbitale and on occasion in aesthetic blepharoplasty, a ptotic lacrimal gland produces a localized lid fullness requiring a simple resuspension. Tears from the orbital lobe pass through the palpebral lobe, which in turn empties into the superolateral conjunctival fornix via six to twelve tear ductules. Tears then pass from this lateral cul-desac to sweep across the cornea and empty into the lacrimal drainage system. The excretory portion of the lacrimal system consists of a lacrimal lake, puncta, canaliculi, sac, and nasolacrimal duct. Tears pass from the lacrimal lake to the puncta into the ampullae and canaliculi. The

Eyelid anatomy Orbital lobe of lacrimal gland

Whitnall’s ligament

53

Levator palpebrae superioris muscle

Lateral horn of levator

Septum orbitale (partially removed)

Palpebral lobe of lacrimal gland

Levator aponeurosis

Superior crus

Medial horn of levator Upper tarsal plate

Medial canthal tendon

Lateral canthal tendon Inferior crus

Lower tarsal plate

Septum orbitale (partially removed)

Capsulopalpebral fascia

Figure 5-10 Eyelid retractors.

upper and lower puncta are 5–7 mm lateral to the medial canthal angle, and the lower puncta is often lateral to the upper. The canaliculi are about 10 mm long (the initial 2 mm run in a vertical direction and the remainder horizontally) and join to form a single duct prior to entering the sac. The lacrimal sac extends inferiorly for approximately 10 mm and gives rise to the nasolacrimal duct, which consists of an interosseous portion and a meatal portion. The duct opens just below the anterior end of the inferior nasal turbinate (Fig. 5-11). Traction on the deep portions of the orbicularis that attach to the surface of the sac creates a relative negative pressure that draws tears through the canaliculi into the sac. Relaxation of the orbicularis oculi allows the lacrimal sac to collapse, and the tears traverse the nasolacrimal duct to the nose.19

Upper punctum

Common canaliculus

Lacrimal sac Ampulla Lacrimal duct

Papilla

Blood supply, lymphatics, and innervation The arterial supply to the eyelids is derived predominantly from the internal carotid system via the ophthalmic artery, although the external carotid system contributes through anastomoses with the angular artery, the infraorbital artery and superficial temporal artery (Fig. 5-12). As the ophthalmic artery emerges from the optic canal it passes lateral to the optic nerve and gives origin to the lacrimal artery and the supraorbital artery. The lacrimal artery passes forward on the upper border of the lateral rectus to supply the lacrimal gland and then pierce the septum, finally dividing into two lateral palpebral branches. After giving off the lacrimal artery, the ophthalmic artery then crosses the nerve to reach the medial orbital wall and divide

Inferior meatus

Figure 5-11 Lacrimal system.

into its terminal divisions, the dorsal nasal and supratrochlear arteries. The two medial palpebral arteries enter the lids above and below the medial canthal ligament, as branches of the ophthalmic artery. In the eyelids the medial and lateral palpebral arteries anastomose to form a marginal tarsal arcade on the surface of the upper and lower tarsal plates 2–4 mm from the lid margins. In the upper lid a second peripheral arcade is formed at the upper border of the tarsal

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Tarsal arcade upper lid

Supraorbital artery and vein Frontal vein Supratrochlear artery

Lacrimal artery

Medial palpebral artery

Lateral palpebral artery

Angular artery and vein

Tarsal arcade lower lid Facial artery and vein

Infraorbital artery

Figure 5-12 Eyelid blood supply.

plate in Müller’s muscle. Along the superior orbital rim, there are a further two arcades, superficial and deep to orbicularis that are predominantly derived from the supratrochlear medially and frontal branch of the superficial temporal laterally.20 The veins of the lids are found mainly in the fornices. They drain predominantly to the venous network of the middle third of the face although there is some connection with the intraorbital venous system via the supraorbital and supratrochlear veins. The lymphatic drainage is in an inferiolateral direction to the preauricular, parotid, and submandibular lymph nodes. There has not been a sufficiently detailed study of the lymphatics to explain the problem of postoperative chemosis. The motor nerve supply to the orbicularis oculi muscle is from branches of the zygomatic division of the facial nerve. Once the branches reach the undersurface of the muscle near the peripheral edge (see midcheek section), they travel in a radial direction towards the lid margins. Preservation of the orbicularis innervation is central to any operative planning, yet the detailed anatomy of this innervation has not been fully defined. In particular, it is not clear if there is a separate nerve supply to the functionally important pretarsal segment of the orbicularis muscle in the lower lid, the fibers of which do not extend to the orbital rim. The levator muscle is supplied by the superior division of the oculomotor nerve after it has supplied the superior rectus muscle. Müller’s muscle is supplied by sympathetic nerves that travel with the arteries.

The sensory supply to the eyelids and the orbital contents are from the ophthalmic and maxillary divisions of the trigeminal nerve. The ophthalmic division divides to pass through the superior orbital fissure as the lacrimal, frontal and nasociliary nerves. These nerves branch and travel forward to eventually supply the upper lid as the lacrimal, supraorbital, supratrochlear and infratrochlear nerves from lateral to medial. The lower lid is supplied from the maxillary division via the zygomaticofacial and the infraorbital nerves.

Midcheek Historically, periocular and midfacial rejuvenation surgery have been treated as separate entities with the orbital rim being considered the anatomical and conceptual barrier to a unified approach. More recently it has become recognized that these areas are interdependent anatomical and surgical regions, particularly at the lid–cheek junction of the lower eyelid. A thorough understanding of midfacial anatomy is therefore essential for any surgeon contemplating oculoplastic surgery. However, the anatomy of the midcheek is complex and has not been well described. It is easier to understand the midcheek when working from basic principles. For this reason a preliminary review of facial anatomy precedes the more detailed discussion. Paul A. Harris and Bryan C. Mendelson

Basic arrangement of facial anatomy

Basic arrangement of facial anatomy Skeleton The bony architecture is the predominant determinant of midfacial contour and is fundamental to facial aesthetics, although the relative thickness of the overlying soft tissue has a significant impact, particularly as it changes with advancing age. This bony platform (Fig. 5-13) provides the base for the attachment of the overlying muscles and ligaments that support the midfacial soft tissue. The surface anatomy should therefore be considered in terms of its relationship to the underlying bony anatomy. The midcheek has an upper and outer prezygomatic part that overlies the bony platform provided by the body of the zygoma. The medial and lower infrazygomatic part of the midcheek covers the vestibule of the oral cavity and overlies the maxilla.

Soft tissue layers The craniofacial soft tissue is formed in two basic layers. These layers are most clearly visualized in the temporal region but they continue into the midface and below (Fig. 5-14). Their identification has facilitated an understanding of the potential ‘spaces’ that exist between the layers and the structures that pass between them. Although the nomenclature has not been consistent, the relationship between the layers in the various regions of the skull and face has been clearly established.21 The outer or superficial layer is mobile, consistent with the movement of the lids and mouth, and the expressive function of the face. This layer incorporates the superficial musculoaponeurotic system (SMAS) in

its deep aspect. The SMAS being the generic name given to this continuous fibromuscular sheet which includes the muscles of facial expression. Parts of the SMAS have specific names in different anatomical regions such as the temporoparietal fascia in the temple and orbicularis oculi in the periorbital region. The remainder of the superficial layer between the SMAS and the dermis contains a variable thickness of subcutaneous fat incorporated within the structural fibrous retinacula cutis. The underlying deep fascial layer of the face is continuous with the facial skeleton periosteum and covers the two great masticatory muscles over the lateral face, as the deep temporal fascia and the masseteric fascia. The muscles of facial expression reside within the SMAS of the superficial layer and insert into the dermis of this layer. These muscles form either large flat sheets that have limited bony attachment and lie almost entirely within the SMAS, e.g. frontalis, platysma, and pars orbitalis of orbicularis oculi, or they have further differentiated to form groups of muscles around the skeletal orifices with an opposing dilator action to one of the sphincteric orbicularis muscles (oris and oculi). Examples of this latter group include the zygomaticus muscles and the elevators and depressors of the lips. These dilator muscles have a deep attachment to the facial skeleton and then traverse the layers of the face to insert into the SMAS or dermis. In contrast to the muscles of mastication, which are deep to the deep fascia of the lateral face, the muscles of facial expression have migrated forward as well as superficial to be in relation to the orifices at the front (anterior) of the face. For functional reasons, movement occurs within the superficial layer itself, as observed in the lips and eyelids. There is also some capacity for areas of the superficial layer to glide over the underlying deep

Superior orbital fissure Frontal bone

Lacrimal fossa

Sphenoid

Figure 5-13 Midfacial and orbital bones.

Palatine

Optic canal

Zygomaticofrontal suture Ethmoid

Whitnall’s tubercle

Lacrimal bone

Zygomaticofacial foramen

Lacrimal fossa

Inferior orbital fissure Zygoma

Infraorbital foramen Maxilla

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56 Temporalis Sub-galea plane

Galea Deep temporal fascia

Zygomatic-cutaneous ligaments Masseteric cutaneous ligament Masseter Skin SMAS Sub-SMAS plane Deep fascia

Figure 5-14 Fascial layers of the face. Modified from Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000; 105:1475–1490.

fascia. A potential cleavage plane therefore exists between the fascial layers that in most regions of the face requires dissection to be revealed. However, in the temple the temporal space is readily demonstrated and in the midcheek the prezygomatic space has also been clearly identified.22 There are lines of fixation of the superficial fascia that define the boundaries of the various spaces and specific zones, through which traverse retaining ligaments, nerves and blood vessels. These ligamentous boundaries in general coincide with the boundaries of the cutaneous aesthetic units. The facial nerve branches which course from deep to the deep fascia to end in the superficial layer, innervating the superficial muscles on their deep aspect, pass through these boundary lines of fibrous attachment. Significantly, the nerves do not pass through the spaces.

Retaining ligaments A specific pattern of ligamentous fixation supports the mobile superficial fascia onto the deep fascia. These

retaining ligaments of the face appear in three forms,2 either (1) specific ligaments, such as the zygomatic and masseteric-cutaneous ligaments; (2) as areas of ligamentous adhesions, such as the main temporal ligament and the lateral orbital thickening; or (3) as membranous septal reflections, such as the superior temporal septum and the orbicularis retaining ligament. It is now appreciated that the retaining ligaments of the face are located in a specific pattern around the orbital and oral cavities. In the orbital region, the arrangement of the ligaments is to form a periorbital septum along the rim (Fig. 5-15). Functionally, this is supported by a specifically arranged pattern of temporal ligaments above and lateral to the orbit. In relation to the oral cavity, another system of ligaments takes the shape of an inverted letter L, with the horizontal component across the body of the zygoma, below the orbital ligaments, and the vertical component extending from the lateral part of the body of the zygoma down the anterior border of the masseter to the mandibular ligaments. Overlying the body of the zygoma are both the lower periorbital ligamentous boundary (above) and the upper perioral ligamentous boundary (below). These two ligamentous systems are separated from each other by a buffer zone, called the prezygomatic space (Fig. 5-16). With the development of aging laxity of the superficial layer, the ligamentous insertion through the superficial fascia becomes apparent as a cutaneous groove or line of concavity, indicating a line of resistance to further sag of the soft tissues, e.g. the midcheek furrow. In contrast, the larger and more mobile, non-attached areas in between these supporting structures undergo greater laxity and displacement to form folds or J-shaped bulges, e.g. the nasolabial fold, malar mound bulge and lower lid bulge.

Skin Facial skin thickness varies between areas and individuals, and undergoes a universal age-related thinning of the dermis. Subcutaneous fat exists throughout the facial skin with connective tissue septa dividing the fat into lobules. The skin and subcutaneous tissue of the face can be divided into aesthetic units, each unit characterized by the skin having a similar color, texture, thickness and mobility. This visual separation becomes more apparent with advancing age. Aesthetic units have an important clinical application to consider in skin resurfacing procedures as well as in surgery. Incisions placed at the boundaries of these units result in less obvious scarring.

Surface anatomy Temporal ligamentous adhesion Superior temporal septum

Supraorbital ligamentous adhesion

Temporalis muscle Periorbital septum Lateral brow thickening Periorbital septum

Lateral orbital thickening Orbicularis retaining ligament

Figure 5-15 Periorbital retaining ligaments. Modified from Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000; 105:1475–1490.

Orbicularis retaining ligament

Orbicularis oculi

SOOF Prezygomatic space

Preperiosteal fat

Zygomatic ligaments

Figure 5-16 Prezygomatic space. Modified from Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002; 110:885–986.

Surface anatomy In the midface, the area known as the midcheek is commonly referred to, particularly in the context of aesthetic surgery, although it does not conform to a classic

anatomical region. By common usage, the midcheek is simply that part of the face visible front on (en face), between the lower lid above and the nasolabial fold below. It has a triangular shape, narrowing medially due to the upward inclination of the nasolabial fold. Its outer part merges imperceptibly around the convexity of the zygomatic substructure onto the lateral face without a defining landmark such as a visible skin crease. The midcheek of a child is characteristically a solitary structure with a homogeneous, uniform rounded fullness of contour. This youthful smooth surface however conceals the structural components that lie within and further subdivide the midcheek. Aging changes result in a profound alteration of contour of the midcheek which progressively reveals three separate structural components. These separate structural components become defined from each other by the appearance of three interconnected grooves or furrows that trisect the original single midcheek mound. The three furrows interconnect much like the three limbs of the italic letter Y (for the right side of the face) (Fig. 5-17). The stem of the Y is formed by the midcheek groove, or furrow which is obliquely oriented and roughly parallel to the nasolabial groove. The upward continuation of that straight stem develops into the nasojugal groove. The side arm of the Y attached to the stem near the top of the midcheek develops into the palpebromalar groove.

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Figure 5-17 Midcheek surface anatomy.

Lid cheek segment Palpebro-malar groove Malar mound

Infrazygomatic Midcheek area furrow

The names given to the three segments are usually only ascribed to their established form when defined by the grooves, but for explanation this terminology can also be applied to the areas of the three potential segments within the uniform youthful midcheek. Laterally, over the prominence of the zygoma, lies the prezygomatic or malar segment which may develop into the malar mound,23 also termed by some authors the malar bag or malar crescent.24 The area medial and inferior to the midcheek furrow is the infrazygomatic area of the midcheek, also termed the nasolabial fold segment (as distinct from the nasolabial groove which is the concavity separating the midcheek from the lip). Between the two upper limbs within the V area is the lid cheek segment. Functionally, the midcheek being part of the anterior face is significant for its intrinsic movements, particularly when compared to the lateral face which has only limited passive movement secondary to movements of either the anterior face or the jaw. Of the three segments, the most mobile is the nasolabial, as it overlies the vestibule of the oral cavity. The lid–cheek junction segment above also has significant movement, more so its upper part to do with contraction of the lower lid. The malar mound segment may have the least active displacement of the midcheek soft tissues, but it eventually develops within its surface the lower crow’s foot and zygomatic smile lines.

Soft tissues In the midcheek, the prezygomatic space is a key space defined by structural ligamentous boundaries.22 It lies between the superficial and deep fascial layers overlying the zygoma (Fig. 5-16). It has a triangular shape with the apex medially and a broader base laterally reflecting the shape of the underlying body and maxil-

Nasojugal groove

lary process of the zygoma. It can be considered to be a transition zone between the mobile periorbital tissues of the lower lid, which contribute to the upper boundary, and the attachments of the more fixed tissues of the infrazygomatic region, which form the floor and inferior boundary. In the midcheek, the pars orbitalis of the orbicularis oculi lies flat across the cheek at a superficial level with a variable descent towards the lip. Accordingly, the superficial fascial layer in this area, which forms the roof of the prezygomatic space, consists of the pars orbitalis of the orbicularis oculi, the orbicularis muscle fascia and a thin layer of suborbicularis oculi fat (SOOF).25 This finely lobulated and distinctly yellow layer of fat can be repositioned in periorbital aesthetic procedures, although it has no intrinsic structural ability and is more likely to be resuspended via fixation of the orbicularis fascia. The orbicularis retaining ligament along the inferior orbital rim separates the lower lid from the midcheek. The quality of the ligament takes different forms along various parts of the rim. The lateral third, which extends around the inferolateral rim up to the lateral orbital thickening, is a firm unyielding ligamentous structure. In the middle third of the rim, between the insertion of the arcuate expansion to the orbital rim and the direct attachment of the orbicularis to the medial rim, this part of the orbicularis retaining ligament is a filmy, distensible, double layered membrane, up to 15 mm long and often containing fat within. This is the highly mobile part which allows upward movement of the top of the cheek on strong squinting and it also provides minimal resistance to bulging of fat from the central lower lid fat compartment over the inferior orbital rim into the upper midcheek. The elevators of the lip have an extensive deep attachment on the zygoma and maxilla with the peri-

Surface anatomy Orbicularis oculi

Prezygomatic space

Zygomaticus major

Zygomaticus minor

Levator labii superioris

Figure 5-18 Origin of lip elevators.

osteal origins of the zygomatic ligaments in close proximity. The combined line of origin of these muscles follows the curvature of the prominence of the body of the zygoma, concave above with the medial end higher than the lateral (Fig. 5-18). From medial to lateral, the broad origin of levator labii superioris begins close to the orbital rim, passing laterally at an incline of nearly 45º away from the orbit. The narrow origin of the zygomaticus minor (4–5 mm wide) is the lowest point of the crescent from the orbital rim. The more cephalad origin of the wider zygomaticus major (8–10 mm wide) is located at least halfway up the zygoma. The prezygomatic space overlies the upper origins of the zygomatic muscles, extending inferiorly to the lower border of the zygoma and defined by the line of zygomatic ligaments. Inferior to the muscle origins and line of zygomatic ligaments is the buccal space and the vestibule of the oral cavity.

In the upper midcheek, the caudal volume displacement of the soft tissue leads to a relative uncovering of the anatomy of the orbit.27 The lid–cheek junction also appears to descend from a position above the orbital rim in youth to a position below the orbital rim with aging (Fig. 5-19). However, it is a change to the underlying anatomy that defines the junction rather than actual stretching of the lower lid skin that takes place. The youthful cheek has a high convex contour that overlies the septum orbitale as far up as the infratarsal crease. With aging, cheek soft tissue volume loss and descent, combined with septal laxity and orbital fat protrusion alter the contour of the lower lid to define a new lid–cheek junction with the appearance of the nasojugal groove medially and the palpebromalar groove inferolaterally (Figs 5-17 & 5-19). The lid appears to lengthen creating a rounded eye and giving the impression that the lid–cheek junction descends with the soft tissue. The lid–cheek junction is therefore not a surface crease but is a surface contour that passively reflects the contour change underlying the skin. The description ‘lid–cheek junction’ is still used regardless of the fact that the location of the contour transition has moved. Accordingly, due to these changes there is a transitional segment of skin, which was originally in the area of the upper cheek and becomes incorporated into the aged lower lid (and yet reverts to become cheek skin again following blepharoplasty). There has not been a specific name given to this transitional segment of skin, which is here called the lid– cheek segment. It should be noted that in youth the lid–cheek segment extends above the orbital rim to the lid–cheek contour transition. The displaced prezygomatic volume accumulates in the infrazygomatic part of the cheek medial to the midcheek furrow, most evident as increasing fullness of the nasolabial fold. This infrazygomatic soft tissue fullness is often termed the malar fat pad,28 and it should be distinguished from the malar mound, which overlies the prezygomatic space.

Aging changes

Blood supply

The visible effects of facial aging are the summation of a complex interplay of factors that take place at all anatomical levels. In addition to these soft tissue changes, the support of the skin and soft tissue by retaining ligaments becomes attenuated, and the face loses volume from adipose, and possibly muscle mass, atrophy. In addition to these soft tissue changes, the facial skeleton undergoes resorption of areas of maxillary and alveolar bone, and parts of the skeleton remodel.26

A rich cutaneous vascular network exists in the face to function as part of the thermoregulatory and emotional response mechanism. In general, the anterior part of the face is perfused by numerous musculocutaneous perforators, whereas the lateral face is supplied by relatively few large fasciocutaneous perforators in predictable locations. This network has been clearly defined in terms of vascular territories, however, in practical terms a medially based facelift flap, raised at whatever level, has a reliable blood supply.29

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Figure 5-19 Aging changes in the lid– cheek junction. A, Youthful appearance of lid–cheek junction above the orbital rim (skin marker). B, Aged appearance of lid–cheek junction below the orbital rim (skin marker).

A

B

In the midface, the blood supply is mainly from branches of the external carotid artery (Fig. 5-20) although as described above, multiple anastomoses exist with branches of the internal carotid artery around the eye. The facial artery supplies the superior and inferior labial arteries to the lips, and the lateral aspect of the dorsum of the nose. The internal maxillary artery gives rise to the infraorbital artery in the pterygopalatine fossa. The infraorbital artery passes through the infraorbital fissure into the orbit. It continues anteriorly in the infraorbital groove and canal to emerge below the inferior orbital margin, where it supplies the lower eyelid and cheek. The infraorbital artery may be damaged during subperiosteal midface lifts as it exits its foramen. The superficial temporal artery is the terminal branch of the external carotid artery arising from within the parotid gland. It travels in the SMAS layer across the zygomatic arch and therefore dissections deep to the SMAS layer protect the superficial temporal artery from injury. Before crossing

the arch, it gives off the transverse facial artery, which supplies the lateral canthal area, by anastomosing with the lateral palpebral arteries.

Innervation The course of the facial nerve and its branches is of the utmost importance to facial rejuvenation surgery (Fig. 5-21). In the midface, damage to a distal branch rarely results in a noticeable deformity because the major nerve divisions cross innervate approximately 70% of the time. However, the frontal and mandibular branches are much more susceptible to significant surgical injury as they are usually terminal branches with very few crossover communications. The exact location of the frontal branch in relation to the SMAS is critical to a safe dissection in the periocular and temporal regions. Pitanguy and Ramos30 first described the frontal branch of the facial nerve as crossing roughly a line from 5 mm below the tragus to

Surface anatomy Superficial temporal

61

Deep temporal

Transverse facial

Infraorbital Angular

Posterior auricular

Posterior superior alveolar

Occipital

Superior labial

Maxillary

Inferior labial External carotid

Submental

Internal carotid Buccal

Common carotid Superior thyroid

Facial

Inferior alveolar Lingual

Figure 5-20 Distribution of the external carotid artery.

Temporal

Zygomatic

Buccal

Cervical

Mandibular

Figure 5-21 Extraparotid branches of the facial nerve.

15 mm above the lateral end of the eyebrow. The anterior branch of the temporal artery is often said to accompany the nerve. More recent studies have shown this nerve to arborize into two to four branches that leave the superior pole of the parotid gland at the level of the zygomatic arch. The nerves then travel on the deep surface of the SMAS plane as they traverse the

zygomatic arch. Dissection of the SMAS layer off the arch can therefore damage these branches. For this reason, most authors recommend either converting to a subcutaneous dissection over the arch or when a subSMAS midface dissection is combined with a superior temporal or brow lift, a ‘meso-temporalis’ is left intact at the level of the arch. The innervation of orbicularis is predominantly from zygomatic branches of the facial nerve that enter the pars orbicularis at or near its inferior-lateral periphery. The limited information available shows that this innervation consists of five or six branches that course over the body of the zygoma (Fig. 5-22). The branches that are at or near the intercanthal line ramify into smaller branches before they reach the orbicularis border, while branches nearer the upper and lower orbital rims cross under muscle for several millimeters before dividing into smaller branches. All branches enter the underside of the muscle and then ramify within the SOOF layer. The lower lid orbicularis receives an additional, inferior branch from the midcheek, which having passed deep to zygomaticus major ascends to cross the inferior border of the orbicularis some 10 mm medial to the zygomaticus major.31 An additional medial innervation is provided by superficial buccal branches of the facial nerve, which course over levator labii superioris and ascend along the lateral border of levator labii superioris alaeque nasi to innervate the orbicularis on the way to innervating procerus and corrugator supercilii.32

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Zygomaticus major

Zygomaticus minor

Levator labii superioris

Figure 5-22 Facial nerve branches to orbicularis oculi. Modified from Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002; 110:885–986.

Surgical applications of midcheek anatomy Similar to surgery of the forehead, there are divergent surgical philosophies regarding the best surgical plane; the decision being between the subperiosteal and composite sub-SMAS approaches. In subperiosteal surgery the benefit of repositioning the periosteum is mediated through the retaining ligaments to the superficial fascia. Although the ligaments are not visualized they are detached at their base from their skeletal attachments as an integral part of the subperiosteal surgery. By contrast, if the dissection plane is beneath the SMAS and the overlying tissue is repositioned, it then becomes necessary to identify and release those retaining ligaments that are providing a resistance to tension-free advancement and redraping of the facelift flap.33 Considerable mobility may remain in the more superficial layers which is taken up by further advancing the SMAS. In the midcheek, the main ligaments of importance requiring release are the orbicularis retaining ligament, the zygomatic ligaments and the masseteric ligaments.

References 1. Muzaffar AR, Mendelson BC, Adams WP: Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110:873–884. 2. Moss CJ, Mendelson BC, Taylor GI: Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000; 105:1475–1490.

3. Kikkawa DO, Lemke BN, Dortzbach RK: Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophth Plast Reconstr Surg 1996; 12:77–82. 4. Lander T, Wirtschafter JD, McLoon LK: Orbicularis oculi muscle fibers are relatively short heterogenous in length. Invest Ophthalmol Vis Sci 1966; 37:1732–1739. 5. Porter JD, Burns LA, May PJ: Morphological substrate for eyelid movements: Innervation and structure of primate levator palpebrae superioris and orbicularis oculi muscles. J Comp Neurol 1989; 287:64–81. 6. Gioia VM, Linberg JV, McCormick SA: The anatomy of the lateral canthal tendon. Arch Opthalmol 1987; 105:529–532. 7. Tyers AG, Collin JRO: Color Atlas of Ophthalmic Plastic Surgery. Edinburgh, Churchill Livingstone, 1995. 8. Zide BM, McCarthy JG: The medial canthus revisited: An anatomical basis of canthopexy. Ann Plast Surg 1983; 11:1–9. 9. Rosenstein T, Talebzadeh N, Pogrel MA: Anatomy of the lateral canthal tendon. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 89:24–28. 10. Knize DM: Discussion to ‘Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus’ and ‘Surgical anatomy of the midcheek and malar mounds.’ Plast Reconstr Surg 2002; 110:897–899. 11. Isse NG: Endoscopic facial rejuvenation. Clin Plast Surg 1997; 24:213–222. 12. Bosch WA, Leenders I, Mulder P: Topographical anatomy of the eyelids, and the effects of sex and age. Br J Ophthalmol 1999; 83:347–352. 13. Myer DR, Linberg JV, Wobig JL, McComick SA: Anatomy of the orbital septum and associated eyelid connective tissues. Ophthal Plast Reconstr Surg 1991; 7:104–113. 14. Siegal R: Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 1984; 13:263–273. 15. Mendelson BC: Fat preservation technique of lower-lid blepharoplasty. Aesthetic Surg J 2001; 21:450–459. 16. Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New York, Raven Press, 1985. 17. May JW, Fearon J, Zingarelli P: Retro-orbicularis oculus fat (ROOF) resection in aesthetic blepharoplasty: a 6-year study in 63 patients. Plast Reconstr Surg 1990; 86:682–689. 18. Persichetti P, Di Lella F, Delfino S: Adipose compartments of the upper eyelid: anatomy applied to blepharoplasty. Plast Reconstr Surg 2004; 113:373–378. 19. Yamamoto H, Morikawa K, Uchinuma E, et al: An anatomical study of the medial canthus using a three dimensional model. Aesthetic Plast Surg 2001; 25:189–193. 20. Kawai K, Imanishi N, Nakajima H, et al: Arterial anatomical features of the upper palpebra. Plast Reconstr Surg 2004; 113:479–484. 21. Accioli de Vasconcellos JJ, Britto JA, Henin D, et al: The fascial planes of the temple and face: an en-bloc anatomical study and a plea for consistency. Br J Plast Surg 2003; 56:623–629. 22. Mendelson BC, Muzaffar AR, Adams WP: Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002; 110:885–896. 23. Furnas DW: Festoons, mounds, and bags of the eyelids and cheek. Clin Plast Surg 1993; 20:367–385. 24. Hamra ST: Composite rhytidectomy. Plast Reconstr Surg 1992; 90:1–13.

References 25. Aiache AE, Ramirez OH: The sub-orbicularis oculi fat pads: An anatomical and clinical study. Plast Reconstr Surg 1995; 95:37–42. 26. Pessa JE, Chen Y: Curve analysis of the aging orbital aperture. Plast Reconstr Surg 2002; 109:751–755. 27. Lucarelli MJ, Kwarg SI, Lemke BN, Kozel JS, Dortzbach RK: The anatomy of midfacial ptosis. Ophthal Plast Reconstr Surg 2000; 16:7–22. 28. Owsley JQ: Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg 1993; 91:463–474. 29. Schuster RH, Gamble WB, Hamra ST, et al: A comparison of flap vascular anatomy in three rhytidectomy techniques. Plast Recontr Surg 1995; 95:683–688.

30. Pitanguy I, Ramos AS: The frontal branch of the facial nerve: the importance of its variations in face-lifting. Plast Reconstr Surg 1966; 38:352–356. 31. Ramirez OM, Santamarina R: Spatial orientation of motor innervation to lower orbicularis oculi muscle. Aesthetic Surg J 2000; 20:107–113. 32. Nemeto Y, Sebino Y, Kaneko H: Facial nerve anatomy in eyelids and periorbita. Japan J Ophthalmology 2001; 45:445–452. 33. Mendelson BC: Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg 2001; 107:1545–1552.

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CHAPTER 6

Brow Lift Techniques Jeffrey E. Janis, Jason K. Potter and Rod J. Rohrich The brow and forehead are frequently a central focus of patients seeking facial rejuvenation. Senescent and actinic changes can significantly impact these areas and result in an aged or tired appearance, or even contribute to functional problems such as visual field obstruction. The rejuvenation of these areas is a critical part in the restoration of facial harmony and the reestablishment of a more youthful appearance. The aesthetic surgeon must possess a thorough understanding of the brow and forehead anatomy, as well as a comprehension of the dynamic interrelationship between the forehead, brow, eyelid, and midface. The surgeon must also be familiar with the various methods available to effect changes in these tissues, as no single technique enjoys universal application (Table 6-I). This chapter will provide the reader a thorough review of the anatomy of the brow and forehead, review the most common techniques for rejuvenation, and provide an algorithm from which to apply them. Jeffrey E. Janis, Jason K. Potter and Rod J. Rohrich

Aesthetics The absolute dimension of the forehead as measured from glabella to trichion, varies from patient to patient. The general characteristics of a pleasing brow have been well described.1,2 The brow and forehead create the upper one third of the face in the aesthetically proportioned face. The anterior hairline is typically 5–6 cm above the brow. The eyebrow forms a subtle arc that peaks at the junction of the middle and lateral thirds, which should correspond to a point above the lateral limbus. This arc is flatter in males. In females, the brow should be 3–5 mm above the superior orbital rim. In males, it should lie at the level of the orbital rim. Medially, the brow should begin at a line drawn perpendicular to the lateral aspect of the ala and passing through the medial canthus. The lateral brow is positioned slightly higher than the medial brow and should end at a point on a line drawn obliquely through the ala and lateral canthus (Fig. 6-1).

Anatomy Landmarks for brow position are based upon the underlying bony anatomy. The superior orbital rim is easily palpable and serves as a fixed position for which to assess brow ptosis. Laterally, the temporal ridge delineates the

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68 E C

B

A

Superior temporal line

D

B

C

A

Figure 6-1 Spatial relationships of the ideal eyebrow. Modified from Westmore; reproduced with permission from Ellenbogen R: Transcoronal eyebrow lift with concomitant upper blepharoplasty. Plast Reconstr Surg 1983; 71:490.

border of the forehead from the temporal fossa (Fig. 6-2). Knize has identified the consistent relationship of several soft tissue structures to the temporal ridge. In this location the soft tissue layers of the forehead and scalp fuse with the periosteum at the zone of fixation (Figs 6-3 & 6-4). A very important and easily overlooked anatomic variable to consider is calvarial thickness, as many of the techniques of brow lifting involve placement of bony fixation to suspend the newly elevated brow. Calvarial thickness may be as thin as 1–2 mm in the temporal region and along the course of the middle meningeal artery.3 The soft tissue anatomy of the forehead, similar to other regions of the face and neck, is arranged in multiple often very subtle layers (Fig. 6-5). The upper forehead is arranged similarly to the scalp with well-defined layers consisting of skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and periosteum. At the origin of the frontalis the galea aponeurosis splits into a superficial and deep plane to encase this musculature. The deep plane splits again in the midforehead region to surround the galeal fat pad, and caudal to the fat pad splits again to form the glide plane space of the brow. The periosteum, subgaleal space, and deep galeal plane are discrete layers except in the lower forehead where these layers fuse and are firmly affixed to the frontal bone. Similarly, the periosteum is relatively loosely attached to the frontal bone over the

Figure 6-2 The forehead and temple subunits. Note that the superior temporal line separates the central forehead from the lateral temporal regions. A, central; B, lateral (temporal); C, eyebrow.

Superior temporal line Inferior temporal line

Occipital bone

Temporal fusion line

Parietal bone Temporal bone Zygomatic bone

Figure 6-3 Drawing of skull showing the location of relevant bony landmarks. The stippled area is the zone of fixation. Modified with permission from Knize DM: An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996; 97:1321–1333.

upper and midforehead, but is firmly attached across the lower forehead. Movement of the brow is produced through the action of brow elevators and depressors, and is enhanced by the presence of the galeal fat pad, glide

Anatomy STF

STL 5–6 mm

ITL

Galea

Frontalis muscle TL

TF

Figure 6-4 Schematic representation of the temporal fossa and forehead structures. Both the confluence of the superficial temporal fascia (STF) with the galea aponeurotica and the confluence of the temporalis fascia (TF) with the frontal bone periosteum are located within the zone of fixation (stippled area). These planes are bonded together and their deeper layers are fixed to bone over the 5- to 6-mm-wide zone of fixation just medial to the temporal fusion line (TL) and the superior temporal line (STL). The lateral margin of the frontalis muscle either terminates or abruptly attenuates over this zone. The inferior temporal line (ITL) of the skull forms the perimeter of the temporalis fascia. The plane of the frontal branch of the facial nerve within the superficial temporal fascia is shown. Modified with permission from Knize DM: An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996; 97:1321–1333.

plane space, and subgaleal space. The major elevator of the brow is the paired frontalis muscle. The frontalis originates from the galeal aponeurosis and inserts into the dermis of the lower forehead. At the level of its insertion, the frontalis interdigitates with fibers of the orbicularis oculi and procerus. As the frontalis contracts and pulls on the orbital portion of the orbicularis, it indirectly elevates the brow via orbicularis dermal insertions. The frontalis elevation is offset by the depressor actions of the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi. The procerus originates from the dorsal surface of the nasal bones and inserts into the dermis in the glabellar region. The orbital portion of the orbicularis oculi originates from the medial canthal region and inserts into the dermis in the region of the medial brow. The corrugator supercilii has both a transverse and oblique head. The

oblique head originates from the superiomedial orbit and inserts into the dermis of the medial brow, whereas the transverse head shares the same origin but inserts into dermis just superior to medial one-third of brow. The depressor supercilii originates from the superiomedial orbit and inserts into the dermis of the medial brow medial to the insertion of the orbicularis. It lies superficial to the corrugator supercilii. The vascular supply to the skin of the forehead is provided by branches of both the internal and external carotid artery systems. Branches of the internal system include the supraorbital and supratrochlear arteries. The supratrochlear vessel is usually identified approximately 1.5 cm from midline whereas the supraorbital vessel exits approximately 2.7 cm lateral to the midline. The superficial temporal artery branch of the external carotid artery system supplies the temporal scalp and forehead. Vast communications exist between these anteriorly based vessels and those of the posterior scalp to provide a rich and overlapping blood supply to the scalp and forehead. Sensation of the forehead is provided mostly by the branches of the supraorbital and supratrochlear nerve, both arising from the ophthalmic division of the trigeminal nerve and emerging with their correspondingly named artery. The supratrochlear nerve pierces the corrugator muscle to provide sensation to the midforehead. The supraorbital nerve provides sensation to the lateral forehead and anterior scalp. It exits from the orbit and splits into a superficial and deep branch. The superficial branch exits the orbit through its foramen or notch and enters the frontalis muscle. It continues cephalad through the frontalis and transitions to a subcutaneous plane running over the surface of the frontalis muscle. This location renders it relatively well-protected from injury during brow lift procedures. The deep branch passes deep to the glide plane space of the brow and superficial to the periosteum initially and then travels superiolaterally through the galeal fat pad. After exiting the galeal fat pad the deep branch travels along the deep galeal plane passing parallel and approximately 0.5–1 cm medial to the superior temporal line. It arborizes into many smaller branches as it approaches the coronal sutures. Contrary to the superficial branch, the deep branch is susceptible to injury during brow lifting procedures. This branch may be injured during the initial incision or during elevation of the flap. Coronal incisions made to the subgaleal or subperiosteal planes always transect the deep branch at the level of the incision.4 The deep branch is also at risk lower over the forehead if the forehead flap is elevated in the subgaleal plane. To preserve the deep branch one must use a non-coronal incision and elevate the flap in the subperiosteal plane.4

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DSO

STF

Frontalis muscle

I II III

TF

SSO

Figure 6-5 Three planes of superficial temporal fascia (STF). Plane I is confluent with the deep galea plane across the zone of fixation (slanted lines). Planes II and III are thin, yet distinct fibrous sheets that rest over temporalis fascia (TF). The frontal branch of the facial nerve (FB) consistently runs just under or within plane I in the anterior temporal region. Frontalis muscle (FM) and deep (DSO) and superficial (SSO) divisions of the supraorbital nerve are indicated. Modified with permission from Knize DM: An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996; 97:1321–1333.

FB

Brow deformities Changes in brow position and of the surrounding soft tissues occur with age and have a profound effect on periorbital aesthetics. The most discernible change is the development of rhytids. Prolonged hyperactivity of periorbital and forehead musculature results in the development of deep furrows perpendicular to the direction of muscle contraction. Deep horizontal furrows of the forehead are attributed to the frontalis, whereas horizontal furrows in the glabellar region are secondary to procerus hyperactivity. Vertical furrows in the glabellar region are a result of corrugator hyperactivity. Transection or resection of the offending musculature during brow lifting procedures can ameliorate these deformities and prevent dynamic accentuation of rhytids from muscle activity. Alternatively, muscle function may be targeted with botulinum toxin, but will require periodic treatments to maintain the result. Brow ptosis is typically a major component of the age-related changes affecting the periorbital region. This is characterized by malposition of the brow and migration of brow skin into the superior lid region creating skin excess, loss of the normal supratarsal

definition and lateral hooding. Although the exact mechanism is not clear, several factors have been proposed for the development of brow ptosis (Fig. 6-6).5 The frontalis muscle suspends the brow and resists the tendency for ptosis. The lateral-most limit of frontalis muscle resting tone extends to the zone of fixation along the temporal fusion line. Lateral to this region, the weight of the unsupported tissue mass over the temporal fossa in association with lateral orbicularis oculi and corrugator muscle activity contribute to the descent of the lateral brow. Manual elevation of the lateral brow will improve the periorbital appearance of most middle-aged persons presenting for facial rejuvenation and is easily demonstrated to the patient. The difficulty lies in surgically recreating the result obtained by digital elevation of the brow during patient evaluation. Ptosis of the brow does not occur evenly across the forehead and in most cases, affects the lateral brow earlier and more markedly than the medial brow. Most surgical procedures are not able to reposition accurately the lateral brow without affecting the medial brow, especially when the medial brow depressors (corrugator) are surgically transected.

Coronal brow lift Temporal fossa soft tissue

TL

Frontalis muscle

Corrugator supercilii muscle

The advantages and disadvantages of each technique are presented in Table 6-1. An algorithm used by the authors for selection of appropriate technique is presented in Figure 6-7.

Coronal brow lift

Orbicularis oculi muscle

Figure 6-6 Forces contributing to lateral eyebrow ptosis. Unsupported eyebrow lateral to the temporal fusion line of the skull (TL) is pushed down by the gravity-driven descent of the temporal fossa soft tissues. The lateral-most limit of frontalis muscle resting tone suspension of the eyebrow extends just over the zone of fixation (slanted lines) along the temporal fusion line of the skull. Hyperactive corrugator supercilii muscle and lateral orbicularis oculi muscle action can antagonize frontalis muscle action and actively facilitate the descent of the superficial temporal fossa soft tissues. Modified with permission from Knize DM: An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996; 97:1321–1333.

Algorithmic approach to surgical rejuvenation of the brow Brow lifting is performed more frequently today as part of a comprehensive facial rejuvenation. Available techniques include the coronal incision, the anterior hairline incision, the direct brow lift (midforehead incision), transpalpebral techniques, limited incision techniques, and endoscopic techniques. A survey of the American Association of Plastic Surgeons demonstrated that open techniques are performed with equal frequency as endoscopic techniques.6 No single technique has been documented to be definitively superior to another; all have their advantages and disadvantages. Selection of the appropriate technique involves both an accurate assessment of the patient’s deformity and incorporation of the individual’s expectations.

This is a powerful technique that provides complete access to all aspects of the aging brow. Due to the length of the coronal incision, coronal brow lift procedures lost favor with many patients and surgeons with the development of smaller incision endoscopic techniques. However, there is a returning popularity of this technique due to the perceived longevity of the result compared to endoscopic techniques. This is attributed to the fact that the redundant tissue is excised and not just repositioned, as is characteristic of endoscopic techniques. Advantages of this procedure include: 1. Direct access to the entire brow. 2. Scar camouflage within hair-bearing scalp. 3. Direct access for transection/ablation of muscles responsible for furrows. 4. Direct excision of redundant tissue. Disadvantages include: 1. Risk of alopecia. 2. Elevation of frontal hairline. 3. Numbness of scalp distal to incision.

Technique The incision location is marked approximately 5 cm posterior to the hairline. Location of the incision should allow for excision of 2–3 cm of scalp and still maintain the final location several centimeters posterior to the anterior hairline. In the temporal region the incision should remain several centimeters posterior to the anterior hairline. The incision may be made continuous with the incision for rhytidectomy, however, an incision along the temporal hair tuft must be made as well to allow removal of redundant facial skin independent of the brow soft tissues. Failure to do so can lead to excision of the temporal hair tuft producing a tell-tale sign of surgery. The incision line and brow are then infiltrated with several milliliters of 1% lidocaine with 1 : 100,000 epinephrine solution for perioperative hemostasis and analgesia. After allowing adequate time for onset of hemostasis, the incision is performed with a #10 blade parallel to the hair follicles down to the level of the subgaleal plane. Hemostasis is obtained with bipolar cautery, being careful to avoid direct cautery of hair follicles.

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Table 6-1 Brow lifting procedure

Procedure

Advantages

Disadvantages

Coronal brow lift

Direct access to entire brow Scar camouflage in scalp Easy access for muscle transection Direct excision of redundant skin

Risk for alopecia Elevation of frontal hairline Numbness of scalp

Anterior hairline lift

Direct access to entire brow Scar camouflage in scalp Easy access for muscle transection Direct excision of redundant skin Prevents elevation of forehead

Scar location Numbness of scalp

Direct brow lift

Ease of access to brow structures Correction of asymmetries

Visible scarring Hypesthesia forehead

Limited incision

Preservation of scalp innervation Preferential lateral brow elevation

Limited access for deep rhytids Limited exposure of corrugator/procerus

Figure 6-7 Algorithm for the treatment of forehead wrinkles. Modified with permission from Rohrich RJ: Discussion of ‘limited incision foreheadplasty’ by DM Knize. Plast Reconstr Surg 1999; 103:285.

Forehead wrinkles

Correction of brow ptosis and dynamic forehead frown lines Long forehead Young/middle-aged patient Mild to moderate brow ptosis (more lateral than medial) Relatively thin skin with good scalp/forehead elasticity Mild to moderate glabellar/forehead rhytids

Component endoscopically assisted or limited incision foreheadplasty

Normal/short forehead Older patient Thick, oily skin with diminished scalp/forehead elasticity Deep glabellar/forehead rhytids

Transcoronal foreheadplasty

The flap is elevated in the subgaleal plane to a level 1– 2 cm above the supraorbital rim. Laterally, it is important to remain deep in the subgaleal plane to protect the temporal branch of the facial nerve. At this point the dissection transitions to the subperiosteal plane. The periosteum is incised sharply and elevated with a #9 periosteal elevator continuing the dissection past the level of the supraorbital rim. It is important to free adequately the tissues over the supraorbital rim to allow superior repositioning of the brow. The supra-

orbital and supratrochlear neurovascular bundles are identified and preserved. Medially the extent of dissection is dependent upon the patient’s preoperative assessment; if the medial brow position is adequate or is at risk for becoming too wide the medial periosteal attachments should not be disrupted. The corrugators, procerus, and frontalis muscles may be resected at this point if indicated. Blunt dissection parallel to the muscle fibers will delineate the corrugators which should be clamped and divided with cautery. Special

Direct brow lift attention is necessary to avoid injury to the adjacent neurovascular structures. Management of the frontalis varies. If horizontal forehead rhytids are prominent, resection of strips of galea and frontalis in these regions allows effective redraping of the skin to help efface the rhytids. If patients are expecting complete resolution of dynamic rhytids from the procedure, this requires more extensive resection of the frontalis musculature. Meticulous hemostasis is achieved with bipolar cautery and the flap is redraped. The brow should be redraped in a superomedial direction to allow preferential elevation of the lateral brow. The flap is initially secured into position with staples to assess the new brow position. Excess scalp is then marked and sharply excised and hemostasis achieved. Closure is accomplished in a layered fashion. The galea is approximated with interrupted 3-0 Vicryl sutures. The epidermal edges may be reapproximated with surgical staples or 4-0 monofilament suture. Drains are typically not placed, however a compression dressing may be applied to help prevent hematoma or seroma formation.

Anterior hairline lift Indications, advantages and disadvantages for an anterior hairline approach are similar to that of the coronal approach except that it is best suited for the patient with a high anterior hairline (>6–7 cm above the brow). Placement of the incision along the anterior hairline prevents further elevation of the hairline.

Technique The proposed incision is marked along the anterior frontal hairline. Laterally, the incision curves gently

into the temporal scalp. The incision line is injected with 1% lidocaine with 1 : 100,000 epinephrine. The incision is performed with a #10 blade. In the frontal region the incision is beveled perpendicular to the hair follicles, as this has been demonstrated to allow regrowth of hair through the healed scar and produce a more aesthetic result (Fig. 6-8).7,8 The forehead flap is then elevated and redraped similarly to the coronal technique. Excision of redundant tissue is performed with a beveled incision, parallel to the initial incision to allow accurate reapproximation of the skin edges at closure. Skin closure is accomplished with 3-0 Vicryl sutures in the galeal plane, followed by a running 5-0 nylon suture to approximate the epidermal edges.

Direct brow lift Direct brow techniques involve placement of access incisions within the forehead skin, potentially producing visible scarring. For this reason patient selection is critical. This technique is usually reserved for males with deep forehead rhytids or with male-pattern hairloss which makes it difficult to camouflage coronal incisions or endoscopic access incisions. Placement of the incision within transverse rhytids or along the eyebrow provides the most aesthetic alternative incision placement. Several variations of direct brow techniques exist. The incisions may be placed within deep transverse rhytids of the forehead that may be isolated above each brow or even as a single incision across the forehead. When separate incisions are made above each brow, they may be placed in rhytids at different levels to assist in camouflaging the incisions. Alternatively the inci-

Figure 6-8 Beveled lift incision: proximal flap (on left) contains deep hair follicles, and the distal flap (on right) will serve as a biologic dressing, allowing the hair follicles to grow into and anterior to the scar. Modified with permission from Camirand A, Doucet J: A comparison between parallel hairline incisions and perpendicular incision when performing a facelift. Plast Reconstr Surg 1997; 99:10–15.

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TL

Frontalis Deep division of Galea muscle supraorbital nerve

1. Ease of access to brow structures. 2. Correction of asymmetric brow ptosis. Disadvantages: 1. Visible scarring. 2. Hypesthesia of forehead/scalp.

Orbital ligament

Technique The ideal patient is male with deep transverse forehead rhytids and a receding anterior hairline. In patients without deep rhytids, consideration can be given to placing the incision along the superior margin of the eyebrow. In the authors’ experience, however, incisions camouflaged within deep rhytids are aesthetically superior to those along the brow margin. Incision location is marked with a surgical marker prior to administration of a local anesthetic solution with epinephrine to prevent distortion of landmarks. After onset of hemostasis, the incision is performed with a #15 blade. The incision is carried to the subcutaneous plane. Sharp dissection is usually required to carry the dissection to the level of the superior brow. A transverse incision is made through the galea approximately 3 cm above glabella and the subgaleal plane is entered to allow access to the corrugators and procerus. To protect sensation to the scalp the incision should not extend past the supraorbital nerves. Transection of the corrugator and procerus is performed under direct visualization. Hemostasis is provided with monopolar or bipolar cautery. The forehead flap is redraped in the appropriate vector to obtain the desired brow effect. Redundant skin is excised from the inferior flap, the amount of which is tailored to differentially elevate the medial or lateral brow. The superior flap is undermined slightly with sharp dissection to allow a precise closure. The brow is secured to the periosteum cephalad with permanent suture. The flaps are approximated in the deep dermal plane with 3-0 Vicryl suture. Epidermal edges may be reapproximated with a running subcuticular or simple suture.

Limited incision forehead lift The limited incision forehead lift was designed to provide an effective means of addressing advanced brow ptosis while minimizing the risk for permanent injury to the supraorbital nerve branches (Fig. 6-9).9

STF

Zygomatic arch

Figure 6-9 Eyebrow elevation through small incision into scalp. A subperiosteal forehead flap is raised and the orbital ligament is transected for maximum upward movement of the superficial temporal fascia. Modified with permission from Knize DM: Limited-excision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 1996; 97:1334.

Advantages: 1. Limited temporal incision avoids transection of the deep division of the supraorbital nerve. 2. Preferentially elevates the lateral brow tissues. 3. Allows for easy placement of durable sutures for suspension of elevated lateral brow segment. 4. May be combined with transpalpebral resection of corrugators when performing concomitant blepharoplasty. Disadvantages: 1. Limited exposure for addressing deep forehead rhytids. 2. Limited exposure to corrugators and procerus.

Technique The vector for lateral brow elevation is determined by manually elevating the lateral brow segment. The temporal incisions are designed perpendicular to this vector and placed 2–3 cm behind the temporal hairline. The incisions are 4–5 cm in length and do not extend medially past the superior temporal line to avoid injury to the deep division of the supraorbital nerve (which

Endoscopic brow lift travels below the deep galeal plane 0.5–1.5 cm medial to the superior temporal line). Blunt dissection should proceed to the level of the underlying deep temporal fascia. The operator can easily confirm this plane as one should be unable to grasp loose tissue above the glistening temporalis fascia in this location. Dissection proceeds anterioinferiorly with blunt-tipped scissors, keeping tips against the deep temporal fascia to protect the temporal branch of the facial nerve that travels within the overlying temporal-parietal fascia. The zone of fixation will be encountered as a tenacious region that resists medial dissection. At this point the dissection should proceed in the subperiosteal plane to release the zone of fixation while protecting the supraorbital nerve. The periosteum should be released medially 2–3 cm and down to the level of the supraorbital rim. Careful scissor spreading perpendicular to the orbital rim releases the periosteal attachments of the brow including the orbital ligament near the zygomaticofrontal suture, in order to allow for brow repositioning. The inferior flap may now be advanced along the desired vector to elevate the brow. Forceps are used to grasp both the superior and inferior flaps to produce overlap of the flaps until the desired brow elevation is obtained. The level of overlap is marked on the inferior flap. A small window of deep temporal fascia is removed exposing the underlying muscle allowing subsequent cicatrix formation between the muscle and superficial fascia to assist in stabilizing the repositioned brow. The superficial fascia of the inferior flap is reapproximated to the superficial fascia of the superior flap with several 2-0 Vicryl sutures. A 3-point suture may be performed to include the deep temporal fascia. Redundant scalp is not excised and skin edges are reapproximated with surgical staples or running 4-0 monofilament suture.

Endoscopic brow lift Endoscopic brow techniques were developed to provide the ability to lift the brow while minimizing the complications characteristic to open techniques such as long scars, hair loss, and scalp parasthesias. Endoscopic surgery can be technically demanding and requires both access to and familiarity with the equipment. The most significant difference between endoscopic techniques and open techniques is that endoscopic techniques provide for repositioning of redundant/ptotic skin whereas open techniques allow excision of redundant skin. Although no studies have demonstrated a clear-cut superiority of one technique versus another, the authors feel that repositioning

tissues does not provide as long lasting a result as excisional techniques. Essential components of the endoscopic brow lift include the creation of an optical cavity within the soft tissue planes of the forehead; release of the lateral periosteal attachments of the lateral brow; and transection of the medially located brow depressors to allow superior repositioning of the brow by the frontalis musculature. Failure to accomplish these goals will compromise the end result. Advantages: 1. Small incisions. 2. Potential for preservation of scalp sensation. 3. Direct visualization of muscle resection. Disadvantages: 1. Technical learning curve. 2. Need for fixation of scalp.

Equipment Detailed discussion of available endoscopic equipment is beyond the scope of this text. There are a multitude of different camera and instrument systems available and in general are selected based upon surgeon preference. For endoscopic facial plastic surgery 4 mm endoscopes are optimal as they are able to provide the lighting and imaging necessary while being small enough for the limited spacial relationships encountered in the facial region. For brow techniques the authors find that use of a 30 degree camera equipped with a retractor hood provides the best opportunity to visualize the areas of interest and to account for the convex curvature of the forehead. Silicone skin protectors are also available to help prevent traction or thermal injury to the port-site skin which may lead to alopecia.

Technique Incisions are located in the hair-bearing scalp and usually consist of a central, lateral and temporal incision. Incisions are vertically oriented, 2 cm in length, and at least 1–2 cm into the hairline. The central incision is located in the midline; the lateral incision should be located above the medial one-third of the brow; the temporal incision should be just medial to a line passing through the lateral ala and lateral brow. Incision locations are injected with 1% lidocaine with 1 : 100,000 epinephrine. The periorbital soft tissues along the superior and lateral orbital rims are infiltrated similarly. The incisions are performed with a #10 blade. The central and lateral incisions are carried through periosteum. A large periosteal elevator is used to

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Brow Lift Techniques elevate the forehead tissues in the subperiosteal plane stopping 2 cm superior to the superior orbital rim to prevent avulsing the supraorbital neurovascular structures. The endoscope may be utilized to perform this release under direct visualization. Blunt dissection is performed through the temporal incision to the level of the deep temporal fascia. Keeping the periosteal elevator against the deep temporal fascia, blunt dissection proceeds inferomedially to release the zone of fixation. At this point the temporal dissection transitions from a subgaleal plane to a subperiosteal plane. Maintenance of the subperiosteal plane of dissection medial to the zone of fixation is important to protect the deep division of the supraorbital nerve. Blunt dissection under direct vision proceeds to release the periosteal attachments along the superior orbital rim and to release the soft tissues surrounding the supraorbital nerve. The supraorbital nerve may be represented by a single bundle or may consist of 2–3 branches exiting the orbit separately. All branches are preserved. Dissection proceeds laterally to release the arcus marginalis along the lateral rim to allow for superior repositioning of the lateral brow. The medial dissection divides the corrugator and procerus if indicated. The corrugator muscle will be visualized adjacent to the supraorbital nerve with fibers oriented inferomedially. Transection of the corrugator is accomplished by grasping the muscle fibers near their insertion on the overlying skin and avulsing them with care to avoid

Table 6-2 Summary of reported complications after open brow lifts and endoscopic brow lifts

Complication

Open (n = 3534) (%)

Endoscopic (n = 3417) (%)

Alopecia

4.0

2.9

Dissatisfaction

0.8

1.8

Scarring

0.8