Putterman's Cosmetic Oculoplastic Surgery, 4th Edition

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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

1

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

5

Chapter

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The History of Cosmetic Oculoplastic Surgery

6

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

9

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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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2. 3.

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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

Chapter 16

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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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26

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

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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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Eyelid and Midcheek Anatomy: Eyelid and Midcheek

46

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

Chapter 48

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Eyelid and Midcheek Anatomy: Eyelid and Midcheek

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

Chapter 50

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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

51

Chapter 52

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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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Brow Lift Techniques sions may be placed along the superior margin of the eyebrow. Advantages:

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

<0.1

Asymmetry

0.8

1.2

Sensory loss

0.1

0.6

Infection

<0.1

<0.1

Lagophthalamus

<0.1

<0.1

Motor deﬁciency

<0.1

<0.1

Abnormal contour

<0.1

<0.1

Hematoma

<0.1

<0.1

Reproduced with permission from Elkwood A, Matarasso A, Rankin M, et al: National plastic surgery survey: Brow lifting techniques and complications. Plast Reconstr Surg 2001; 108(7):2143–2150.

the neurovascular bundles. Complete release of the corrugator is conﬁrmed with identiﬁcation of the brow fat pad that lies superﬁcial to the corrugator. The procerus is divided similarly centrally in the glabellar region. The cavity is then irrigated and meticulous hemostasis is accomplished. The brow is then elevated to its desired position. Typically the lateral brow requires preferential elevation. This may be accomplished by redraping the lateral brow tissues in a superiomedial vector. Brow ﬁxation may be accomplished in a wide variety of ways,10 but is typically accomplished with either a ﬁxation screw or creation of a cortical tunnel for suture ﬁxation. Animal studies have demonstrated that periosteal readherence requires at least 6 weeks, with complete adherence by 12 weeks.11 Therefore suture selection should be directed towards the use of a material that provides secure brow position for 6–12 weeks. The authors’ preferred method is to perform a cortical tunnel in the frontal bone over the midportion of the brow along the desired vector using a 4 mm long 2.0 mm drill. Two separate, opposing drill holes are made through the superﬁcial cortex that communicates in the diploic cancellous space. A 2-0 PDS suture is then passed through the tunnel and used to secure a strong bite of galea in the inferior edge of the incision. The brow is then redraped and manually held in position while the suture is tied. The procedure is repeated on the contralateral side. The incisions are closed with staples. Other methods of acceptable ﬁxation include Lactosorb (Walter Lorenz) resorbable endobrow screws, and titanium screws. The Lactosorb polymer has been shown to resorb over the course of 12 months and therefore will maintain brow position long enough for adhesion to develop. The screw may be palpable initially, but the patient can be reassured it is temporary. Titanium screws offer permanent ﬁxation, but may require removal if palpability is objectionable to the patient. Endotine Forehead 3.5 (Coapt Systems, Paola Alta, CA) is a resorbable device for rapid ﬁxation of the brow tissues. The device consists of ﬁve 3.5-mm prongs that are set into the skull with a single drill hole. The device has been reported to be palpable up to 24 weeks. Due to issues with palpability, the device is recommended for patients with scalps 5–6 mm thick.12

Postoperative care In the immediate postoperative period attention is given to minimization of edema and protection of the eyes. The head of the bed is maintained in an elevated position and ice therapy is placed on the operative site. The authors prefer Swiss Eye Therapy (Invotech International Inc., Jacksonville, FL) gel eye masks to provide

References therapeutic cooling to the tissues of the periorbital region where edema is most problematic. The packs should be replaced every 30 minutes and continued for the ﬁrst 24 hours. If ice packs are used they should be wrapped in a moist cloth to prevent hypothermic injury to the tissues. If brow lifting is performed in conjunction with blepharoplasty, lagophthalmos may be present postoperatively. In this situation the surgeon must provide means to prevent desiccation of the cornea. Artiﬁcial tears are used and administered by the patient as needed during the day. At bedtime a small portion of lacrilube or ophthalmic ointment is placed in the inferior fornix to maintain a moist environment during sleep. Suture lines are cleansed with dilute hydrogen peroxide two to three times daily and the incision line dressed with antibiotic ointment. After three to four days, the wound has reepithelialized and the ointment is therefore discontinued to prevent skin sensitivity from developing.

Complications See Table 6-2. Complication rates, in general, are very low for brow lift procedures. The most frequent complications include scalp numbness, incisional alopecia, unacceptable scarring, hematoma, infection, facial nerve injury. Depending on the technique used for brow rejuvenation, scalp numbness is usually more a sequela of the procedure and not a true complication. It is important to educate the patient that all techniques except limited incision subperiosteal approaches cause numbness of the posterior scalp. Even endoscopic techniques that proceed in the subgaleal plane will injure the deep branch of the supraorbital nerve. If the patient is clearly aware of this preoperatively it is less burdensome to the surgeon. Alopecia is prevented with careful attention and meticulous handling of the scalp tissues. When possible, cautery should be avoided around the hair follicles. Use of bipolar cautery will limit the zone of thermal injury to minimize collateral injury when cautery is necessary. Incisional alopecia accentuates the appear-

ance of scars on the scalp and might make an otherwise acceptable scar extremely noticeable. Unacceptable scarring is a result of poor planning and traumatic handling of tissue. Proper planning will orient incisions appropriately to maximize the aesthetic result. Tension-free closure with careful approximation of skin edges further optimize wound appearance. Injury to the temporal branch of the facial nerve is prevented by a thorough understanding of the local anatomy coupled with careful and precise dissection of the temporal region.

References 1. Gunter JP, Antrobus SD: Aesthetic analysis of the eyebrows. Plast Reconstr Surg 1997; 99:1807–1816. 2. Fruend RM, Nolan WB: Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females. Plast Reconstr Surg 1996; 97:1343–1348. 3. Knize DM, Drisco M: The Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia, Lippincott Williams and Wilkins, 2001. 4. Knize DM: Reassessment of the coronal incision and subgaleal dissection for foreheadplasty. Plast Reconstr Surg 1998; 102:478–489. 5. Knize DM: An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996; 97:1321–1333. 6. Elkwood A, Matarasso A, Rankin M, et al: National plastic surgery survey: Brow lifting techniques and complications. Plast Reconstr Surg 2001; 108:2143–2150. 7. Camirand A: Facelifts and browlifts: Amelioration of scars. Can J Plast Surg 1999; 7:27–34. 8. Camirand A, Doucet J: A comparison between parallel hairline incisions and perpendicular incision when performing a facelift. Plast Reconstr Surg 1997; 99:10–15. 9. Knize DM: Limited incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 1996; 97:1334–1342. 10. Rohrich RJ, Beran SJ: Evolving ﬁxation methods in endoscopically assisted forehead rejuvenation: Controversies and rationale. Plast Reconstr Surg 1997; 100:1575–1582. 11. Romo T, Sclafani AP, Yung RT, et al: Endoscopic foreheadplasty: A histologic comparison of periosteal reﬁxation after endoscopic versus bicoronal lift. Plast Reconstr Surg 2000; 105:1111–1117. 12. Evans GRD, Kelishadi SS, Ho KU, et al: Heads up on brow lift with coapt systems’ endotine forehead technology. Plast Reconstr Surg 2003; 113:1504–1505.

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CHAPTER 7

Treatment of Upper Eyelid Dermatochalasis with Reconstruction of Upper Eyelid Crease: Skin-Muscle Flap Approach Allen M. Putterman I treat only about 10 percent of my patients with dermatochalasis (excess skin) and herniated orbital fat of the upper eyelid by performing an upper eyelid blepharoplasty with skin or skin-muscle resection alone. In 90 percent of patients, I perform a skin and orbicularis oculi muscle resection with or without fat removal, but with reconstruction of the eyelid crease. The skin-muscle resection with crease reconstruction allows less skin to be removed and thereby decreases lagophthalmos (incomplete eyelid closure), which is especially important in patients with low basic tear secretion. Also, I ﬁnd that most patients with upper eyelid dermatochalasis have ill-deﬁned eyelid creases and eyelash ptosis (inversion of lashes), and reconstructing the creases helps these problems also. This approach also allows for resection of orbicularis muscle, which might be redundant if skin is removed alone. Finally, it provides access for other procedures, such as redepositing a lacrimal gland, performing an internal brow lift, and performing levator aponeurosis resection–ptosis surgery.

Preparation for surgery The patient’s entire face is prepared with povidone-iodine (Betadine) soap and paint. The patient is draped so that the entire face is exposed. Topical tetracaine is applied over each eye. A scleral contact lens is placed over the eye and under the eyelids.

Surgical technique Skin marking A line is drawn with a methylene blue marking pen, beginning at the lateral canthus and extending in a horizontal direction of approximately 1 cm. This line marks the site of the lower lateral canthal incision. The site of the predetermined eyelid crease is then marked. When the surgeon is drawing the eyelid crease marks, the eyebrow must be elevated to reduce the excess

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Treatment of Upper Eyelid Dermatochalasis with Reconstruction of Upper Eyelid Crease upper eyelid skin fold and to make the upper eyelid skin taut and the lashes slightly everted. If this is not done, the crease may result in being much higher than desired because the skin is usually loose before it is marked. The temporal, central, and nasal crease sites are marked by placing a millimeter ruler so that the zero line is at the eyelid margin. The distances above the eyelid margin can then be viewed and marked with a specially designed marking instrument. In women, the temporal mark usually is placed 10 mm above the upper eyelid margin; the central mark, 11 mm above the margin; and the nasal mark, 9 mm above the margin. In men, the marks are usually 9 mm temporally, 10 mm centrally, and 8 mm nasally. The temporal, central, and nasal marks are then connected and are extended with a line, which begins at the punctum and ends at the lateral canthus (Fig. 7-1A). The line sweeps laterally approximately 1 cm temporal to the lateral canthus in a slightly upward direction. There should be at least 5 mm of skin between this line and the line placed for the lower lateral incision. A smooth forceps is used to grasp the crease line at the center of the eyelid with one blade. The other blade is used to pinch upper eyelid skin at various positions until, when the forceps is closed, all the redundant upper eyelid skin is eliminated and there is no eversion of the lashes and no lifting of the eyelid from its apposition to the lower eyelid margin (Fig. 7-1B).

A

Once this position is determined, a dot is made with the marking pen at the top blade of the forceps. Similar marks are made nasally and temporally after the amounts of extra skin are determined in these positions. The three superior dots are connected and joined with the nasal and temporal ends of the eyelid crease line (Fig. 7-1C). The opposite eyelid is marked in the same manner. To ensure symmetry, the surgeon then compares the measurements of the eyelid crease and the amount of skin to be excised temporally, nasally, and centrally in the two eyelids. Skin-muscle excision Several milliliters of 2 percent lidocaine (Xylocaine) with epinephrine is injected subcutaneously in the areas of the marked ellipse as well as between the upper eyelid margin and eyelid crease across the eyelid. A No. 15 Bard-Parker blade is used to make an incision through skin at the marked lines. A 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superﬁcial tarsus at the center of the upper eyelid just above the eyelid margin. Approximately 12.5 cm of suture is left on each arm, and a knot is tied at this end. The traction suture is used to pull the upper eyelid straight downward while a toothed forceps is used to grasp the upper eyelid centrally just above the crease incision and to pull upward and outward.

B

Figure 7-1 A, A line is drawn on the eyelid at the level of the eyelid crease. B, A smooth forceps is used to eliminate redundant upper eyelid skin and to slightly evert the eyelashes.

Preparation for surgery A blunt Westcott scissors is used to make a buttonhole incision in orbicularis muscle and to sever central orbicularis muscle at the skin crease level (Fig. 7-1D). With the scissors directed superiorly and inward, the orbicularis muscle can be penetrated and the suborbicularis space entered without injury to the levator aponeurosis and other important eyelid structures. This maneuver is possible because the orbicularis muscle is ﬁrmly attached to skin, whereas the orbital septum, levator aponeurosis, Müller’s muscle, and conjunctiva stay deep surrounding the globe. The orbicularis muscle is then undermined temporally and nasally at the site of the eyelid crease while the surgeon keeps the eyelid in the same position with the traction suture and forceps. The orbicularis muscle is severed along the incision site of the eyelid skin crease with the use of a disposable cautery (Fig. 7-1E), a Colorado needle, a sapphire-tipped scalpel neodymium : YAG (Nd : YAG), or a carbon dioxide (CO2) ultrapulse laser. Each instrument coagulates blood vessels as it cuts through tissues.1 When this has been accomplished, the surgeon should be able to view the levator aponeurosis. At times, orbital septum is in the way and must be identiﬁed with the use of a forceps. The orbicularis muscle at the superior skin incision site is then severed with a disposable cautery (Fig. 7-1F), Colorado needle, or the Nd : YAG or CO2 ultrapulse laser. Thereby, an ellipse of skin and orbicularis muscle is excised with simultaneous cauterization of blood vessels.

C

Isolation and excision of orbital fat The septum is pulled upward and outward. Then the Westcott scissors, a disposable cautery, Colorado needle, or Nd : YAG or CO2 ultrapulse laser is used to penetrate orbital septum and suborbicularis tissue just beneath the orbital septal rim until herniated orbital fat is visible (Fig. 7-1G). The orbital septum and suborbicularis fascia are opened from the nasal to temporal aspect of the eyelid; when this is accomplished, the surgeon should see nasal, central, and, at times, central-temporal herniated orbital fat pads. Usually, the nasal fat is white, whereas the central and central-temporal fat is yellow and very loose. Bleeding is controlled with the cautery. The capsule over the nasal fat pad is then penetrated with Westcott scissors. The eye is pushed on through the upper eyelid, and the nasal fat that herniates upon gentle pressure applied to the eye is grasped with a straight forceps (Fig. 7-1H). With a No. 15 Bard-Parker blade, the surgeon severs the fat along the hemostat. Cotton-tipped applicators are placed under the hemostat, and a Bovie cautery is applied to the hemostat to coagulate any vessels within the fat pad. A forceps is used to grasp the fat beneath the hemostat as the hemostat is released. This gives the surgeon a chance to inspect the fat stump for any residual bleeding before it is allowed to retract into the orbit. An alternative is to remove the herniated orbital fat with a laser.

D

Figure 7-1—cont’d C, Connection of superiorly marked dots to the nasal and temporal ends of the eyelid crease incision line. D, A blunt Westcott scissors is used to make a buttonhole incision in the orbicularis oculi muscle.

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82

F

E

G

H

Figure 7-1—cont’d E, The orbicularis oculi muscle along the lid crease incision is severed with a disposable cautery. F, A disposable cautery is used to cut the orbicularis oculi muscle at the superior border of the skin incision. G, The orbital septum and suborbicularis tissue are penetrated with Westcott scissors just beneath the orbital septal rim until herniated orbital fat is visible. H, The nasal fat pocket is removed.

The central and central-temporal fat pads are at times removed in a similar manner. At present, there is an advantage in most patients not to remove central and central-temporal upper eyelid orbital fat. This avoids hollowing of the superior eyelid sulcus and superior migration of the upper eyelid crease. If an internal brow lift or levator aponeurosis advancement or resection is contemplated, it is performed at this time (see Chapters 10 and 12). There is no fat at the temporal extreme of the upper eyelid. If the surgeon sees prolapse of tissue at this

position, it is most likely a prolapsed lacrimal gland rather than orbital fat. If a prolapsed lacrimal gland is seen, it is treated by suture redepositing of the gland in the lacrimal fossa rather than by excision, which can cause a dry eye.2 Reconstruction of eyelid crease The upper eyelid crease is formed by placing three 6-0 white polyester ﬁber (Mersilene) sutures to connect orbicularis muscle with the levator aponeurosis. These are placed in the nasal, central and temporal positions.

Preparation for surgery 83

I

K

J

L

Figure 7-1—cont’d I, A 6-0 polyester ﬁber (Mersilene) suture enters the superior surface of the levator aponeurosis and exits through the inferior surface. Then the suture passes through the orbicularis oculi muscle. J, The 6-0 polyester ﬁber suture passes through the levator aponeurosis inferiorly to superiorly. K, Three 6-0 polyglactin (Vicryl) sutures are passed through skin, levator aponeurosis, and skin centrally, temporally, and nasally to further establish the eyelid crease. L, The eyelid skin is united with a continuous 6-0 black silk running suture, which is passed nasally to temporally.

Two toothed forceps are used to grasp the skin at the eyelid crease position, and the skin is pulled to the extent that skin between the lashes and the crease is taut and the lashes are slightly everted. The surgeon notes the position at which the skin overlaps the levator aponeurosis. This determines the position to suture orbicularis muscle to the levator aponeurosis in order to form the eyelid crease. The 6-0 polyester ﬁber suture is ﬁrst passed through the levator aponeurosis superiorly to inferiorly. The suture is then passed nasally to temporally through adjacent orbicularis muscle of the lower skin ﬂap (Fig. 7-1I). The suture is next passed through the levator aponeurosis inferiorly to superiorly (Fig. 7-1J). When the

suture is drawn up and tied with four knots, the orbicularis muscle of the lower skin ﬂap will unite with the levator aponeurosis to form a crease at this position. The surgeon should measure the distance between the eyelid margin and the site of the suture to make sure that it is at the desired level. To further establish the eyelid crease (Fig. 7-1K), the surgeon then passes three 6-0 polyglactin (Vicryl) sutures through the skin, the levator aponeurosis, and the skin centrally, temporally, and nasally. Last, the skin is united with a continuous 6-0 black silk running suture, which is passed nasally to temporally (Fig. 7-1L) and one temporal 6-0 polyglactin (Vicryl) suture.

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84

Figure 7-2 A, Preoperative appearance of a patient with dermatochalasis (excess skin) of upper eyelid with ill-deﬁned creases. B, Postoperative appearance after excision of upper eyelid skin, the orbicularis oculi muscle, and fat with crease reconstruction. The lower eyelids were also treated with external blepharoplasty.

A

B

Postoperative care

Sequelae

For 3 hours postoperatively, the patient applies cold compresses to the eyelids. Ophthalmic signs are closely observed. The recovery room staff checks the patient every 15 minutes for the ability to count ﬁngers and to make sure that there is no severe pain or proptosis. If the patient demonstrates either an inability to count ﬁngers or proptosis or complains of severe pain, the surgeon is called immediately, because these problems may indicate a retrobulbar hemorrhage, which has the potential to cause blindness.3 For 24 hours postoperatively, the patient or the patient’s family continues to apply cold compresses to the eyelids and checks for the ability to count ﬁngers every hour (other than during sleep). If the patient cannot count ﬁngers or if there is severe pain or proptosis, he or she should immediately return to the surgical facility or other emergency facility for evaluation of a possible retrobulbar hemorrhage. Six days postoperatively, the 6-0 black silk skin sutures are removed. The polyglactin sutures are usually removed 2–3 weeks postoperatively or are allowed to dissolve spontaneously.

Postoperative ecchymosis and edema of the eyelid are to be expected. Most patients think that their appearance is acceptable, and they are ready to go out in public a week after the procedure. When an upper eyelid crease has been formed, the patient experiences a slight amount of postoperative ptosis and has difﬁculty looking upward. These problems gradually resolve over the ﬁrst 2 postoperative months. Some patients are emotionally depressed several weeks after surgery because their appearance is not back to normal, but this unhappiness commonly goes away at about 6 weeks after surgery. The appearance of the eyelids generally continues to improve over the course of 1 year after the operation. Figure 7-2 shows the preoperative appearance and postoperative results in a patient who underwent upper eyelid surgery with the skin-muscle ﬂap approach.

Postoperative complications The main complication is asymmetry of the eyelid creases and folds. If this is noted postoperatively, the surgeon can make an adjustment by removing the poly-

References glactin sutures from the eyelid in which the crease is too high. Slight asymmetry, however, usually resolves spontaneously over the ﬁrst few months. If there are distinct differences between the eyes, further eyelid skin can be removed or the crease can be placed at a higher level on the side that is too low. Suture cysts are common and are believed to occur by healing beneath the skin where the sutures are in place. If these persist, they are removed 2 months postoperatively by light hydrolysis with a Birtcher hyfrecator. Upper eyelid ptosis rarely occurs and can be treated by ptosis surgery. A retrobulbar hemorrhage associated with loss of vision is treated by removal of the upper eyelid sutures and control of the hemorrhage.

Results I have performed upper eyelid blepharoplasty with crease reconstruction in more than 3000 patients, with a high rate of good results.

References 1. Putterman AM: Scalpel neodymium : YAG laser in oculoplastic surgery. Am J Ophthalmol 1990; 109:581–584. 2. Leone CR: Treatment of a prolapsed lacrimal gland. In: Putterman AM (ed). Cosmetic Oculoplastic Surgery 3e. Philadelphia: Saunders, 1993:169–176. 3. Putterman AM: Temporal blindness after cosmetic blepharoplasty. Am J Ophthalmol 1975; 80:1081–1083.

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CHAPTER 8

Upper Blepharoplasty: Volume Enhancement via Skin Approach: Lowering the Upper Lid Crease Steven Fagien Over the years, success of a particular surgical procedure, even aesthetic, has been measured mostly by perceived outcome and to some degree by the frequency of complications. Since the overwhelming majority of aesthetic periorbital ‘complications’ have occurred with lower blepharoplasty, most of the attention on newer and improved techniques has focused on the lower periorbita1–6 (see Chapters 14–19, Lower blepharoplasty). As functional misadventures are a much less encountered occurrence after upper blepharoplasty, complacency with existing methods and perpetuation of illperceived solutions to rejuvenation of the upper periorbita prevail.7,8 With rare exception, the approach to upper blepharoplasty has not been particularly physiologic or individualized and the universal application of traditional remedies for upper periorbital rejuvenation has translated to mediocrity.7–9 The prevailing perception has been that the appearance of the aged upper eyelid is primarily due to excessive skin, muscle, and fat often in conjunction with brow descent. Additionally, there is the confounding erroneous memory in many individuals of what their upper periorbita looked like in youth. Finally, there is the inﬂuence of the ‘famous and beautiful’ people on what patients may request for their eventual appearance despite their conﬁguration in earlier years (Fig. 8-1) that may explain some of the historical aesthetic desires as well as changes in ideas and what is currently expected after surgery. Steven Fagien

The consultation As with all surgical approaches to rejuvenation, we must take into account what are the actual changes that occur in the upper periorbita and whether the existing methods consider these occurrences for a wide variety of individual presentations (Fig. 8-2). Do these techniques result in a rejuvenative appearance or simply achieve a ‘cause and effect’ outcome whereby an altered appearance replaces youth? (Fig. 8-3). And, ultimately, what surgical procedures are some patients willing to undergo and what do they expect from surgery?

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Figure 8-2 This 40-year-old patient shows many of the typical changes that occur, especially in the upper eyelid with aging of the periorbita. What are the anatomic changes that cause this?

A

B Figure 8-1 A & B, These ‘movie stars’ of the past exhibit what was felt at the time to be an aesthetically pleasing appearance to the upper eyelid. Both exhibited mild degrees of upper eyelid ptosis that accentuated the deep supra-tarsal fold/sulcus. Many surgical procedures were derived in an attempt to duplicate this appearance even in the patient that did not exhibit lid ptosis. A, With permission from Corbis. Copyright © Bettmann/Corbis; B, With permission from Corbis. Copyright © Underwood & Underwood/Corbis.

Often when a patient consults with one or a number of surgeons in consideration of rejuvenation of the upper periorbita, the possibility of brow lift is discussed. Some surgeons may suggest that a patient requires a brow lift while others may not. What is

the basis of this inconsistency and what has been the justiﬁcation and anatomic rationalization of either approach? Moreover, if the patient who presents for upper periorbital rejuvenation has a mild to moderate degree of perceived brow ptosis and refuses to undergo a brow lift of any sort, are there other methods that can signiﬁcantly improve the appearance without the incorporation of browplasty/pexy? We are all aware that at times particular procedures are offered for lack of knowledge or ability to achieve a desired effect in another, perhaps more accurate, manner. For instance, when consulting with a young female who presents for improvement of the appearance of the upper periorbita, what are the ﬁndings on examination that suggest a particular approach? How much has the eyebrow actually descended and why would one then offer a brow lift if there has been little change over the patient’s lifetime? (Fig. 8-4). What has been the justiﬁcation and anatomic rationalization of any given approach?9 What effects have been ignored with this approach that could be improved upon? Is there ever an indication for a 35 to 40-year-old (or younger) to have a brow lift? (Fig. 8-5). Have we considered what this individual patient’s brow position was in youth? Why, in fact, are many patients resistant to brow lifts? What should we strive for to accomplish the most acceptable and aesthetic rejuvenative result? A review of some simple but common observations of the changes in the aging upper periorbita for a majority of our patients sheds more light on which surgical solutions are both physiologically and aesthetically feasible (Figs 8-2, 8-6):

· ·

The upper eyelid and periorbita have more volume in youth. The youthful and aesthetic upper eyelid crease is more often in a low position.

The consultation 89

A Figure 8-5 Would there ever be an indication to perform a brow lift on this conﬁguration if the patient presented for periorbital rejuvenation?

B Figure 8-3 This patient presented to her surgeon for cosmetic rejuvenation of the eyelids. Surgery was performed and she was unhappy with the result. What techniques were performed that caused the changes noted and what could have been done to avoid the unwanted effects?

Figure 8-6 This exempliﬁes the aging changes that can occur around the periorbita with the red arrows pointing to the aged left side of this patient. A true rejuvenative appearance should consider techniques that restore the youthful complement as in the direction of the green arrows pointing toward this patient’s right side.

· Figure 8-4 This individual exhibits the youthful and aesthetic fullness to the ‘lid–brow junction’ and a well positioned lateral eyebrow. With permission from Corbis. Copyright © Royalty-free/Corbis.

·

·

·

A convexity and fullness of the lid–brow junction forms the upper aspect of a biconvexity that is divided by the lateral commissures and continues more caudally onto the lower eyelid and the lid– cheek junction.

·

Eyebrows do descend but this typically occurs at a later age (lateral greater than medial). The appearance of upper eyelid skin ‘excess’ is inﬂuenced by position and volume of the upper periorbita and eyebrow, and reduced skin elasticity. Volumetric deﬂation of the upper eyelid and lid– brow junction impart a ‘ﬂatness’ in appearance (replacing the fullness/convexity). The orbicularis oculi although in close anatomic proximity to skin, is less affected anatomically and histologically with age, but its function has signiﬁcant inﬂuence on periorbital soft tissue position.10

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Eyebrow position and volume The term brow ptosis suggests a descent of the eyebrow position from its ‘normal’ state. Obviously some younger individuals with ‘low’ brows may request a ‘change’ or improvement of their brow position much as one would desire otoplasty or rhinoplasty (Fig. 8-5). Additionally, many patients will present wishing for surgical correction to accomplish more pretarsal ‘show’ A for reasons that include creating more area to apply cosmetics, a mistaken memory of what their upper eyelid looked like in youth, or simply their desired outcome. A review of old photographs is most often revealing, yet the ultimate determination must rest on the choice of each individual patient. Careful analysis including the use of morphing techniques as shown by Lambros11 and others,12 repeatedly and consistently has shown that the deﬂationary effects from facial volume loss with age can yield the apparent and illu- B sionary effects of facial soft tissue ptosis. These misperFigure 8-7 A, This patient had undergone a four-lid ceptions include an illusion of brow ptosis in some blepharoplasty elsewhere and was unhappy with the individuals that is due to soft tissue volume depletion, appearance. Her concerns related to a lower appearance of particularly in the temporal and lateral infrabrow the eyebrow, a sunken appearance to both the upper and regions, which may have prompted a brow lift when lower eyelid and increased appearance of ‘wrinkles’. replacement of soft tissue volume has been shown to B, Restylane was administered in this patient to the lateral enhance aesthetics (Fig. 8-7)13 (see Chapter 23). There infrabrow region for brow lift effect with extended are also some individuals who would have comproapplication to the lower eyelid and lateral canthus to improve volume. mised aesthetic results by not undergoing the necessary brow lift. Which individuals then, beneﬁt from which procedures?

The upper eyelid crease and fold What has been less understood, are the actual changes that occur to the upper eyelid crease and fold. Often the position of the eyelid crease is obscured by the appearance of redundant upper eyelid skin and fold displacement. A careful analysis of the crease in most individuals shows varied change from youth. The changes may also be asymmetric in any one individual (Fig. 8-8). This includes an elevated crease that may manifest in one or both upper eyelids. The solution has been, in most cases, to raise the eyelid crease of the affected upper eyelid with the excision of ‘excess’ soft tissue with or without brow lift. This maneuver, however, is routinely and repeatedly performed without respect for the presenescent appearance or understanding of the actual age-related changes of the upper periorbita (Figs 8-2, 8-3, 8-6). The routine applications of traditional concepts in incision placement and soft tissue excision have also plagued some other technical aspects in upper blepharoplasty. The usual design of the upper eyelid crease

Figure 8-8 This patient presented with marked asymmetry of her upper eyelids that appeared to get much worse in recent years.

commonly involves the use of 10 mm or greater (height) eyelid crease incision with excision of skin, orbicularis oculi muscle, and preaponeurotic fat.7,8 This is customary whether or not upper blepharoplasty is performed with or without a brow lift. In part, the basis of this approach has been an attempt to elevate the upper eyelid crease, in essence, to expose a greater amount of the pretarsal surface and to ‘debulk’ the

Comparative anatomy and aesthetics of upper eyelid ptosis and periorbital aging upper eyelid fullness by en-bloc or separate resection of skin and muscle.8 This approach, however, facilitated additional steps in upper blepharoplasty that are also aesthetically detrimental, including better access to the preaponeurotic fat (resulting in further soft tissue reduction and volume depletion) and the levator aponeurosis for supratarsal ﬁxation. Concerns with a lower placed incision included possible visibility of the upper eyelid incision scar, inability to achieve adequate ﬁnal pretarsal exposure, and risk to the levator aponeurosis insertion to the pretarsal surface, especially when utilizing a full thickness skin muscle excision whether removed in separate ‘layers’ or ‘en-bloc.’ The long-term consequences of the traditional approach, however, can be suboptimal. Deep or ‘hollow’ upper eyelid sulci are common effects, presumably from overresection of soft tissue (Fig. 8-3), especially fat. In some, the upper eyelid crease scar becomes hypopigmented (Fig. 8-9) and usually more visible with time, usually at a much higher level (15–20 mm). This is especially true in the patient with a prominent globe, negative upper periorbital vector, or in those who habitually elevate their eyebrows for a variety of reasons. The color transition can also at times become quite obvious, as the upper edge of the incision is placed in the darker and thicker sub-brow skin. The pretarsal skin also becomes progressively less taut (more ‘crepey’ in appearance) due to the sliding effect

as most original points of ﬁxation have been compromised by over-dissection.

Comparative anatomy and aesthetics of upper eyelid ptosis and periorbital aging Some of the changes that can occur in the aging upper periorbita parallel the ﬁndings seen with true upper eyelid ptosis at any age. Alternative and improved surgical repair has shed light on the effects that can be created by alterations in the upper eyelid crease. Often in those with signiﬁcant blepharoptosis, there is an apparent, unusually elevated (from youth), upper eyelid crease, at times >15–20 mm (Fig. 8-10A). This is also typically associated with a deep, hollow, upper eyelid sulcus and apparent volume depletion from either fat atrophy or retraction of the central preaponeurotic fat pad. This is further accentuated by the patient’s subconscious efforts to raise the eyebrow in an attempt to elevate the upper eyelid to enhance visual function (Figs 8-10A, 8-11A). Although the mechanism for these latter changes has been challenged (in both

A

A

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B Figure 8-9 This patient, who had surgery performed elsewhere many years prior, exhibits many of the ﬁndings of a sub-optimal design for upper blepharoplasty including a high-placed eyelid crease, dyschromia, iatrogenic lid ptosis, and volume depletion.

Figure 8-10 A, This young patient exhibited severe upper eyelid ptosis and lateral canthal dystopia. The upper eyelid crease conﬁguration is similar to that occurring with volume loss with age as well as over-zealous resection of soft tissue (including fat). B, A more youthful and aesthetic appearance is achieved after upper lid ptosis repair by Müller’s muscle conjunctival resection that also lowers the upper eyelid crease.

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(posterior approach/soft tissue sparing such as the Müller’s muscle conjunctival resection) even combined with skin excisional blepharoplasty may improve the upper eyelid soft tissue plane relationships by recreating supratarsal volume that re-establishes the youthful upper eyelid appearance (Figs 8-10, 8-11, see Chapter 11). The analogy of the aging upper periorbita with upper blepharoptosis and a greater sense of the physiologic and anatomic changes that occur in upper facial aging suggest a more sound and logical approach for rejuvenation.

Advanced rejuvenative upper blepharoplasty from technique to aesthetics

A

B Figure 8-11 A, Similar to the previous ﬁgure, this patient presented for periorbital rejuvenation when she was made aware of her upper eyelid ptosis. B, After four-lid blepharoplasty and Müller’s muscle conjunctival resection for upper lid ptosis correction.

non-surgical and post-surgical14 states) I believe that it is, in part, a result of atrophic orbital effects causing loss of adherence of the multiple eyelid layers with subsequent loss of the lower positioned upper eyelid crease of youth. With this, the relationship of the levator aponeurosis and orbital septum loses the tight compartmentalization of the central preaponeurotic fat that is normally sandwiched between the levator aponerosis and orbital septum that now can retract into the orbit. Traditional methods of blepharoptosis repair using levator advancement or resection techniques have had much less predictable inﬂuences on the eyelid crease. These techniques led to variable excision of the skin and orbicularis oculi muscle, septum, and preaponeurotic fat in order to address the presumed levator aponeurosis dehiscence for repair. I believe this yields less aesthetic results and contributes to the appearance of upper periorbital aging. Minimally invasive surgical solutions to blepharoptosis repair15

A careful analysis of the goals in upper blepharoplasty should include an individualized approach that considers the patient’s desires and appearance in youth. Preoperative planning is essential, as it is to other facial aesthetic surgical procedures. This should include the appreciation of volume shifts manifesting brow and orbital fat malposition, volume loss manifesting either deepening of the upper sulcus or dermatochalasis, position of the upper eyelid crease currently and in youth, and attention to the brow position and contour. The incision placement, plane of dissection, soft tissue excision, and maintenance of orbital volume shifts, all inﬂuence the effects achieved in upper blepharoplasty. Surgical maneuvers in each of these areas can dramatically affect outcome. When done in error, these techniques can produce effects that are surgical in appearance, or when appropriately performed, can regain youth without the stigma of surgery. By keeping the crease incision low (i.e. lower portion of upper eyelid crease incision made at 7–10 mm), there is minimal disruption to the majority of the upper eyelid and crease structures (Fig. 8-12). The lower crease incision, as low as 7 mm, is usually reserved for some males or Asian upper eyelid conﬁgurations (see Chapter 9), while a majority of patients beneﬁt from eyelid crease incision in the 8–10 mm range. Those individuals with a deep upper eyelid sulcus either from hereditable factors or related to varying degrees of upper blepharoptosis that defer surgical correction of the lid malposition, are most appropriate for the higher 10 mm or more incision. Since there is commonly no advantage to involving the orbicularis oculi muscle, the excision should therefore include skin only (Fig. 813B). Although traditionally, a strip of orbicularis muscle at the lower edge of the wound is excised, there is no enhancement of rejuvenative effects with this

Advanced rejuvenative upper blepharoplasty from technique to aesthetics maneuver. Theoretic reasons for removing orbicularis to effect a scar at the lower skin edge most often results in disturbances in the existing upper eyelid layer attachments that can cause not only unpredicted cicatrizations, but long-term crepeyness of the pretarsal skin. Preservation of orbicularis also adds to upper eyelid

Upper demarcation follows brow contour

Lower demarcation 7–10 mm from lid margin

x x

x

7–10 mm

Medial extent at punctum

10–12 mm

Lateral extent 10–12 mm from lateral canthus

Figure 8-12 A careful evaluation and particular attention to precise incision planning can lead to a more accurate and youthful result and reduce the stigma of surgery. This serves as a guide to the most common presentations.

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volume enhancement by plicating the bulk of orbicularis muscle with approximation of the skin edges by skin closure (Fig. 8-14). This effect can also be more profound, physiologic, and predictable than that which can be accomplished by injecting autologous fat. Enhancing a limited transorbicularis cicatrix (via electrocautery) may be essential for realignment of the eyelid crease at this lower level by effecting adhesions through orbicularis muscle to the dermis at the lower edge of the incision in a more extensive and permanent way then suture ﬁxation. The suborbicularis ﬁbrosis achieved with cautery may be more important for both effecting an adherent relationship between skin– orbicularis, septum, and levator aponeurosis and drawing skin and orbicularis from the eyelid margin to effect a smoother pretarsal surface (Fig. 8-13). The upper eyelid and eyebrow relationship, I believe, has also been poorly understood in the traditional approaches to upper blepharoplasty. This may be why browplasty has been so freely offered or performed. The youthful upper eyelid fold in most patients is usually quite distant from the eyebrow. This relationship can be dramatically altered with over-excision of upper eyelid soft tissue in traditional blepharoplasty techniques. For instance, with typical skeletonization of the upper eyelid from over-resection of skin and fat with elevating the upper eyelid crease, individuals with even modest brow

C

Figure 8-13 A, Aging periorbita with loss of crisp upper eyelid crease attachments. B, Skin excision with complete preservation of orbicularis oculi muscle. Diathermy to the lower edge/pretarsal segment allows for a transorbicular cicatrix for re-establishment of the lower placed upper eyelid crease. C, Skin closure with orbicularis muscle intact causes an ‘accordion effect’ whereby volume is improved in the supratarsal segment.

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B

Figure 8-14 A higher magniﬁcation view of the prior ﬁgure in cross-section shows skin closure with intact orbicularis and the effect of orbicularis ‘bulking’ to improve supratarsal volume.

Lower positioned upper eyelid fold

Youthful fullness/volume

Raised upper eyelid fold

BFD=X’

BFD=X

A

Volume depletion, actual and apparent, from over-excision of skin/muscle/fat and elevated brow

B

Figure 8-15 The effect of a brow lift is oftentimes to reduce the diminished brow-to-fold distance (BFD) that is induced by over-zealous excision of soft tissue during traditional upper blepharoplasty. Furthermore, a brow lift will then expose the volume depletion created. This can often be avoided with more accurate incision design, excision, and preservation during upper blepaharoplasty.

ptosis would require browplasty in order to achieve greater aesthetics. This would in effect enhance the distance between the upper eyelid fold and the lower brow edge (brow-fold distance/BFD) (Fig. 8-15).16 Could we not accomplish however, in these individuals, a similar and possibly more rejuvenative and physiologically (as well as anatomically) correct effect by these more modern/advanced approaches with upper eyelid aesthetic surgery? In other words, by creating or maintaining the lower positioned upper eyelid crease with appropriate rejuvenative techniques we can achieve the same or improved brow-to-fold distance without the need for browplasty. Finally, volume considerations of the upper eyelid/ brow have been confused or mostly ignored. The deﬂationary effect afforded by soft tissue shifts and volume loss is what I believe contributes more to the appearance of (pseudo-) excessive upper eyelid skin and eyelid

fold changes than do gross changes in brow position or true skin excess. Similarly, although for no apparent aesthetic reason, the concept of excision of ROOF fat has been popularized. I believe that in most situations, there is no reason to cause this unaesthetic volume depletion by direct fat excision and we would fare better by a more physiological approach to the descended fat (i.e. repositioning). The debulking of the lateral upper eyelid orbicularis muscle has also been routinely performed with upper blepharoplasty and yields similar unaesthetic effects. Both of these added steps in upper blepharoplasty further reduce the browto-fold distance and thereby may compromise the youthful upper periorbital conﬁguration in many patients. Excision of orbicularis oculi also can add to brow ptosis as remaining functioning orbicularis can now more directly effect brow position with contraction that is reduced or nulliﬁed by preserving

Advanced rejuvenative upper blepharoplasty from technique to aesthetics 1. Fig. 8-17A: The design of the upper eyelid crease is determined by several factors including position of the native or senescent crease, brow position, and upper periorbital vector analysis. Typically, the crease demarcation is at 7–10 mm centrally in contrast to traditional approaches that have been at 10 mm or above and tapers slightly toward the eyelid margin medially and laterally. In the presence of any degree of brow ptosis, an attempt is made to lower the crease as much as possible. This allows for the effective (but conservative) skin excision with the upper edge of the elliptical demarcation, to be as distant from the thicker skin of the brow as possible. The brow-to-fold distance is thereby maximized to reduce the ptotic brow appearance. In the presence of the protuberant eye, the crease height is also set low as there is a tendency to have an accelerative cephalad crease migration in this situation. The medial extent of the crease demarcation is usually the upper lacrimal punctum and courses inferiorly toward the eyelid margin. The lateral extension of the upper eyelid

orbicularis muscle. Enhanced volume can also be effectively regained by autologous fat or hyaluronic acid injection (Fig. 8-7) to this area that can also have illusionary effects of eyebrow position.13 Fixation of the lateral periorbita and prevention of postoperative lateral brow descent can also be afforded by suspension of the lateral orbicularis to the adjacent orbital rim similar to the description by Zarem.17 A browpexy effect is also achieved through creative use of the lateral retinacular suspension4 (Fig. 8-16; see Chapter 15). Volume preservation yields the most aesthetic surgical remedy and combined with effective lateral browpexy achieved with retinacular suspension allows for rejuvenation of the lateral brow, crease, and commissure relationship afforded by enhanced blepharoplasty techniques.

Technique See Figure 8-17. My approach to upper blepharoplasty in the appropriate patient who has crease and volume alterations as described is as follows:

A

B Figure 8-16 A & B, Although lateral retinacular suspension is performed primarily for lower eyelid and canthal support with lower blepharoplasty, precise and accurate placement with exit of the suture at a higher level of the orbital rim through the periosteum can facilitate a browpexy effect with stabilization of the tail of the brow to avoid postoperative descent. The invagination and bolstering effect by this maneuver, also aids in a small way to give the illusion of enhanced volume in the infrabrow region.

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B

C

D

E

F

Figure 8-17 A, Skin demarcation for crease creation; here placed at approximately 9 mm centrally and tapering medially and laterally. The lateral extent will usually be around 10 mm or so depending on patient presentation. B, A ‘skin pinch’ technique is used to determine the amount of skin to excise. The endpoint is NOT the appearance of eversion of the lid/ lash margin and is usually the (maximum) amount that does not cause any change in the lid position with the pinch. C, The upper demarcation usually follows the contour of the eyebrow. This amount would be far too much if skin AND muscle were to be excised. D, After inﬁltration with local anesthetic the incision is followed closely and precisely to the demarcations. E, Diathermy is applied for hemostasis and especially to inferior wound edge to create a transorbicular cicatrix which is felt by the author to be even more effective than deeply placed crease sutures. Note: orbicularis oculi is completely intact. F, Through the intact orbicularis muscle, accurate and appropriate amounts of medial/orbital or (if necessary) medial/central preaponeurotic fat can be excised through a small ‘button hole’ incision.

crease that will serve as the lateral extent of the ﬁnal elliptical demarcation is dependent on similar conditions that determine the height of the crease. Lateral brow ptosis that will be more obvious and applicable in males, will require a more lateral extension of the crease/ellipse to remove the lateral ‘hood.’ The lateral extent of the demarcation is rarely greater than 10–12 mm from the lateral commissure. The protuberant eye will usually have less lateral hooding and therefore the lateral extent will be more conservative. 2. Fig. 8-17B: The determination of excessive skin is made by the ‘pinch technique’ and serves only as a guide to the maximum allowable skin resection. The endpoint is that of skin tautness without the eversion of the lash-margin. 3. Fig. 8-17C: The design of the ellipse is facilitated by drawing the upper elliptical edge that closely follows the contour of the brow. Usually, the amount of skin excision should ultimately be less than this speciﬁed amount. 4. Fig. 8-17D: The injection and inﬁltration of local anesthesia with epinephrine should be limited to the subcutaneous space, since this will be plane

of dissection (aided by hydraulic expansion by local anesthetic injection) and will limit ecchymoses by avoiding transorbicularis injury. The incision should be through skin only and dissection begins at the lateral ellipse with skin excision only. 5. Fig. 8-17E: Hemostasis is accomplished by monopolar cautery. Liberal application at the lower edge of the wound allows for creation of an adhesive interface at the lower edge of the wound. This facilitates establishment of the crease at this position, enhanced by transorbicularis ﬁbrosis that aids in crease establishment and causes a cephalad subcutaneous/muscular and septal/ aponeurotic adhesion. This ultimately maintains the tautness of the pretarsal soft tissue. 6. Fig. 8-17F: A small ‘button-hole’ through orbicularis muscle and orbital septum is made at the medial extent of the elliptical wound to accommodate medial orbital fat excision when necessary. Minimal, or none, of the preaponeurotic fat is reduced or excised and if necessary can also be retrieved from this small wound. In a rare situation, the orbicularis muscle of the upper eyelid, more centrally, can be

Results 97

A A

B

B Figure 8-18 Orbicularis muscle is entirely intact. This is one of the few areas in facial surgery where skin (only) excision and closure is aesthetically performed.

incised (not excised) at the highest portion nearest to the upper edge of the wound for further manipulation of the preaponeurotic fat. 7. Figs 8-18, 8-19: The upper eyelid wound is then closed with multiple interrupted 6-0 nylon sutures. If retinacular suspension is to be performed, the outer one-fourth of the wound remains ‘open’ until the lower blepharoplasty and canthopexy is performed and skin closure is then completed using the same nylon suture. Due to enhanced inﬂammation produced by cautery and the fact that skin is closed over a greater degree of upper eyelid

Figure 8-19 Skin closure with orbicularis muscle intact yields a volumetric enhancing effect.

bulk since the orbicularis muscle is plicated producing a desirable volume-enhancing effect with greater tension on the skin wound, the sutures remain for seven days with an opportunity to leave one or two of the interrupted sutures intact for 2 or 3 days longer. This is to avoid wound dehiscence.

Results The results using these concepts and techniques for rejuvenation of the upper periorbita are shown in Figures 8-20 to 8-33.

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A

A

B

B Figure 8-20 A, This patient presented for surgical correction of periorbital aging. Volume loss and shifts created a more visible medial pretarsal area and ‘hooding’ of the lateral upper eyelid. B, After volume enhancing upper blepharoplasty (and lower blepharoplasty).

Figure 8-21 A, This patient presented with periorbital aging at age 48. B, Volume enhancing upper blepharoplasty with lowering of the upper eyelid crease and lower blepharoplasty via lateral retinacular and orbicularis muscle suspension established youthful contours.

A A

B B Figure 8-22 A, This patient presented with awareness of volume loss of the upper periorbita left greater than right. B, Repositioning of the upper eyelid crease with volume enhancing upper blepharoplasty restored the (illusion) of ‘full’ upper eyelids that she had in younger years.

Figure 8-23 A, This patient of part Asian descent noted profound hooding and ‘skin excess.’ She recalls ‘never’ having signiﬁcant ‘pretarsal show’ but desired a slightly higher upper eyelid fold to place cosmetics. B, Surgery is performed as described with slightly higher placement of the crease incision.

Results 99

A A

B Figure 8-25 A, Although skin quality is rarely if ever improved with any surgical endeavor, the general appearance can be positively inﬂuenced, as shown here in a patient with arguable mild brow ptosis and severe periorbital elastosis. B, After volume-enhancing upper blepharoplasty combined with lower blepharoplasty.

B Figure 8-24 A, This patient, also of part Asian descent, noted a ‘ﬂatness’ to the upper eyelids with ‘hanging’ upper eyelid skin. B, Careful crease placement reduces ‘ﬂatness’ and regains the youthful upper eyelid volume.

A A

B B Figure 8-26 A, This patient, too, exhibits signiﬁcant brow ptosis and it was recommended to her to have a brow lift (which she refused) by several surgeons on various consultations. B, Volume enhancing upper blepharoplasty (with lower blepharoplasty) was performed that reestablished her youthful conﬁguration.

Figure 8-27 A, This patient presented for periorbital rejuvenation. She had mild Graves’ exophthalmos with minimal symptoms and desired a youthful, yet undetectable enhancement. B, After upper and lower blepharoplasty; maintaining a lower positioned upper eyelid crease and volume in individuals like her avoids the postoperative appearance of accentuated exophthalmos and the stigma of surgery.

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A

A

B Figure 8-28 A, This 40-year-old female had no concerns of an aging appearance with any other facial regions except ‘hooding’ of the upper eyelids. B, Volume enhancing upper blepharoplasty afforded a more youthful and aesthetic appearance without the stigma of surgery.

A

B

B Figure 8-30 A, Upper eyelid crease/fold asymmetry is more common and disconcerting with aging. B, Differential excision and crease placement is administered.

Figure 8-29 A, This patient presented for upper blepharoplasty. She complained of progressive ‘hanging’ of her upper eyelid skin. She was aware that she has always had only modest visibility of her upper eyelids due to ‘fullness’ that was present at youth. Nonetheless, she was strongly desirous of having more ‘pre-tarsal show’ than she had in youth, but felt after reviewing her options that this would be an aesthetic improvement that she would be happy with. B, After upper blepharoplasty with complete orbicularis preservation with placement of the eyelid crease at a higher (11 mm) level. Note despite the elevated lid fold that she has still regained a volumetric convexity in the supra-tarsal/infra-brow region.

Discussion 101

A

A

B

B Figure 8-31 A, This patient presented for improvement of the appearance of her upper periorbita. She also disliked the asymmetric appearance and liked her ‘left eye appearance much better than right.’ B, A higher crease placement was made with differential surgical excision to satisfy her requests.

Figure 8-32 A, This patient with dark skin presented for upper blepharoplasty 10 years after satisfaction with lower blepharoplasty performed with orbicularis and lateral retinacular suspension. She was bothered by progressive upper eyelid ‘hooding.’ B, After upper blepharoplasty. Accurate incision/crease placement and orbicularis muscle sparing allowed for symmetric youthful upper eyelid folds.

Discussion Unfortunately, as in many other areas of the face, the traditional approach to upper blepharoplasty has involved over-excessive incision/excision/dissection, disinsertion, and mobilization. This approach had also been customary in traditional browplasty, facelift, canthoplasty, lower blepharoplasty, and blepharoptosis repair. Similar and related results in upper blephaA roplasty are thereby encountered, such as an exaggerated postoperative regression from what appears to be an initially satisfactory result. Disappointment may then follow. Over-dissection of the anterior upper eyelid structures (orbicularis, levator aponeurosis, and septum) can result in loss of a tight adherences and conjoined fascial relationships of the anterior lid lamellar structures that are replaced by cicatrix of soft tissue layers that are not normally in contact with each other (skin to septum/tarsus etc.). This sometimes results in loss of normal upper eyelid function (including but not B limited to blepharoptosis and lagophthalmos), incarcerative brow descent, late cephalad migration of the Figure 8-33 A, This 35-year-old female disliked the upper eyelid crease, irregularity and loss of crispness appearance of her upper eyelids which she described as ‘puffy and hanging.’ B, After upper blepharoplasty. of the eyelid crease and crepeyness of the pretarsal

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Upper Blepharoplasty: Volume Enhancement via Skin Approach: Lowering the Upper Lid Crease skin. The illusion of volume depletion can also result by disruption and manipulation of the preaponeurotic fat pad, even when direct excision is avoided. Additionally, excision of orbicularis muscle has other potential detrimental changes including disruption of the deeper structures, the orbital septum and levator aponeurotic insertions. This can also result in a loss of the usual dynamic sliding/gliding14 effects only present in the non-operative or minimally traumatized state that can manifest as problematic cicatricial interface changes such as lagophthalmos or blepharoptosis. Lagophthalmos is usually due to a cicatrix involving the orbital septum. Blepharoptosis is often secondary to either simple levator aponeurotic disinsertion or a limiting mechanical effect from superior migration of the cicatrized orbital septum, orbicularis oculi, or overexcised skin. Disruption or excision of the preaponeurotic fat pad may also have effects on the native cushioned interaction of these multiple and complex soft tissue layers. Some dynamic function of the upper eyelid that could have potential effects on ocular lubrication may be lost. Lastly, whether addressing upper or lower blepharoplasty, the potential adverse effects to patients with borderline or manifest tear deﬁciencies by altering orbicularis function whether by cicatrization or denervation, must be borne in mind. Other aesthetic and functional considerations include the seemingly paradoxical effect of enhancing vertical palpebral aperture by extirpating orbital orbicularis. This is as a result of disturbing the antagonist relationship with the levator muscle and subsequent elevation of the upper eyelid margin (that has been also shown with chemodenervation10) as careful analysis of many postoperative photos may reveal an increase in the upper eyelid margin to pupil distance (MRD) of a small but signiﬁcant proportion. Fortunately, in many instances, this potential effect is probably coincidently nulliﬁed by a slight disinsertion or cicatrization (by septum) of the levator aponeurosis with this maneuver. The application of supratarsal ﬁxation, in the traditional sense, utilized these concepts with creation of adherences of the advancing edge of the levator aponeurosis to skin.18–21 On the other hand, the native fascial relationship can be almost entirely preserved or restored (even in situations of signiﬁcant asymmetry [Fig. 8-21]) by minimal dissection and excision with the added advantage of the improved real or apparent volume. Finally, aesthetics have been traditionally inﬂuenced by trendsetters, sometimes without anatomic basis. A high lid crease and deep upper sulcus may have at one time been the desired aesthetic effect (Fig. 8-1), however currently most fashion/supermodels display a ‘full’ upper eyelid with retained youthful volume and a lower positioned upper eyelid crease. Eyebrows have

been traditionally and routinely elevated, in part, to raise the upper eyelid skin fold in keeping with this trend. I believe the recent change in appeal actually reﬂects what is characteristic of the youthful eye and the desire to reproduce what we see on young faces. Simply visualize the periorbita of an adolescent youth or even a younger child. What is so strikingly apparent when carefully analyzed is the youthful volume that conceals any concern of the position of the (typically low) upper eyelid fold or brow. Despite these observations, we must consider whether these youthful characteristics are possible and/or appropriate in some individuals. For instance, the elderly female with a dramatic loss of skin elasticity and volume loss of the upper periorbita, individuals with a normally elevated eyelid crease, or those that simply prefer a higher lid fold, may simply be interested in improvement and symmetry rather than reversal. For a host of reasons, true rejuvenation may be difﬁcult and sometimes less preferable, and these individuals may be happier with an elevated eyelid crease with more ‘pretarsal show’ (Figs 8-30, 8-31) than a lower positioned upper eyelid crease. As in other areas of the face, a prospective analysis of the changes that occur in the upper periorbita and a greater appreciation of the anatomy of facial aging has provided for sound concepts and techniques toward rejuvenation. Precise patient selection and modiﬁcations based on presentation will always yield greater aesthetic effects.22

Conclusion We must educate all those who present for aesthetic surgery on what procedures will yield particular effects, which they may or may not be pleased with. This is inﬂuenced by preconceived notions of not only what to expect from surgery, but possibly what they have already been told, read, or seen in others. Some individuals will be understanding and completely convinced and satisﬁed and ultimately pleased with the results, while others may not. Despite all of our efforts to relay this useful information, there may still be the necessity for compromise as even enlightened patients may still desire and request effects that are not necessarily rejuvenative. Over 15 years of experience with this technique for upper eyelid aesthetic surgery suggests that this approach best considers the physiologic changes that occur in the aging of this region, and delivers results that are the most rejuvenative, with less stigmata of surgery. The illusion and reality of volume replace-

References ment are successfully achieved by surgical methods that are mindful of the necessity of enhancing and preserving the youthful eyelid crease and fullness of the periorbita that has been lacking with traditional excisional methods.

References 1. Flowers RS: Canthopexy as a routine blepharoplasty component. Clin Plast Surg 1993; 20:331. 2. Jelks GW, Jelks EB: Repair of lower lid deformities. Clin Plast Surg 1993; 20:417. 3. Glat PM, Jelks GW, Jelks EB, Longaker M: Evolution of the lateral canthoplasty: Techniques and indications. Plast Reconst Surg 1997; 100:1396. 4. Fagien S: Algorithm for canthoplasty. The lateral retinacular suspension: A simpliﬁed suture canthopexy. Plast Reconst Surg 1999; 103:2042. 5. 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. Oper Tech Plast Reconst Surg 1998; 5:121. 6. Hester TR, Codner MA, McCord CD, Nahai F, Giannopoulos A: Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: Maximizing results and minimizing complications in a 5-year experience. Plast Reconstr Surg 2000; 105:393. 7. Carroll RP, Mahanti RL: En bloc resection in upper eyelid blepharoplasty. Ophthal Plast Reconst Surg 1992; 8:47. 8. Perkins SW, Latorre RC: Blepharoplasty: A facial plastic surgeon’s perspective. In Romo T, Millman AL (eds): Aesthetic Facial Plastic Surgery: A Multidisciplinary Approach, pp 262–287. New York, Thieme Medical Publishers Inc., 2000.

9. Ramirez OM: Why I prefer the endoscopic forehead lift. Plast Reconstr Surg 1997; 100:1033. 10. Fagien S: Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: Adjunctive use in facial aesthetic surgery. Plast Reconstr Surg 1999; 103:791. 11. Lambros V: Restoring the Youthful Upper Eyelid. Panel. The Annual Meeting of the American Society of Aesthetic Plastic Surgeons (ASAPS). The New York Hilton; New York, NY. May 5, 2001. 12. Fagien S: Restoring the youthful upper eyelid. Panel. The Annual Meeting of the American Society of Aesthetic Plastic Surgeons (ASAPS). The New York Hilton; New York, NY. May 5, 2001. 13. Lambros V: Fat injection for the aging midface. Oper Tech Plast Reconstr Surg 1998; 5:129. 14. Siegel, RJ: Levator aponeurosis has dynamic insertion. Letter to the editor. Plast and Reconst Surg 2000; 106:735. 15. Putterman AM, Urist MJ: Muller’s muscle-conjunctival resection: Technique for treatment of blepharoptosis. Arch Ophthalmol 1975; 93:619. 16. Fagien S: Eyebrow analysis after blepharoplasty in patients with brow ptosis. Ophthal Plast Reconstr Surg 1992; 8:210. 17. Zarem HA, Resnick JL, Carr RM, Wootton DG: Browpexy: Lateral orbicularis muscle ﬁxation as an adjunct to upper blepharoplasty. Plast Reconstr Surg 1997; 100:1258. 18. Siegel RJ: Contemporary upper lid blepharoplasty – tissue invagination. Clin Plast Surg 1993; 20:239. 19. Flower RS: Upper blepharoplasty by eyelid invagination: Anchor blepharoplasty. Clin Plast Surg 1993; 20:193. 20. Sheen JH: Supra tarsal ﬁxation in upper blepharoplasty. Plast Reconstr Surg 1974; 54:424. 21. Ellenbogen R, Swara N: Correction of asymmetrical eyelids by measured levator adhesion technique. Plast Reconstr Surg 1982; 69:433. 22. Fagien S: Advanced rejuvenative upper blepharoplasty. Enhancing aesthetics of the upper periorbita. Plast Reconstr Surg 2002; 110:278.

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Upper Blepharoplasty in the Asian Patient William P. Chen Because the anatomy of the Asian eyelid differs from that of the Caucasian eyelid, I believe that a separate chapter emphasizing the difference is important. In the ﬁrst edition, I showed how to westernize, or occidentalize, the Asian appearance by constructing an eyelid crease similar to the technique used in Caucasians. It later became apparent that most Asians would like to enhance their appearance by having a crease that conforms with Asian features, and this chapter was added. William Chen describes the many variations in upper eyelid creases. He emphasizes that many Asians have what he refers to as a nasal tapering type of crease, in which the crease converges and tapers to the eyelid margin nasally, while other Asians possess a crease that is parallel to the eyelid margin. With a nasally tapered crease, it is important that the reconstructed upper eyelid crease extends to this inside nasal fold. Forming a parallel crease nasally in such a patient leads to a duplicated nasal crease and, frequently, to an unhappy patient. Dr Chen also emphasizes removing a small amount of preaponeurotic fat and pretarsal tissue. He creates an eyelid crease by suturing skin to the levator aponeurosis along the superior tarsal border, at 6.5–7.5 mm above the eyelid margin (10–11 mm in a Caucasian). I vary my technique slightly by excising the superior pretarsal tissues and by passing sutures through tarsus and then the levator aponeurosis and skin. I also have the patient sit up on the operating table to make sure that the creases are forming in the desired positions. Allen M. Putterman

A review of the medical literature published in English reveals more than 50 major articles describing upper eyelid surgery in Asians. Most of the articles describe the technique of construction of an upper eyelid crease in a patient without the crease. Authors of some of the earlier reports aimed to westernize the patient’s appearance, whereas other authors insisted on creating a crease alone and preserving the Asian features. In this chapter, before I review the steps of upper eyelid blepharoplasty in Asians, I explain the basic difference between Asians and Caucasians with respect to ethnic differences in eyelid creases, the anatomy of the face and upper eyelids, and the psychological and aesthetic needs of the patient.

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Ethnic differences Depending on the study and the population sampled, approximately 50 percent of the Asian population have upper eyelid creases (including Chinese, Koreans, and Japanese – all descendants of the Han race). The remaining 50 percent are not born with an eyelid crease or may have only rudiments of a crease. Asians who do not have an eyelid crease have been described as having ‘single eyelids.’ Those with a distinctive crease (‘double eyelids’) appear to have two segments of eyelid skin between the eyebrow and the eyelashes. The upper eyelid crease seems to be present in most Caucasians. A person with an eyelid crease appears to have a wider palpebral ﬁssure or a bigger eye than a person without an eyelid crease, even though the physical dimensions of the palpebral ﬁssures are the same.

Orbital fat

Orbicularis oculi muscle Orbital septum Levator aponeurosis Muller’s muscle Superior tarsus Conjunctiva

Inferior tarsus

Inferior orbital septum Orbicularis oculi muscle Malar fat pad

Psychological and aesthetic needs The desire of some Asian women to have an eyelid crease surgically formed as a way to beautify themselves (i.e. to have ‘bigger’ eyes) is sometimes perceived as an attempt to westernize (occidentalize) their appearance. In my opinion, most of the individuals who want to have an eyelid crease placed do not wish to appear Caucasian, although they are well aware that western surgical techniques make this cosmetic change possible. Some people argue that because very few of these operations were performed until after World War II, it must be the inﬂuence of westerners that catalyzed this enthusiasm for placement of an upper eyelid crease in Asians. From my extensive travels in Asia, it is my perception that this concept of beauty reaches even the most remote area and that the desire for ‘double eyelids’ did not start just in the last 60 years. These patients need only to be aware that such surgical procedures are available without necessarily wanting to resemble Caucasians or even knowing what westernized means. Furthermore, I do not believe that Asian patients who live in the Western Hemisphere want to have the procedure to blend in with Caucasians.

Anatomy Upper eyelids The difference between the Asian and Caucasian eyelid lies at the lower point of fusion of the orbital septum with the levator aponeurosis.1 In Caucasians (Fig. 9-1),

Suborbicularis oculi fat Orbital fat

Capsulopalpebral fascia

Figure 9-1 Schematic drawing showing a cross-section of Caucasian upper eyelid.

the orbital septum fuses with the levator aponeurosis at approximately 8–10 mm above the superior tarsal border, limiting the downward extent of the preaponeurotic fat pads while allowing the terminal interdigitations of the aponeurosis to insert toward the subdermal surface of the pretarsal upper eyelid skin, starting along the superior tarsal border and heading inferiorly. As a result, when the levator muscle contracts and pulls the upper eyelid up, the skin forms a crease above the superior tarsal border and the skin above the crease forms the fold. In Asians who do not have this crease (Fig. 9-2), as suggested by the anatomic studies of Doxanas and Anderson,1 the point of attachment of the orbital septum to the levator aponeurosis is lower, frequently as low as the superior tarsal border. This position allows the preaponeurotic fat pads to be present at a lower point on the upper eyelid, giving it a fuller appearance, and is found conjointly with a lack of attachment of the terminal strands of the levator aponeurosis from attaching to the subdermal surface of the pretarsal upper eyelid skin. The result is an apparently pufﬁer ‘single eyelid’ without a crease (Fig. 9-3A).

Preoperative counseling Orbital fat

Orbicularis oculi muscle Orbital septum Levator aponeurosis Muller’s muscle Superior tarsus Conjunctiva

Figure 9-2 A midsagittal section through an Asian upper eyelid without a crease. The orbital septum is usually seen fused to the levator aponeurosis along the superior tarsal border in an Asian without an upper eyelid crease.

Eyelid crease The conﬁguration of the crease in the upper eyelids of Asians varies greatly. As I describe in other publications,4–6 the crease may be absent in one eye (see Fig. 9-3A) and present in the other. It may be continuous (see Fig. 9-3B) or discontinuous (see Fig. 9-3C). The crease may be partial or incomplete (usually present from the medial canthal angle and then fading laterally) (see Fig. 9-3D), and there may be multiple creases on an eyelid (see Fig. 9-3E). Individuals who have a continuously formed eyelid crease may have either the inside-fold (nasal tapering) type of crease (see Fig. 9-3F) or a crease that is more parallel to the ciliary margin from the medial canthus to the lateral canthus (see Fig. 9-3G). With the inside-fold type, the crease may start from the medial canthal angle and gently ﬂare away from the eyelid margin as it reaches the lateral canthal region (lateral ﬂare) (see Fig. 9-3F); more often, it may start in the medial canthal angle and run fairly parallel to the ciliary margin from the middle of the eyelid onward. Asians rarely have an eyelid crease with a semilunar shape, as in Caucasians, in whom either end of the crease is closer to the respective canthal angle than the central portion of the crease (see Fig. 9-3H).

Preoperative counseling In terms of fat distribution and compartments, Uchida2 ﬁrst described the presence of four areas of fat pads in Asian eyelids:

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Subcutaneous fat. Pretarsal fat. Central fat pads, which are more appropriately termed submuscular or preseptal fat pads. Preaponeurotic fat pads, which he termed ‘orbital fat pads’.

Face Onizuka and Iwanami3 note that Asians, particularly the Japanese, have a ﬂat face and a head shape that is mesocephalic. The eyes tend not to be recessed deep in the orbit. These authors also ﬁnd the lateral canthus to be 10 degrees superior to the medial canthus. They believe that creating an upper eyelid crease and removing any upper lid hooding would make the palpebral ﬁssure appear wider and more open, which is aesthetically pleasing. I do not believe that all Asians have a lateral canthus 10 degrees above the medial canthus; however, certainly some of the other observations by these authors may be true.

The shape of the crease is clearly an important factor for the surgeon to discuss with the patient before surgery. The patient will need to be informed of the desirability of either a nasally tapered crease or a parallel crease and the undesirability of a semilunar crease, which is truly a Caucasian crease and appears incongruous on the face of an Asian. The ultimate decision, of course, rests with the patient. Nevertheless, none of my Asian patients chose the semilunar crease after I explained to them the different crease conﬁgurations and their prevalence in Asians. Most of the patients I encounter know what they want in terms of the crease conﬁguration and its degree of prominence. They may be unaware, however, that swelling accompanies the procedure or that sutures are used. These are important points that need to be addressed with the patient preoperatively.7

Surgical techniques There are two approaches to the creation of an upper eyelid crease: (1) conjunctival suturing and (2) external incision. The early champions of the conjunctival suturing technique include Mutou and Mutou,8 BooChai9 who practices external incision as well, and some

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G

H Figure 9-3 Schematic diagrams (A–G) showing the different conﬁgurations of creases in the Asian upper eyelid. A, Absence of a lid crease and fullness of upper eyelid. B, Continuous crease. C, Discontinuous crease. D, Incomplete crease. E, Multiple creases. F, Inside fold with tapering of the eyelid crease toward the medial canthal angle and gentle lateral ﬂare of the crease. G, Parallel crease. H, Typical Caucasian eyelid crease.

of the surgeons in Japan. The advantage is that it is a relatively non-invasive technique. The major drawback is that the crease may disappear with time. Early proponents of the external incision approach include Sayoc10–15 and Fernandez.16 This technique is preferred in the Western Hemisphere and is also practiced in Taiwan and Hong Kong.

Conjunctival suturing In the conjunctival suturing technique, the eyelid is ﬁrst anesthetized with local inﬁltration of lidocaine (Xylocaine). The upper eyelid is everted, and three doublearmed sutures are placed from the conjunctival side in a subconjunctival fashion above the superior tarsal

Surgical techniques border. Then either of the two following techniques is performed: Alternative 1: Both ends of the suture pass through to the skin side; then one end is again passed subcutaneously to exit through the second needle’s exit site on the skin. The two ends are tied and buried subcutaneously. (Or one end of the suture goes through the eyelid and exits through a stab skin incision; the other end goes through skin next to the stab incision and is repassed subcutaneously to join the ﬁrst suture that exited through the stab incision. The two suture ends are tied in the stab incision and buried.) The suture knot encompasses Müller’s muscle, levator aponeurosis, and some pretarsal orbicularis muscle, creating a scarring process between the subdermal tissue along the superior tarsal border and the levator aponeurosisMüller’s muscle complex. Alternative 2: Without piercing the skin, one end of the double-armed suture is passed through Müller’s muscle and levator aponeurosis to the subcutaneous plane along the superior tarsal border. With the needle staying subcutaneously, the suture arm is passed back through the same tissue and exits conjunctivally. The two ends of the suture are knotted and buried within the conjunctiva above the superior tarsal border. The effect is the same as that of the ﬁrst alternative. I have seen quite a few Asian patients who underwent these procedures overseas and complained of corneal irritation.

External incision I favor the external incision technique and perform it as follows. Premedication and anesthetic agents The patient usually receives 10 mg of diazepam (Valium) and 5 mg of hydrocodone (Vicodin) by mouth 1 hour before the procedure. One drop of topical anesthetic, 0.5 percent proparacaine (Ophthaine), is instilled on each cornea for comfort during surgical preparation. The upper eyelid receives a subcutaneous injection along the superior tarsal border, consisting of 0.25–0.5 ml of a mixture of 1 ml 2 percent lidocaine with a 1 : 100,000 dilution of epinephrine diluted with 9 ml of injectable normal saline. During the next 5 minutes, one can see the vasoconstrictive effect of the mixture even though the epinephrine was diluted ten times (1 : 1,000,000). The purpose of this preinﬁltration is to allow for a relatively painless injection because the pH of acidic 2 percent lidocaine is restored closer

to neutrality when it is diluted with the buffering action of injectable normal saline. Then I inject 0.5–1 ml of the 2 percent lidocaine with a 1 : 100,000 dilution of epinephrine (5 ml mixed with 100 units of hyaluronidase) in the suborbicularis plane along the superior tarsal border. The hyaluronidase promotes dispersion of the anesthetic and greatly reduces any tissue distortion. Rarely, when confronted with a patient with low tolerance to pain, I supplement the local ﬁeld inﬁltration with a frontal nerve block. The eyelids and face are then prepared in the usual fashion for ophthalmic surgery. The eyes are again given a drop of tetracaine for enduring corneal anesthesia. Corneal protectors are applied over each eye. Marking the eyelid crease With the eyelid everted, the vertical height of the tarsal plate over the central portion is measured with a caliper. In Asians, the vertical height of the tarsus is usually 6.5–8.5 mm. This measurement is then transcribed on the external skin surface on the central part of the upper eyelid using methylene blue on a ﬁne point. This marking directly overlies the superior tarsal border centrally. If a crease is to be nasally tapered, I mark the medial one-third of the incision line to taper toward the medial canthal angle or to merge with the medial canthal fold. The lateral one-third is marked in either a leveled or a ﬂared conﬁguration. For the parallel crease, the measured height of the superior tarsal border is drawn on the skin surface across the eyelids. To create adequate adhesions, it is necessary to remove some subdermal tissue. A strip of skin measuring approximately 2 mm is then marked above and parallel to this lower line of incision. Again, in the patient who desires a nasally tapered conﬁguration, I taper this upper line of incision toward the medial canthal angle or merge it with any medial canthal fold that may be present (Fig. 9-4A). Incision and excision An incision is then carried out using a No. 15 (BardParker) surgical blade along the upper and lower lines, and I cut just below the subcutaneous plane. Fine capillary oozing is stopped with a delicate bipolar (wetﬁeld) cautery (see Fig. 9-4B). The strip of skin is excised with scissors. The superior tarsal border is still covered by pretarsal and preseptal orbicularis oculi muscle, the terminal portions of the septum orbitale, and the anteriorly directed terminal ﬁbers of the levator aponeurosis behind the septum. Then I retract the incision wound superiorly and use a ﬁne-tipped monopolar

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Upper Blepharoplasty in the Asian Patient cautery in the cutting mode to incise through the orbicularis muscle and orbital septum along the upper skin incision. In Asians, even though the orbital septum is now only 2–3 mm above the superior tarsal border, it is readily opened, and preaponeurotic fat pads can be seen bulging forward in most cases. The septum is opened horizontally (see Fig. 9-4C), and this strip of preseptal orbicularis muscle and orbital septum hinged along the superior tarsal border is then carefully excised. Depending on the degree of fullness of the upper eyelid, either none or a small amount of the preaponeurotic fat pad is excised with sharp scissors (see Fig. 9-4D). Any bleeding points in the fat pads are controlled with light application of the wet-ﬁeld cautery. The fat excision often requires a small local supplement of lidocaine in the space beneath the preaponeurotic fat pads. The terminal portion of the levator aponeurosis is now seen along the superior tarsal border. To facilitate the infolding of the surgically created crease, I further excise a 2–3 mm strip of pretarsal orbicularis muscle along the lower skin incision (see Fig. 9-4E). Some authors routinely debulk the entire pretarsal tissue, believing that it is better to have only skin along the anterior surface of the tarsus. My experience has not been so, and I remove pretarsal tissue only if pretarsal fat is quite apparent and threatens the surgical formation of the desired upper eyelid crease. In the pretarsal plane of an Asian eyelid, there are very few, if any, terminal interdigitations of the levator aponeurosis to the dermis in a creaseless eyelid. I refrain from vigorous dissection along the pretarsal plane, as I believe that this creates long-term postoperative edema and increases the risk of the undesirable formation of more than one crease. Furthermore, Asians who have a natural eyelid crease often have some degree of pretarsal fullness along the area between the crease and the eyelashes. Skin closure To create adequate adhesion between the terminal portions of the levator aponeurosis above the superior tarsal border to the crease incision lines, I use 6-0 non-absorbable (silk or nylon) sutures to pick up the lower skin edge, the levator aponeurosis along the superior tarsal border, and the upper skin edge and then tie each of these as an interrupted suture (see Fig. 9-4F). Usually, besides the central stitch, two or three sutures are placed medially and two laterally. With these ﬁve or six crease-forming sutures in place, the rest of the incision may be closed with 6-0 or 7-0 nylon in a continuous or subcuticular fashion (see Fig. 9-4G).

Postoperative care The wound is cleaned daily and covered with antibiotic ointment. Diuretics and steroids are not usually given. The sutures are removed in 5–7 days, depending on the suture material.

Patient psychology: postoperative expectations Postoperatively, the eyelid crease invariably appears high; the patient should again be reminded after the operation that this seeming ‘overcorrection’ is from tissue swelling. I usually inform my patients to expect a certain degree of postoperative edema to last for at least two months and that the crease conﬁguration may vary from month to month and from one eyelid to the other. When the patients are instructed not to expect a stable and satisfactory appearance for 6 months, I ﬁnd that they are much more accepting of the normal wound-healing process (Fig. 9-5). I also inform my patients to expect a 5 percent chance of needing touch-up revisions if the crease formation is inadequate. This is a realistic estimate in my practice, and most patients feel comfortable with it.

Complications Complications are similar to those seen with any blepharoplasty operation and may include hemorrhage, grossly asymmetric creases, obliteration or fading of the crease, prolonged postoperative edema, hypertrophic scar formation, excessive fat removal with a hollowed eye appearance, and formation of multiple creases. The detailed description of correction of some of these problems is beyond the scope of this chapter. Interested readers may ﬁnd helpful ideas in References 5 and 17. I have seen other complications develop in two unusual cases. In one of my patients, the crease was obliterated after 6 months by proliferation of submuscular (preseptal) fat of the upper eyelid in conjunction with a 35 percent weight gain during recovery from anorexia nervosa. Another patient had a low tolerance to pain and hardly moved her upper eyelids for 1 week postoperatively; the crease formed poorly in this patient. Since then, I have encouraged my patients to practice upgaze and downgaze after the ﬁrst 48 hours to facilitate the formation of subdermal-levator aponeurosis adhesions.

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E F Figure 9-4 A, The vertical height of the central portion of the upper tarsus is transcribed onto the skin surface centrally. This serves as the central point for the lower line of incision, with the overall line dictated by the shape of the crease desired. The upper line of incision usually includes 2 mm of skin. B, After the incisions are made, a wet-ﬁeld cautery is applied for hemostasis and a surgical cautery is used to incise through the orbicularis oculi muscle along the superior incision site. C, The orbital septum is ﬁrst opened with a monopolar cautery along the upper line of incision. It is then extended horizontally with Westcott spring scissors. D, A small amount of the preaponeurotic fat pad is excised. E, From 2–3 mm of the pretarsal orbicularis muscle is excised along the inferior edge of the skin wound. F, Placement of an interrupted suture from the skin to the levator aponeurosis to the skin.

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reach adulthood; one possible explanation is development of the nasal bridge. Second, Asians tend to have more reactive skin and tend to have hypertrophic scarring in the thick medial canthal skin area. Third, a nasally tapered crease that merges with the origin or a mild epicanthus tarsalis provides an aesthetically natural eyelid crease, as observed in Asians who have a crease.

References

G Figure 9-4—cont’d G, Skin closure using placement of ﬁve to six interrupted 6-0 sutures to form the crease and a continuous suture to approximate the edges of the wound.

A

B Figure 9-5 A, Preoperative appearance. B, One month after upper blepharoplasty.

Epicanthal folds Medial canthal folds, as found in Asians, should not be equated to pathologic epicanthal folds as found in congenital blepharophimosis syndrome. The literature includes many articles dealing with this topic.18–29 I tend to be conservative in my treatment and, with few exceptions, refrain from correcting epicanthal folds in Asians, for several reasons:

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First, many Asians appear to have epicanthus palpebralis (a fold equally divided between the upper and lower eyelid) when they are young but then appear to have epicanthus tarsalis when they

1. Doxanas MT, Anderson RL: Oriental eyelids: An anatomic study. Arch Ophthalmol 1984; 102:1232– 1235. 2. Uchida J: A surgical procedure for blepharoptosis vera and for pseudo-blepharoptosis orientalis. Br J Plast Surg 1962; 15:271–276. 3. Onizuka T, Iwanami M: Blepharoplasty in Japan. Aesthetic Plast Surg 1984; 8:97–100. 4. Chen WP: Asian blepharoplasty. J Ophthalmic Plast Reconstr Surg 1987; 3:135–140. 5. Chen WPD: Asian Blepharoplasty and the Eyelid Crease, with DVD (second edition). Philadelphia, Butterworth Heinemann, 2006. 6. Chen WP: Concept of triangular, rectangular and trapezoidal debulking of eyelid tissues: Application in Asian blepharoplasty. Plast Reconstr Surg 1996; 97:212–218. 7. Chen WPD, Khan JA, McCord Jr CD: Color Atlas of Cosmetic Oculofacial Surgery (Textbook). Edinburgh, Butterworth Heinemann, Elsevier Science, 2004. 8. Mutou Y, Mutou H: Intradermal double eyelid operation and its follow-up results. Br J Plast Surg 1972; 25:285–291. 9. Boo-Chai K: Aesthetic surgery for the oriental. In Barron JN, Saed MN (eds): Operative Plastic and Reconstructive Surgery, vol 2, pp 761–773. New York, Churchill Livingstone, 1980. 10. Sayoc BT: Plastic reconstruction of the superior palpebral fold. Am J Ophthalmol 1954; 38:556–559. 11. Sayoc BT: Simultaneous construction of the superior palpebral fold and ptosis operation. Am J Ophthalmol 1956; 41:1040–1043. 12. Sayoc BT: Absence of superior palpebral fold in slit eyes. Am J Ophthalmol 1956; 42:298–300. 13. Sayoc BT: Surgical management of unilateral almond eye. Am J Ophthalmol 1961; 52:122. 14. Sayoc BT: Anatomic considerations in the plastic construction of a palpebral fold in the full upper eyelid. Am J Ophthalmol 1967; 63:155–158. 15. Sayoc BT: Surgery of the oriental eyelid. Clin Plast Surg 1974; 1:157–171. 16. Fernandez LR: Double eyelid operation in the oriental in Hawaii. Plast Reconstr Surg 1960; 25:257–264. 17. Weng CJ, Nordhoff MS: Complication of oriental blepharoplasty. Plast Reconstr Surg 1989; 83:622–628. 18. Johnson CC: Epicanthus. Am J Ophthalmol 1968; 66:939–946. 19. Verwey A: Der Maskenhafte Antlitz und seine Behandlung. Z Augenheilkd 1909; 22:241.

References 20. Lessa S, Sebastia R: Epicanthoplasty. Aesthetic Plast Surg 1984; 8:159–163. 21. Von Ammon FA: Klinische Darstellungen der Krankheit des Auges und Augenlider. Berlin, G Reimer, 1841. 22. Von Arlt CF: Erweiterung der Bidspalte Kantoplastik. In Graef-Saemisch Handbuch des Augenheilkunde, vol 3, p 443. Leipzig, Wilhelm Engelmann, 1874. 23. Berger E, Loewy R: Nouveau procédé opératoire pour l’épicanthus. Arch Ophthalmol 1889; 18:453. 24. Mustarde JC: The treatment of ptosis in epicanthal folds. Br J Plast Surg 1959; 12:252.

25. Converse JM, Smith B: Naso-orbital fractures and traumatic deformities of the medial canthus. Plast Reconstr Surg 1966; 38:147. 26. Spaeth EB: Further considerations on the surgical corrections of blepharophimosis (epicanthus). Am J Ophthalmol 1956; 41:61. 27. Spaeth EB: Further considerations on the surgical correction of blepharophimosis and ptosis. Arch Ophthalmol 1964; 71:510. 28. Blair VP, Brown JP, Hamm WG: Correction of ptosis in epicanthus. Arch Ophthalmol 1932; 7:831. 29. Matsunaga RS: Westernization of the Asian eyelid. Arch Otolaryngol 1985; 111:149–153.

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Upper Blepharoplasty Combined with Levator Aponeurosis Repair* John R. Burroughs, William M. McLeish and Richard L. Anderson Defects or stretching of the levator aponeurosis are the most common causes of blepharoptosis seen in patients seeking cosmetic eyelid surgery. Upper eyelid blepharoplasty lends itself well to simultaneous correction of blepharoptosis via repair of aponeurotic defects. Blepharoplasty without correction of a preexisting blepharoptosis may aggravate the blepharoptosis. There are several advantages to the use of a combined procedure: 1. Both procedures can be addressed at the same setting with the use of a single incision. 2. The procedures directly correct anatomic defects responsible for dermatochalasis and blepharoptosis and prevent further stretching of the aponeurosis. 3. The conjunctival surface is left undisturbed, leading to less postoperative edema, discomfort, and corneal irritation. The fact that none of the elements responsible for production of the trilaminar tear ﬁlm are removed decreases the potential for postoperative tear ﬁlm dysfunction. The technique of combined blepharoplasty with aponeurotic ptosis repair has proved tremendously successful and is applicable for many patients seeking cosmetic eyelid surgery. John R. Burroughs, William M. McLeish and Richard L. Anderson

Evaluation Preoperative recognition of ptosis is extremely important because postoperative eyelid height asymmetry will not go unnoticed by the scrutinizing patient and the blepharoptosis is frequently more apparent after excess skin is removed. A systematic preoperative evaluation of all patients desiring cosmetic eyelid surgery identiﬁes the presence of ptosis as well as other eyelid and upper facial maladies. The examination should also serve to thoroughly educate the patient and engender an amicable and trusting relationship between the patient and physician. *Dr. Burroughs and Dr. McLeish have no ﬁnancial disclosures. Dr. Anderson is a paid consultant of Allergan Pharmaceuticals, but otherwise has no ﬁnancial disclosures.

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Upper Blepharoplasty Combined with Levator Aponeurosis Repair The preoperative examination entails a thorough review of the physical relationships of the patient’s entire upper face. The heights and contours of the upper eyelids are noted with the forehead and eyebrows in a relaxed, natural position. An asymmetric or heavily furrowed brow often masks the presence of ptosis. Frequently, redundant upper eyelid skin must be gently elevated out of the way to visualize the lid margin and the natural eyelid crease, which is typically elevated by an aponeurosis disinsertion. The amount of levator function present should be recorded. Levator aponeurosis disinsertion results in ptosis with normal levator function. If the levator function measures less than 12 mm, the cause should be sought. The eyelid skin should be examined for scars from previous surgery or trauma. Any lagophthalmos should be noted, as its presence may help to identify a previously uncorrected congenital ptosis or the presence of signiﬁcant internal scar tissue or symblepharon. Bilateral ptosis with poor levator function may be the only feature of a systemic condition such as chronic progressive external ophthalmoplegia. Variable ptosis and levator function are classically associated with myasthenia gravis. Conditions associated with poor levator function require specialized care, and affected patients may not be candidates for a combined blepharoplasty and aponeurotic ptosis repair.

Upper eyelid crease Symmetry between the two upper eyelids is of paramount importance in achieving the desired cosmetic result. Correct placement of the eyelid crease incision, therefore, is one of the most important steps in the combined blepharoplasty and aponeurotic ptosis repair procedure. The central eyelid crease height should usually be 9–12 mm above the lid margin. It should taper temporally to a height of 5–6 mm above the lateral canthus and medially to 6–7 mm above the punctum. The conﬁguration of this incision roughly corresponds to the superior border of the tarsal plate, the level at which the levator aponeurosis normally sends ﬁbers through the orbicularis oculi muscle to the skin. The incision continues temporally approximately 1 cm beyond the lateral canthus in a natural skin crease. One should avoid the temptation to extend the incision beyond this point in an attempt to incorporate temporal crow’s feet (rhytids) into the excision. The skin beyond the lateral orbital rim is thicker and less forgiving than eyelid skin, and the incision scar in this area may be visible for months after surgery. Rhytids in the temporal region are best addressed by an upper

facial rhytidectomy and not through an ‘extended blepharoplasty’ procedure. Alternatively, Botulinum toxin A (Botox®), chemical peeling, and carbon dioxide (CO2) laser resurfacing has proved quite effective in the treatment of temporal rhytids and are an excellent treatment option for individuals who do not require extensive skin excision. During simultaneous aponeurotic ptosis repair, there is a tendency for the eyelid crease to establish itself lower than the originally desired height. This occurs when the surgeon must expose the tarsal plate to facilitate placement of tarsal sutures. If desired, the surgeon can counter this tendency by minimizing dissection to the superior border of the tarsal plate, by not excising any pretarsal orbicularis muscle, and by placing aponeurotic sutures at the desired eyelid crease height.

Surgical technique The skin incision is marked superiorly to circumscribe redundant skin and orbicularis muscle tissue. The surgeon establishes the proper amount of skin and muscle that can be safely excised by placing one blade of a smooth forceps on the marked eyelid crease incision and gently pinching sufﬁcient redundant tissue between it and the second blade of the forceps to cause the lid margin to just begin to evert. We use the extra ﬁne point skin marker by ScanlanTM (800-328-9458) as it has an ultra ﬁne tip and allows precise marking. This maneuver is repeated along the length of the eyelid crease incision, and the superior extent of the incision is marked with a pen at each location (Fig. 10-1A). As a general guide, the superior limb of the incision should be at least 10–12 mm below the inferior margin of the eyebrow at the midpupillary position to ensure adequate anterior lamella remains to allow for complete eyelid closure and to prevent iatrogenic brow ptosis. After the skin markings have been completed, the tissues are inﬁltrated with 2 percent lidocaine with 1 : 100,000 epinephrine to facilitate hemostasis, which takes place approximately 5–10 minutes following injection. No hyaluronidase is used, as it may enhance deep penetration of the local anesthetic, which may result in diminished levator function and subsequent difﬁculty adjusting the eyelid to the proper height. After anesthesia is obtained, a 4-0 silk traction suture may be passed through the upper lid margin and secured to the drape below for ﬁxation. The skin incision is made with a No. 15 Bard–Parker or diamond blade. The skin-muscle ﬂap is excised as a single unit with tenotomy scissors or a cutting cautery unit. Elevation of the skin-muscle ﬂap exposes the suborbicular

Surgical technique fascia plane and the orbital septum, greatly speeding the dissection and protecting the levator aponeurosis from iatrogenic damage (Fig. 10-1B). Hemostasis is controlled with bipolar cautery. We have found the non-stick SILVERGlideTM (800-259-6156) bayonet electrocautery forceps allow rapid cauterization of large areas without the need to frequently re-clean the tips during cauterization of multiple sites of bleeding. Novice surgeons may he unsure whether they are viewing the orbital septum or the aponeurosis at this point. By grasping the structure with a forceps and pulling inferiorly, the surgeon can immediately make the correct identiﬁcation. The orbital septum fuses with the arcus marginalis at the orbital rim and is immobile. In contrast, the levator aponeurosis travels inferiorly with little resistance and elevates if the patient is asked to look superiorly. Once identiﬁed, the septum is incised centrally. The septum is opened several millimeters above the tarsal plate, where the preaponeurotic fat protects the underlying aponeurosis from accidental injury. The opening in the septum is then extended the length of the eyelid incision. The central preaponeurotic fat compartment is bluntly teased into view. This fat is yellow and generally contains few vessels. The redundant fat can be sculpted with tenotomy scissors. We have found that clamping the fat before excision is not required and bleeding vessels are meticulously cauterized. Sculpting of fat should always be anterior to the orbital rim. The fat is generally trimmed to a level just outside the orbital rim. Caution must be exercised to not oversculpt, which will yield a displeasing aged appearing eyelid. The medial fat pocket is more extensive than the central pocket. It can be discerned from the medial compartment by its whiter coloration, thicker or denser consistency, and greater vascularity. Frequently, sharp lysis of normally occurring ﬁbrous septa is required before the fat in this compartment presents itself. Gentle retropulsion of the globe further enhances delivery of the fat. Hemostasis is particularly important in this region because the medial fat pad contains terminal branches of the ophthalmic artery and multiple large-caliber veins. Bleeding from these vessels can be signiﬁcant and, if inadequately controlled, can result in vision-threatening orbital hemorrhage.1 Furthermore, blind cautery in this area can lead to damage to the trochlea and to subsequent diplopia.2 For these reasons, we advocate care to not excise too much fat from the medial and central fat pockets because this can create a depression and hollowed appearance (Fig. 10-1C). Aggressive inferior dissection in this area can damage the medial horn of the levator aponeurosis, aggravating ptosis and ‘lateralization’ of the tarsal plate, as described by Shore and McCord.3

Temporally, the position of the lacrimal gland should be noted. A prolapsing lacrimal gland creates fullness in this area, which can masquerade as fat prolapse and even temporal brow ptosis.4 A prolapsed lacrimal gland needs to be repositioned within the lacrimal gland fossa. One should avoid the temptation to excise the gland, which will result in diminished aqueous tear production and dry eye symptoms. With the appropriate preaponeurotic fat now removed, the underlying aponeurosis is visualized. Rarely, a distinct disinsertion between the tarsus and the leading edge of the aponeurosis is encountered (Fig. 10-1D). This is easily recognized because the peripheral arcade running through Müller’s muscle just above the superior border of the tarsal plate is clearly visible. More commonly a rareﬁed and stretched aponeurosis or an aponeurosis with extensive fatty inﬁltration is found (Fig. 10-1E). At this point, a single-armed 5-0 polyglactin 910 (Vicryl) suture on a spatula needle is passed vertically in a partial-thickness fashion through the superior border of the tarsal plate just medial to the pupil. The suture position corresponds to the highest point of the natural eyelid contour. We have found that vertical suture passes produce a smoother eyelid contour and less tendency to cause eversion of the lid margin than the more frequently described horizontal mattress suture techniques. It is imperative that the suture bites be placed at the superior border of the tarsal plate to avoid creating an ectropion of the upper eyelid or lowering of the eyelid crease. The needle is then regrasped and passed through the disinserted edge of the levator aponeurosis (see Fig. 10-1D). No attempt is made to dissect the strongly adherent and vascular Müller’s muscle off the undersurface of the aponeurosis. Any bleeding is immediately controlled with a bipolar cautery to avoid creating a hematoma in Müller’s muscle, which can complicate adjustment of the eyelid height and contour. The suture is permanently tied. All subsequent suture passes between the aponeurosis and the tarsus will also be permanently secured at the time of the procedure. Other surgeons have advocated the use of temporarily tied, adjustable aponeurotic sutures, which can be manipulated during the perioperative period to alter the eyelid height as needed.5 We have found these sutures to be awkward to use; more importantly, they have not improved our results over spreading the incision apart and removing the deep suture if overcorrected in the 1–2 week postoperative period. With the central suture permanently set, the patient is asked to open his or her eyes, and the height of the

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A

B

C D

E

Figure 10-1 A, Ellipse of upper eyelid skin to be removed is outlined. B, Elevation of the skin and orbicularis oculi muscle ﬂap facilitates dissection just deep to the suborbicular fascial plane, thus helping to prevent iatrogenic damage to the levator aponeurosis. C, The medial fat pad and redundant central fat may be conservatively sculpted by sharp excision with tenotomy scissors. D, Alternative 1: The spontaneously disinserted edge of the levator aponeurosis is identiﬁed. The 5-0 polyglactin (Vicryl) sutures are passed vertically through the superior border of the tarsal plate and then passed through the disinserted edge of the levator aponeurosis. E, Alternative 2: Fatty inﬁltration of the levator aponeurosis. No distinct disinsertion is noted.

F

G

H

I

K J Figure 10-1—cont’d F, Alternative 2: Excision of the pretarsal orbicularis muscle bares the superior aspect of the tarsal plate. G, Alternative 2: The levator aponeurosis is elevated off the underlying Müller’s muscle to the desired level. H, Alternative 2: The 5-0 polyglactin sutures are passed vertically through the superior border of the tarsal plate and then through the levator aponeurosis at the desired height. I, Alternative 2: The redundant levator aponeurosis is excised. J, The 5-0 polyglactin sutures are secured. K, Skin closure with interrupted 6-0 plain gut sutures.

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Upper Blepharoplasty Combined with Levator Aponeurosis Repair eyelid is examined with reference to the superior limbus and the height of the contralateral eyelid. If the height of the eyelid margin appears appropriate, the patient may be placed in the sitting position and the eyelid height is reconﬁrmed if another check is desired. An eyelid height 1–2 mm higher than the intended ﬁnal position is usually ideal because the eyelid will settle as the effects of the epinephrine dissipate and orbicularis function returns. If the eyelid height is undercorrected, the suture is removed and repositioned higher on the aponeurosis. Once the desired height is achieved additional sutures may be passed in an identical manner at the temporal and nasal limbal positions (see Fig. 10-1D). Oftentimes, excellent eyelid height and contour may be achieved with only a single suture pass. The temporal suture if used should be undercorrected to avoid temporal ﬂare as temporal overcorrection is a frequent complication of surgeons just beginning with aponeurotic repair. Temporal suture placement is seldom used in our practice except in congenital cases or decreased levator function. Again, the height and contour of the eyelid are reassessed in up and downgaze. When an attenuated aponeurosis is still attached to the tarsus in blepharoptosis cases a thin strip of pretarsal orbicularis muscle and attenuated aponeurosis is excised along the superior border of the tarsal plate (Fig. 10-1F). This maneuver bares the superior border of the tarsal plate of the soft tissue and the aponeurotic adhesions and freshens the edge of the aponeurosis, which will ensure solid reﬁxation. This step may result in the lowering of the eyelid crease as already discussed. The 5-0 polyglactin sutures are passed through the tarsal plate in the manner previously described and are then passed through and above the leading edge of the aponeurosis. The amount of levator advancement and resection is determined by eyelid positioning as previously discussed. If more than 4 mm of aponeurotic advancement is required, the aponeurosis is sharply dissected off the underlying Müller’s muscle to the desired level, and the redundant aponeurosis is excised (Fig. 10-1, G–I). No attempt is made to resect Müller’s muscle. The lid height is again checked with the patient in both up and downgaze. If there is any question about the desired height of the eyelid, it is always safest to err on the side of overcorrection, as this can easily be corrected postoperatively. Once the appropriate eyelid height is reached, the temporal and nasal sutures may be placed if necessary (Fig. 10-1, H–J). The blepharoplasty incision is closed with 6-0 plain gut sutures (Fig. 10-1K). These sutures dissolve in 10–14 days, eliminating the need for suture removal. Interrupted sutures are preferred because they produce

better wound apposition and allow egress of postoperative wound ﬂuid. Only the skin layer is closed. The septum should never be incorporated into the closure because doing so could result in postoperative lagophthalmos. A redundant medial skin fold or ‘dog ear’ can he excised in a triangular fashion. Because the orbital septum is fully opened and the redundant preaponeurotic fat is sharply excised in addition to removal of a strip of pretarsal orbicularis muscle, a strong eyelid crease is achieved without the need for supratarsal ﬁxation sutures. We generally avoid the use of supratarsal ﬁxation sutures, as they have been associated with recurrent ptosis, epithelial inclusion cysts, suture abscesses, and asymmetric eyelid creases.

Adjunctive procedures Many of the patients presenting to us for ‘droopy’ eyelids have a component of both blepharoptosis and dermatochalasis. We therefore highly advise our patients to have both elements addressed. Even if the major problem is ptosis, we will usually remove an appropriate amount of any excess skin and ﬁnd that a wide, typical upper blepharoplasty incision to be cosmetically superior to smaller incision techniques. Adjunctive procedures that we often perform through the typical upper blepharoplasty incision include internal brow elevation, glabellar furrow reduction, and lateral canthopexy.6 We strongly encourage internal brow elevation for any patient who has less than 10 mm of skin between the upper eyelid crease and the inferior brow cilia and are not interested in more aggressive brow elevation. It is ideal for heavy ptotic brow fat pads. This procedure involves the sculpting of the brow fat pads, and release of the orbital ligament in the upper eyelids. The glabellar furrows may effectively be reduced by partially resecting the corrugator and depressor superciliaris muscles through the upper blepharoplasty incision, which gives a permanent Botox®-like effect and has been very useful for those with headaches in this area.7

Postoperative care Postoperatively, the patient is instructed to apply cold compresses to the eyelids for 2 days and to place lubricating drops and ointment in the eyes for several days to weeks until eyelid closure becomes complete. A mild to moderate amount of temporary lagophthalmos is expected postoperatively. Postoperative edema usually clears in 2–4 weeks, but if necessary a Medrol dose pack often helps in more severe cases. We have also

Results found arnica montana and vitamin C to reduce postoperative bruising and hasten resolution. Patients should refrain from taking aspirincontaining or non-steroidal anti-inﬂammatory products as well as garlic, ginger, ginkgo, ginseng, and mega-dose vitamin E for at least 2 weeks before surgery. They also should limit sun exposure to the incision sites to avoid skin and wound discoloration.

Complications The most common postoperative complications are mild lagophthalmos and exposure keratitis. In almost every case, these complications are self-limiting and respond to topical lubricants and eyelid massage. Other complications include occurrences of wound dehiscence, wound infection, temporary eyelash eversion, rare epithelial suture cysts, and allergic dermatologic and conjunctival reactions from antibiotic ointments.

Treatment of overcorrection and undercorrection

local anesthesia is required for this procedure. After the lid height is corrected, the wound is closed with one or two 6-0 plain gut sutures.

Undercorrection Signiﬁcant undercorrections are much more difﬁcult to correct. To repass sutures through the tarsal plate and aponeurosis, almost the entire length of the skin incision must be reopened. Once the height of the eyelid is reset, the contour must be readjusted. In effect, the procedure is repeated to correct an undercorrection. For this reason, it is best to achieve a slight overcorrection rather than an undercorrection in aponeurotic blepharoptosis repair. If an obvious undercorrection (>2 mm) needs to be repaired, it is best to do so within the ﬁrst two postoperative weeks to take advantage of the relative ease of dissection afforded by the original procedure. If the undercorrection is minimal (1 mm) or considerable swelling is present we advocate observation of the eyelid until the postoperative edema has cleared before any additional intervention is pursued. In cases with decreased levator function we have found some patients require a small superior tarsectomy to adequately elevate a signiﬁcantly ptotic eyelid.

Overcorrection Postoperative management of lid height asymmetry is relatively simple with the external aponeurotic ptosis repair and can usually be performed in the ofﬁce.8 Small overcorrections generally respond to gentle massage of the eyelid for 5–10 minutes four times a day. To accomplish this, we have the patient hold his or her eyebrow up with one hand while pushing the eyelid both down and in with the index ﬁnger of the other hand. This massage can begin as soon as the skin incisions have healed. Signiﬁcant overcorrections noted in the ﬁrst 10 days after the procedure can be corrected by opening a portion of the wound and removing one or more of the 5-0 polyglactin sutures suspending the aponeurosis to the tarsal plate. The area surrounding the eyelid crease incision is usually relatively free of sensation during the ﬁrst few days postoperatively, and typically, minimal

Results The combined upper eyelid blepharoplasty and external levator aponeurotic ptosis repair procedure has been performed in over 3000 patients over the past three decades (Figs 10-2 and 10-3). Good to excellent results, as determined by symmetric lid contour and central lid height within 1 mm of the desired position, were achieved with a single procedure in over 90 percent of patients. Primary overcorrections requiring removal of aponeurotic sutures in the ofﬁce occurred in less than 2 percent of patients; all instances were successfully corrected. Primary undercorrections were noted in fewer than 3 percent of patients. Some of these patients required a second procedure with more aggressive aponeurotic advancement. Late blepharoptosis recurrence

Figure 10-2 Preoperative (A) and postoperative (B) appearance following combined upper eyelid blepharoplasty and aponeurotic ptosis repair. A

B

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Figure 10-3 Preoperative (A) and postoperative (B) appearance following combined upper eyelid blepharoplasty and aponeurotic ptosis repair. A

B

(occurring more than 6 months following the initial procedure) was seen in less than 1 percent of patients. Most of these recurrences were in patients noted to have fatty inﬁltration of the aponeurosis at the initial procedure. At the time of the second operation, most of these patients were found to have attenuation of the aponeurosis immediately above the tarsal plate or increased degeneration and fatty inﬁltration. Very few true disinsertions were encountered. Presumably, the levator aponeurosis in this group of patients is inherently weak and prone to stretching and future degeneration. The technique of combined blepharoplasty with aponeurotic ptosis repair has proved tremendously successful. With a thorough knowledge of the eyelid anatomy, proper suture placement, and careful intraoperative assessment or heights and contours, the surgeon can accurately correct dermatochalasis and blepharoptosis using this technique in almost every patient seeking cosmetic eyelid surgery.

References 1. Anderson RL, Edwards JJ, Wood JR: Bilateral visual loss after blepharoplasty. Ann Plast Surg 1980; 5:288–292. 2. Wesley RE, Pollard ZF, McCord CD: Superior oblique palsy after blepharoplasty. Plast Reconstr Surg 1980; 66:283–287. 3. Shore JW, McCord CD: Anatomic changes in involutional blepharoptosis. Am J Ophthalmol 1984; 98:211–227. 4. Smith B, Petrelli R: Surgical repair of prolapsed lacrimal glands. Arch Ophthalmol 1978; 96:113–114. 5. Collins JR, O’Donnell BA: Adjustable sutures in eyelid surgery for ptosis and lid retraction. Br J Ophthalmol 1994; 78:167–174. 6. Burroughs JR, Bearden WH, Anderson RL, McCann JD: Internal brow elevation at blepharoplasty. Arch Facial Plast Surg 2006; 8:36–41. 7. Bearden WH, Anderson RL: Corrugator superciliaris muscle excision for tension and migraine headaches. Ophthal Plast Reconstr Surg 2005; 21:418–422. 8. Jordan DR, Anderson RL: A simple procedure for adjusting eyelid position after aponeurotic ptosis surgery. Arch Ophthalmol 1987; 105:1288–1291.

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CHAPTER 11

Müller’s Muscle–Conjunctival Resection–Ptosis Procedure Combined with Upper Blepharoplasty Allen M. Putterman and Steven Fagien Patients often present for cosmetic rejuvenation of the upper periorbita and the examination reveals both dermatochalasis and upper eyelid ptosis. In these situations it is both possible and preferable, to combine an upper blepharoplasty with ptosis surgery. Although this technique is commonly performed through an external approach with levator aponeurosis advancement or resection, many cosmetic surgeons do not appreciate the possibility of combining an internal Müller’s muscle–conjunctival resection with an external upper blepharoplasty, especially when the skin and orbicularis oculi muscle are excised and an eyelid crease is reconstructed. This chapter demonstrates how to combine a Müller’s muscle resection with an upper blepharoplasty, a procedure we have performed for many years. We have found that this combined procedure gives us both superior results compared with the levator aponeurosis procedure with upper blepharoplasty, especially in those patients that desire a lower positioned upper eyelid crease and/or whose upper eyelids elevate to normal levels after administration of phenylephrine. The phenylephrine test also can be helpful in identifying candidates for this combined procedure. Allen M. Putterman and Steven Fagien

The Müller’s muscle–conjunctival resection–ptosis procedure, described in 1975 by Putterman and Urist, is a technique in which Müller’s muscle in the upper eyelid is partially resected and advanced.1 The exact mechanism by which the correction of ptosis is achieved is probably due to a number of effects that include resection and advancement of Müller’s muscle as well as the secondary effects of advancing the levator aponeurosis to the superior tarsal border. The classic approach to the treatment of a variety of lid ptosis presentations has been mostly through variations of an external (skin-muscle incision) approach through the upper eyelid crease whereby the anatomic ‘defect’ is visualized and presumably repaired (see Chapter 10). This approach, however, more often requires the cooperation of the patient during the surgical procedure and heralds a host of potential variabilities that include, but are not limited to, sedative effects, local anesthetic

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Müller’s Muscle–Conjunctival Resection–Ptosis Procedure Combined with Upper Blepharoplasty effects, edema, and performance anxiety on both the patient’s and surgeon’s part. To the contrary, the Müller’s muscle conjunctival resection can be performed with continuous IV sedation or even general anesthesia as it does not require intraoperative patient cooperation. The procedure is used to treat a variety of upper eyelid ptosis and can be combined with an upper blepharoplasty with or without crease reconstruction via a skin ﬂap or a skin-muscle ﬂap approach. The procedure has the many advantages over other ‘posterior approach’ lid ptosis procedures and the external approaches that includes the preservation of upper eyelid tarsus (which creates less risk of sutureinduced keratopathy and theoretically preserves structural and functional aspects of the upper eyelid), repositions the elevated (involutional) eyelid crease to a lower positioned and more youthful level, and can more predictably improve upper eyelid position (MRD) and contour. In addition, the usual skin-muscle and fat excision that is performed for a host of reasons, including adequate exposure to the levator aponeurosis (that can be volume depleting to the upper eyelid), can be avoided if desired. There also is rarely a need for additional surgery to treat residual ptosis or overcorrections. This procedure that was originally felt to be effective mostly in individuals with only mild to moderate upper eyelid ptosis and/or had a positive response to neosynephrine eye drops, can in fact be applied in most all types of ptosis presentations.

Diagnosis and preoperative evaluation Two tests are done preoperatively to determine optimal candidates for the Müller’s muscle–conjunctival resection procedure:

· ·

Margin reﬂex distance-1 (MRD1) measurement. Phenylephrine test.

MRD1 test The MRD1 measurement is used to assess the upper eyelid levels (see Chapter 3, Fig. 3-8). It should be performed both before and during the phenylephrine test. The difference in MRD1 between the normal and ptotic sides indicates the degree of ptosis. The normal MRD1 ranges from approximately 3.0 mm to 4.5 mm, and this value is used as a reference in bilateral cases. The MRD1 measurement has the advantage of being able to quantify the ptosis alone without the palpebral ﬁssure width. This is preferred because there is a

Müller’s muscle in the lower eyelid that can also respond to phenylephrine. Measuring the palpebral ﬁssure width would lead to an erroneous interpretation of the upper eyelid level after instillation of phenylephrine.

Phenylephrine test The MRD1 is again measured, this time after instillation of 2.5 percent or 10 percent phenylephrine drops. The patient can be partially reclined and their head is tilted backward, the upper eyelid is lifted, and the patient is instructed to gaze downward. Several drops of phenylephrine are dripped between the upper eyelid and the globe. To minimize the entry of phenylephrine into the nasal cavity and the potential side effects of systemic absorption in those potentially at cardiovascular (rare) risk, the examiner or patient may use the ﬁnger to digitally compress the canaliculi for 10 seconds. Topical anesthetic is often useful to reduce or avoid the stinging that can occur with application of neosynephrine. This step may be repeated immediately two more times. One minute later, two additional drops may be applied. Three to ﬁve minutes after instillation of the phenylephrine, the MRD1 is measured. Side effects, such as myocardial infarction and hypertension, have been reported after instillation of phenylephrine drops,2 but are exceedingly rare. Therefore, it is important to determine that the patient does not have a signiﬁcant cardiac risk before the phenylephrine test is performed. In our collective experience this has, however, rarely posed a problem but if there is ever a signiﬁcant concern then the patient’s primary care physician or cardiologist should be consulted. Glatt and Putterman3 have compared test results using 2.5 percent and 10 percent phenylephrine. It appears that both solutions are effective in determining candidates for the Müller’s muscle–conjunctival resection procedure, but that the 2.5 percent solution may theoretically result in fewer vasoactive side effects. Our experience has been primarily with the 10 percent solution. Patients should be warned regarding the likely pupillary dilation after this test which may yield transient photophobia and visual blurring. If there is a history of glaucoma, it may be prudent to contact their ophthalmologist regarding any concerns of pupillary dilation. Finally, regarding other symptomatology after these tests, it is not uncommon for patients to experience transient ocular irritation that might relate to dryness or exposure symptoms and indicate to the surgeon the possibility of dry eye symptoms after surgery.

Surgical technique

Indications The procedure is primarily used to treat blepharoptosis in patients whose upper eyelids elevate after phenylephrine administration as described. Candidates for this procedure usually have minimal congenital contribution to their ptosis, may present with varying degrees of acquired unilateral or bilateral ptosis, or may have had prior unsuccessful external approach lid ptosis surgery. The procedure is especially useful in those individuals who have had upper blepharoplasty where the lid ptosis was unsuccessful or not addressed, and where additional external approach surgery may be both difﬁcult and/or risky. In rare situations, this procedure can be performed with good results in those people who respond poorly to neosynephrine. It is our preferred method of upper lid ptosis correction in those individuals who demonstrate ptosis and also present for upper blepharoplasty.

Goal of the operation The procedure should result in highly cosmetically acceptable upper eyelid levels and contours on both sides, restoration of the youthful eyelid crease, as well as improvement of vision in those with demonstrable visual loss related to upper eyelid malposition, especially on downgaze during reading. It provides a more global aesthetic periorbital solution for individuals who present for cosmetic blepharoplasty and exhibit the varying degrees of unilateral or bilateral blepharoptosis.

Surgical technique Anesthesia Local anesthesia is preferred in adults. The upper eyelid skin to be removed is marked according to the technique for upper blepharoplasty with crease reconstruction (see Chapter 7) or without crease reconstruction (see Chapter 8) (Fig. 11-1A). A frontal nerve block is used with local anesthesia to avoid swelling and bruising of the upper eyelid by local inﬁltration, which would make the operation more difﬁcult and inexact.4 After the upper eyelid is marked for blepharoplasty and the chosen sedative is administered, a 23-gauge retrobulbar needle is inserted into the superior orbit, entering just under the midsuperior orbital rim lateral to the supra-orbital notch (Fig. 11-1B). The needle hugs the roof of the orbit during insertion until a depth of up to 4 cm is reached; then 1.5 ml of 2 percent lido-

caine (Xylocaine) with epinephrine is injected. Alternately, bupivicaine (Marcaine) may be used to prolong the anesthetic effect. Another 0.5 ml of the anesthetic solution is injected subcutaneously over the central upper eyelid just above the lid margin (where a traction suture of 4-0 silk is placed), and a small amount may be injected under the lines marked on the upper eyelid (Fig. 11-1C).

Marking areas of excision and resection A scratch incision is made over the marked upper blepharoplasty demarcations (Fig. 11-1D). A 4-0 black silk traction suture is inserted through skin, orbicularis muscle, and superﬁcial tarsus 2 mm above the lashes at the center of the upper eyelid. Care must be taken to avoid a full thickness penetration with this maneuver and injury to the corneal surface. A medium-sized Desmarres lid retractor is used to evert the upper eyelid and to expose the palpebral conjunctiva from the superior tarsal border to the superior fornix. Topical tetracaine drops may be applied over the upper palpebral conjunctiva especially when light or no sedation is administered. A caliper set at the determined amount of resection (i.e. 8.5 mm in a unilateral repair in those whose neosynephrine test restored the upper eyelid to the desired position), with one arm at the superior tarsal border, facilitates insertion of a 6-0 black silk suture through the conjunctiva 8.5 mm above the superior tarsal border (Fig. 11-1E). One suture bite centrally and two others approximately 7 mm nasal and temporal to the center mark the site. The preferred placement of the 6-0 black silk marking suture is 8.5 mm above the superior tarsal border (in those individuals with unilateral ptosis whose neosynephrine test brings them to a symmetric and satisfactory postion), but the suture may be placed 4.0–9.5 mm above the border if the response of the upper eyelid level to the phenylephrine test is slightly greater or less than desired. The smaller resections (in the 4.0–6.0 mm range) are typically more technically difﬁcult to administer using the prescribed clamp, described below. The placement of this marking suture should be through conjunctiva only as penetration to and through Müller’s muscle may cause signiﬁcant bleeding.

Separation of Müller’s muscle from the levator aponeurosis A toothed forceps is used to grasp conjunctiva and Müller’s muscle between the superior tarsal border and the marking suture and to separate Müller’s muscle from its loose attachment to the levator aponeurosis (Fig. 11-1F). This maneuver is possible because

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Figure 11-1 A, Outline of skin or skin and orbicularis oculi muscle to be excised. B, Administration of anesthesia before the Müller’s muscle–conjunctival resection. A 4-cm, 23-gauge retrobulbar needle is inserted along the central orbital roof to its full length. An injection of 1.5 ml of 2 percent lidocaine with epinephrine achieves a frontal nerve block and avoids inﬁltration of the eyelid. C, A second injection of 0.5 ml of 2 percent lidocaine with epinephrine is given subcutaneously over the central upper eyelid above the lashes. D, Scratch incision over marked upper eyelid.

Müller’s muscle is ﬁrmly attached to conjunctiva but only loosely attached to the levator aponeurosis (see Chapter 5).

Clamp application Although this procedure can be performed with a variety of clamps and other instruments, it is much more easily and precisely performed with a particular

instrument made for this procedure. One blade of this specially designed Müller’s muscle–conjunctival resection–ptosis clamp (Bausch & Lomb Storz Company, Manchester, MO) should be placed at the level of the marking suture. Each tooth of this blade engages each suture bite that passes through the palpebral conjunctiva (Fig. 11-1G). The Desmarres retractor is then slowly released (with the handle of the retractor brought from the

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H Figure 11-1—cont’d E, The upper eyelid is everted over a Desmarres retractor, and a 6-0 black silk marking suture is placed through conjunctiva 4–9.5 mm above the superior tarsal border. One suture bite is taken centrally, and one bite is made 7 mm nasal and temporal to the central bite. F, A toothed forceps is used to separate the conjunctiva and Müller’s muscle from its loose attachment to the levator aponeurosis at various sites between the upper tarsal border and the marking suture. G, A clamp is positioned so that each tooth of one blade engages each site of the marking suture; the other blade is above the superior tarsal border. H, As the Desmarres retractor is gradually released through rotation, the other clamp blade slides over tarsus as its teeth engage conjunctiva and Müller’s muscle above the superior tarsal border.

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Müller’s Muscle–Conjunctival Resection–Ptosis Procedure Combined with Upper Blepharoplasty resting cephalad postion to a caudal position) as the other blade of the clamp engages conjunctiva and Müller’s muscle adjacent to the superior tarsal border (Fig. 11-1H). Any entrapped tarsus is then released from the clamp with the surgeon’s ﬁnger (Fig. 11-1I). The clamp is compressed, and the handle is locked. This leads to the incorporation of conjunctiva and Müller’s muscle between the superior tarsal border and the marking suture. The upper eyelid skin is pulled in one direction while the clamp is pulled simultaneously in the opposite direction (Fig. 11-1J). During this maneuver, the surgeon may feel a sense of attachment between the skin and the clamp. If this occurs, a greater amount of the levator aponeurosis may have been inadvertently trapped in the clamp. In this situation, the clamp should be released and reapplied into its proper position. This maneuver is possible because the levator aponeurosis sends extensions to orbicularis muscle and skin to form the lid crease (see Chapter 5).

Suturing and resection of conjunctiva and Müller’s muscle With the clamp held straight up/vertically, a 5-0 doublearmed plain catgut mattress suture is run 1.5 mm below the clamp along its entire width in a temporal to nasal direction in a horizontal mattress fashion, through the upper margin of the tarsus on one side and through Müller’s muscle and conjunctiva on the other side, and vice versa (Fig. 11-1K and L). The sutures are placed approximately 2–3 mm from each other. The surgeon uses a No. 15 surgical blade to excise the tissues held in the clamp by cutting between the sutures and the clamp. The knife blade is rotated slightly, with its sharp edge hugging the clamp (Fig. 11-1M). As the tissues are incised and separated from the clamp, the surgeon and the assistant watch to ensure that the plain catgut sutures on each side are not inadvertently severed by this maneuver. Bleeding will likely be encountered after this incision and almost always ceases once the conjunctiva is closed. Injudicious use of cautery at this point might also result in an inadvertent severing of the plain catgut suture which will prove problematic and therefore should be avoided. The Desmarres retractor is used again to evert the eyelid while gentle traction is applied to the 4-0 black silk centering suture. The nasal end of the suture is then run continuously in a temporal direction; the suture passes should be about 2 mm apart through the edge of superior tarsal border, Müller’s muscle, and conjunctiva (Fig. 11-1N). Commonly, this suture just connects the edges of conjunctiva.

During continuous closure with the 5-0 plain catgut suture, the surgeon must be careful to avoid cutting the original mattress suture. This is facilitated by the surgeon’s using a small suture needle (S-14 Spatula, Ethicon) in addition to observing the mattress suture position during each suture bite during the conjunctival closure, and by the assistant’s applying continuous suction or swabbing with cotton-tip applicators along the incision edges. If the original horizontal mattress placement is too close to the clamp edge (within 1.5 mm or so) then this will be more difﬁcult. The 5-0 plain catgut suture ends are passed through each side of the conjunctiva and Müller’s muscle before they exit through the temporal end of the incision (Fig. 11-1O). Once each arm of the suture reaches the temporal end of the eyelid, the suture ends are connected with a serreﬁne clamp. This is done to ensure that this suture is not inadvertently cut with the skin-muscle ﬂap of the upper blepharoplasty procedure to follow and, if so, it can be more easily identiﬁed. Alternately, if a skin ﬂap upper blepharoplasty (without muscle excision) is performed, the suture can be tied (described below) at this time.

Upper blepharoplasty Several milliliters of same anesthetic solution is injected subcutaneously over the upper eyelids. Then an upper eyelid blepharoplasty is performed (as described in Chapters 7 and 8) through the steps of skin5 or skin and orbicularis muscle resection, excision of fat, and completion of hemostasis (Fig. 11-1P); however cautery should be minimized to avoid cutting the plain suture. If not already performed, the eyelid is again everted with a Desmarres retractor, the 5-0 plain catgut suture arms are tied with 4–5 knots, and the ends are cut close to the knot. In this way, the knot can be buried subconjunctivally, lessening postoperative keratopathy and surface irritation. After this step, the crease sutures are placed and the skin is closed (see Chapter 7) (Fig. 11-1Q). If no crease is reconstructed, the skin is sutured at this time, as described in Chapter 8.

Postoperative care Patients are observed postoperatively, as with blepharoplasty in general, to make sure that there is no excessive bleeding or possibility of retrobulbar hemorrhage, which has the potential for causing blindness. The patient applies cold compresses to the eyelids for the ﬁrst 24 hours postoperatively. A topical antibiotic such as gentamicin (Garamycin) or a combination antibiotic/ corticosteroid (TobraDex) ophthalmic ointment on the

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Figure 11-1—cont’d I, Before locking the clamp, the surgeon slides out any entrapped tarsus. J, The closed clamp includes 4–9.5 mm of conjunctiva and Müller’s muscle just above the superior tarsal border. Clamp and skin are pulled in opposite directions to ensure that the levator aponeurosis is not caught in the clamp. K and L, A 5-0 plain catgut mattress suture runs in a temporal to nasal direction about 1.5 mm distal to the clamp; each suture bite includes upper tarsus, Müller’s muscle, and conjunctiva. M, Conjunctiva–Müller’s muscle is excised by running a No. 15 surgical blade against the edge of the clamp. N, The nasal suture arm runs continuously in a nasal to temporal direction through the edges of conjunctiva, Müller’s muscle, and tarsus.

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Figure 11-1—cont’d O, Each arm of the suture passes through conjunctiva and Müller’s muscle and exits through the temporal incision; the suture arms are tied. P, Excision of outline ellipse of skin and orbicularis muscle with a disposable cautery. Q, Placement of three 6-0 polyglactin (Vicryl) sutures uniting skin and levator aponeurosis. A 6-0 continuous silk suture closes the skin. Parts B, C, and E–O, Modiﬁed from Putterman AM, Fett DR: Müller’s muscle in the treatment of upper eyelid ptosis: A ten-year study. Ophthalmic Surg 1986; 17:354–356. With permission.

eye can be used once or twice a day for the ﬁrst week or two. The patient may also use a sterile eyewash applied to cotton pads to wipe over the eyelids twice a day for 2 weeks after surgery. Patients are instructed for the ﬁrst 2 weeks after surgery to bathe or shower only from the neck down and to wash their hair so as to avoid an abundant contact of soap and water with the eyes.

Results The average follow-up is 3.3 months, but varies from 2 weeks to 7 years. Follow-up generally lasts until the patient’s eyelids cease to change. The MRD1 at stabilization of lid levels is considered the ﬁnal result. In most patients with acquired ptosis (90 percent in the experience of AMP), the ﬁnal eyelid level after treatment is within 2 mm of the opposite eyelid. In 88 percent of these treated eyelids, an MRD1 of 1.5–5 mm is achieved.6

Patients with congenital ptosis have a ﬁnal eyelid level after treatment within 1.5 mm of the opposite eyelid. In 84 percent of these treated eyelids, an MRD1 of 2.5–5 mm is achieved. Rarely, in less than 2 percent of patients, additional surgery may be required to treat residual ptosis. This is most often achieved with a levator aponeurosis procedure (see Chapter 10). However in rare situations an internal-approach resection may be repeated. Occasionally, the upper eyelid is too high (overcorrection). If this elevation occurs, the patient massages the upper eyelid downward while simultaneously ﬁxating the brow 2–4 times each day for 1–4 weeks. If a gross overcorrection is encountered in the ﬁrst 7–10 days, the plain suture can either simply cut or cut and excised followed by massage until the satisfactory eyelid position is achieved. If massage is ultimately ineffective or does not bring the upper lid to an optimum level, an external levator recession may be performed.

Alternative techniques

Alternative techniques The Müller’s muscle–conjunctival resection procedure has an advantage over the Fasanella–Servat procedure because it allows the tarsus to be preserved.7,8 This also carries less risk of suture keratopathy because the sutures are at the superior tarsal border instead of 3– 4 mm closer to the eyelid margins, as in the Fasanella

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procedure. This operation is also superior to the levator aponeurosis advancement/resection procedures because results are much more predictable and there is less need for subsequent surgery.8,9 We have collectively performed this procedure on more than 2000 upper eyelids. In a report of results in 232 of the treated lids, 230 lids had levels that were considered cosmetically acceptable (Figs 11-2, 11-3, 11-4, 11-5, 11-6).6

Figure 11-2 A, Preoperative appearance of a patient with bilateral upper eyelid ptosis associated with dermatochalasis (excessive skin) and herniated orbital fat of all four eyelids. B, After instillation of phenylephrine in both upper fornices with elevation of both upper eyelids. C, After a bilateral Müller’s muscle–conjunctival resection– ptosis procedure and excision of skin, orbicularis muscle, and orbital fat from both upper eyelids with eyelid crease reconstruction.

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Figure 11-3 A, Preoperative appearance of a patient with upper eyelid ptosis associated with dermatochalasis and herniated orbital fat of all four eyelids. B, After instillation of phenylephrine in both upper fornices with elevation of eyelids to normal levels. C, After bilateral Müller’s muscle–conjunctival resection– ptosis procedure with excision of skin, orbicularis oculi muscle, and orbital fat from the upper eyelids and eyelid crease reconstruction. A lower eyelid external blepharoplasty using a skinmuscle ﬂap approach (see Chapter 16) was performed simultaneously.

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B Figure 11-4 A, Preoperative appearance (oblique view to illustrate apparent volume/crease changes) of a patient with bilateral upper eyelid ptosis with associated dermatochalasis and herniated orbital fat of all four eyelids. B, After bilateral Müller’s muscle–conjunctival resection–ptosis procedure with excision of upper eyelid skin without orbicularis oculi muscle excision and medial orbital fat combines with lower blepharoplasty using a skin ﬂap approach and lateral retinacular suspension canthoplasty (see Chapter 15). Note how despite excising upper eyelid skin, the repositioning of the upper eyelid crease at a lower level restores the (illusion) of volume to the upper periorbita. Courtesy of Steven Fagien.

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B Figure 11-5 A, Preoperative appearance of a patient with unilateral right upper eyelid ptosis with associated dermatochalasis and herniated orbital fat of all four eyelids. B, After right Müller’s muscle–conjunctival resection–ptosis procedure with excision of upper eyelid skin without orbicularis oculi muscle excision and medial orbital fat combines with lower blepharoplasty using a skin ﬂap approach and lateral retinacular suspension canthoplasty (see Chapter 15). Note again how despite excising upper eyelid skin, the repositioning of the right upper eyelid crease (via the Müller’s muscle ptosis surgery and upper blepharoplasty) at a lower level restores the illusion of volume to the upper periorbita to achieve symmetry. Courtesy of Steven Fagien.

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B Figure 11-6 A, Preoperative appearance of a patient with bilateral upper eyelid ptosis (right much greater than left and the patient only perceives the ‘droop’ on the right side) with associated brow ptosis, dermatochalasis and herniated orbital fat of all four eyelids. The patient refused a brow lift. B, After right 4.0 mm Müller’s muscle–conjunctival resection–ptosis procedure with excision of upper eyelid skin without orbicularis oculi muscle excision and medial orbital fat combines with lower blepharoplasty using a skin ﬂap approach and lateral retinacular suspension canthoplasty (see Chapter 15). Note again how despite excising upper eyelid skin, the repositioning of the right upper eyelid crease (via the Müller’s muscle ptosis surgery and upper blepharoplasty) at a lower level restores the illusion of volume to the upper periorbita to achieve symmetry. The appearance of improved upper periorbital volume by skin excision with orbicularis muscle preservation also reduced the worsening of the brow ptosis while improving the appearance of the upper eyelids. Courtesy of Steven Fagien.

References 1. Putterman AM, Urist MJ: Müller’s muscle–conjunctival resection: Technique for treatment of blepharoptosis. Arch Ophthalmol 1975; 93:619. 2. Fraunfelder FT, Scaﬁdi A: Possible adverse effect from topical ocular 10% phenylephrine. Am J Ophthalmol 1978; 85:447–453. 3. Glatt HJ, Fett DR, Putterman AM: Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis. Ophthalmic Surg 1990; 21:173. 4. Hildreth HR, Silver B: Sensory block of the upper eyelid. Arch Ophthalmol 1976; 77:202–231.

5. Fagien S: Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper periorbita. Plast Reconstr Surg 2002; 110:278. 6. Putterman AM, Fett DR: Müller’s muscle in the treatment of upper eyelid ptosis: A ten-year study. Ophthalmic Surg 1986; 17:354–356. 7. Fasanella RM, Servat J: Levator resection for minimal ptosis: Another simpliﬁed operation. Arch Ophthalmol 1961; 65:493–496. 8. Putterman AM, Urist MJ: Müller’s muscle–conjunctival resection–ptosis procedure. Ophthalmic Surg 1978; 9:27–32. 9. Jones LT, Quickert MH, Wobig JL: The cure of ptosis by aponeurotic repair. Arch Ophthalmol 1975; 93:629–634.

CHAPTER 12

Internal Brow Lift: Browplasty and Browpexy Allen M. Putterman An internal brow lift offers the patient a method of raising the eyebrow without any additional incisions or scars; however, it is useful only for mild brow ptosis that is conﬁned to the central and temporal aspect of the eyebrow. The technique does not lift the nasal brow, reduce excessive tissue above the nose, or treat overaction of the corrugator or procerus muscle. Nonetheless, I have been using this technique for several decades and ﬁnd it invaluable in many cases. Allen M. Putterman

There are some patients who have a unilateral brow ptosis that leads to asymmetric upper eyelid creases and folds (Fig. 12-1). In these patients, the internal brow lift not only makes the brows more symmetrical but also helps symmetry of the upper eyelid creases and folds. There are also many patients who do not demonstrate signiﬁcant brow ptosis preoperatively. Before blepharoplasty, these patients keep their brows lifted almost constantly to reduce excessive upper eyelid skin folds. After upper blepharoplasty, these patients no longer have to lift their brows to be able to see better and, therefore, develop ptotic brows. The internal brow lift is thus advantageous in this group of patients, as well. The surgeon can identify such a patient preoperatively by evaluating brow levels with patient’s forehead muscles in repose. Some cases of upper eyelids ‘fullness’ are due to a thickened temporal brow fat. In this group of patients, excision of brow fat through a blepharoplasty signiﬁcantly improves the effect of traditional blepharoplasty. The internal brow lift (browpexy) and excision of excessive brow fat (browplasty) are important adjunctive procedures in selected blepharoplasty patients.1–3

Anatomic considerations The eyebrow and its surrounding soft tissues represent a specialized anatomic region of the face and the superﬁcial sliding muscle plane of the forehead. Cadaveric studies by Lemke and Stasior4 have helped to deﬁne the brow-eyelid anatomic unit and its importance in repair of brow ptosis and dermatochalasis. A fat pad exists beneath the eyebrow, from which dense attachments secure the brow to the supraorbital ridge. This fat pad enhances eyebrow

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Figure 12-1 Patient with unilateral ptotic eyebrow which leads to asymmetrical upper eyelid folds.

motility, especially laterally, where it is most pronounced (Fig. 12-2A). The brow fat pad often extends inferiorly into the suborbicularis fascia-preseptal plane in the upper eyelid and can be mistaken for orbital fat by the novice blepharoplasty surgeon (Fig. 12-2B). Both the size and position of the brow fat pad contribute to the gender differences in eyebrow appearance, which the surgeon must take into consideration. In women, the brow is generally arched and above the level of the supraorbital rim; in men, it is ﬂatter and positioned at the level of the supraorbital rim. The fat pad in men is more prominent, producing a fuller appearance in the lateral brow area. Surgical manipulation of the size and position of the fat pad should respect these variations in men and women so that a natural and aesthetically pleasing result is obtained. Early ptosis of the brow occurs most commonly over the lateral brow. The ﬁrm attachments of the brow fat pad to the supraorbital rim periosteum extend only over the medial one half to two thirds of the orbit around the supraorbital ridge prominence. Laterally, the attachments are weaker. In addition, the frontalis muscle of the forehead supports the medial two thirds of the eyebrow and interdigitates with the orbicularis muscle. However, because the frontalis muscle ﬁbers do not extend as far laterally as the lateral brow, frontalis muscle contraction cannot effectively prevent lateral eyebrow ptosis. The supraorbital artery and nerve emanate from the supraorbital notch and pass superiorly within the medial portion of the eyebrow fat pad. For this reason, fat pad debulking and internal eyebrow lifting should involve only tissue lateral to the supraorbital notch, so

that damage to the sensory nerves of the forehead is avoided.

Indications Dermatochalasis (excessive skin) can often be dramatically improved with simple upper blepharoplasty alone. When ptotic eyebrows accompany dermatochalasis, however, they often accentuate the upper eyelid abnormality and should be taken into consideration during surgery. Debulking of the sub-brow fat pad via the blepharoplasty incision is an effective way to reduce the excessive fullness occasionally present in the lateral brow and can produce a more aesthetic overall result. This browplasty procedure is particularly important in women, in whom a thickened sub-brow fat pad can create a masculine appearance. In patients with mild to moderate brow ptosis, plication of the brow above the supraorbital rim through the blepharoplasty incision can reduce the brow component of the upper lid dermatochalasis. This is especially helpful in patients with unilateral brow ptosis with asymmetric eyelid creases and folds. (In these patients a traditional upper blepharoplasty will lead to persistence of the asymmetric upper eyelid creases and folds.) This restores the natural height and curvature of the brow, thus enhancing the result of blepharoplasty. Although the coronal and endoscopic forehead lift procedures provide the most pronounced correction of forehead and glabella laxity, these techniques may be more extensive than the patient or surgeon desires. It

Browplasty in selected patients with ‘fullness’ of the lateral brow in whom there is no signiﬁcant element of brow ptosis. Many patients have mild to moderate brow ptosis or unilateral brow ptosis without a signiﬁcant thickening of the sub-brow fat pad. Although the debulking aspect of the browplasty procedures is not necessary in these patients, occasionally some amount of sub-brow fat needs to be removed so that periosteum for browpexy can be exposed. (However, I have gained respect for the sub-brow fat providing an aesthetically pleasing appearance and therefore either leave it intact or do a minimal incision in most cases.) I have also found the internal brow approach to be useful in lowering an abnormally high eyebrow that occurs from ﬁxation of the brow to periosteum from trauma.5 In these cases the brow is sutured to the level of the superior orbital rim.

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Surgical technique The amount of brow lift desired is determined while the patient is seated on the operating table. The site of the blepharoplasty is marked in the upper lid crease, and the supraorbital notch is palpated and marked to localize the supraorbital nerve and vessels (Fig. 12-3). The patient can then be reclined, and the upper eyelid and brow inﬁltrated with 2 percent lidocaine with epinephrine.

Browplasty

B Figure 12-2 A, Frontal illustration of a ptotic left brow. The brow and the sub-brow fat pad extend below the orbital rim (dotted line), and brow ptosis is more prominent temporally. B, Midsagittal illustration of the ptotic brow with inferior extension of the sub-brow fat pad anterior to the orbital septum. Note the relation of the thick ptotic sub-brow fat pad anterior to the orbital septum and orbital fat.

should be emphasized that the internal browpexy procedure does not replace conventional brow lifts and should not be done in patients with severe brow ptosis (see Chapter 6). The browpexy and browplasty procedures described later can be used together or separately as an adjunct to standard blepharoplasty in carefully selected patients. The browplasty technique can be used alone

After the standard blepharoplasty excision of the skin and orbicularis muscle, the dissection is extended superiorly toward the brow in the submuscular plane in the postorbicularis fascia (Fig. 12-4A and B). Dissection should extend approximately 1–1.5 cm above the superior and lateral orbital rim. The brow fat pad can then be identiﬁed overlying the lateral orbital margin. As has been emphasized, excision of the fat pad should be conﬁned to the lateral aspect of the brow to avoid injury to the medial supraorbital neurovascular complex. Only partial sub-brow fat is removed as some fat should be retained over the orbital bone to avoid a depression of skin in this area. Following identiﬁcation and exposure of the brow fat pad, an elliptical section measuring 1–1.5 cm vertically and tapering nasally and temporally can be marked with methylene blue (Fig. 12-5A). The fat pad is then removed on bloc from the central third of the superior orbital margin and laterally as far as the frontozygomatic structure (Fig. 12-5B). The fat pad should be removed down to, but not including the periosteum but leaving a thin layer of fat over the periosteum. The periosteum and

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Figure 12-3 The supraorbital notch is marked, and a line is made above the brow to indicate the location of the supraorbital nerve.

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a superﬁcial layer of fat should remain intact so that adhesions can be avoided in an area designed for motility. Also, some fullness in this area is aesthetically desirable. If brow ﬁxation or elevation is not desired, the blepharoplasty can then be completed.

Browpexy Fixation or plication of the brow to the supraorbital rim periosteum can provide elevation of the ptotic or lax brow. One to three 4-0 polypropylene (Prolene) sutures are passed transcutaneously from the lower edge of the brow hairs into the previously dissected sub-brow space approximately 1 cm apart (Fig. 126A). The transcutaneous introduction of the sutures allows the surgeon to mark the position of the brow hairs while working underneath the dissected ﬂap. Each suture is then passed through periosteum approximately 1–1.5 cm above the supraorbital rim (Fig. 12-6B). At this stage of the procedure, the height and curvature of the brow can be adjusted according to the patient’s gender. Placing the more central suture slightly higher allows the characteristic arch of the female brow to be restored or preserved. The sutures are then passed again into the sub-brow muscular tissue at the level of the original transcutaneously passed marking suture (Fig. 12-6C). It is important to engage ﬁrm subcutaneous tissue so that the polypropylene browpexy sutures have the desired effect. The surgeon must, however, avoid suturing into the very superﬁcial sub-brow tissues. This can lead to a dimpling of the skin as well as erosions of superﬁcial tissues over the sutures and exposure of the sutures.

B Figure 12-4 A, A frontal illustration of browplasty. A skin-muscle eyelid crease approach is used to expose the sub-brow fat pad. The plane of dissection is in the submuscular postorbicularis fascia. B, Midsagittal illustration of browplasty.

The original transcutaneous suture end is then pulled through the skin under the ﬂap. The sutures are tied carefully over a 2–3 inch piece of 4-0 silk knot releasing suture in an attempt to avoid overtightening the 4-0 polypropylene loop (Fig. 12-6D). The patient is sat up on the operating table and the brow position is studied. If the brow is too high or low or if the arch is unsatisfactory, then the 4-0 silk suture is pulled to release the Prolene tie and the suture is replaced until

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Figure 12-5 Illustrations of browplasty technique. A, After an eyelid crease incision is made, the upper eyelid skin is retracted superiorly. The thick sub-brow fat pad is exposed and marked with methylene blue. B, The surgeon uses a cutting-cautery unit to resect the superﬁcial sub-brow fat pad, leaving the periosteum and a thin layer of sub-brow fat intact.

the desired brow position is achieved. Ideally, these subcutaneous sutures should provide a mild browlifting effect and still allow the brow a good range of mobility (Fig. 12-6E). I perform the internal brow lift with the septum still covering the levator aponeurosis to avoid a high upper eyelid crease from forming by orbicularis muscle attaching to the levator. Once the brow is placed in the proper position, I penetrate the orbital septum and suborbicularis fascia and then excise herniated orbital fat. When I form a lid crease by suturing skin to levator aponeurosis, I also include the inferior edge of the orbital septum-suborbicularis fascia. This technique provides a layer between orbicularis muscle and levator aponeurosis and avoids the complications of a crease that is too high and an eyelid that will not elevate properly. Once the brow is set in the proper position, the surgeon penetrates the orbital septum and suborbicularis fascia. This is achieved by pulling the upper lid downward with a 4-0 silk traction suture that has been placed through central skin, orbicularis and superﬁcial tarsus. The orbital septum and suborbicularis fascia are picked up with toothed forceps and pulled upward and outward. The tented inferior aspect of the septum and suborbicularis fascia is penetrated with Westcott scissors until the subseptal space can be see (Fig. 12-7A). The area then is widened by spreading the scissors blades.

With the eyelid still kept in this position with traction suture and forceps, one blade of the Westcott scissors is used to penetrate the central opening in orbital septum-suborbicularis fascia and is slid across the temporal eyelid. Cutting with the Westcott scissors proceeds anteriorly, and the septum-suborbicularis fascia is cut at its inferior aspect (Fig. 12-7A). The maneuver is repeated over the nasal half of the orbital septum-suborbicularis fascia. The maneuver creates a ﬂap of septum-suborbicularis fascia that has an inferior edge close to the superior tarsal border (Figs 12-7B and C). An eyelid crease is formed by attaching three 6-0 white polyester ﬁber (Mersilene) sutures from the orbicularis muscle of the lower skin ﬂap to levator aponeurosis. Next, three 6-0 white polyglactin (Vicryl) sutures are sewn to connect skin to levator aponeurosis and to the inferior edge of the septum-suborbicularis fascia ﬂap (Figs 12-7D and E). One of these sutures is placed centrally, and one is placed nasally and temporally. The skin is closed with a 6-0 black silk suture run continuously.

Complications One complication of internal brow lifts is dimpling of the skin in the area of the sutures if they pass too close to the skin. Most of the time, this problem

A D

B

E

C Figure 12-6 Illustrations of internal browpexy technique. A, A 4-0 polypropylene (Prolene) suture is passed transcutaneously from the lower edge of the brow hairs into the previously dissected sub-brow space. B, The 4-0 polypropylene suture is sewn through the remaining sub-brow fat and periosteum above the orbital rim. C, The suture is then passed again into the sub-brow muscular tissue at the level of the original transcutaneously passed marking suture. The transcutaneous suture is removed. D, The surgeon ties the suture in a loop over a 4-0 silk knot releasing suture if adjustment is necessary. Care is taken to avoid overtightening the suture once adequate placement is achieved, which may immobilize the brow. E, Midsagittal section of completed browpexy.

Complications 141

A

B

D C

Figure 12-7 A, After the brow has been elevated through internal ﬁxation sutures, the suborbicularis fascia-septal layer is entered at its inferior position and is severed temporally and nasally. This is facilitated by pulling the upper eyelid downward with traction suture while lifting the central orbicularis fascia-septal tissue upward and outward with a forceps. B, Two toothed forceps grasp the inferior edge of the suborbicularis fascia-septal tissue after it has been severed from its inferior attachment slightly above the superior tarsal border. C, The surgeon uses two toothed forceps to lift the suborbicularis fascia-septal layer upward and outward, thereby exposing the orbital fat and levator aponeurosis. D, Orbital fat is occasionally excised, and the levator aponeurosis is attached to the superior edge of the tarsal orbicularis. Then 6-0 polyglactin (Vicryl) sutures pass through the inferior skin edge, levator aponeurosis, and inferior edge of the suborbicularis fascia-septal layer and exit through the superior skin edge. Three sutures are placed to add to formation of the crease and to ensure that the suborbicularis fascia-septal layer covers the levator aponeurosis. E, Cross-section of eyelid and eyebrow, as depicted in Fig. 12-7D.

E

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Internal Brow Lift: Browplasty and Browpexy can be determined during the surgical procedure and replacement of the suture can avoid the complication. If dimpling is noted postoperatively, it will usually resolve in a few months, but if not, then massaging the area frequently resolves the problem. In a few patients in whom I originally performed the internal brow lift, a high upper eyelid crease was created that made it difﬁcult for the patients to look upward. The patients found this crease objectionable. One possible cause of this complication is that the orbital septum and the suborbicularis fascia slid upward with the brow elevation. This allowed the orbicularis oculi muscle to fuse to levator aponeurosis at a high level. To help prevent this complication, I perform the excision of skin and orbicularis and browpexy or browplasty without penetrating the orbital septum and suborbicularis fascia. Once this is accomplished, I penetrate orbital septum and suborbicularis fascia, excise herniated orbital fat, and perform eyelid crease reconstruction. I then incorporate the inferior edge of the orbital septum-suborbicularis fascia ﬂap to the inferior edge of the levator aponeurosis and to each edge of the skin wound. This technique enhances the crease and forms a barrier between the orbicularis muscle and the levator aponeurosis. I believe that this modiﬁcation decreases the potential complication of a high upper eyelid crease, which would cause the patient difﬁculty in looking upward. Complications of the browpexy and browplasty procedures, as with routine blepharoplasty, are few but notable. During exposure and debulking of the subbrow fat pad, the surgeon may notice a signiﬁcant venous plexus lying below and within the fat pad. Approximate cautery may be necessary to obtain adequate hemostasis and prevent postoperative hematoma. In addition, removal or disruption of this venous network may contribute to prolonged postoperative eyelid edema. Although a small amount of brow asymmetry may be unavoidable and acceptable, occasionally the extent of asymmetry may be unacceptable. This complication may be due to unilateral failure of the browpexy second-

ary to ‘cheesewiring’ of the suture through subcutaneous tissue. It can usually be avoided if the subcutaneous suture is passed into the sub-brow muscular tissue. If too much brow fat is removed, it can lead to a depression of brow skin. This can be avoided by leaving a thin layer of sub-brow fat. As stated previously, the internal browpexy procedure works well for mild to moderate brow ptosis and as an adjunct to blepharoplasty in selected patients. This procedure in patients with severe brow laxity commonly yields unsatisfactorily results.

Results I have used the browplasty and/or browpexy procedures over the past two decades in more than 100 selected patients undergoing upper blepharoplasty and have had good results (Figs 12-8 and 12-9). The browplasty fat removal technique has been uniformly successful in predictably debulking the thick, full lateral brow fat pad in selected patients. Most patients tolerate the somewhat prolonged postoperative edema and the transient lateral brow numbness quite well. Similarly, the internal browpexy procedure yields good results once the surgeon gains adequate experience with the technique. Single suture browpexy for correction of mild lateral brow ptosis has consistently yielded excellent results in our patients. Occasionally, brow asymmetry has been encountered in patients with more marked brow ptosis in whom the browpexy procedure required more than two ﬁxation sutures. Recurrent brow ptosis does often occur, at least partially, within 12 months of the internal suture browpexy procedure. Since I have added the above modiﬁcations to the internal brow lift, no patient undergoing this procedure has developed an undesirable upper eyelid crease or has experienced any difﬁculty in looking upward.

Results

Figure 12-8 A, Preoperative photo of patient with fullness of temporal subbrow due to thickened sub-brow fat. B, Same patient after excision of subbrow fat (browplasty).

A

B

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Figure 12-9 A, Preoperative photo of patient with unilateral brow ptosis leading to asymmetrical upper eyelid folds. B, Same patient after elevation of ptotic eyebrow that not only leads to more symmetric brows but also more symmetric upper eyelids folds.

A

B

References 1. McCord CD, Doxanas MT: Browplasty and browpexy. An adjunct to blepharoplasty. Plast Reconstr Surg 1990; 86:248–254. 2. May JW, Pearon I, 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.

3. Stasior OG, Lemke BN: The posterior eyebrow ﬁxator. Adv Ophthalmic Plast Reconstr Surg 1983; 2:193–197. 4. Lemke BN, Stasior OG: The anatomy of eyebrow ptosis. Arch Ophthalmol 1982; 100:981–986. 5. Putterman AM: Treatment of retracted eyebrow through eyelid approach. Am J Ophthalmol 1994; 118:674–676.

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CHAPTER 13

Treatment of Upper Eyelid Retraction: Internal Approach Allen M. Putterman For more than 30 years, I have preferred treating upper eyelid retraction secondary to thyroid ophthalmopathy with an internal rather than external approach. Excellent results, high patient satisfaction, and minimal need for secondary surgery lead to my bias toward this approach. The main disadvantage of treating upper eyelid retraction from an internal approach is that the procedure is slightly more cumbersome if an external cosmetic blepharoplasty is needed simultaneously. It requires the surgeon to perform the retraction surgery from an internal approach and the blepharoplasty from an external approach. Allen M. Putterman

Upper eyelid retraction, a manifestation of thyroid ophthalmopathy, often continues after the underlying systemic disease has been successfully treated. Upper eyelid retraction not only is cosmetically deforming because the amount of exophthalmos is exaggerated, but also contributes to corneal and conjunctiva exposure and to ocular irritation. Upper eyelid retraction surgery occasionally is combined with retraction surgery of the lower eyelid, with or without lateral tarsorrhaphies (see Chapter 18). If there is minimal upper eyelid retraction, the surgery can be combined with an upper eyelid skin muscle-fat excision without eyelid reconstruction; if the retraction is moderate or severe, the external tissue excision is deferred to a second sitting since I am concerned that tightening of the skin might interfere with the results of the upper eyelid retraction surgery. Upper eyelid retraction can be performed in patients who do not require orbital decompression or strabismus surgery. If strabismus surgery is required, the eye muscle surgery is performed ﬁrst. Usually, thyroid surgery is considered once the eyelid retraction, ocular proptosis, and strabismus are stable for at least 6 months. In this chapter, I describe a technique that Urist and I reported on in 1972, in which Müller’s muscle is excised and the levator aponeurosis is recessed from an internal approach.1 The procedure is performed with sensory but not motor anesthesia. The eyelid level is controlled intraoperatively while the patient is seated up on the operating table. Treatment of upper eyelid retraction not only places the upper eyelid in a more normal position but also decreases the exophthalmic appearance and relieves ocular irritation and keratopathy.

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Anatomy Müller’s muscle in the upper eyelid originates from the levator aponeurosis approximately 15 mm above the superior tarsal border and inserts onto the superior tarsal border (Fig. 13-1). This muscle spans the horizontal dimension of the eyelid, is ﬁrmly attached to conjunctiva on its posterior surface, and is loosely

Preseptal fat

Orbital fat

attached to the levator aponeurosis on its anterior surface. Müller’s muscle resembles other smooth muscle tissue and is approximately 1 mm thick.

Margin reﬂex distance-1 It is important to assess the upper eyelid levels with the margin reﬂex distance-1 (MRD1) measurement (see Chapter 3, Fig. 3-8).

Surgical technique Anesthesia

Orbicularis oculi muscle

In this procedure, only local anesthesia is used. Anesthesia given in this manner maintains the eyelid level at its preoperative position while providing an absence of lid sensation. The patient is given no preoperative medication. Lidocaine hydrochloride (0.25 ml of a 2 percent concentration) with epinephrine is injected subcutaneously into the center of the upper eyelid just above the lid margin. A 4-0 silk suture is placed in the center of the upper eyelid 2 mm above the eyelash line, through the skin, orbicularis muscle, and anterior tarsus (Fig. 13-2). Topical 0.5 percent tetracaine drops are applied to the eye, and a scleral lens is placed over the globe to protect it during surgery.

Septum Levator aponeurosis Müller’s muscle Superior tarsus Conjunctiva

Inferior tarsus Müller’s muscle Inferior orbital septum Orbicularis oculi muscle

Conjunctival dissection

Malar fat pad Suborbicularis oculi fat Orbital fat

A

Tarsus

B

Tarsus

Capsulopalpebral fascia Müller’s muscle

With a Desmarres retractor, the surgeon everts the upper eyelid to expose the superior palpebral conjunctiva. The upper palpebral conjunctiva is ﬂooded with 0.5 percent tetracaine drops. Cotton-tipped applicators

Müller’s muscle

Figure 13-1 A, Cross-section of upper and lower eyelids depicting structures in various layers. B, Müller’s muscle.

Figure 13-2 Placement of traction suture.

Surgical technique saturated with tetracaine also are rolled over the conjunctiva. Then, 0.25–0.5 ml of 2 percent lidocaine with epinephrine is injected subconjunctivally adjacent to the superior tarsal border over the entire width of the eyelid (Fig. 13-3). The conjunctiva is grasped just over the superior tarsal border at the temporal aspect of the eyelid and is severed with Westcott scissors. The surgeon inserts straight, sharp-pointed iris scissors between the conjunctiva and Müller’s muscle and spreads the scissors blades to separate conjunctiva from the muscle (Fig. 13-4).

Conjunctiva is severed from the superior tarsal border (Fig. 13-5). The surgeon further dissects conjunctiva from the muscle by spreading the scissors blades between the two tissues to the superior fornix (Fig. 13-6). The surgeon can facilitate this dissection by observing the points of the blades through the translucent conjunctiva. Sharp dissection with the iris scissors releases any remaining attachments between conjunctiva and Müller’s muscle.

Müller’s muscle dissection The surgeon grasps Müller’s muscle with a toothed forceps at the temporal aspect of the eyelid just above

Figure 13-3 Subconjunctival administration of an anesthetic agent. Figure 13-5 Severing of the conjunctiva from the superior tarsal border.

Figure 13-4 Dissection of the conjunctiva from Müller’s muscle above the tarsal border.

Figure 13-6 Further dissection of the conjunctiva from Müller’s muscle.

147

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Treatment of Upper Eyelid Retraction: Internal Approach the superior tarsal border. The muscle is pulled outward, and the Desmarres retractor is pulled simultaneously in the opposite direction. Müller’s muscle is cut from the tarsus temporally (Fig. 13-7). Müller’s muscle is then undermined from the levator aponeurosis at the level of the superior tarsal border (Fig. 13-8). Müller’s muscle, which is all the tissue attached to the top of the tarsus, is severed over the temporal two-thirds of the eyelid (Fig. 13-9). Wet cotton-tipped applicators are used to dissect Müller’s muscle bluntly from its loose attachment to the levator aponeurosis. This dissection is performed approximately 10–12 mm above the superior tarsal

border over the temporal one half to two thirds of the eyelid (Fig. 13-10). The scleral lens is removed, and the patient is brought to a sitting position by raising the head of the operating table. The levels of the upper eyelids are evaluated while the patient looks in the primary and up and down positions of gaze and widely opens his or her eyelids. If the upper eyelid is at a satisfactory position, the head of the operating table is lowered and the patient lies down. The section of Müller’s muscle that has been detached is clamped with a straight hemostat at its base and is excised. Bleeding from the stump of

Figure 13-7 Severing of temporal Müller’s muscle.

Figure 13-9 Severing of Müller’s muscle from the superior tarsal border.

Figure 13-8 Dissection of Müller’s muscle from levator aponeurosis. A Desmarres retractor and Westcott scissors are pulled away from each other.

Figure 13-10 Blunt dissection with a cotton-tipped applicator separates Müller’s muscle from loose attachment to the levator aponeurosis.

Comments 149

Müller’s muscle is carefully controlled with a disposable cautery. If there is residual retraction, Müller’s muscle is released to 10–15 mm above the tarsus over the temporal two-thirds to three-fourths of the eyelid. It is better to be conservative in releasing Müller’s muscle nasally because a nasal ptosis can easily occur.

Levator stripping Again, the patient is brought to a sitting position and the eyelid levels are evaluated. If the eyelid is still retracted, overaction of the levator muscle is implicated and this muscle must be released. The patient lies down, and the scleral lens and Desmarres retractor are reapplied. With the eyelid everted, the ﬁbers of the levator aponeurosis that pass over the anterior surface of the tarsus are exposed. Using two toothed forceps, the surgeon grasps the superﬁcial layers of the levator aponeurosis at the level of the superior tarsus. The levator aponeurosis layers are stripped vertically, layer by layer, along the sections of the eyelid that remain retracted (Fig. 13-11A & B). The patient is brought to a sitting position at various times during the levator aponeurosis stripping procedure until a desirable end point is reached. This gradual, step-by-step lengthening of the levator aponeurosis allows the retraction of the eyelid to be corrected slowly and precisely.

A

Müller’s muscle excision The detached part of Müller’s muscle is then clamped with a straight hemostat at its base and is excised (Fig. 13-12). Pulling the conjunctival ﬂap downward with a cotton-tipped applicator brings the stump of Müller’s muscle into view and facilitates cauterization of any bleeding areas.

Conjunctival reattachment When a desired eyelid level is achieved, either by excision of Müller’s muscle alone or in conjunction with the stripping of the levator aponeurosis, the conjunctiva is sutured to the superior tarsal border with a continuous 6-0 plain catgut suture (Fig. 13-13). In most cases, I remove the 4-0 black silk traction suture placed in the upper eyelid at the beginning of the procedure. However, if I have performed a signiﬁcant amount of levator recession, I tape the 4-0 black silk traction suture to the patient’s cheek to put a small amount of stretch on the upper eyelid and then apply a light pressure dressing. This traction suture is removed on the ﬁrst postoperative day. The upper eyelid should be at approximately the midpupil on the ﬁrst postoperative day. If it appears

B Figure 13-11 A&B, Stripping of the levator aponeurosis.

too high on the ﬁrst postoperative day or starts retracting during the ﬁrst postoperative weeks, the patient is instructed to massage the eyelid downward while raising the eyebrow upward.

Comments The excision of Müller’s muscle and levator aponeurosis in the manner described is a highly successful technique for treating thyroid-related retraction of the upper eyelid (Figs 13-14 and 13-15). The procedure is based on the theory of the physiologic and anatomic origin of the condition. It is a relatively simple technique that does not alter the major anatomic relationship in the eyelid by the implantation of a foreign body or by distortion of the tissues. With the patient sitting up at various times during the procedure, the surgeon can make adjustments by progressively recessing Müller’s muscle and levator

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Figure 13-12 Excision of Müller’s muscle and recession of the levator aponeurosis.

Figure 13-13 Suturing of the conjunctiva to the superior tarsal border.

Figure 13-14 Bilateral upper eyelid retraction secondary to thyroid ophthalmopathy before (A) and after (B) excision of Müller’s muscle and recession of the levator aponeurosis through an internal approach. The herniated orbital fat in both lower eyelids was removed through an internal approach simultaneously.

A

B

References

Figure 13-15 A, Patient with thyroid upper eyelid retraction and herniated lower eyelid fat. B, Same patient after excision of Müller’s muscle and levator recession. Patient also had transconjunctival lower eyelid fat removal.

A

B

aponeurosis until the desired eyelid level and arch are achieved. Overcorrection can be recognized during the surgery and dealt with by reattaching the recessed tissues to tarsus or skin. The levator muscle obeys Hering’s Law of equal upper eyelid innervation. I therefore believe that during surgery on a patient with unilateral retraction the affected eyelid should be placed at a slightly higher level than that of the unaffected eyelid to ensure symmetry postoperatively. During bilateral surgery, the more retracted eyelid is operated on ﬁrst and is placed at an acceptable level. This eyelid commonly becomes ptotic, probably secondary to edema or innervation changes when the second eyelid is being operated on. To avoid a postoperative ptosis of the second eyelid, one should place it at the same level the ﬁrst eyelid was originally placed rather than matching it to the position that the ﬁrst eyelid obtains at this point in the procedure.

Results I have performed this procedure on close to 1000 upper eyelids. The results have been studied in several previously reported publications.1–4 The success rate of

bringing the upper eyelid close to a normal level is approximately 90 percent. In approximately 10 percent of cases, the eyelid is retracted or ptotic and requires secondary surgery. If the eyelid continues to be retracted, secondary treatment with an external levator recession is recommended. If the eyelid is ptotic, I perform a full thickness resection ptosis procedure over the ptotic areas5 or I employ an external approach and perform a levator aponeurosis advancement technique similar to that described in Chapter 10.

References 1. Putterman AM, Urist M: Surgical treatment of upper eyelid retraction. Arch Ophthalmol 1972; 87: 401–405. 2. Chalﬁn J, Putterman AM: Muller’s muscle excision and levator recession in upper lid: Treatment of thyroid-related retraction. Arch Ophthalmol 1979; 97:1487–1491. 3. Putterman AM: Surgical treatment of thyroid-related upper eyelid retraction. Trans Am Acad Ophthalmol Otolaryngol 1981; 88:507–512. 4. Putterman AM, Fett DR: Muller’s muscle in the treatment of upper eyelid retraction: a 12-year study. Ophthalmic Surg 1986; 17:361–367. 5. Bassin R, Putterman AM: Full Thickness resection ptosis procedure (in press).

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CHAPTER 14

Transconjunctival Approach to Resection of Lower Eyelid Herniated Orbital Fat Allen M. Putterman

The transconjunctival approach to removal of herniated orbital fat is the preferred method of treatment in patients who have only herniated orbital fat with minimal or no evidence of dermatochalasis (excess skin) and no hypertrophic orbicularis oculi muscle. This technique is also especially advantageous for: • Younger patients with large amounts of herniated orbital fat. • Patients who have had previous blepharoplasties in whom an external approach might lead to eyelid retraction or ectropion. • Patients with lower eyelid retraction secondary to thyroid disease in whom hard-palate grafts are required (Chapter 18). • Patients with wrinkled or minimally excessive lower eyelid skin in whom plication of the lateral canthi or laser resurfacing of lower eyelid skin is useful (see Chapter 15). If there is horizontal lower eyelid laxity, this procedure can be easily combined with a horizontal eyelid tightening through a tarsal strip procedure (see Chapter 1). Many patients want this approach done because it eliminates external scarring and produces less ecchymosis; however, it has been my experience that many patients develop conjunctival chemosis and slight redundancy and wrinkling of skin compared with those who were treated with the external approach. Therefore, I ﬁnd that more frequently I am combining this approach with a lower eyelid skin ﬂap dissection and excision with orbicularis tightening. A contraindication to this procedure is with patients with minimal lower eyelid fat, inferior orbital rim or nasojugal hollowing and depression. In these patients, fat repositioning or cheek–midface lifting are indicated (Chapters 17 and 19). Allen M. Putterman

Chapter 156

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Transconjunctival Approach to Resection of Lower Eyelid Herniated Orbital Fat

Surgical technique The transconjunctival procedure is performed with the patient under local anesthesia. Two percent lidocaine (Xylocaine) with 1 : 100,000 epinephrine is injected subcutaneously at the center of the lower eyelid just beneath the lashes. An additional anesthetic agent is injected into each fat pad. To inject the anesthetic into the nasal, central, and temporal fat pad, the surgeon inserts a 25-gauge, 0.8-cm needle just above the inferior orbital rim and directs it downward slightly until it penetrates its entire length (0.8 cm). The barrel of the syringe is withdrawn to make sure that no blood has been entered, and approximately 0.5 ml of the agent is injected into each of the three fat pads. A 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superﬁcial tarsus at the center of the eyelid. The surgeon pulls the eyelid downward with a traction suture as the assistant everts the lower eyelid over a small Desmarres retractor to expose the inferior palpebral conjunctiva. Additional anesthetic is injected subconjunctivally over the inferior palpebral conjunctiva across the eyelid. Topical tetracaine is instilled over the eye, and a scleral lens is placed over the eye to protect it. Two percent lidocaine with epinephrine is also injected subcutaneously over the center of the upper eyelid, and a 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superﬁcial tarsus to pull the upper eyelid upward. A Colorado needle or disposable cautery (Solan Accu-Temp, Xomed Surgical Products, Jacksonville, FL) is applied to the inferior palpebral conjunctiva. The Colorado needle or cautery are used to cut conjunctiva from the medial to temporal end of the eyelid halfway between the inferior palpebral fornix and the inferior tarsal border (Fig. 14-1). The surgeon grasps the inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent, more superior edge with forceps and the assistant pulls the Desmarres retractor downward (Fig. 14-2). The two forceps are pulled apart. Further dissection with the Colorado needle or disposable cautery is carried out through Müller’s muscle and capsulopalpebral fascia until fat is seen. A 4-0 black silk double arm suture is passed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and the suture arms are pulled upward and clamped to the drape (Fig. 14-3). A small Desmarres retractor is placed over the lower eyelid and is pulled downward and outward to expose the orbital fat. With the use of cotton-tipped applicators, disposable cautery, and Westcott scissors, blunt

Figure 14-1 A Colorado needle is applied to the inferior palpebral conjunctiva halfway between the fornix and the inferior tarsal border and is used to severe the conjunctiva from medial to temporal end of the eyelid.

dissection is carried out to isolate the three orbital fat pads. The central and nasal fat pads are divided by the inferior oblique muscle, which can be easily seen through the internal approach and should be identiﬁed to avoid injury to the structure. Also, the nasal and central fat pads are found in a slightly more temporal position than when they are isolated through an external approach. The temporal herniated orbital fat is isolated, and the fat that prolapses with gentle pressure on the eye is clamped with a hemostat and cut along the hemostat blade with a No. 15 Bard–Parker blade. Then cottontipped applicators are placed underneath the hemostat as a Bovie cautery is applied over the fat stump. The surgeon grasps the fat with a forceps before it is allowed to slide back into the orbit to make sure that there is no residual bleeding that might cause a second retrobulbar hemorrhage.1 After the ﬁrst temporal fat pad is removed, the surgeon applies additional pressure to the eye to determine whether there is a second temporal fat pad.2 If a second temporal fat pad is found, it is also removed. The central and nasal fat pads are then removed in a similar manner (Fig. 14-4). The 4-0 silk suture that attaches conjunctiva, Müller’s muscle, and capsulopalpebral fascia to the

Complications 157

Figure 14-2 With forceps, the surgeon and surgeon’s assistant grasps the inferior and superior edges, respectively of the severed palpebral conjunctiva to facilitate dissection of Müller’s muscle and capsulopalpebral fascia with the Colorado needle.

superior drape is then removed. Conjunctiva is reapproximated with three 6-0 plain catgut buried sutures (Fig. 14-5). Gentamicin (Garamycin) is applied over the eye.

Postoperative care No dressings are used after surgery. The patient is instructed to apply ice cold compresses on the eyelids. Pads 4 by 4 inches, soaked in a buckle of saline and ice are applied with slight general pressure to the lids. When the pads become warm, they are dipped again into the saline and ice and reapplied. This process is repeated for 24 hours. The application should be fairly constant for the few postoperative hours. After that the compresses are applied for about 15 minutes with a 15-minute rest period in between until bedtime. The applications are resumed on awakening. To reduce edema postoperatively the patient lies in bed with the head approximately 45º higher than the rest of the body. Nurses should check for bleeding associated with proptosis, pain, or loss of vision every 15 minutes for the ﬁrst two to three hours postoperatively or until the patient leaves the surgical facility. Every hour thereafter until bedtime, the family or patient should monitor the patient’s ability to count

Figure 14-3 A 4-0 double-armed black silk suture is placed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and is pulled upward and clamped and taped to the drapes.

ﬁngers and should check for residual proptosis and pain. If the patient cannot count ﬁngers or has marked proptosis or pain, the family should take him or her to the emergency room. If loss of vision occurs secondary to retrobulbar hemorrhage, it could easily be detected by opening the incision involved.1 Garamycin ointment is applied to the eyes twice a day for the ﬁrst two weeks.

Complications Several patients in whom I performed the transconjunctival approach had postoperative residual dermatochalasis, which needed to be removed through an external approach or a laser skin resurfacing. Better patient selection or combined initial procedure with skin ﬂap excision or orbicularis muscle plication could have prevented this problem. Although this procedure has not caused any motility problems, in several patients in whom this procedure was combined with a tarsal strip procedure, ocular

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158

Figure 14-4 The surgeon removes the temporal, central, and nasal orbital fat pads by cutting along the hemostat blade with a #15 Bard-Parker blade and then applying a Bovie cautery to the fat stump.

Figure 14-5 The conjunctiva is reapproximated with three 6-0 plain catgut buried sutures.

motility restriction and diplopia occurred secondary to scar tissue that developed between the globe and the temporal inferior orbital wall.3 There is also the possibility of residual herniated orbital fat in which case a second transconjunctival approach removal is indicated. Although a sunken lower eyelid is possible, it is fortunately rare with good patient selection. If it occurs, it can be treated with a cheek mid-face lift (Chapter 23), or fat injections, or grafts.

Results I have performed the transconjunctival approach in more than 1000 patients (Figs 14-6 & 14-7). The procedure has the advantage of causing less eyelid retraction and ectropion than with the skin ﬂap or skin muscle ﬂap approaches because the external lamellae is not manipulated. I believe that there is less

Results

Figure 14-6 A, Preoperative appearance of a patient with herniated orbital fat of both lower eyelids with no signiﬁcant dermatochalasis (excessive skin). B, Postoperative appearance after resection of orbital fat using the transconjunctival approach.

A

B Figure 14-7 A, Thyroid ophthalmopathy patient with lower eyelid fat associated with exophthalmas and eyelid retraction. B, Same patient after transconjunctival lower eyelid fat removal. Patient also had upper eyelid Müller’s muscle excision, lower eyelid hard palate graft, lateral tarsorrhaphies and upper eyelid nasal fat removal. A

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Transconjunctival Approach to Resection of Lower Eyelid Herniated Orbital Fat ecchymosis because the orbicularis muscle and skin are not severed. There tends to be more conjunctival chemosis immediately postoperatively with this procedure than with the external technique. If it occurs, it is treated with pressure applied over the closed eyelids.4 Because the procedure is more difﬁcult to master than the external approach, a surgeon should not perform this procedure without prior exposure to it.

References 1. Putterman AM: Temporary blindness after cosmetic blepharoplasty. Am J Ophthalmol 1975; 80:1081–1083. 2. Putterman AM: The mysterious second temporal fat pad. Ophthal Plast Reconst Surg 1985; 1:83–86. 3. Putterman AM: Acquired strabismus following cosmetic blepharoplasty [Letter to the Editor]. Plast Reconst Surg 2004; 113:1069–1071. 4. Putterman AM: Treatment of conjunctival prolapse. Arch Ophthalmol 1995; 113:553–554.

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CHAPTER 15

Lower Blepharoplasty: Blending the Lid/Cheek Junction with Orbicularis Muscle and Lateral Retinacular Suspension Steven Fagien

Similar to many facial aesthetic procedures, the current methods used in lower blepharoplasty have evolved for many reasons, including the lack of satisfaction with previous methods, complications arising from traditional surgical approaches, a better understanding of the anatomy of the aging periorbita and appreciation of the components of youth. Traditional lower blepharoplasty, for instance, performed 20 years ago typically incorporated a lower eyelid, infraciliary skin/muscle ﬂap and excision of orbital fat through this incision by violating the orbital septum and performed without routine canthal reinforcement. The surgical efforts were basically a perceived solution to the antiquated notion of getting rid of ‘excess’ soft tissue (skin, muscle, and fat) in addition to straightforward access to lower eyelid fat without regard for the concurrent senescence of supporting structures. Depending on the patient’s presentation as well as the aggressiveness of the surgical procedures, a varying degree of lower eyelid malposition was met, and fortunately dissatisfaction of the overall appearance of the lower periorbita was uncommon. Patients could usually detect an overall improvement (‘bags were gone’) of their appearance and often accepted a varying degree of lid malposition, hollowness, and scarring as routine (Fig. 15-1). These results were often published with great pride, as the perception of the improvement in the few noted areas and the lack of options available fostered the acceptance of these results. Even the most noted surgeons were achieving these results and many were complacent that this was ‘the best that could be done.’ The emergence of a greater appreciation of the ‘oculoplastic surgeon’ to a large degree emanated from referrals by these noted surgeons whose patients experienced eyelid changes that were outside the acceptable range (lid retraction, ectropion, lagophthalmos, onset or exacerbation of long-term dry eye symptoms, etc.) (Fig. 15-2). Based primarily on the ophthalmologist’s exposure to periorbital anatomy and lower eyelid reconstruction, repair of lid malposition and the like were accomplished via procedures to horizontally tighten or shorten the lower eyelid to better position the eyelid/globe interface and effectively aid lower eyelid posture. The improvement of sometimes disastrous situations was

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162 appreciated despite the reality that the lid changes could rarely be fully restored (Fig. 15-3). Surgeons who treated these problems usually incorporated techniques such as the lateral tarsal strip1 or other methods that shortened the lower eyelid horizontally2 in an attempt to reduce vertical lower eyelid distraction by increasing horizontal lid tension. The improvement was notable and became the accepted standard of care. These procedures, in most cases however, might have been avoided if a lower eyelid/canthal reinforcement was performed at the time of the initial surgery. Why, however, were these latter procedures not routinely performed? Steven Fagien

One possible explanation for the avoidance of routine canthal support is that the anatomy of the lateral canthus and traditional canthal reinforcement procedures are both complex to understand and the reconstruction of the lower eyelid and lateral canthus commonly heralded complications including asymmetry, canthal misalignment and eventual shortening of the horizontal palpebral aperture after ﬁxation was lost. Instead of incorporating methods that were proactive in supporting the lower eyelid, many surgeons either avoided lower blepharoplasty, accepted varying mild to moderate degrees of eyelid malposition, or adopted other procedures that were suboptimal in restoring the youthful complement. The transconjunctival approach to removal of lower eyelid fat then became popular due to the negligible change in lid position,3 while at the same time improving lower eyelid ‘bags’ (Fig. 15-4). Except for the rare very young

individual with good soft tissue tone and elasticity, the improvement of the lower eyelid ‘bulges,’ however, were often met with worsening of the appearance of the lower eyelid skin surface, either relating to a deﬂationary effect and diversion of attention from bags to lower eyelid skin/soft tissue quality. It is my opinion that for all the wrong reasons, laser skin resurfacing of this region then became more popular, combined with transconjunctival removal of fat, in order to improve

A

B Figure 15-1 This patient underwent upper and lower lid blepharoplasty elsewhere. She acknowledges that she had profound lower eyelid ‘bags’ before surgery but did not expect, as she describes it, the signiﬁcant change of the lower eyelid and canthal position, ‘rounding’ of her eye shape, or the ‘hollowness’ that resulted.

Figure 15-2 A, This patient presented elsewhere for fourlid blepharoplasty to improve the appearance of the aging and ‘tired’ eyelids. B, One year after an ‘aggressive’ four-lid blepharoplasty utilizing skin, muscle, and fat excision to the upper eyelids and a skin muscle ﬂap approach to the lower eyelids, also with over-zealous excision of skin, muscle and fat without canthal support.

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B B Figure 15-3 This patient had undergone upper and lower blepharoplasty and then was referred for evaluation and treatment of left lower eyelid ectropion and lagophthalmos with exposure symptoms left greater than right. The surgical solution here might be a horizontal eyelid shortening procedure such as the lateral tarsal strip.

the appearance of the skin.4 This anatomic and surgical oversimpliﬁcation (volume depleting the lower eyelid by fat removal combined with exfoliating the skin) can produce signiﬁcant improvement to the appearance of the lower periorbita.5 I too employed this procedure earlier in my practice and realized that with signiﬁcant degrees of application of laser energy to improve lower eyelid skin appearance, eyelid retraction was at the very least temporary, and canthal support (via a simple suture canthopexy without surgical release) could maintain or improve the lower eyelid posture. While I was not convinced that horizontal shortening type procedures like the lateral tarsal strip were prudent in such situations, I explored the ability to effectively suspend the lateral canthus via suture, hopefully in a way that was better than prior attempts at suture canthopexy6 (Fig. 15-5). This was obviously not the ﬁrst suture canthopexy procedure developed. One glimpse at the 1993 issue of

Figure 15-4 A, The patient proﬁle that beneﬁts most from transconjunctival resection of lower eyelid fat only, is a young individual with excellent skin, muscle and tendon tone. B, After transconjunctival resection of lower eyelid fat without canthopexy.

Clinics in Plastic Surgery edited by Dr Robert Flowers7 reveals the current thinking on a spectrum of canthal support procedures. Most suture suspension procedures were considered unsatisfactory, with the exception of those that required minimal support (usually in the younger patient) as it was felt that loss of ﬁxation (long-term) was inevitable. Techniques evolved and were modiﬁed8 that included the incorporation of drill holes through the lateral orbital rim for individuals where either periosteum in this region was deemed inadequate,7 or where it was presumed that failed canthopexy often related to a point of disinsertion. On the other hand, I felt that good periosteal purchases (ﬁxation) were likely to be more long lasting than the entrance of the suture (below) through the lateral canthal ligament.6,9 The lateral retinacular suspension was essentially another variety of suture canthopexy, whereby the canthal system was reinforced by a suture suspension that was delivered through a lower eyelid incision with the opportunity of using variable vectors of support by exiting the suture through the upper

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B Figure 15-5 A, This patient presented with complaints of ‘excessive upper eyelid skin’ and ‘wrinkled and baggy lower eyelids.’ She was also interested in improving the skin dyscromias of her lower eyelid and cheek. B, After upper and lower blepharoplasty with lower eyelid carbon dioxide laser skin resurfacing and lateral retinacular suspension performed through a 3 mm incision at the lateral commissure.

eyelid at a multitude of levels (Fig. 15-6). It seemed clearer to me later that with ongoing orbicularis muscular function at the lateral canthus with subconscious and frequent animation, that the likely point of eventual disinsertion would be here at the lateral commissure rather than at the periosteum at the orbital rim. While I recognized the need for some sort of canthal support in patients undergoing CO2 laser skin resurfacing to the lower eyelid and canthus, I was then unsure of how long the supportive effects could be expected. I began incorporating a lateral retinacular suspension procedure routinely with my laser skin resurfacing procedures to the lower eyelid through a 2–3 mm incision at the lateral commissure (Fig. 15-7). I found that reinforcing the polypropylene suture with Vicryl sutures (see p. 171) at the commissure either reduced or slowed down the disinsertion at the lateral canthal tendon and often many months (even years) later found that the suture was still attached to the lateral orbital rim. As

this maneuver aided my many patients who had undergone laser skin resurfacing, I then began to extend the lateral retinacular suspension procedure to skin ﬂap lower eyelid surgery which has been the mainstay of my lower blepharoplasty to date. It has also been my opinion that despite the fact that skin quality appearance could be improved by laser skin resurfacing, the aging pathology of the lower periorbita as well illustrated by Drs Harris and Mendelson in their facial anatomy chapter in this book (see Chapter 5) and other writings10,11 indicates that it rests greatly on the orbicularis muscle and its retaining ligaments (Figs 15-8, 15-9). I believe this is due to a complicated combination of life-long animation, descent and hypotonia of the orbicularis, and atrophy of the adjacent periorbital soft tissue (skin, subcutaneous fat, ligamentous attachments) that allows the lower orbital fat to be anteriorly displaced combined with radial expansion of the soft tissues which better explains the lower periorbital ‘bulges’ (Fig. 15-10). As I believe that laser skin resurfacing was an abbreviated remedy, I also realized that skin–muscle ﬂap surgery was often ineffective in signiﬁcantly improving the lower eyelid skin. In lieu of this, I began re-exploring the use of skin ﬂap dissection in an attempt to create an advancement ﬂap of skin only (that contracts as do all advancement ﬂaps) which would hopefully improve the lower eyelid skin rhytids and overall appearance. This plane of dissection also interrupts the attachments of orbicularis to the deep dermis which is a component of the cause of lower eyelid rhytids. Combined with adequate stabilization of the lower eyelid and lateral canthus via effective canthopexy and orbicularis muscle suspension, the skin tightening improved its appearance without inducing lid malposition. After many procedures utilizing this technique, it became clearer to me that this approach could improve lower eyelid skin appearance, at times to the same degree as laser skin resurfacing. The advantage of this approach also allowed me to expose the orbital component of the orbicularis oculi muscle throughout the lower eyelid and at the lateral canthus for further rejuvenative reﬁnement. Another reason to expose the orbicularis oculi muscle (via a carefully executed skin ﬂap dissection) is for the ability to precisely address the hypotonic and less-supported orbicularis muscle. The ability to accurately and individually manipulate orbicularis muscle after a skin–muscle ﬂap dissection, on the other hand, is dramatically diminished by deﬁnition, with this commonly used approach. Thereby, the use of a skin–muscle ﬂap without independent orbicularis suspension reduces the transmission of tension across most of the lower periorbita to accomplish the desired effects. The extent of the dissection of the skin ﬂap in this procedure will

Lower Blepharoplasty: Blending the Lid/Cheek Junction with Orbicularis Muscle and Lateral Retinacular Suspension

Figure 15-6 The lateral retinacular suspension can compensate for individual orbital morphology and suture placement is inﬂuenced by the desired result as well as the globe and canthal position in relation to the bony orbit.

Orbicularis oculi muscle Orbital septum Lat. Orbital rim

Lat. Canthal tendon Orbicularis oculi muscle Lat. Retinaculum

B A

Figure 15-7 After ﬁnding retinacular suspension canthopexy very effective in lower blepharoplasty with laser skin resurfacing in maintaining lid and canthal position, I began applying this in a similar fashion to lower blepharoplasty via a skin ﬂap through the existing incision.

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Orbicularis muscle

Orbital rim

Lateral canthal tendon Inferior lateral retinaculum

Lid/Cheek junction in youth Apparent lid/cheek junction with age

Figure 15-8 Periorbital soft tissue is attached to the bony orbit through a vast retaining ligament system. With age, the ligamentous structures attenuate resulting in shifts and ptosis of the visible eyelid structures yielding real and illusionary effects such as descent of the ‘lid–cheek’ junction.

Figure 15-10 This middle-aged man presents for periorbital rejuvenation. Note the appearance of lower periorbital bulges that likely occur, at least in part, due to attenuation of ligamentous attachment and integrity of the canthal ligaments and the orbicularis retaining ligaments as well as reduced skin elasticity. Soft tissue shifting manifests as anterior displacement of the orbicularis oculi muscle system and lower orbital fat. A sound solution to rejuvenation takes these perceived changes into account.

Figure 15-9 Cross-section showing possible changes and shifts of periorbital soft tissue as a result of attenuation of ligamentous attachments.

Transconjunctival fat maintenance, lower eyelid skin ﬂap with orbicularis oculi and lateral retinacular suspension depend on both how much skin quality improvement (vertical dissection and eventual excision) is optimal and how much orbicularis muscle will be mobilized independent of the skin ﬂap. A secondary effect of incision through the orbicularis composite at the lateral commissure is to release the superﬁcial head of the lateral canthal tendon from components of the inferior retinaculum. In addition, the ability to use the orbicularis muscle to reinforce the lower eyelid provides for a better environment (along with canthopexy) for the safe excision of lower eyelid skin. Through this lateral orbicularis muscle dissection the surgeon also has the ability to enter what has been called the ‘lateral tarsal strap’12 which is a conﬂuence of lateral retinacular soft tissue that attaches to the lateral inferior orbital rim. Those that had been well versed in canthal surgery realized that even when performing a lateral tarsal strip canthoplasty, full release of the lateral canthal tendon and lateral tarsus is only achieved by incising beneath the lower eyelid retractors at the lateral inferior orbital rim. This allows repositioning of the commissure in a way that a simple suture canthopexy can not. Typical canthopexy sutures placed without lysis of the orbital attachments likely regress fully to the original position, and at times are even inferiorly and dystopically malpositioned due to the false sense of security of the initial canthopexy procedure that encourages removal of skin (and at times muscle) from this region. Full or partial release of the lateral canthal tendon from the inferior retinaculum including orbicularis and the ‘lateral strap’ allows for a more complete mobilization of the lateral canthal tendon through the ability to manipulate the superﬁcial head of the lateral canthal tendon. I ﬁnd this maneuver essential in not only the ability to manipulate orbicularis muscle for tightening and for dissection (if necessary) of the orbicularis retaining ligaments to the orbital rim, but again for release of the inferior retinacular component of the lateral commissure to facilitate long-term effective canthal suspension. A full release of the deep head to the lateral canthal tendon can also (rarely necessary, especially in primary lower blepharoplasty) be performed if an even higher position of the lateral commissure is required. Lateral retinacular suspension then becomes more effective as a permanent canthoplasty procedure, as with advanced healing as the suture suspension effect is lost, yet the elevated position of the commissure ‘scars’ into this position quite securely. Once the lateral retinacular suspension is performed orbicularis manipulation is then carried out through this incision. Skin re-draping and excision is then performed and each component proceeds with as much fortitude as required with the prior step reinforcing the lower eyelid in a way that facilitates the lower eyelid soft tissue manipulation and excision.

Transconjunctival fat maintenance, lower eyelid skin ﬂap with orbicularis oculi and lateral retinacular suspension Steps 1. Injection of local anesthesia If upper blepharoplasty is performed, as mentioned in the upper blepharoplasty chapter (see Chapter 8), the lateral 1/4 of the upper eyelid remains open prior to the lower blepharoplasty. In this situation, the lower eyelid has already been injected with the preferred anesthetic mixture (I use a 50 : 50 combination of 2% lidocaine with epinephrine 1/200,000 dilution and 0.75 bupivicaine) using a ﬁne, short (1/2 inch; 27–30 g) needle and under loop magniﬁcation the infratarsal, subconjunctival space has been inﬁltrated. Usually 1–2 ml of the anesthetic agent is all that is required if adequate IV sedation is concurrently administered. Skin inﬁltration with anesthetic is performed later, after satisfactory transconjunctival fat contouring. 2. Transconjunctival approach to lower eyelid fat maintenance A medium-sized DesMarres eyelid retractor is used to inferiorly displace the lower eyelid by the assistant and the inferior fornix and inferior tarsal region is exposed (Fig. 15-11). There always seems to be a question of

Figure 15-11 The lower eyelid transconjunctival incision.

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Lower Blepharoplasty: Blending the Lid/Cheek Junction with Orbicularis Muscle and Lateral Retinacular Suspension the exact and ideal location of the incision for this approach. Simply stated, the incision should be placed where the fat is most easily accessible. In some patients this is mid-way between the inferior tarsal border and the inferior fornix and sometimes when fat is more posteriorly located (as in the lateral fat pad) the incision is contoured deeper into the inferior cul-de-sac and more distant from the inferior tarsus. With counter (posterior) ballotment of the globe using an acrylic eyelid plate over the protective corneal/scleral contact lens, the fat ‘bulge’ is quite readily seen in most patients. A ﬁne-tip needle Bovie cautery is then used to incise through conjunctiva and the lower eyelid retractors in pure cutting mode. This reduces the ‘char’ and allows for a precise incision and minimizes lateral thermal coagulation of the soft tissues. Although there is a mild degree of coagulation which is afforded via this method, however, any signiﬁcant bleeding should be addressed with the coagulation mode. I begin by exposing the fat pads through this incision, however addressing contouring of the lateral (most posterior and superiorly placed position pad) ﬁrst (Fig. 15-12). This is often the pad that is left untreated (or under-treated) as when the more medial fat pads are addressed the lateral pad may be more difﬁcult to expose. Conservative amounts of fat may be excised, however when minimal fat is noted, diathermy only may be used to approach

‘shrinkage’ of the lower periorbital fat pads. The lower eyelid skin has not yet been injected until this point, and the evaluation of the anterior surface contours for the determination of optimal fat maintenance is more easily detected. In the scenario of a signiﬁcant ‘tear trough deformity’ a small pocket is dissected through the transconjunctival incision medially and orbicularis muscle at the medial orbital rim is reﬂected from periosteum (Fig. 15-13). This maneuver in itself may be sufﬁcient to diminish a mild depression, however if the contour defect is signiﬁcant, a free fat graft that is obtained from a region where fat was excised in either the upper or lower eyelid is positioned into the ‘pocket’ (Fig. 15-14). Contouring is performed to the extent that the lower periorbital bulges are satisfactorily transposed, excised or shrunk to the point of optimal ‘concavity’ when the globe is balloted posteriorly with the surgeon’s ﬁngers. At times even with diathermy alone there appears to be a signiﬁcant excavation of the anterior surface, however as the patient is typically supine this will give a false impression of ‘overcorrection.’ Again, this can easily be discerned by depressing the globe posteriorly and watching the contours, and the surgeon should proceed slowly and precisely while continuously observing the anterior lower eyelid (skin) surface until the contours are satisfactory with this maneuver.

Figure 15-12 Conservative fat excision via a transconjunctival approach. Advantages include precise and calculated excision titrated to a visual endpoint as well as release of the lower eyelid retractors that aids in an improved lower eyelid position.

Figure 15-13 The medial ‘tear trough’ if present can be addressed through the same conjunctival incision. If mild, blunt dissection/reﬂection of the medial orbicularis oculi muscle attachments to the infero-medial bony orbit adjacent to the visible ‘trough’ is carried out. The same dissection is used in preparation for transposition or placement of a fat graft.

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Figure 15-15 After fat maintenance, a lower eyelid subciliary incision is made. Figure 15-14 A free fat graft can be placed into the ‘pocket’ and secured (if necessary) to the periosteum (after incision) with absorbable sutures.

3. Lower eyelid skin incision and skin ﬂap dissection After this is achieved, the anterior skin surface is injected with the anesthetic solution subdermally and avoidance of injection into the orbicularis muscle is attempted. While the identical procedure (transconjunctival) is performed on the contralateral side, vasoconstriction and anesthetic effect to the skin and muscle is then achieved. Once transconjunctival fat maintenance procedures are performed on the contralateral side, attention is redirected to the ﬁrst side. A skin incision is then made just beneath the eyelashes using a #15 Bard-Parker blade and extends in the same line (latitude) through the lateral canthus rather than a downward distraction of the incision which is typically and erroneously (in my opinion) performed (Fig. 15-15). A 4-0 silk traction suture is then placed through a more central aspect of the lower eyelid through tarsus for upward traction and the assistant then places cotton tip application or digital traction to the lower eyelid skin ﬂap. Meticulous dissection is then performed (I prefer a battery-powered disposable cautery) to create an adequate skin ﬂap depending on the pathology presented (Fig. 15-16). If there is signiﬁcant redundant skin, especially when combined with dense rhytid, a widely undermined skin ﬂap may be performed. Care must be taken to avoid ‘button-holing’ through the skin surface which can be avoided by careful application by both you and your assistant. Dissection is carried laterally beyond the commissure to expose the superior-lateral retinaculum and orbicularis muscle in

Figure 15-16 Subdermal dissection (a skin ﬂap) is performed and the extent is dependent on the amount and type of skin pathology to address as well as the extent of the exposure of the lateral orbicularis muscle and inferior retinaculum required.

this region. Subcutaneous veins can be treated with diathermy through the skin dissection. 4. Orbicularis muscle incision and dissection Once the skin dissection is performed the same hand held cautery unit is used to incise through orbicularis muscle 2–3 mm below the lateral commissure (Fig. 15-17) beginning at about the level of the commissure laterally to the lateral extent of the skin incision or as

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Figure 15-17 After orbicularis muscle and the inferior retinaculum has been adequately exposed, the amount of orbicularis muscle to be incised (horizontally) is determined by the amount of orbicularis that requires mobilization and suspension to achieve the desired effect.

Figure 15-18 The orbicular incision releases the orbicularis muscle at the inferior retinaculum from the caudal edge of the lateral canthal tendon. The extent of dissection will depend on many factors including the amount of vertical displacement (elevation) desired with the canthoplasty.

wide as necessary to mobilize orbicularis muscle appropriate for each patient (Fig. 15-18). Dissection is performed to the lateral orbital rim and for as much release as required for both mobilization of orbicularis muscle, release of the inferior retinaculum from the lateral canthal tendon, and release of the inferior ‘tarsal strap’ depending on how much super placement is required (Fig. 15-19). It is uncommon to require dissection along the more medial aspects of the inferior orbital rim to disinsert or completely release the orbicularis retaining ligaments. 5. Lateral retinacular (canthal) suspension A double arm 4-0 or 5-0 polypropylene suture is then placed through the lateral canthal ligament. I prefer the use of a polypropylene suture on a cardiovascular taper needle (US Surgical, Norwalk, CT) as this causes minimal to no shearing of the periosteum and the taper point puncture to periosteum is more likely to remain secure. Each arm of the suture is brought through periosteum (in most instances) at the level of the lateral tubercle but will vary depending on the patient’s orbital morphology and the position of the commissure desired (see Chapter 4). As the upper blepharoplasty procedure has maintained all orbicularis muscle (see Chapter 8) this maneuver is performed mostly by palpation whereby the dominant hand advancing the surgical needle and needle holder is used to place the suture through the lateral canthal tendon, through to the inner aspect of the lateral orbital rim through perios-

Figure 15-19 Further dissection after the initial orbicularis muscle incision also is dependent on several factors. Release of the deeper attachments (especially a cicatrix in secondary blepharoplasty situations) will allow for more mobilization and is dependent on the amount of movement required.

Transconjunctival fat maintenance, lower eyelid skin ﬂap with orbicularis oculi and lateral retinacular suspension teum (Fig. 15-20). The non-dominant hand grasping a toothed forceps is used to palpate the exit of the suture through periosteum and direct this through the orbicularis muscle at the lateral upper eyelid. Sutures are usually placed 2–3 mm apart for the canthal suspension. Once satisfactory placement is made, the suture is tied beneath the cuff of orbicularis at the lateral upper eyelid wound (Fig. 15-21). Varying degrees of reinforcement with a loop of polypropylene at the lateral canthus (prior to tying) can be achieved by a 6-0 Vicryl ‘lasso’ suture around each arm of the penetration of the polypropylene suture at the lateral canthal tendon. This increases the drag coefﬁcient whereby a typical monoﬁlament suture would simply ‘cheesewire’ through the tissue. By securing each arm of the suture to the lateral canthal tendon with the ‘lasso’ suture the polypropylene canthal suspension suture remains secure for a much longer period of time that translates to a more secure canthopexy. One should be certain that the suture knot is adequately positioned beneath a cuff of the orbicularis muscle (to reduce visibility and palpability of the suture long-term) and that there is a secure ‘purchase’ at the lateral orbital rim periosteum as superﬁcial placement will yield both a signiﬁcantly more brief suspension effort which could be problematic with signiﬁcant muscle and skin manipulation and postoperative edema and/or misalignment of the lower eyelid and globe interface. After

Figure 15-20 After the necessary release is achieved, the lateral commissure can be repositioned that is now independent of the inferior attachments. The vector and direction of suture suspension/placement will vary (see Fig. 15-6) and is dependent on both the orbital morphology and the desired effect.

securing the polypropylene suture the upper eyelid wound closure is completed using the interrupted or continuous 6-0 nylon sutures. 6. Orbicularis oculi muscle suspension Attention is then directed to the orbicularis muscle ﬂap. Depending on the effect desired 1, 2, or 3 sutures using 4-0 or 5-0 Vicryl on a small P2 half circle cutting needle is used whereby the orbicularis muscle is both plicated and advanced to the lateral orbital rim periosteum medially and the temporalis fascia laterally (if applicable) (Figs 15-22, 15-23). One should see the restoration of tension of the lower eyelid orbicularis muscle that raises the eyelid/cheek junction without distracting the lateral commissure and lateral lower eyelid from the globe. This is more easily achieved when the secure lateral retinacular suspension is entirely independent of the orbicularis muscle suspension procedure. 7. Skin redraping, excision, and closure Once this lateral retinaculum and orbicularis suspension is performed, a very secure lower eyelid and lateral canthus is visualized. Skin redraping is performed. Skin excision can vary from no skin excision to at times signiﬁcant skin excision depending again on patient presentation (Figs 15-24 to 15-27). Skin closure is performed with interrupted or continuous 6-0 nylon

Figure 15-21 After retinacular suspension, the upper eyelid wound is closed. Attention is now directed to orbicularis muscle suspension that is now independent of the suspension of the lateral commissure.

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Figure 15-22 Usually 1 to 3 sutures (most commonly 1 or 2) of 4-0 or 5-0 Vicryl are placed towards the cephalad portion of the wound through the lateral orbital rim periosteum medially, and the temporalis fascia (if necessary) laterally and then advance the ﬂap of orbicularis muscle to this region.

Figure 15-23 A second lateral suture is placed if necessary.

Figure 15-25 Skin is conservatively redraped and excised so that the edges meet prior to suture placement.

Figure 15-24 After orbicularis muscle suspension, skin redraping and excision is performed.

Figure 15-26 Skin closure without tension.

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Figure 15-27 After suture removal.

Figure 15-28 A simple suture tarsorrhaphy is seen here at the extreme lateral aspect opposing the upper and lower eyelid.

sutures. At times an intramarginal lateral suture tarsorrhaphy is performed to promote good lateral lid position in the immediate postoperative period (Fig. 15-28). After the protective corneal/scleral contact lens is removed the lower eyelid traction suture is then elevated to the suprabrow region with 1/2 Steri-strip bandages to varying degrees, being sure to allow for at least satisfactory patient vision in the ﬁrst day, however, elevating the lid to a secure position to facilitate the use of cold compresses by the patient without distorting the lid position (Fig. 15-29). Patients are seen on the ﬁrst postoperative day when the eyelid traction suture is removed. This improves vision signiﬁcantly, however, the patients must be warned and instructed that vision will likely be variably impaired in lieu of the eyelid swelling, lower eyelid tightening, canthal suspension and elevation, as well as the use of topical ointments which will interfere with

Figure 15-29 Traction (‘Frost-type’) sutures remain in for the ﬁrst 24 hours.

clear vision. All sutures can be removed at or about one week postoperatively. Results with this technique in a variety of patients with different presentations are presented here. The steps in all patients are similar; what is different in each is the degree for which each step is undertaken. For instance, those individuals with minimal skin quality changes require less of a skin ﬂap dissection. Some patients with signiﬁcant lower eyelid laxity might require the variation of the canthal suspension suture (of heavier gauge, i.e. 4-0 polypropylene), position, or vector of canthal/retinacular support. For instance, a particular orbital conﬁguration and lower eyelid laxity may require the placement/entrance of the suspension suture at the lateral commissure (Fig. 15-10) with supraplacement, in contrast to some individuals with minimal lower eyelid laxity that might be concerned with any change in the lower eyelid slope or canthal position, even short-term. These latter type of individuals might also beneﬁt from a less hearty suture (5-0 polypropylene) without incorporation of the lasso suture (Vicryl) and placement of suture lateral to the commissure without supraplacement. Individuals with signiﬁcant orbicularis descent and/or with a prominent malar bag might require signiﬁcant dissection and release of the retaining ligaments and orbicularis muscle, where others with minimal descent might require the minimum dissection and ﬁxation. Delivering the best possible result depends on the ability to detect the individual’s situation at hand and deliver with precision the effects that will most accurately restore the youthful complement (Figs 15-30 to 15-46).

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A

B Figure 15-30 A, This 26-year-old female presents with ‘lower eyelid bags.’ Skin elasticity is excellent, however she has predisposed lower eyelid retraction that is familial. B, After lower blepharoplasty with lateral retinacular suspension. No infraciliary skin ﬂap was performed.

A

B Figure 15-31 A, This 23-year-old female also presents with ‘lower eyelid bags.’ Skin elasticity is excellent, however she has predisposed lateral canthal dystopia. B, After lower blepharoplasty with lateral retinacular suspension. No infraciliary skin ﬂap was performed.

A

B Figure 15-32 A, This 37-year-old male presented for the correction of lower eyelid ‘bags’ as well as ‘hollowing and shadowing’ beneath the lower eyelid bags. B, After lower blepharoplasty including treatment of the tear trough by orbicularis muscle reﬂection (without fat transposition or grafting), orbicularis muscle and lateral retinacular suspension.

Transconjunctival fat maintenance, lower eyelid skin ﬂap with orbicularis oculi and lateral retinacular suspension 175

A

B Figure 15-33 A, This 60-year-old gentleman presented for periorbital rejuvenation. B, After upper and lower blepharoplasty with lower eyelid orbicularis oculi muscle suspension and lateral retinacular canthoplasty.

A

B Figure 15-34 Oblique views of patient in Fig. 15-33. Note the elevation of the lower eyelid/cheek junction provided by orbicularis oculi muscle suspension.

A

B Figure 15-35 A, This 50-year-old gentleman presented for periorbital rejuvenation. He was not interested in laser skin resurfacing. B, After upper and lower blepharoplasty with lower eyelid skin ﬂap, orbicularis oculi muscle and lateral retinacular suspension.

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176

A

B Figure 15-36 A, This 54-year-old male presented for periorbital rejuvenation. B, After upper and lower blepharoplasty with orbicularis oculi support and lateral retinacular suspension canthoplasty.

A

B Figure 15-37 A, This 40-year-old female presented with signiﬁcant lower eyelid ‘bags’ requesting periorbital rejuvenation. Thyroid function testing was repeatedly normal. B, After upper and lower blepharoplasty and orbicularis muscle/lateral retinacular suspension. Thyroid function tests became abnormal 2 years after surgery.

A

B Figure 15-38 A, This 40-year-old female presented with large ‘lower eyelid bags.’ B, After lower blepharoplasty with skin ﬂap, orbicularis muscle and lateral retinacular suspension.

Transconjunctival fat maintenance, lower eyelid skin ﬂap with orbicularis oculi and lateral retinacular suspension 177

A

B Figure 15-39 A, This 50-year-old male presented for periorbital rejuvenation. There was a vague, remote personal history of thyroid disease and conﬁrmed high myopia. B, After upper and lower blepharoplasty with oribularis muscle and lateral retinacular suspension.

A

B Figure 15-40 A, This 45-year-old female with a known history of thyroid disease presented with concerns only related to ‘lower eyelid bags.’ She did not want any change in her eyelid shape and liked her ‘big eyes.’ B, After lower eyelid blepharoplasty with orbicularis oculi muscle suspension and with lateral retinacular canthoplasty. Note the preservation of eyelid shape despite signiﬁcant skin and muscle manipulation of the lower eyelid.

A

B Figure 15-41 A, This 55-year-old female presented for periorbital rejuvenation. B, After upper and lower blepharoplasty with skin ﬂap, orbicularis oculi support and lateral retinacular suspension canthoplasty.

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178

A

B Figure 15-42 A, This 34-year-old female presented with a desire for improvement of upper eyelid ‘heaviness’ and lower eyelid ‘bags’. B, After upper blepharoplasty and lower blepharoplasty utilizing orbicularis muscle and lateral retinacular suspension.

A

B Figure 15-43 A, This 50-year-old female presented for periorbital rejuvenation. B, After volume enhancing upper blepharoplasty combined with lower blepharoplasty utilizing a skin ﬂap, orbicularis oculi suspension and lateral retinacular canthoplasty.

A

B Figure 15-44 A, This 40-year-old female presented for periorbital rejuvenation. She was unhappy with the appearance of upper eyelid skin redundancy and lower eyelid ‘bags.’ She also requested a return of the ‘almond shape’ to her eyes that were very dramatic in her younger years. B, After upper and lower blepharoplasty with skin ﬂap, orbicularis oculi suspension and lateral retinacular canthoplasty.

References 179

A

B Figure 15-45 A, This 60-year-old female presented with complaints of looking ‘tired’. Examination showed signiﬁcant maxillary hypoplasia with an associated lower eyelid ‘tear trough’, and lower eyelid bulging due, in part, to fat herniation. B, After upper and lower blepharoplasty with lower eyelid lateral orbicularis oculi support, medial orbicularis oculi release for improvement of the tear trough, and lateral retinacular suspension canthoplasty.

A

B Figure 15-46 A, This 50-year-old female presented for periorbital rejuvenation. B, After volume enhancing upper blepharoplasty combined with lower blepharoplasty utilizing a skin ﬂap, orbicularis oculi suspension and lateral retinacular canthoplasty.

References 1. Anderson RL, Gordy DD: The lateral tarsal strip procedure. Arch Ophthalmol 1979; 97:2192. 2. Tenzel RP: Surgical treatment of complications of cosmetic blepharoplasty. Clin Plast Surg 1990; 5:517. 3. Baylis HI, Long JA, Groth MJ: Transconjunctival lower eyelid blepharoplasty. Technique and complications. Ophthalmology 1989; 96:1027. 4. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD: Pulsed carbon dioxide laser resurfacing of photoaged skin. Arch Dermatol 1996; 132:395. 5. Alster TS, Lewis AB: Dermatologic laser surgery. A review. Dermatol Surg 1996; 22:797. 6. 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. Oper Tech Plast Reconstr Surg 1998; 5:121.

7. Flowers RS: Canthopexy as a routine blepharoplasty component. Clin Plast Surg 1993; 20:351. 8. Jelks GW, Jelks EB: Repair of lower lid deformities. Clin Plast Surg 1993; 20: 417–425. 9. Fagien S: Algorithm for canthoplasty: The lateral retinacular suspension: A simpliﬁed suture canthopexy. Plast Reconstr Surg 1999; 103:2042. 10. Mendelson BC, Muzaffar AR, Adams WP: Surgical anatomy of the mid-cheek and malar mounds. Plast Reconstr Surg 2002; 110:890. 11. Stuzin JM, Fagien S, Lambros VS: Surgical anatomy of the ligamentous attachments of the lower eyelid and lateral canthus. Surgical anatomy of the mid-cheek and malar mounds by Mendelson BC, Muzaffar AR, Adams WP. [Discussion] Plast Reconstr Surg 2002; 110:905. 12. Flowers RS, Nassif JM, Rubin PAD, Hayakawa T, Lehr SK: A key to canthopexy: The tarsal strap. A fresh cadaveric study. Plast Reconstr Surg 2005; 116:1752.

CHAPTER 16

Treatment of Lower Eyelid Dermatochalasis, Herniated Orbital Fat, and Hypertrophic Orbicularis Muscle Skin-Muscle Flap Approach Allen M. Putterman

A skin-muscle ﬂap approach to removal of lower eyelid skin and fat was my favorite approach until about ﬁve or so years ago. I now believe that whenever the orbicularis oculi muscle can be preserved, there are advantages in eliminating postoperative eyelid retraction and ectropion as well as possibly decreasing postoperative edema from lymphatic drainage interruption. I, therefore, ﬁnd that I am removing or repositioning lower eyelid orbital fat through an internal transconjunctival approach and removing and tightening lower eyelid skin through a skin ﬂap approach combined with a lateral orbicularis ﬂap lift. I tend to limit the skin-muscle ﬂap approach to selected patients who have excessive lower eyelid skin and orbicularis usually associated with cheek bags and festoons who choose not to have a cheek–midface lift (Chapter 17). It is also useful when combined with a capsulopalpebral advancement entropion procedure. It is also rare that I do this approach without combining it with a lateral canthal tendon tightening through a tarsal strip procedure. I do believe that in a textbook on cosmetic oculoplastic surgery, it is important to include all forms of treatment including techniques that are more rarely done. Allen M. Putterman

Preparation for surgery The patient’s entire face is prepared with povidone-iodine (Betadine), soap and paint. The patient is draped so that the entire face is exposed. Topical tetracaine is applied over each eye. A scleral contact lens is placed over the eyes and under the eyelids to protect the eyes from foreign objects, to prevent the operating lights from bothering the patient, and to avoid causing the patient distress from seeing the procedure being performed.

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Surgical technique A line is drawn beginning at the lateral canthus and extending approximately 1 cm in an almost horizontal direction. Several milliliters of 2 percent lidocaine with epinephrine is subcutaneously injected diffusely across the lower eyelid. Also, a 25-gauge, 1.5-cm needle is passed through the nasal lower lid skin just above the skin of the inferior orbital rim and then over the inferior orbital rim in a slightly downward direction to avoid penetrating the eye. The needle is inserted for approximately 1 cm, and 0.5–1 ml of 2 percent lidocaine with epinephrine is injected. This is repeated centrally and temporally. A No. 15 Bard-Parker blade is used to make a skin incision 1.5 mm beneath the lower lid lashes (Fig. 16-1). The incision begins below the punctum and extends temporally for a distance of 2–3 mm temporal to the lateral canthus. The incision is extended for another 1 cm in an almost horizontal direction. A 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superﬁcial tarsus of the central lower eyelid and is used to pull the lower eyelid upward. With a toothed forceps, the surgeon grasps the central lower lid at the skin incision site and pulls the eyelid downward and outward. A Westcott scissors is used to penetrate the central orbicularis muscle, with the scissors tips pointed inward and downward (Fig. 16-2). The suborbicularis space should be seen. The Westcott scissors is inserted into the space, and its blades are spread to elongate this dissection. The traction suture and forceps are kept in the same position as the orbicularis muscle is severed along the incision site with Westcott scissors (Fig. 16-3) or other

Figure 16-1 Incision of infralash and lateral canthal skin.

suitable instrument. A disposable cautery (Solan AccuTemp, Xomed Surgical Products, Jacksonville, FL), Colorado needle, sapphire-tipped scalpel neodymium : YAG laser, or carbon dioxide laser (see Chapter 22) can also be used.1 These four instruments coagulate blood vessels while they simultaneously cut the orbicularis muscle. Blunt dissection with a cotton-tipped applicator or Westcott scissors is applied under the orbicularis muscle (Fig. 16-4). This step should allow visualization of the nasal, central, and temporal herniated orbital fat pads (Fig. 16-5).

Figure 16-2 Westcott scissors are used to penetrate the central orbicularis oculi muscle, with the scissors tips pointed inward and downward.

Figure 16-3 The orbicularis oculi muscle is severed along the skin incision site with Westcott scissors.

Surgical technique 183

Figure 16-4 Blunt dissection with Westcott scissors is applied under the orbicularis muscle.

Figure 16-5 The nasal, central, and temporal herniated orbital fat pads are now visible.

A 4-0 black silk traction suture is placed through the orbital septum and is used to pull the lower lid skin ﬂap downward. It is secured to the drape with a hemostat. The lower eyelid is pulled upward with the central traction suture, which is attached to the superior drape. Any remaining bleeding vessels are coagulated with a disposable cautery. A Westcott scissors or disposable cautery is used to make a small opening in the temporal orbital fat capsule. The surgeon pushes on the eye and the fat that prolapses with gentle pressure applied to the eye is clamped with a hemostat, and the tissues above the

Figure 16-6 Fat is clamped with a hemostat and cut with a No. 15 Bard-Parker blade slid over the hemostat.

hemostat are cut with a No. 15 Bard-Parker blade that is slid over the hemostat (Fig. 16-6). Cotton-tipped applicators are applied under the hemostat, and a Bovie cautery is used to coagulate the fat stump. Before releasing the hemostat, the surgeon grasps the orbital fat beneath the hemostat with a forceps. The fat is inspected for bleeding before it is allowed to retract into the orbit. Bleeding can lead to retrobulbar hemorrhage and the potential for blindness.2 After the temporal orbital fat pad is removed, the surgeon pushes on the eye again to ensure that the entire pad has been removed. Commonly, after removal of the temporal orbital fat pad, a second temporal fat pad appears when the surgeon pushes on the eye. This may be a second temporal fat pad that is not apparent until the ﬁrst pad is removed, or it may be a deeper portion of the temporal fat that becomes visible after the anterior part is removed.3 In either case, the surgeon must remove the second pad in order to prevent postoperative fullness in the temporal aspect of the eyelid. Once the temporal fat is completely removed, the central and nasal fat pads are removed in a similar manner. The central and nasal fat pads are separated by the inferior oblique muscle, and the nasal fat pad is white. The patient is then asked to look upward while the lower lid skin-muscle ﬂap is draped over the incision site (Fig. 16-7). If the patient is sedated, the assistant pushes on the eye by applying pressure to the scleral protective lens. This causes the lower eyelid to elevate and simulates the lower eyelid position in upgaze. The skin and orbicularis muscle that drape over the incision site are excised with Westcott scissors. This excision is

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184

Figure 16-7 The skin and orbicularis muscle are draped over the incision site and are excised.

Figure 16-9 A 6-0 black silk suture is run continuously from the lateral canthus to the temporal end of the incision. A second 6-0 black silk suture is run continuously from the nasal end of the incision to the lateral canthus.

the incision to the lateral canthus (Fig. 16-9). Several 6-0 interrupted Vicryl sutures are used to reinforce the temporal incision.

Postoperative care

Figure 16-8 A strip of orbicularis muscle is routinely excised over the superior skin muscle ﬂap, temporally to nasally, for a distance 4–5 mm beneath the ﬂap.

performed temporally over the lateral canthal incision site and then horizontally over the incision site of the lower lid skin from lateral canthus to punctum. With two toothed forceps, the surgeon grasps the skin-muscle ﬂap nasally and temporally and pulls it downward. A strip of orbicularis muscle is routinely excised over the superior skin-muscle ﬂap temporally to nasally for a distance of 4–5 mm beneath the ﬂap (Fig. 16-8). (This prevents postoperative fullness in that area.) If orbicularis muscle is noted to be hypertrophic preoperatively, it is now excised over the sites noted preoperatively in the same manner as the strip that is routinely taken. Bleeding is controlled with a disposable cautery. The surgeon sutures the skin by running a 6-0 black silk suture continuously from the lateral canthus to the temporal end of the incision site. A second 6-0 black silk suture is run continuously from the nasal end of

For two to three hours postoperatively the patient applies cold compresses to the eyelids. Ophthalmic signs are closely observed. The recovery room staff checks the patient every 15 minutes for the ability to count ﬁngers and to make sure there is no severe pain or proptosis. If the patient demonstrates either an inability to count ﬁngers, proptosis, or complains of severe pain, the surgeon is called immediately, because these problems may indicate a retrobulbar hemorrhage, which has the potential to cause blindness.2 For 24 hours postoperatively the patient or the patient’s family continues to apply cold compresses to the eyelids and check for the ability to count ﬁngers every hour (other than during sleep). If a patient cannot count ﬁngers or if there is severe pain or proptosis, he or she should immediately return to the Surgical Facility or other Emergency Facility for evaluation of a possible retrobulbar hemorrhage. Four to six days postoperatively, the 6-0 black silk skin sutures are removed. I usually remove Vicryl sutures 2–3 weeks postoperatively or allow them to dissolve spontaneously.

Postoperative complications Lower eyelid ectropion and retraction are possible complications from lower external blepharoplasty. Usually, these complications can be prevented by

References

Figure 16-10 Before (A) and after (B) skin-muscle ﬂap treatment of lower eyelid dermatochalasis (excess skin) and herniated orbital ﬂap. The patient’s upper eyelids were treated simultaneously with a skin-muscle resection and crease reconstruction (see Chapter 7).

A

B

careful preoperative assessment of patients with horizontal eyelid laxity who have the potential for development of these problems and by a simultaneous tarsal strip procedure in these patients (see Chapter 17). Should these complications occur, however, they can be treated with a tarsal strip postoperatively (see Chapter 17). If too much skin is removed, a cicatricial ectropion can occur. If this happens, skin grafting or a cheek lift, in addition to the tarsal strip procedure, is needed (see Chapter 17). Another complication is loss of eyelashes. This can be prevented if the incision is placed 1.5 mm beneath the lash line, with minimal cauterization of the areas from which the eyelash follicles emanate. There is no satisfactory treatment of loss of eyelashes. Suture cysts are possible postoperatively. They can be treated by light hydrolysis 2 months postoperatively with a Birtcher hyfrecator.

If a retrobulbar hemorrhage occurs, the sutures of the lower lid should be removed immediately and bleeding controlled.

Results More than 3000 patients have been treated with this technique with excellent results (Fig. 16-10).

References 1. Putterman AM: Scalpel neodymium : YAG laser in oculoplastic surgery. Am J Ophthalmol 1990; 109: 581–584. 2. Putterman AM: Temporary blindness after cosmetic blepharoplasty. Am J Ophthalmol 1975; 80: 1081–1083. 3. Putterman AM: The mysterious second temporal fat pad. Ophthalmic Plast Reconstr Surg 1985; 1:83–86.

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CHAPTER 17

Cheek–Midface Lift Allen M. Putterman With age, the cheek migrates inferiorly and nasally (Fig. 17-1). This contributes to inferior orbital rim hollowing, a circle effect of the lower eyelids and cheek, a ﬂattening of the cheek, cheek bags (festoons), and nasolabial fold. In the past, these problems have been treated with facelifts, excision of cheek bags, and cheek implants. Hester and McCord1,2 popularized the cheek–midface lift through an external lower blepharoplasty approach. This procedure originally was done by reattaching the suborbicularis orbital fat (SOOF) in a more normal position along with a full thickness resection of the lower eyelid to stabilize the lid. The procedure has been modiﬁed multiple times and at present, I perform the procedure by suspending an orbicularis muscle ﬂap along with tarsal strip and skin ﬂap procedures. The operation places the ptotic cheek in a more normal position, relieves cheek bags, ﬁlls in the hollow inferior orbital rim with cheek fat, makes the midface more convex, and decreases the nasolabial fold depression. It also gives the effect of cheek implantation, adds skin to the lower eyelids for the treatment of cicatricial ectropion, and reduces the hollowing of the lower eyelid that sometimes occurs secondary to overzealous fat removal in lower blepharoplasty. At times the procedure is performed with lower eyelid fat excision, and at times it is done with repositioning of the nasal and central lower eyelid fat pads into the inferior orbital rim hollowing area along with temporal fat resection. The tarsal strip procedure is performed to stabilize the lower eyelid and to prevent retraction and ectropion of the lower lid. Allen M. Putterman

Preparation for surgery The patient’s entire face is prepared with povidone-iodine (Betadine), soap, and paint. The patient is draped so that the entire face is exposed. Topical tetracaine is applied over each eye. A scleral contact lens is placed over the eyes and under the eyelids to protect the eyes from foreign objects, to prevent the operating lights from bothering the patient, and to avoid causing the patient stress from seeing the procedure being performed. A marking pen is used to create a lateral canthal line, which begins at the lateral canthus and extends in a horizontal direction for approximately 1–11/2 cm.

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188

Figure 17-1 Inferior and nasal descent of the cheek fat that occurs with aging. The more superior outlined area depicts the normal position of the cheek fat.

Figure 17-2 A Westcott scissors is used to sever the lateral canthus.

Surgical technique A mixture of 40 ml of 0.5 percent lidocaine (Xylocaine) with 1 : 200,000 epinephrine, and 4 ml of 0.5 percent plain bupivacaine (Marcaine) is prepared. Several milliliters of the mixture is injected subcutaneously and diffusely across the lower eyelids. A 25-gauge 1.5 cm needle is passed through the nasal lower eyelid just above the inferior orbital rim and then over the inferior orbital rim slightly in a downward direction to avoid penetrating the eye. The needle is inserted for approximately 1 cm and 0.5–1 ml of the anesthetic mixture is injected. This is repeated centrally and temporally. A mark is applied with a blue marking pen to the area of the infraorbital foramen and several milliliters of the same anesthetic mixture is injected around the exit of the infraorbital nerve. Approximately 20 ml of the solution is injected subperiosteally over the cheek down to the upper gum and nasolabial fold areas. Approximately 1/2 cc of the anesthetic is also injected subcutaneously at the center of the upper eyelid just above the lid margin. A 4-0 black silk suture is passed through skin, orbicularis and superﬁcial tarsus at the center of the upper eyelids and the sutures are left long so that they can be attached to the drape with hemostats to lift the upper lid upward. A similar 4-0 black silk suture is placed through skin orbicularis and superﬁcial tarsus of the center of the lower eyelid just adjacent to the lid margin, and again left long for traction. A #15 Bard-Parker blade is then used to make an incision through skin over the lateral canthal mark from the lateral canthus temporally in a horizontal direction for 1 to 11/2 cm. A Westcott scissors is then used to sever the lateral canthus (Fig. 17-2). A Colo-

Figure 17-3 Incision of skin and orbicularis from the lateral canthus to approximately 1–1.5 cm temporal to the lateral canthus.

rado needle then incises the orbicularis muscle from the lateral canthus throughout the length of the skin incision (Fig. 17-3). The lower limb of the lateral canthal tendon is severed (Fig. 17-4). A small Desmarres retractor everts the lower eyelid. One to two cubic centimeters of the anesthetic mixture is then injected subconjunctivally from the inferior tarsal border to the inferior fornix across the eyelid. The Colorado needle is then used to cut conjunctiva from the caruncle to the temporal aspect of the eyelid midway between the inferior tarsal border and the inferior fornix (Fig. 17-5). The surgeon grasps the central inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent, more superior edge, with another forceps. The two forceps are pulled apart, and then the Colorado needle is applied across the eyelid between the two severed conjunctival layers through Müller’s muscle and capsulopalpebral fascia until fat is seen (Fig. 17-6).

Surgical technique 189

Figure 17-4 The lower limb of the lateral canthal tendon is severed.

Figure 17-6 The surgeon grasps the central inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent more superior edge with forceps. The forceps are pulled apart and the Colorado needle severs Müller’s muscle and capsulopalpebral fascia along the course of the severed palpebral conjunctiva.

Figure 17-5 A Colorado needle is used to cut through lower palpebral conjunctiva from the caruncle to the temporal end of the eyelid midway between inferior tarsal border and inferior fornix.

A 4-0 double arm black silk suture is passed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia with each suture arm. The sutures are then drawn upward and attached to the drape with a hemostat (Fig. 17-7). A small piece of tape is applied over any exposed needle to avoid needle sticks and to allow the suture to be reused, if needed. Usually the needle is cut and removed from the operating ﬁeld.

A small Desmarres retractor is placed over the superior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and is pulled downward and outward to expose the orbital fat. With the use of cotton-tipped applicators and Westcott scissors, blunt dissection is carried out to isolate the three orbital fat pads. The central and nasal fat pads are divided by the inferior oblique muscle, which can easily be seen through the internal approach and should be identiﬁed to avoid injury to this structure. Also, the nasal and central fat pads are found in a slightly more temporal position than when they are isolated through an external approach. The temporal herniated orbital fat is isolated, and the fat that prolapses with general pressure on the eye is clamped with a hemostat and cut along the hemostat with a #15 Bard-Parker blade (Fig. 17-8). Then cotton tip applicators are placed under the hemostat and a Bovie cautery is applied over the fat stump. The surgeon grasps the fat with the forceps before it is allowed to slide back into the orbit to make sure there is no residual bleeding that might cause a retrobulbar hemorrhage. After the ﬁrst temporal fat pad is removed, the surgeon applies additional pressure to the eye to determine whether there is a second temporal fat pad.4 If found, it is removed in a similar manner. At times, the central and nasal fat pads are removed, and sometimes they are repositioned into the inferior orbital rim hollowing. This is a surgical judgement that is made depending on the severity and amount of

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Cheek–Midface Lift

190

Figure 17-8 The surgeon removes the temporal orbital fat pad routinely and occasionally also the central and nasal orbital fat by cutting along the hemostat blade with a #15 Bard-Parker blade, and then applying a Bovie cautery over the fat stump. At times the nasal and central fat pads are repositioned (see Figs 17-22 & 17-23). Figure 17-7 A 4-0 double arm silk suture has each arm passed through the inferior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and the suture ends are secured to the superior drape to pull these structures upward. A small Desmarre retractor is placed over the superior edge of conjunctiva, Müller’s muscle, and capsulopalpebral fascia and is pulled downward and outward to expose the orbital fat.

orbital fat present preoperatively, as well as how much hollowing there is at the inferior orbital rim and nasaljugal fold areas. If the decision is made to remove the fat, then the nasal and central orbital fat pads are removed in a similar manner to the description of the removal of the temporal fat pads. If the decision is made to reposition the nasal and central orbital fat pads, this is deferred until later in the procedure to avoid having to deal with the fat and sutures at this stage of the procedure.

Dissection of cheek periosteum A medium size Desmarres retractor is used to retract conjunctiva, Müller’s muscle, and capsulopalpebral fascia over the inferior orbital rim. Using blunt dissection with a smooth end of a Tenzel periosteal elevator, the periosteum over the inferior orbital rim and lateral

orbital rim are isolated. A Colorado needle or #15 Bard-Parker blade is used to incise periosteum several millimeters beneath the orbital rim from the nasal inferior orbital rim all the way across the orbit sweeping up into the lateral orbital rim (Fig. 17-9). The sharp edge of the Tenzel periosteal elevator is used to reﬂect periosteum from the incision in a downward direction over the cheekbone (Figs 17-10 & 17-11). The surgeon should take care to avoid the area of the infraorbital foramen and nerve by palpating the inferior orbital foramen which was previously marked with a marking pen and by dissecting inferior to this position. Most of the time, it is unnecessary to dissect periosteum nasal to the infraorbital canal; leaving periosteum nasal to the infraorbital nerve allows the nasal area to act as fulcrum for the cheek lift. However, if the purpose of the surgery is to add skin to the lower eyelid in the treatment of cicatricial ectropion or to reposition the nasal and central lower eyelid orbital fat pads, then dissection nasal to the infraorbital nerve is performed (Fig. 17-12). During the periosteal dissection, small blood vessels such as the temporal zygomatic artery are commonly encountered; these are treated with the Colorado needle to coagulate these areas and thereby to avoid bleeding.

Surgical technique 191

Figure 17-9 A #15 Bard-Parker blade is used to incise periosteum several millimeters beneath the inferior orbital rim throughout the extent of the rim. The dissection is then carried out over the inferior lateral orbital rim.

Figure 17-10 The sharp edge of Tenzel periosteal elevator is used to reﬂect periosteum from the inferior and lateral orbital rim. The large Desmarre retractor is used to retract the eyelid and orbital tissues downward.

Figure 17-11 The dull edge of the Tenzel periosteal elevator is used to dissect periosteum from the cheekbone. An Army-Navy retractor facilitates this dissection.

Figure 17-12 The diagonal lines indicate the area of periosteal dissection, which is under the infraorbital canal and extends to the nasolabial fold as well as to the upper gum. If there is lower eyelid retraction or cicatricial ectropion or if nasal and central orbital fat pads are to be repositioned, then periosteum is also dissected under the orbital rim nasal to the nerve.

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Cheek–Midface Lift Also should there be any bleeding from other areas of the cheekbone, the Colorado needle can be used to coagulate those, as well as in order to create a dry ﬁeld. Periosteum is dissected inferiorly to the level where the cheekbone is and dips inward, which should be close to the upper gum. Nasally and inferiorly, the periosteal dissection extends into the nasolabial fold, with the surgeon taking care not to penetrate into the nasal cavity. Palpation of the periosteal elevator through the external skin and internal nares facilitates the dissection of the nasolabial fold. Also the dissection in the nasolabial fold area is more superﬁcial to decrease the furrow of the nasolabial fold. The use of an ArmyNavy retractor to lift the dissected cheek tissue outward and downward aids in the visualization of the dissection site. A #11 Bard-Parker blade is used to incise the periosteum at the inferior aspect of the dissection, which

should be at the area where the cheek bone depresses inward (Fig. 17-13). The surgeon should be careful to penetrate only the periosteum and not any of the more superﬁcial tissues. Once the periosteum has been incised over the entire horizontal dimension of the inferior aspect of the ﬂap, the periosteum is reﬂected superiorly for approximately 1 cm with the Ramirez endoforehead periosteal spreader (Snowden-Pencer 88-5080, No. 7) to sweep the periosteum upward (Fig. 17-14). When this is accomplished, the surgeon places his or her index ﬁnger into the subperiosteal space, engages the area of the periosteal incision site, and lifts the periosteum upward and outward (Fig. 17-15). With this maneuver, the surgeon should feel a release of tissue that allows the patient’s cheek to move upward and outward. The procedure is facilitated by an Adson forceps pulling the lateral canthal orbicularis upward and outward.

Figure 17-13 A #11 Bard-Parker blade is used to incise periosteum at the inferior edge of the periosteal ﬂap, while an Army-Navy retractor pulls the cheek tissue outward and downward.

Surgical technique

Figure 17-14 A Ramirez endoforehead periosteal spreader is used to sweep the incised periosteum upward and to reﬂect it from the subperiosteal tissues.

Figure 17-15 The surgeon places his or her ﬁnger under the periosteal ﬂap and palpates the dissected and reﬂected periosteum. If any attachments are inhibiting upward movement of the cheek ﬂap, they are dissected with the surgeon’s ﬁnger in a sweeping motion that releases periosteum upward.

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Cheek–Midface Lift A 4 by 4 gauze saturated in the anesthetic mixture is rung out and inserted over the cheek in the subperiosteal plane for hemostasis. During this time the surgeon begins operating on the opposite lower eyelid and cheek area to allow the anesthetic mixture to control hemostasis over the next 10 to 15 minutes. The gauze is then removed and using an Army-Navy retractor to expose the area of the dissection site, any remaining bleeders are cauterized.

Tarsal strip procedure The protective scleral contact lens is removed. A forceps is used to grasp the temporal aspect of the lower eyelid and to pull it temporally and slightly superior until slight tension of the eyelid is achieved (Fig. 17-16). A scratch incision is made with No. 11 BardParker blade at the aspect of the lower eyelid margin that is now adjacent to the temporal cut edge of the upper eyelid margin (Fig. 17-17). A measurement is made with a ruler from the temporal cut end of the lower eyelid to the scratch incision, which determines the length of the tarsal strip. (It is best to be conservative in size of the tarsal strip since, if it is under too great tension, there is more chance of lateral canthal deformities.) The surgeon then divides the eyelid into two lamellae by cutting with a Westcott scissors along the gray line from the temporal end of the eyelid to the scratch incision site (Fig. 17-17). The Westcott scissors is used to remove skin and orbicularis from the anterior aspect of the tarsus of this eyelid segment (Fig. 17-18). A disposable cautery is used to cut through conjunctival, Müller’s muscle, and capsulopalpebral fascia at the inferior tarsal edge. Bleeding is controlled with a dis-

Figure 17-16 The temporal eyelid margin is grasped with forceps and is pulled temporally and upward.

posable cautery. The surgeon scrapes the conjunctival epithelium on the posterior surface of the tarsus with a No. 15 Bard-Parker blade to prevent epithelial inclusion cysts (Fig. 17-19). Each arm of a 4-0 Polypropylene (Prolene) doublearmed suture is passed internally to externally through the tarsal strip at the junction of the strip and eyelid (Fig. 17-20). The strip is pulled temporally until the area of the Polypropylene suture is adjacent to the lateral orbital wall. The strip is drawn superiorly and internally until it seems to be an acceptable position. The temporal lower eyelid should also be in contact with the eye, not displaced anterior to the eye. If the patient’s eye is proptotic, as in thyroid disease, the tarsal strip should be placed more anteriorly than for a recessed or enophthalmic eye. Once the desired lateral position is determined, each arm of the 4-0 Polypropylene suture is passed internally to externally through the

Figure 17-17 A scratch incision is made on the lower eyelid margin at the nasal end of the tarsal strip. The surgeon divides the eyelid into two lamellae by cutting along the grayline from the temporal end of the eyelid to the scratch incision site.

Figure 17-18 The posterior superior edge of the eyelid margin is excised.

Surgical technique 195

Figure 17-21 The Polypropylene is passed internally to externally through the lateral orbital periosteum. Figure 17-19 The conjunctival epithelium on the posterior surface of the tarsus is scrapped off.

judged. If the lateral canthus is too high or low or too anterior or posterior, the knot-releasing suture is grasped with a forceps at each end of the 4-0 black silk suture and is pulled outward to release the knot. The suture arms are removed from the lateral wall periosteum or upper lateral canthal tendon and placed in a new position. This procedure is repeated until the desired position of the lateral canthus and lower eyelid is achieved.

Repositioning of the nasal and central lower eyelid fat pads Figure 17-20 Each arm of the 4-0 Polypropylene (Prolene) double-armed suture is then passed internally to externally through the tarsal strip at the junction of the strip and eyelid.

lateral orbital periosteum or through the upper limb of the lateral canthal tendon at this position (Fig. 17-21). The suture is tied with the ﬁrst tie of the surgeon’s knot over a 4-0 black suture knot-releasing suture (the piece of silk is approximately 5 cm long and does not have a needle attached to it). It is important, in placement of the tarsal strip, that the lower eyelid not retract further from the inferior corneal limbus and pull behind and under the eye. Excessive tension on the eyelid can lead to lower eyelid retraction. The cheek periosteal release and tarsal strip procedure is then performed on the opposite side. The patient is seated up on the operating table, and the position of the lateral canthus is compared with the other side. The top of the metal ruler is aligned with each medial canthus, and the level at which the ruler bisects each lateral canthus is noted. The position of the lower eyelid adjacent to the eyes is also

If the nasal and central orbital fat has been removed, the conjunctiva is closed at this point. However, if there is a relatively deep inferior orbital hollowing or nasaljugal fold, the nasal and central fat pads are repositioned at this point. The 4-0 knot releasing sutures is grasped with forceps at each end and the 4-0 Polypropylene tarsal strip suture is released. The nasal and central fat pads have their outer capsule open and with blunt dissection with cotton tip applicators, a stalk of nasal and central orbital fat pads are formed. Each of these fat pads should easily slide inferiorly into the position of the inferior orbital rim hollowing. A 4-0 Polypropylene (Prolene) double-armed suture is passed through the distal end of each of these fat pads (Fig. 17-22). This needle passes through multiple bites of distal fat and is treaded so that as much of the distal end of the fat pad is captured with the needle and suture. Each arm of the 4-0 Polypropylene suture on the nasal fat pad is passed over the maxillary bone to a position inferior to the hollowed inferior orbital rim area, and then through periosteum orbicularis muscle and out skin. The other 4-0 Polypropylene suture that passes through the central fat pad is passed in a similar manner slightly more centrally than the ﬁrst sutures (Fig. 1723). The needles are taped to the drape at this point.3

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Figure 17-22 A 4-0 Polypropylene (Prolene) doublearmed suture is passed through the distal end of the nasal and central fat pads.

Figure 17-24 The conjunctiva is reapproximated with three 6-0 plain catgut buried sutures.

exits at the cut edge at the temporal upper lid (Fig. 1725). When this suture is drawn up and tied, it reforms the angle of the lateral canthus and the knot is buried. The Polypropylene tarsal strip suture is then tied with approximately four knots. A 4-0 Polyglactin (Vicryl) suture is passed through periosteum adjacent and temporal to the Polypropylene knot. It is then passed through the tarsal strip internally to externally and is tied. This suture further secures the tarsal strip to periosteum and buries the Polypropylene suture. The excessive tarsal strip temporal to the Polyglactin suture is then severed (Fig. 17-25). Figure 17-23 Each of the arms of the 4-0 Polypropylene (Prolene) sutures of the nasal and central fat pad are passed over the maxillary bone to a position inferior to hollowed inferior orbital rim area, and then through periosteum, orbicularis muscle, and out skin.

Conjunctival closure The 4-0 silk suture that attaches conjunctiva, Müller’s muscle, and capsulopalpebral fascia to the drape is then severed. Conjunctiva is reapproximated with three 6-0 plain catgut buried sutures (Fig. 17-24). Completion of tarsal strip is accomplished with a 5-0 chromic suture passed from the nasal end of the tarsal strip through the lower eyelid gray line margin exiting at the gray line several millimeters from the tarsal strip. The suture then is passed through the upper eyelid margin and

Formation of the orbicularis ﬂap The orbicularis muscle of the lateral canthus is grasped with a forceps and pulled upward. A Westcott scissors is then used to dissect temporal lower eyelid and lateral canthal skin from the orbicularis (Fig. 17-26). A small Desmarres retractor is then placed over this skin ﬂap while the orbicularis is still being pulled upward and any bleeding is controlled with a disposable cautery. A 4-0 Polypropylene double-armed suture is passed through periosteum over the lateral orbital wall just temporal to the tarsal strip. A forceps is used to pull the orbicularis ﬂap upward and outward to the point where the cheek and midface are in good position and the inferior orbital rim hollowing is resolved. This will determine the position that the suture will be placed through the orbicularis ﬂap.

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Figure 17-25 A 5-0 chromic catgut suture passes through the grayline of the upper and lower eyelids and exists through the cut end of the temporal wound. Once the 4-0 Polypropylene (Prolene) tarsal strip suture is tied down, the excessive strip is excised.

Figure 17-27 A 4-0 Polypropylene (Prolene) doublearmed suture is passed through periosteum over the lateral orbital wall, and then through the orbicularis ﬂap.

Figure 17-28 The two Polypropylene (Prolene) sutures passing through periosteum and temporalis muscle and orbicularis ﬂap are tied to secure the ﬂap. Figure 17-26 The orbicularis muscle of the lateral canthus is pulled upward with forceps as a Westcott scissors is used to dissect temporal lower eyelid and lateral canthal skin from the orbicularis.

One arm of the 4-0 Polypropylene suture is then passed internally to externally through the orbicularis ﬂap at the site where the ﬂap now meets the lateral canthus. The same arm of the suture is then passed externally to internally (Fig. 17-27). The suture is tied with three throws over a 4-0 black silk knot releasing suture that has no needle and is approximately 5 cm long. The procedure is then performed on the opposite side. The patient is then sat up on the operating table, and the positions of the cheek and midface are compared with each other. If there is one side higher or lower than the other then the knot releasing suture is

removed and the suture is replaced until the desired effect is achieved. Once this is accomplished, the knot releasing suture is removed and the Polypropylene sutures are tied with approximately four knots. Another 4-0 Polypropylene suture is passed through temporalis fascia and lateral orbital wall just temporal to the ﬁrst suture. The arm of the suture is then passed internally to externally through the orbicularis ﬂap and then externally to internally so that when that suture is drawn up and tied, it further secures the orbicularis ﬂap (Fig. 17-28). If there is any dimpling that occurs in the skin, then further dissection is carried out between the skin and orbicularis muscle until the dimple disappears (Fig. 17-29). The part of the orbicularis ﬂap that drapes over the lateral canthal skin is then severed and bleeding is controlled with a disposable cautery (Fig. 17-30). This

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Figure 17-29 If there is any dimpling of the skin, then further dissection is carried out between and orbicularis muscle until the dimple disappears.

Figure 17-31 The cheek fat and suborbicularis orbital fat (SOOF) are elevated to a more superior temporal position by the securing of the orbicularis ﬂap. The inferior outlined area indicates the original downward displaced position of the SOOF, and the superior outline indicates the corrected position.

Figure 17-30 The part of the orbicularis ﬂap that drapes over the lateral canthal skin is then severed.

places the suborbicularis orbital fat (SOOF) back into its normal position (Fig. 17-31). A 6-0 Vicryl suture is then passed through orbicularis at the superior aspect of the lateral canthus and then internally to externally through the cut edge of the superior orbicularis ﬂap. The suture is then passed externally to internally so that when the suture is drawn up and tied, it secures orbicularis to orbicularis and covers the Polypropylene suture knots (Fig. 17-32).

Skin dissection With a No. 15 Bard-Parker blade, the skin is incised about 2 mm beneath the cilia beginning 1–2 mm temporal to the punctum and extending across the horizontal length of the eyelid to 2–3 mm lateral to the lateral canthus (Fig. 17-32). The skin is dissected from orbicularis muscle with Westcott scissors (Fig. 17-33). The correct subcutaneous plane is judged by observing the spread scissors blades through the translucent skin.

Figure 17-32 A 6-0 Vicryl suture secures orbicularis muscle ﬂap to orbicular muscle superior to the ﬂap, and thereby covers the Polypropylene (Prolene) suture knots. The skin is incised about 2 mm beneath the cilia beginning 1–2 mm temporal to the punctum and extending across the horizontal length of the eyelid.

With one blade of the scissors placed beneath the skin and the other at the skin edge, the subcutaneous attachments are severed. The skin usually is undermined from the orbicularis muscle to the level of the inferior orbital rim. If there is tenting of the orbicularis muscle, a small amount of superﬁcial orbicularis is trimmed with Westcott scissors, and bleeding is controlled with a disposable cautery (Fig. 17-34) (Solan Accu-Temp, Xomed Surgical Products, Jacksonville, FL). The skin ﬂap is then draped over the incision site while the assistant pushes on the eye by way of the contact lens; this

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Figure 17-33 The skin is dissected from orbicularis muscle. Figure 17-35 The skin ﬂap is draped over the incision site while the assistant pushes the eye by way of a contact lens.

Figure 17-34 If there is tenting of the orbicularis muscle a small amount of superﬁcial orbicularis muscle is trimmed.

pushes the lower lid upward and simulates its position on upgaze (Fig. 17-35). The skin that drapes the incision is excised with a small vertical triangle along the inferior lash line, and a larger lateral triangle temporal to the lateral canthus (Figs 17-36 & 17-37). To avoid an ectropion, it is better to tighten the lower eyelid skin with the lateral triangle than the vertical one.

Skin closure A 6-0 black silk suture passes through the temporal lower eyelid skin at the lateral canthal angle site, and catches a slight amount of orbicularis and tendon, as well. The suture is drawn up and tied with three knots, and only one end is cut. A 6-0 Vicryl suture is then passed through the temporal lower eyelid skin edges picking up a slight amount of the inferior tarsal border. When the suture is drawn up and tied, it unites the temporal skin to the inferior tarsal border and prevents

Figure 17-36 The skin that drapes over the eyelid is excised along the inferior lash line.

overriding of the lower eyelid skin. Several 6-0 Vicryl sutures are then passed through the skin edges over the area temporal to the lateral canthus. The 6-0 silk suture is then run continuously from lateral canthus to temporal wound edge. Another continuous 6-0 black suture is run continuously across the eyelid in a nasal to temporal direction with fewer bites, because this incision site is under minimal tension (Fig. 17-38).

Completion of fat repositioning If the fat has been repositioned the two 4-0 Polypropylene sutures, that are redepositing the nasal and central orbital fat pads, are tied with multiple knots

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Figure 17-37 A triangle of skin that drapes over the lateral canthus is also excised.

Figure 17-38 The skin is closed with running 6-0 black silk sutures, as well as several interrupted 6-0 Vicryl sutures.

over cotton plegets to secure the fat in the hollowed areas (Fig. 17-39). The contact lenses are removed and Garamycin ointment is applied over the sutures sites and eyes. Cold compresses are applied.

Postoperative care No dressings are used after surgery. The patient is instructed to apply ice-cold compresses on the eyelids. Pads 4 × 4 inches soaked in a bucket of saline and ice, are applied with slight pressure to the lids. When the pads become warm, they are dipped again into the saline and ice and reapplied. This process is repeated for 24 hours. The application should be fairly constant

Figure 17-39 The two 4-0 Polypropylene (Prolene) sutures that reposition nasal and central orbital fat are secured by tying these sutures over cotton plegets.

for the ﬁrst few postoperative hours. After that the compresses are applied for about 15 minutes with a 15-minute rest period in between until bedtime. The applications are resumed on awakening. To reduce edema postoperatively, the patient lies in bed with the head approximately 45º higher than the rest of the body. I also routinely use systemic steroids and antibiotics after surgery. Nurses should check for bleeding associated with proptosis, pain, or loss of vision every 15 minutes for the ﬁrst 3 hours postoperatively or until the patient leaves the surgical facility. Every hour thereafter until bedtime, the family or patient should monitor the patient’s ability to count ﬁngers and should check for unusual proptosis and pain. If the patient cannot count ﬁngers or has proptosis or pain, the family should take him/her to the emergency room. If loss of vision occurs secondary to retrobulbar hemorrhage, it could be detected quickly and treated by opening the incision involved.5 The 6-0 black silk sutures are removed 6 days postoperatively. The 4-0 Polypropylene sutures that reposition the fat are removed at the same time. The 6-0 Polyglactin sutures are removed 3 weeks postoperatively, if they have not dissolved by this point.

Complications Patients should be aware that they may have an Asian appearance immediately after surgery, which should resolve spontaneously. They should also be told that they may still have a slight puckering or dimpling at the temporal lower eyelid from the Polypropylene cheek sutures, which should resolve spontaneously after the next few months. If it does not, further skin dissection or removal of sutures can be done. Occasionally patients

Results will have discomfort or an inﬂammatory reaction from the buried Polypropylene sutures. If this is the case they can always be removed. The incision site under the eyelashes usually heals quite well. Should there be any unusual scarring in the lateral canthal area, excision and revision of this can be done. I have had several patients that have had parasthesia over the cheek area immediately postoperatively which resolved within a month. I have also had several patients that have had webbing or rounding of the lateral canthal area, which has responded to a small lateral canthotomy and suturing of the temporal cut ends of skin and conjunctiva together. I have had one patient with and lower eyelid cicatricial ectropion and retraction from a previous procedure that developed postoperative diplopia. This resolved spontaneously.

A

B

In all of the procedures that I have performed, I have not had any long-term complications.

Results More than 500 patients have been treated with excellent result (Figs 17-40 to 17-42). The rate of patient satisfaction has been high. The main complaints initially used to be skin puckering, which has been resolved for the most part by wider dissection of skin from orbicularis and excision of tented orbicularis during the procedure. Also in a number of patients I have had to remove the buried Polypropylene sutures, revise lateral canthal scars, and perform lateral canthotomies to eliminate webs or rounded lateral acanthi.

Figure 17-40 A, Preoperative photograph of a patient with cheek depression and hollowing over the inferior orbital rim as well as upper eyelid ptosis. She had previously undergone a facelift and 4-lid blepharoplasty performed by another surgeon. B, The same patient after cheek and midface lift. The cheek is in a higher, more temporal normal position, simulating a cheek implant. In addition the hollowing over the inferior orbital rim is decreased and the nasolabial fold depression is softened. A bilateral upper and lower blepharoplasty and a bilateral upper Müller’s muscle conjunctival resection ptosis procedure was performed simultaneously.

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A

B Figure 17-41 A, Patient with sagging midface preoperatively. B, Same patient after cheek and midface lift, which restored her cheeks to a more normal position, giving the appearance of cheek implants. An upper and lower blepharoplasty and a Müller’s muscle resection ptosis procedure were also performed.

References 203

B

A

Figure 17-42 A, Patient with cheek–midface ptosis, brow and upper eyelid ptosis, and excessive skin and fat of all four eyelids. B, Same patient after cheek–midface lift. Patient also had a bilateral Müller’s muscle resection ptosis procedure, excision of excessive eyelid fat and skin, and an endoscopic forehead lift.

References 1. Hester TR Jr., Codner MA, McCord CD Jr.: Subperiosteal maler cheek lift with lower lid blepharoplasty. In McCord CD Jr. (ed): Eyelids Surgery: Principles and Techniques, pp 210–215. Philadelphia, Lippincott-Raven, 1995. 2. McCord CD Jr.: Lower lid blepharoplasty. In McCord CD Jr. (ed): Eyelid Surgery: Principles and Techniques,

pp 196–209, Philadelphia, Lippincott-Raven, 1995. 3. Putterman AM: Avoidance of needle stick injuries during reuse of surgical needles. Plastic and Reconstr Surg 2003; 112:333–334. 4. Putterman AM: The mysterious second temporal fat pad. Ophthal Plast Reconst Surg 1985; 1:83–86. 5. Putterman AM: Temporary blindness after cosmetic blepharoplasty. Am J Ophthalmol 1975; 80:1081–1083.

CHAPTER 18

Treatment of Lower Eyelid Retraction with Recession of Lower Lid Retractors and Placement of Hard-Palate or Allogeneic Dermal Matrix Spacer Grafts Allen M. Putterman and Steven Fagien Treatment of lower eyelid retraction is common in patients with thyroid ophthalmopathy. It may also occur as a complication of previous blepharoplasty procedures, both cosmetic and functional. Treatment consists of recessing the lower lid retractors and placing a spacer between them and the inferior tarsal border. Present options include hard-palate grafting for the spacer because (1) it provides a mucous membrane lining to the internal lower lid; (2) it is rigid and ﬂat; and (3) it is autogenous. A useful alternative however is using an allogeneic spacer graft to avoid issues relating to harvesting and also to reduce operative time. A lower internal blepharoplasty along with lower retraction surgery is commonly performed. This approach differs slightly from the transconjunctival approach to resection of lower eyelid herniated orbital fat (see Chapter 14), in that the retractor incision is made at the inferior tarsal border rather than 5–6 mm inferior to the inferior tarsal border. Allen M. Putterman and Steven Fagien

The most common cause for lower eyelid retraction today relates to eyelid malposition caused by cosmetic lower blepharoplasty. Lower eyelid retraction also frequently occurs in patients with thyroid ophthalmopathy. At times, it is associated with exophthalmos. In other cases it is an entity in itself, presumably secondary to contracture of the inferior rectus muscle, which then lowers the eyelid through its attachment to the capsulopalpebral fascia and the capsulopalpebral fascia attachment to the tarsus. This not only creates a cosmetic disturbance but also leads to ocular irritation and keratopathy. Most patients who present with dissatisfaction after lower blepharoplasty complain or have symptoms related to lower eyelid malposition combined with a more ‘round’ appearance to the eye that is secondary to an increased vertical palpebral aperture and a shortened horizontal aper-

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Treatment of Lower Eyelid Retraction with Recession of Lower Lid Retractors ture. Often, mild to even moderate degrees of lower eyelid retraction need not be addressed depending upon the patient’s concerns, desires and expectations. Frequently, lower eyelid retraction is minimal and can be ignored. If, for instance, the patient with thyroid disease undergoes an orbital decompression for treatment of exophthalmos, the eye will commonly descend, thus making the lower eyelid retraction less apparent. If the retraction is moderate to severe and a decompression is not in the picture, the lower eyelid retraction should be treated. If a patient presents with lower eyelid retraction after blepharoplasty that is mild and without symptoms, they may have options for correction that are dependent upon what they are willing to endure regarding the surgical procedure, recovery, and ﬁnal result. Other causes can include orbital morphological situations such as maxillary hypoplasia with the so-called ‘negative vector’, or globe-related changes such as buphthalmos or high axial myopia. The most common cause for lower eyelid retraction in our practices is a complication of lower blepharoplasty. An assessment of the type and amount of lower eyelid malposition can be performed on gross inspection and digital palpation of the lower eyelid. In the situation related to thyroid ophthalmopathy or other orbital morphological contributions, there is usually not a cicatricial component to the eyelid malposition. In the postoperative (blepharoplasty) variety, one must differentiate between a posterior or middle lamellar cicatrix versus a cicatrix mostly related to skin shortage (overzealous removal of lower eyelid skin, or skin/ muscle). With the latter, posterior spacer grafts will be less effective in restoring normal lid position (due to skin shortage); however it has become more popular even in this scenario as patients wish to avoid visible external scarring. Lower eyelid retraction can be formally measured by determining the distance from the lower eyelid to the inferior limbus of the eye in the primary position of gaze. This measurement is made not only centrally but also nasally and temporally. Another method involves measuring the distance from a light reﬂex that is made to shine on the cornea to the lower lid as both patient and examiner look in the primary position of gaze, that is, the margin reﬂex distance-2 (MRD2) (see Chapter 3, Fig. 3-9).1 Normally, the lower eyelid rests at the inferior limbus. Measurements of retraction greater than 2 mm may be enough to warrant retraction surgery. We prefer to treat cases of lower eyelid retraction (that do not exhibit a primary component of skin shortage) secondary to the variety of causes mentioned above that include thyroid disease and blepharoplasty complications by recessing the lower lid retractors

and placing a hard-palate or allogeneic dermal graft between the recessed retractors and the inferior tarsal border. The purpose and utility of a posterior eyelid lamellar spacer graft in the aforementioned situations is to promote a normal lower eyelid position when the lower eyelid retractors or cicatrix is released/removed so that these options (autogenous or allogeneic) provide a stent to prevent or reduce recurrences. Presently we also use two different commercially available dermal matrix grafts, Alloderm TM (LifeCell, Woodlands, TX) and Dermaplant TM (Collagen Matrix Technologies, Boca Raton, FL). The hard-palate graft presents a surface that is not only ﬂat and rigid but also lined by oral mucous membrane, which simulates the conjunctiva. The allogeneic dermal graft requires in-vivo epithelialization to produce a soft interface between the lower eyelid and the globe. The treatment of lower eyelid retraction by recession of the lower lid retractors and placement of spacer grafts can be performed in conjunction with excision or transposition of herniated orbital fat through an internal lower eyelid approach. The procedure for recession of lower eyelid retractors and placement of a hard-palate graft with excision of herniated orbital fat, or placement of an allogeneic dermal spacer graft is described under ‘Surgical technique’.

Preparation before surgery (with the implementation of a hard palate graft) At some time before surgery, it is our preference when a hard palate graft is the chosen spacer graft, to work with a dentist who constructs a custom-ﬁtted plastic plate that will ﬁt onto the roof of the patient’s mouth.2,3 This plate is attached to several teeth with extensions that come off the plastic plate. After retrieval of the hard-palate grafts and the placement of an absorbable gelatin sponge (Gelfoam) to the donor site, the plastic plate is inserted onto the roof of the mouth. The plate provides comfort and maintains hemostasis.

Surgical technique Hard palate harvesting and grafting Local anesthesia with intravenous sedation is usually used. Topical tetracaine is applied over the eye. A corneo-scleral contact lens is placed over the eye and under the upper and lower eyelids to protect the eye and minimize the patient’s discomfort from the operating lights. The patient is prepared and draped in the

Surgical technique usual fashion, similar to that used for upper or lower blepharoplasty (see Chapters 7, 14 and 16). The mouth is prepared with povidone-iodine (Betadine) sponges rubbed over the teeth, hard palate, and tongue surface. Two percent lidocaine (Xylocaine) with epinephrine is injected subcutaneously and diffusely throughout the lower eyelid. Injections of 2 percent lidocaine with epinephrine (∼0.5 ml) also are given into each fat pad. This is done via a 25-gauge needle inserted over the temporal, central, and nasal inferior orbital rim, for a distance of 1 cm, and aimed downward during each insertion. Additional 2 percent lidocaine with 1 : 100,000 epinephrine is injected into the central aspect of the upper eyelid just above the eyelashes. A 4-0 black silk suture is placed through skin, orbicularis oculi muscle, and superﬁcial tarsus at the center of the upper eyelid. The suture is used to pull the upper eyelid upward. Another 4-0 black silk suture is placed through skin, orbicularis muscle, and superﬁcial tarsus at the center of the lower eyelid to evert the eyelid over a Desmarres retractor. Two percent lidocaine with epinephrine is injected subconjunctivally inferior to the inferior tarsal border and diffusely across the eyelid.

Recessing the lower eyelid retractors Whether a hard palate graft or allogeneic spacer is used, the technique for recessing the lower eyelid retractors is basically the same. The goal is to release the lower eyelid retractors and/or cicatrix to optimize the lower eyelid position followed by placement of an inter-positional graft to maintain this correction. A toothed forceps grasps the conjunctiva, Müller’s muscle, and the capsulopalpebral fascia at the temporal aspect of the eyelid, just beneath the inferior tarsal border (Fig. 18-1A). With a Westcott scissors, the surgeon penetrates this tissue and severs it from the inferior tarsal border. The Westcott scissors enters this opening and passes between capsulopalpebral fascia and orbicularis muscle across the eyelid (Fig. 18-1B). The surgeon facilitates this maneuver by separating the Westcott scissors blades during the passage and by pulling the scissors upward toward the conjunctival surface. At the same time, the surgeon’s assistant is releasing the Desmarres retractor slightly or pulling the skin surface outward. Because skin (and scar tissue in previously operated lower eyelids) is ﬁrmly attached to the orbicularis muscle and the conjunctiva is ﬁrmly attached to Müller’s muscle and capsulopalpebral fascia, the two lamellae separate in opposite directions during this maneuver. While the eyelid structures are kept in these positions, the Westcott scissors is withdrawn and one blade

is reinserted into the separated plane. Using the scissors, the surgeon severs the conjunctiva, Müller’s muscle, capsulopalpebral fascia, and scar tissue where present just beneath the inferior tarsal border (Figs 18-1C to 1E). During this step, the surgeon must be careful to minimize incision of the orbicularis muscle, as this can interfere with the vascular supply to the eyelid margin and cilia, which might result in visible surface (and other soft tissue) contour abnormalities and the loss of eyelashes. When ﬁrst learning this technique, the surgeon should sever the conjunctiva and Müller’s muscle in one step and the capsulopalpebral fascia in another step. A toothed forceps is used to grasp the central conjunctiva, Müller’s muscle, and the capsulopalpebral fascia. The surgeon pulls these tissues in a direction towards the eye, while the assistant pulls the skin and orbicularis muscle away from the eye with the 4-0 black silk suture attached to the lower eyelid or with the eyelid everted over a Desmarres retractor. A Westcott scissors is used to penetrate the area between these retracted lamellae (Fig. 18-1F). The scissors should fall into the suborbicularis space. At this step, the surgeon should be able to visualize the white capsulopalpebral fascia surface on the internal surface and the reddish orbicularis muscle on the outer surface. These landmarks are less easily visualized in the previously operated eyelid. While still keeping the eyelid structures pulled in these directions, the surgeon uses the Westcott scissors to separate the remaining nasal and temporal tissues (Fig. 18-1G). (The Westcott scissors should hug the capsulopalpebral fascia surface rather than the orbicularis muscle surface.) Alternatively, this separation can be accomplished with a Colorado needle, a laser, or a disposable surgical (battery-operated) cautery (Solan Accu-Temp, Xomed Surgical Products, Jacksonville, FL). Bleeding is controlled with a disposable cautery. A 4-0 black silk, double-armed suture is then placed through the conjunctiva, Müller’s muscle, and the capsulopalpebral fascia at the center of the lower eyelid. The suture is passed through the gray line of the central upper eyelid and exits through the orbicularis muscle and skin. The surgeon ties the suture with one tie of a surgeon’s knot and then a shoelace tie. The suture in the upper eyelid is pulled upward and attached to the drape with a hemostat. This causes the eye to be covered and also places tension on the lower lid retractors and the graft.

Excision of herniated orbital fat A small Desmarres retractor is used to evert the lower eyelid and pull skin and the orbicularis muscle outward

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A

B

C

D

Figure 18-1 A, A scissor is used to sever the conjunctiva, Müller’s muscle, and the capsulopalpebral fascia at the temporal end of the lower eyelid, just below the inferior tarsal border. B, The scissors passes anterior to the tarsus in order to enter the space between the capsulopalpebral fascia and the orbicularis muscle. C, One blade of the scissors passes anterior to the tarsus until its tip is adjacent to the eyelid margin. The other blade of the scissors is external to the inside of the eyelid. D, The scissors is rotated below the tarsal border.

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E F

G

H

Figure 18-1—cont’d E, A Desmarres retractor pulls the skin and orbicularis muscle downward while the conjunctiva, Müller’s muscle, and the capsulopalpebral fascia are cut adjacent to the tarsal border. F, A Desmarres retractor pulls the skin and orbicularis muscle downward while the conjunctiva, Müller’s muscle, and the edge of the capsulopalpebral fascia are pulled upward and outward with forceps. A Westcott scissors separates loose connective tissue between the orbicularis muscle and the capsulopalpebral fascia to enter the orbicularis space. G, Loose connective tissue is then severed temporally from the central opening of the suborbicularis space. H, Herniated orbital fat is exposed between the capsulopalpebral fascia and the septum.

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I L

J

M

K

Figure 18-1—cont’d I, Herniated orbital fat is severed. J, A hard-palate mucosal graft is harvested from the roof of the patient’s mouth. K, Severed borders of conjunctiva, Müller’s muscle, and capsulopalpebral fascia are sutured to the hard-palate graft so that the mucosal surface faces the eye. L, The hard-palate graft is sutured to the inferior tarsal border. M, With 4-0 black silk sutures, the lower eyelid is pulled upward toward the eyebrow.

Surgical technique away from the eye. With the use of cotton-tipped applicators, the temporal, central, and nasal orbital fat pads are isolated and the inferior oblique muscle is identiﬁed (Fig. 18-1H). The capsule of the fat pads is then opened. Fat that prolapses with general pressure can be excised or transposed. If excised, it may be clamped with a hemostat (AMP), and the tissues held in the hemostat are cut free by running a No. 15 Bard-Parker blade over them (Fig. 18-1I). Cotton-tipped applicators are applied under the hemostat, and a Bovie cautery is applied to the fat stump. As the hemostat is released, the surgeon grasps and inspects the fat stump to make sure that there is no bleeding before allowing the fat pad to retract into the orbit. This maneuver is continued temporally, centrally, and nasally until fat no longer prolapses with general pressure applied on the eye. The 4-0 silk suture that is connecting the retractors of the lower eyelid to the upper eyelid is then released. The lower eyelid is then placed in normal position, and the contact lens is removed. At this point, the lower eyelid margin should rest at a normal position at the inferior limbus and should be easily pulled upward. If not, it may be necessary to further recess the lower lid retractors. Once the desired position is achieved, the surgeon everts the lower eyelid and measures the distance between the recessed lower lid retractors and the inferior tarsal border centrally, nasally, and temporally. This distance is approximately the vertical dimension required of the ‘space’ (hardpalate or allogeneic) graft. The allogeneic grafts are usually ‘over-sized’ by at least 20 percent to compensate for shrinkage that is inevitable.

Obtaining the hard-palate graft A Jennings oral retractor is used to open the patient’s mouth. A tongue blade is used to depress the tongue downward. The hard palate is then dried with a 4 × 4 gauze pad. A methylene blue marking pen is used to draw the dimensions of the hard-palate graft. Commonly, this begins just posterior to the furrows that separate the hard-palate graft from the upper gum. The temporal aspect of the graft is usually the temporal aspect of the hard palate, and the central aspect is several millimeters temporal from the center of the hard palate. The posterior aspect is commonly at the junction where hard palate meets soft palate. Usually, two hard-palate grafts are taken, one for each lower eyelid. Each of these areas is marked on the hard palate at the same time. Two percent lidocaine with epinephrine is injected submucosally surrounding the areas marked on the

hard palate. We usually give this injection about 10 minutes before we are ready to take the hard-palate graft so that hemostasis from the epinephrine has time to take place. A No. 15 Bard-Parker blade is used to incise the outlined areas of the hard-palate donor site (Fig. 18-1J). The Bard-Parker blade and a No. 66 Beaver blade are used to remove the hard-palate graft. The assistant pushes the tongue downward and suctions blood from the graft site during this step. Suction must also be maintained in the posterior pharynx to prevent the patient from swallowing any blood or saliva. Bleeding is controlled with an absorbable gelatin sponge applied to the graft site. Occasionally, one must use microﬁbrillar collagen hemostat powder (Avitene). The gelatin sponge is pushed up against the hard palate with a tongue blade or the surgeon’s ﬁnger for several seconds, and the mouth retractor is removed. Then the hard-palate prosthesis, custom constructed preoperatively, is applied over the roof of the mouth.4,5 The graft is trimmed on its internal surface to free any excessive tissue so that only oral mucous membrane and hard palate remain. The graft is placed in gentamicin (Garamycin) solution for several minutes and is rinsed with balanced salt solution.

Sizing of the allogeneic dermal matrix grafts As when utilizing a hard palate graft, an estimate of the size of the graft is based on the degree of lower eyelid retraction. Commonly the horizontal dimension of the graft closely matches the width of the transconjunctival incision (that can extend from the far medial to lateral canthus) and the vertical dimension is approximately twice the amount of lid retraction in millimeters. Before the procedure commences, the appropriately sized graft is place in a bath of diluted Bacitracin solution where it remains until the recipient bed is prepared and measured for graft sizing.

Suturing the hard-palate graft to lower eyelid retractors and tarsus muscle The inferior edge of the graft is sutured to the lower eyelid retractors with a 5-0 chromic catgut suture run nasally to temporally (Fig. 18-1K). Each bite of the suture passes through the lower lid retractors and then the inferior edge of the hard-palate graft. The graft is placed so that the internal surface of the graft facing the eye is the mucosa-lined tissue. The contact lens is removed, and the lower eyelid is placed in normal position. The surgeon judges the

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are tied over cotton pledgets to keep the lower eyelid on an upward stretch. Gentamicin ointment is applied to the eyes and to the sutures.

amount of excessive hard-palate graft that extends above the lower eyelid margin and trims this tissue off. Because it is usually better to have a slightly excessive hard-palate graft rather than a sparse one, the trimming of the excessive tissue should be done sparingly. Next, the superior edge of the hard-palate graft is secured to the inferior tarsal border with another 5-0 chromic catgut suture (Fig. 18-1L). The suture is run continuously nasally to temporally and with the temporal and nasal knots buried deeply. A suture tarsorrhaphy is formed nasally and temporally, with two 4-0 black silk, double-armed sutures. Each suture passes through the skin and orbicularis muscle of the lower eyelid and exits through the gray line. The sutures then enter the skin and orbicularis muscle above the eyebrow (Fig. 18-1M). The protective corneoscleral contact lens is removed, and a 24- or 48-hour collagen shield is placed (optional) over the eye to reduce ocular discomfort. The sutures

Suturing the allogeneic dermal graft to lower eyelid retractors and tarsus muscle The suturing of this graft is very similar to how the hard palate graft is sutured to the recipient bed. In the case of post-blepharoplasty lower eyelid retraction (regardless of the graft composition), one must be certain to release the entire cicatrix that allows for the most likely reversal of the lid malposition as well as optimal sizing of the donor graft (Fig. 18-2). A canthoplasty can be performed simultaneously with the placement of either the hard palate graft or allogeneic graft (see Chapter 15).5,6 A suture tarsorrhapy is also placed as with the hard palate graft (medial and lateral) and patching is optional. Traction (frost-type) sutures may also be placed for the ﬁrst several days.7

A

B

C

D Figure 18-2 A, The lower eyelid has been everted over a large Desmarres retractor and an incision has been made using a No. 15 Bard-Parker blade through conjunctiva and the lower eyelid retractors just beneath the inferior tarsal border. B, Dissection proceeds (release of the cicatrix and recession of the posterior lower eyelid lamellar soft tissue) until the lower eyelid cicatrix and palpable resistance to elevation has been resolved. C, The allogeneic spacer graft (here Dermaplant™) is sized appropriately to accommodate the tissue void created by step B. D, The graft is secured by (here using 7-0 Vicryl) suture with careful attention to bury the knots, especially at the cephalad aspect.

Results

Postoperative care Eye care To keep the graft ﬂat against its orbicularis muscle bed, we prefer to apply a dressing of an eye pad, 4 × 4 cotton pads, and tape (Microfoam, 3M Company, St. Paul, MN), to be reapplied for several days. However, if surgery is performed on both lower eyelids simultaneously, a pressure dressing is not applied. Instead, the patient is instructed to apply cold compresses to their eyelids for the ﬁrst 24 hours postoperatively. It is important, however, to check under the dressings to make sure that excessive bleeding or a retrobulbar hemorrhage has not resulted from the fat removal. This is done frequently during the ﬁrst few hours postoperatively, and then the patient’s family are instructed how to do it periodically thereafter. The dressing is removed and reapplied the next day. The patient is placed on a regimen of systemic antibiotics for 1 week and is instructed to apply gentamicin or another ophthalmic antibiotic ointment to the eye and sutures twice a day for 2 weeks postoperatively. Forty-eight hours after surgery, the dressing, if applied, is completely removed and the patient is able to see through a separation of upper and lower eyelids, even with the tarsorrhaphy sutures in place. The tarsorrhaphy sutures are usually removed 1 week after surgery.

Mouth care Where a hard palate graft has been harvested, the patient should remove the plastic plate from the roof of the mouth before eating after 2 days of continued wear. Patients should gargle twice a day with an antiseptic mouthwash, such as cetylpyridinium (Ce¯pacol). They also may use a numbing mouthwash, such as 2 percent viscous lidocaine. Most patients use the roof plate for approximately 1 week postoperatively, and then they are usually comfortable. Granulation of the roof of the mouth usually takes place 1 month after the procedure.

Complications Complications include overcorrections and undercorrections, which can be diffuse or segmental regardless of the graft selection. Rarely, there may be a complete loss of the graft (and affect) that is more prevalent with the use of allogeneic grafts due to their dependence on

remaining intact long enough to get host integration. However, with the autogenous grafts, complete loss of the graft is unusual. If slight retraction occurs, upward massage may be helpful. If moderate residual retraction results, further grafting may be necessary. Other problems consist of loss of cilia and surface soft tissue contour abnormalities, which can be due to severing of the orbicularis muscle, and interference with the vascular supply to the eyelid and can also relate to vascular compromise from prior surgery. Entropion and ectropion are other potential complications. If these occur, they are treated by appropriate correction procedures. At times, the ectropion can be eliminated simply by removal of excessive hard-palate grafting. Conjunctival granulomas occasionally occur, and these can be easily treated by a simple excision. In our experience, we have encountered several cases of nasal entropion with the use of a hard palate graft, which was treated by (1) splitting the eyelid into two lamellae; (2) excising the skin, orbicularis muscle, and offending eyelashes; and (3) letting the area granulate. Several cases of focal granulomas have been treated by simple excision. In a couple of patients, the hard palate extended upward over the tarsal border and required trimming of the exposed material. Late postoperative regression (especially with allogeneic grafts) is dependent on a variety of factors related to both applicability, technique (i.e. sizing, application) and host factors (including amount and extensiveness of prior surgery) that may not be predictable.

Results Collectively, we have treated lower eyelid retraction in thyroid disease and post blepharoplasty situations in over 300 eyelids. Approximately 100 of these procedures have been completed with hard-palate grafts, more than 100 procedures utilized acellular dermal grafts, and the remainder involved the use of sclera or ear cartilage (Figs 18-3 to 18-5). Results were superior with hard-palate grafting or dermal grafts, and complications were minimal. In no patient was there a need to add or remove the hard palate. In a select few acellular dermal grafting was repeated within the ﬁrst year for loss of affect from rapid graft resorption. In most cases, this procedure has successfully relieved lower lid retraction, improved the aesthetic appearance of the lower periorbita, and reduced the patient’s ocular irritation, and keratopathy (Figs 18-6 to 18-8).

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A

Figure 18-3 A, Preoperative appearance of a patient with thyroidrelated retraction of all four eyelids associated with lower eyelid herniated orbital fat. B, Same patient after lower lid elevation by recession of the retractors, placement of a graft between the retractors and the inferior tarsal border, and internal fat excision. The upper eyelids were lowered simultaneously by excision of Müller’s muscle and recession of the levator aponeurosis through an internal approach (as described in Chapter 13), and lateral tarsorrhaphies were performed.

B

Figure 18-4 A, Preoperative photograph of patient with lower eyelid retraction after cosmetic blepharoplasty. B, Postoperative photograph after recession of lower eyelid retractors and hard palate graft. A bilateral tarsal strip procedure was also performed. A

B

Results 215

A

B Figure 18-5 A, This patient presented with bilateral lower eyelid retraction after a cheek lift was performed (elsewhere) without canthoplasty. B, Six months after lower eyelid retractor release, placement of an acellular dermal matrix graft, and lateral retinacular suspension canthoplasty.

A

B Figure 18-6 A, This patient developed lower eyelid malposition after upper and lower blepharoplasty performed elsewhere. B, Six months after lower eyelid retractor and cicatrix release and placement of acellular dermal matrix grafts with lateral retinacular suspension canthoplasty.

A

B Figure 18-7 A, This patient had undergone several previous eyelid surgical procedures (elsewhere) with persistent orbital ﬁssure asymmetry that related mostly to a relative right lower eyelid retraction that could not be corrected with several canthoplasty procedures performed (also elsewhere) in an attempt to regain symmetry. She felt the ‘right was too big’ and desired correction to result in this side looking ‘more like her left eye’. B, Six months after release of the right lower eyelid cicatrix and placement of an acellular matrix graft (Dermaplant) with lateral retinacular suspension canthoplasty.

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Figure 18-8 A, Pre-operative appearance of a patient with thyroid ophthalmopathy with severe upper and lower eyelid retraction, exophthalmos, exposure signs and symptoms, desiring correction and aesthetic enhancement. B, Six months post-operative appearance after upper eyelid retractor recession (see Chapter 13), lower eyelid retractor recession with Dermaplant spacer grafts, and lateral retinacular suspension canthoplasty.

B

A

References 1. Putterman AM: Basic oculoplastic surgery. In Peyman G, Sanders D, Goldberg MF (eds): Principles and Practices of Ophthalmology, vol 3, p 2248. Philadelphia, WB Saunders, 1980. 2. Mauriello JA Jr, Wasserman B, Allee S, et al: Molded acrylic mouthguard to control bleeding at the hard palate graft site after eyelid reconstruction. Am J Ophthalmol 1992; 113:342–344. 3. Shorr N, Enzer YR: Letter to the editor re Mauriello JA Jr, Wasserman B, Allee S, et al: Molded acrylic mouthguard to control bleeding at the hard palate graft site after

4. 5.

6.

7.

eyelid reconstruction. Am J Ophthalmol 1992; 114:779–780. Terino EO: Alloderm acellular dermal graft. Clin Plast Surg 2001; 28:83–99. Fagien S, Elson ML: Soft tissue augmentation with allogeneic human tissue collagen matrix (Dermalogen and dermaplant). Clin Plast Surg 2001; 28:63–81. Fagien S: Algorithm for canthoplasty. The lateral retinacular suspension: A simpliﬁed suture canthopexy. Plast Reconst Surg 1999; 103:2042. Fagien S: Tarsorrhaphy and eyelid traction sutures. In Levine MR (ed): Manual of Oculoplastic Surgery, pp 183–187. Edinburgh, Butterworth-Heinemann, 1996.

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CHAPTER 19

Fat Repositioning in Lower Blepharoplasty Robert Alan Goldberg The objective of facial rejuvenative surgery is to restore a youthful contour. With age, changes occur in the lower eyelid and cheek that involve descent of the cheek tissues as well as prolapse of orbital fat in the lower eyelid. Perhaps even more importantly, deﬂation occurs: there is loss of volume in the subcutaneous and deep fat pads in the periorbital region. Val Lambros1 (see Chapter 2) has articulated beautifully the concept that focal loss of volume, often in areas of cutaneous attachment of the skin to deep structures, can mimic descent of the soft tissue. In the periorbital area, focal loss of volume along the orbital rim can unveil the contours of the orbital fat bound by the arcus marginalis, and of the suborbicularis oculi fat (SOOF) limited by the orbitomalar ligament. This results in the formation of a tear trough groove at the level of the inferior orbital rim. Filling the areas of periorbital deﬂation can be a powerful rejuvenative technique. One useful option, when adequate orbital fat is available for transposition, is the transposition of fat over the orbital rim onto the superior face of the maxilla. In this chapter, I will describe the transconjunctival approach to orbital fat repositioning. Robert A. Goldberg

Lower eyelid fat transposition is a step in the evolution of blepharoplasty surgery. Thirty years ago, lower blepharoplasty was viewed as an operation to remove skin and fat in the lower eyelid. This often produced rounding of the lateral canthal angle, lower eyelid retraction with scleral show, and did not improve skin quality in the lower eyelid. The transconjunctival approach to fat excision was reintroduced 20 years ago, and over the last 10 years, we have been simultaneously treating skin quality with chemical peeling and ablative or non-ablative laser treatments. The newest stage of evolution of lower blepharoplasty is an understanding of the concept of fat preservation. Loss of fat in the face is an aging change. Although some young patients do have a true excess or atypically prolapsed orbital fat compartment with a substantial bulge in the lower eyelid that is treated with fat removal, many older patients who come in for rejuvenation of the lower eyelid and midface have contours that are characterized by hollows over orbital rim. This contour is related to the bony support of the underlying maxilla and is accentuated when the maxilla is relatively hypoplastic. A tear trough deformity is unveiled by deﬂation of the overlying tissues; it is located along the inferior orbital rim between the demarcation of the septal attachment above and the cheek fat pad and SOOF below. When

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Fat Repositioning in Lower Blepharoplasty deﬂation results in a tear trough depression or orbital rim hollow, removing orbital fat alone may accentuate the tear trough deformity. For these patients, who present with a double convexity contour of the lower eyelid and cheek, the orbital fat is better repositioned over the rim rather than excised.

Surgical technique The depth of the tear trough deformity (nasojugal fold) and orbital rim hollow is evaluated preoperatively with regard to the medial and lateral extent, and depth. Preoperative assessment must also consider the distribution and contour of the medial, central and lateral fat pockets. Although the lateral orbital hollowness that is present in some patients represents an aesthetic deformity, the amount of lateral orbital fat that is available for repositioning into this area is generally inadequate to successfully correct this ‘hollow orbit deformity.’ Therefore, the lateral orbital fat is more commonly excised than repositioned, and residual lateral hollowness is treated with hyaluronic acid gel or free fat transfer. The tear trough is marked with a surgical marking pen on the skin surface before surgery begins, in order to guide the intraoperative placement of the fat pedicle. The initial portion of the surgery is identical to any other transconjunctival blepharoplasty, with a forniceal incision and wide open sky exposure of the individual fat pockets (Fig. 19-1). The lateral and central fat pockets may be debulked as determined preoperatively. Next, the arcus marginalis is identiﬁed. The inferomedial orbital rim is palpated with the tips of a Stevens’ scissors and blunt dissection on the palpable bony orbital margin reveals the white tissue condensation representing the arcus marginalis (Fig. 19-2). Cutting cautery is useful to control bleeding from the small bony perforators that sometimes occupy this area, and to cut through the periosteum to reach the bony surface of the maxilla. Dissection is then carried out over the orbital rim by lifting the periosteum using a sharp elevator, taking care to keep the arcus marginalis and orbital septal attachment intact. The entire area of intended fat pedicle placement is undermined guided by the previously placed blue marks (Fig. 19-3). Some surgeons have suggested that the suborbicularis (supraperiosteal) plane is preferable. However, the subperiosteal plane has the advantage of being relatively blood free and straightforward. The periosteum in this area is fairly loose and the fat can be easily repositioned into the subperiosteal pocket. It is important to create an adequately large pocket, typically extending 15 to 20 mm onto the maxillary

Figure 19-1 A conjunctival incision is made 4 mm from the inferior edge of the tarsal plate, in order to expose the orbital fat pads. Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

Figure 19-2 The orbital rim is exposed at the level of the arcus marginalis, using blunt dissection. Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

face. The extent of subperiosteal dissection is individualized to the patient as it determines the size and shape of the eventual volume redistribution. Typically, the dissection will extend onto the nasal bridge and involve release of at least part of the origin of the levator alaqui nasi muscle. Centrally, the origin of the levator labii superiorioris is typically undermined, with care taken to avoid injury to the inferior orbital neurovascular bundle that emanates from its foramen just below the origin of this muscle. The subperiosteal pocket is extended medial, and often lateral, to the infraorbital nerve.

Discussion Medial, central, and sometimes lateral fat pedicles are created using gentle dissection. Often, the largest fat pedicle is created from the medial fat pocket. Although there are some large vessels in the medial fat pad (and it is preferable to avoid cutting across them), the fat pedicle is essentially a random ﬂap. The stalk of the pedicle should be large enough to provide reasonable blood supply, but small enough to avoid pulling on the orbital connective tissue system as the pedicle is transposed over the rim. We most often construct a ‘T’ shaped pedicle with a base measuring 5 to 10 mm in diameter. The central fat pocket is variable in size, occasionally larger than the medial pocket. The pedicles are transposed over the orbital rim and placed

into the predissected pocket and distributed evenly within it (Fig. 19-4). Forced ductions of the globe are then checked to be sure that the fat is not attached by the pedicle to the motility system of the orbit: there should be no movement or tugging on the pedicle as the globe is rotated. A number of different techniques are available to ﬁxate the pedicles within their subperiosteal pocket. The pedicle can be sutured to the trailing edge of the SOOF fat using buried absorbable sutures, but exposure of the deep aspect of the pocket can be difﬁcult. Another technique involves fastening to the tip of the fat pedicle a double armed 6-0 gut suture (or polypropylene pullout suture, without knots) in a fashion analogous to imbricating the extraocular muscles during strabismus surgery. These sutures are then externalized from the deep margin of the subperiosteal pocket out to the skin. Another method utilizes an externalized 6-0 polypropylene ‘cage’ suture to ﬁxate the pedicle into the ﬂap. Three or four lazy loops are passed from the lower eyelid, across the pedicle just above the bony orbital rim, and exiting on the upper cheek (Fig. 19-5). These loops form a ‘cage’ that keeps the pedicle in position during the early healing phase. The sutures are removed at three to ﬁve days.

Discussion Figure 19-3 A subperiosteal pocket is dissected in the intended area of fat repositioning. Typically the dissection extends onto the face of the maxilla 1–2 cm from the orbital rim, and includes parts of the origins of the levator alaeque nasi and levator labialis superioris muscles. Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743– 748, with permission of Lippincott, Williams and Wilkins.

Periorbital hollows appear with age, and must be appropriately diagnosed and treated in order to optimally rejuvenate the lower eyelid and midface. The concept of ﬁlling the inferior orbital rim trough using alloplastic implants or fat is not new.2–9 The transconjunctival approach can be utilized to place an alloplastic implant, reposition fat, and perform a midface lift. The advantages of this approach include

Figure 19-4 Central and medial fat pads are dissected into pedicles and then transposed over the orbital rim into the subperiosteal pocket. Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

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Orbital fat Arcus Tear trough SOOF fat

A

Figure 19-5 A&B, 3–4 externalized loops are utilized to maintain the fat pedicle in position as an externalized ‘cage,’ or alternatively 3–4 individualized pull-out mattress sutures can be used. Adapted from Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105(2):743–748, with permission of Lippincott, Williams and Wilkins.

B

a decreased risk of lower eyelid retraction (since the orbital septum is not violated) and the absence of a cutaneous scar.10 In the past, the arcus marginalis release was often performed in a supraperiosteal suborbicularis plane. It was believed that this may lead to a more natural contour and perhaps a better blood supply.10 However, the supraperiosteal plane is more vascular, and bleeding from branches of the angular artery is often a problem. In contrast, the subperiosteal plane is an easier dissection plane and is essentially avascular, therefore, minimal or no bleeding is encountered. Blood supply does not seem to be a problem although in either plane, the fat pedicle probably has some degree of ischemia and variable absorption can occur. The margins of the subperiosteal pocket have a natural tapering shape due to the periosteal attachment to bone. Therefore, the subperiosteal plane provides a natural contour to the fat and may decrease the chance that the borders of the fat pedicle will create a visible demarcation. Complications are generally similar to complications of traditional transconjunctival blepharoplasty. The most worrisome potential complication is double vision.11 The orbital motility system is complex, and subtle perturbations caused by mechanical disruption or scar tissue formation can result in restriction of ocular motility and double vision. It may not be possible to completely avoid this complication, but gentle

dissection, judicious use of cautery, and careful checking of globe rotation after the pedicles are transposed, may decrease the incidence of postoperative diplopia. Lower eyelid retraction is another potential competition of fat repositioning; careful dissection at the arcus marginalis, to minimize risk of injury to the orbicularis or orbital septum, may decrease the risk of lower eyelid retraction. Options to ﬁll the periorbital hollows include free autogenous grafts such as fat, synthetic injectable ﬁllers, and orbital fat repositioning. When adequate orbital fat is available for transposition, the technique of fat repositioning provides a subtle but long lasting change in the contour of the lower eyelid. It is not as powerful as an alloplastic implant such as the Flowers tear-trough implant,2 but has the advantage of vascularized autogenous tissue. Due to the additional dissection required to create the subperiosteal pocket, there is a longer period of postoperative edema compared to the more limited dissection of standard fat removal lower blepharoplasty. In addition, some patients may experience hardening of the fat pedicle during the ﬁrst three postoperative months. This may represent a combination of postsurgical ﬁbrosis and some degree of liponecrosis and lipogranuloma formation. This usually resolves by six months. The survival and persistence of the transposed fat is variable (Figs 19-6 to 19-8), however, almost all patients experience a longterm improvement in contour.

Discussion

Figure 19-6 Example of moderate to good survival of transposed fat at 6 months. A, Preoperative view. B, Postoperative 6 months, demonstrating smooth ﬁlling of the nasojugal groove.

A

B

Figure 19-7 Example of moderate survival of transposed fat at 8 months. A, Preoperative view.

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Figure 19-7—cont’d B, Postoperative 8 months.

B

Figure 19-8 Example of minimal fat survival. A, Preoperative view. B, Minimal survival of fat at 3 months postoperative.

A

B

References

References 1. Lambros VS: Discussion of ‘The midface sling: A new technique to rejuvenate the midface’ by Yousif NJ, Matloub H, Adam N, Summers AN. Plast Reconst Surg 2002; 110(6):1554–1555. 2. Flowers RS: Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993; 20: 403–415. 3. Steinsapir KD, Shorr N: Suborbital augmentation. In: Bosniak S (ed): Principles and Practice of Ophthalmic Plastic and Reconstructive Surgery. Philadelphia: Saunders; 1996:484–503. 4. Goldberg RA, Baylis HI, Goldey SH: Transconjunctival lower blepharoplasty. In: Bosniak S (ed): Principles and Practice of Ophthalmic Plastic and Reconstructive Surgery. Philadelphia: Saunders; 1996:626–631. 5. Loeb R: Naso-jugal groove leveling with fat tissue. Clin Plast Surg 1993; 20(2):393–400.

6. Loeb R: Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 1981; 8:757–776. 7. Hamra ST: Arcus marginalis release and orbital fat reposition in midface rejuvenation. Plast Reconst Surg 1995; 92(2):354–362. 8. Hamra ST: The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clinics Plast Surg 1996; 23(1):17–28. 9. Eder H: Importance of fat conservation in lower blepharoplasty. Aesthetic Plast Surg 1997; 21:168–174. 10. Baylis HI, Long JA, Groth MJ: Transconjunctival lower eyelid blepharoplasty. Techniques and complications. Ophthalmology 1989; 96:1027–1032. 11. Goldberg RA: Transconjunctival orbital fat repositioning: Transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000; 105:743–748. 12. Goldberg RA, Yuen VH: Restricted ocular movements following lower eyelid fat repositioning. Plast Reconstr Surg 2002; 110:302–305.

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CHAPTER 20

Alloplastic Contouring for Suborbital, Maxillary, Zygomatic Deﬁciencies Edward O. Terino Alloplastic facial contouring has evolved from being an ‘ancillary procedure’ to a standard valuable tool in the armamentarium of aesthetic facial surgeons over the last 25 years. This author has pioneered most of the implants and techniques now used by surgeons worldwide.1 These have proven over time to create contour corrections of permanence and with minimum (less than 1%) morbidity. The many myths about alloplastic augmentation have been dispelled by the author from his 30 years of experience conﬁrming that these techniques can now be used safely and effectively by any well-trained plastic surgeon who has an interest in 3-dimensional aspects of aesthetic facial surgery. Steven Fagien

According to my original anatomic zonal concepts of the facial skeleton (Fig. 20-1) the suborbital zygomatic region is comprised of: (1) Zone 1, the major body of the malar bone deﬁned medially from the infraorbital nerve and laterally by the beginning of the middle third of the zygomatic arch and (2) Zone 3, the paranasal suborbital zone which extends from the nasal bone – maxillary tissue to the infraorbital nerve. This zone contains the well-described ‘tear trough’ sulcus. The suborbital region has commanded signiﬁcant attention over the past 10 years due to the advent of upper midface suspension techniques designed to improve a tired, hollow appearance from the depression of the lid-cheek junction2,3 (Fig. 20-2) which occurs mostly with the aging process but also as a hereditary variant. Moreover, it has now been validly established by prominent investigators that the aging process of the upper midface results largely from atrophy or shrinkage of the volume of fat contained in the periorbital and malar region that is present in the youthful phases of life, birth to age 30 on the average4,5 (Fig. 20-3). In this chapter, I will discuss the signiﬁcant aesthetic improvements of the suborbital and malar region which can be accomplished with alloplastic augmentation as well as from the useful adjuncts of upper midface suspension, lateral brow–temple contouring, and lateral canthopexy techniques. Alloplastic implants designed speciﬁcally for the suborbital tear trough malar region can eliminate the need for techniques using fat rearrangement in the inferior orbital and suborbital region (Fig. 20-4). These fat manipulations may produce undesired sequelae such as lower lid retraction (ectropion) and visible unattractive irregular ‘lumpiness.’

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Lateral brow ptosis

Tear trough sulcus Fat atrophy below orbital rim (suborbital sulcus)

4 2 1 5

3 Nasolabial fold

Pre-jowl fold (marionette crease)

Figure 20-1 The author’s practical model of anatomic analysis deﬁnes ﬁve skeletal zones of the face. Alterations of volume within each zone produce contour changes, which are easily predictable.

Figure 20-3 The aging process of the periorbital region produces atrophy and shrinkage of the volume contained in the periorbital and malar region.

Historical background The importance of the lower eyelid-cheek junction has been appreciated by plastic surgeons over the past decade. In the early 1970s and 1980s, the standard surgical treatment for ‘tired eyes’ consisted of removal of fat and skin or skin and muscle from the lower eyelids.6 This universally produced either an unattractive vertical shortening of the lower lid or an accentuated hollowness under the eyes or both (Fig. 20-5). By the 1990s patients and surgeons alike began to realize that this original technique contributed to a haggard, unattractive periorbital appearance of aging.

Suborbital maxillary volume/ malar suborbital deﬁciences

Figure 20-2 Illustration demonstrating the ‘tired,’ hollow appearance that occurs at the lid-cheek junction from aging and heredity.

A medial sulcus just lateral to the nasal pyramid, which extends distally for 2.5 cm obliquely towards the angle of the mandible, has been termed a ‘nasojugal’ sulcus or ‘tear trough.’7,8 However, either by heredity or mainly with aging changes, this suborbital depression continues beneath the entire lower eyelid. This volume deﬁciency is not at the level of the inferior orbital rim as originally thought by plastic surgeons. Instead, it occurs consistently at a measured distance of 8 to 10 mm below the orbital rim. This observation

Suborbital maxillary volume/malar suborbital deﬁciences

Figure 20-4 A–C, Several alloplastic implant designs are commercially available to reconstruct the suborbital region permanently and predictably.

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Figure 20-5 A&B, Examples of surgical blepharoplasty results from the 1970s and 1980s removing both fat and skin from the lower eyelids.

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was made by me early in the 1980s, when postoperative blepharoplasty patients began complaining about their more tired, ‘hollow’ look. The etiology of why such a depression in this area appears as early as the third decade of life and certainly by the late 40s and early 50s has been unclear. Recently, however, largely through the photographic and computer studies of Lambros,4 it is now agreed upon that a true atrophy or involution of fat occurs in the upper two-thirds of the face and largely in the periorbital region. This disappearance of fat correlates with the increased appearance of a suborbital hollowness, which creates a tired, haggard appearance. When indeed, as in many instances, weakening of the orbicularis oculi muscle and orbital septum occurs, permitting the intraorbital fat to protrude forward into what has been commonly called ‘fat bags,’ the suborbital hollow sulcus is accentuated even further. Ambient light creates a highlight on the top of the fat bag ‘mountains’ while a shadow is created in the suborbital ‘valley.’ The juxtaposition of the positive and negative contours enhances the tired ‘ring’ appearance at the lid–cheek junction. This suborbital sulcus is further accentuated by relative and absolute anatomic skeletal bony deﬁciencies of the inferior orbital malar zygomatic complex. The treatment of the suborbital sulcus has been evolving for at least 25 years. In 1983, prompted by

complaints of patients about the increased hollowness of their orbital region from traditional blepharoplasty I began transplanting autogenous tissues such as fat, temporalis fascia, temporalis muscle, and galea into the suborbital region below the orbital rim behind the orbicularis oculi muscle and over the SOOF tissues9 (Fig. 20-6). This area has now become recognized as the true area of deﬁciency, which produces a tired appearance from the fat atrophy, which accompanies aging. These transplanted tissues were successful because they improved most people while in others that they left something to be desired. Overall, this experience proved to the author that there was a true need for a more permanent augmentation of this region. Recognizing the limitations of autologous techniques (resorption and shrinkage) I felt that an implant could be designed to ﬁt the suborbital region to improve contours from either aging or heredity, which gave an unattractive appearance. My tissue transfer technique when a lower blepharoplasty was performed for ‘fat bags,’ the fat was excised

A

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B Figure 20-6 A, Pieces of temporalis fascia, temporalis muscle and galea. B, Aspirated autologous fat.

Figure 20-7 A, Auricular cartilage graft from the ear. B, Same graft placed in suborbital location.

Suborbital maxillary volume/malar suborbital deﬁciences tangentially from lateral to medial canthus, leaving a medial vascular pedicle. A small instrument such as a curved hemostat was introduced beneath the orbicularis muscle to tunnel from lateral to medial, grasping the fat pedicle and pulling it into the suborbital sulcus. When upper eyelid surgery was performed simultaneously, the strip of orbicularis muscle routinely removed, was also placed into the suborbital sulcus in a similar

A

fashion. When combined with rhytidectomy, the author often used segments of temporalis fascia including muscle or even large amounts of galea and on occasion ear cartilage (Fig. 20-7). These procedures were performed in 150 to 200 patients at that time. Although these transplantation methods could be demonstrated in the long-term (see photographs at six months to one year, Figs 20-8 & 20-9) the results were

B Figure 20-8 A&B, Patients circa 1985 exhibiting long-term improvement in the lid–cheek junction from autologous tissue transplantation.

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elevated the orbicularis in the cheek above or below the periosteum and fat could be transposed over the orbital rim and sutured into the SOOF.12 A further reﬁnement was the release and reset of the orbital septum.13 Elimination of the ‘tired look’ is very adequately accomplished with upper midface suspension because it provides the advantage of elevating the lower, thicker tissues of the cheek up over the thin suborbital sulcus adding additional thickness to the transposed fat thus providing a most consistent and excellent blending of the lid-cheek junction (Figs 20-10 & 20-11). A suborbital tear trough malar implant with transverse dimensions of 6 cm, a vertical dimension of 3.2 cm and a thickness of 3 or 4 mm will also blend the lid–cheek junction well without the need for an extensive midface submalar and lateral orbital temple brow dissection required for an upper and mid face ‘lifting’ procedure.

A

The alloplastic solution

B Figure 20-9 A, Pre-op markings of site of placement of autologous tissue transplants into suborbital sulcus in 1985. B, Signiﬁcant improvement at 1 year following transplantation.

only partially successful in improving the suborbital sulcus with volume addition, assessed at a 50–70 percent improvement, 50–70 percent of the time. Lumps and irregularities using these tissue transplantation techniques were infrequent because the tissues were carefully distributed beneath the thickness and padding of the intact orbicularis muscle. In 1998 Hamra10 (evolving from the work of Loeb),11 developed zygo-orbicular complex dissection techniques. At the same time subperiosteal midface suspension procedures evolved.2 These newer dissections

Deﬁciencies of the facial skeleton in the suborbital malar zygomatic region can be hereditary or posttraumatic. My original experience which motivated investigations into corrections of these deﬁciencies began with maxillofacial deformities resulting from poorly reduced suborbital or trimalar fractures. In the late 1960s utilization of alloplastic materials such as hand-carved Silastic sponge could produce a very successful improvement towards normal. This positive experience prompted me to develop alloplastic anatomic contour silastic implants for the malarzygomatic midface region. In the early 1980s, I conceived of an implant designed to ﬁll the inferior orbital rim and suborbital sulcus. Flowers by the 1990s8 carried this thought forward and his present day tear trough implants were developed and are obtainable through Implantech Corporation, Ventura, California. However, these implants stop short of the lateral orbital rim and malar portion of the zygomatic malar complex. Patients sometime complain of slight visibility and palpability or contour irregularity at that location. This slight contour discrepancy has been disturbing to some very particular Southern California patients whom I have consulted. It became obvious to me that a signiﬁcant percentage, probably at least 50 percent of patients with a tired, suborbital appearance, especially in the age group below 50 years, have an associated suborbital bony and malar deﬁciency. Therefore, the concept of a comprehensive suborbital malar shell or a malar tear trough implant seemed optimal to solve this problem in many individuals (Fig. 20-12).

Facial balance

Figure 20-10 A&B, An upper midface suspension as well as fat transposition provides a two-layer superimposed padding to improve the suborbital sulcus, left preoperative, right postoperative, one year following upper midface suspension, fat transposition, and lateral canthopexy.

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The suborbital tear trough malar implant has proven highly successful in approximately 20 patients over the past 18 months (Fig. 20-13). There has been a great increase in the number of patients who in consultation complain of a tired appearance, consisting of the anatomic features described above. This chapter will describe in detail the techniques for correction of suborbital malar deﬁciencies by means of a tear trough and/or a suborbital malar tear trough implant without upper midface suspension techniques.

Facial balance Facial aesthetics depends on facial balance. The interrelationship of the volume–mass elements of the face

constitutes the basis for attractiveness, which we perceive as ‘beauty.’ The major volume–mass elements of the face are (1) the upper one third forehead segment; (2) the malar midface middle-third segment; (3) the nose volume prominence; and (4) the lower third mandibular jaw line segment (Fig. 20-14). When one or more of these predominates in size (volume and mass), the others appear less signiﬁcant. When one or more of these are reduced in size, the others attain a larger appearance. In aesthetic facial surgery, alterations of volume and mass can be successfully and permanently produced with alloplastic augmentation. Although autologous techniques, i.e. fat (fascia, muscle, etc.) are used and can achieve some degree of permanence, controversy still exists as to whether or not these autologous tissue

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Figure 20-11 A&B, Another example of the successful technique of upper midface suspension combined with fat rearrangement over the orbital rim to improve the lid–cheek junction, left preoperative, right 10 months postoperative, upper midface and lateral upper midface suspension, fat transposition and lateral canthopexy.

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Figure 20-12 Illustration showing the anatomic design of the new suborbital malar tear trough implant. The illustration also delineates anatomic zones 1, 2 and 3 of the maxillary zygomatic bone.

2 1

3

Facial balance

Figure 20-13 Left, preoperative view; right, six months following suborbital malar tear trough implant for improving the lid–cheek junction in a 54-year-old male from aging changes combined with an infraorbital maxillary hereditary bone deﬁciency.

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B

Figure 20-14 The major sculptural volume mass elements of the face are illustrated.

Brow

Nose

Malar-midface (cheek)

Mandible (chin-jawline)

changes can be permanent. Such autologous techniques need multiple treatments and donor site operations. Moreover the percentage of successful volume augmentation with each technique is unpredictable from patient to patient. These procedures do not lend themselves to the needs of today’s cosmetic surgery patients who are oriented towards minimally invasive techniques, which

do not remove them very long or repeatedly from the mainstream of either their social or professional lives. In addition autologous fat injection techniques produce extensive and extreme swelling and discoloration, which can persist for months. It is a well known fact that edema of the midface requires much longer to subside than that of the chin or jaw line region.

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Upper midface suspension If a subperiosteal midface suspension technique is intended, the dissection is simply extended up along the lateral orbital rim. This is done in combination with a lateral temple brow dissection done through a limited access temporoparietal incision of approximately 7–10 cm. The tunnel created permits access to suspend the midface using a 3-0 PDS suture and securing it to the temporalis fascia (Fig. 20-15). The midface dissection is done to liberate the soft tissue layers from the malar bone on the subperiosteal level and also down onto the surface of the masseter muscle to the level of the buccal space. The inferior limit of the dissection is the buccal fat pad (Fig. 20-16). In my opinion, the ideal location for the midface suspension suture should be through the periosteum margin, where it has been elevated at the inferior border of the malar bone. This periosteal tissue is strong enough to allow for maximum tension suspension. Moreover by not placing the suture at a more inferior location, traumatic functional damage to zygomatic muscle elements or seventh nerve branches innervating the zygomatic muscle complex are avoided.

The periorbital region

lower eyelids conclusively produce more of an unattractive aging effect because the orbit becomes depleted of volume from both the surgery and the natural aging process. Highly unattractive and deforming alterations of the lower lid are common with traditional blepharoplasty techniques (Fig. 20-17). It is for these reasons that I have abandoned skin and fat removal from the lower eyelid as well as fat removal from the upper eyelid over the past 10 years. Only minimal amounts of skin are necessary to bring about a more youthful change to the upper eyelid and without resection of orbicularis muscle or fat.

Extent of midface subperiosteal space dissection

Masseter muscle Buccal fat

As previously mentioned the periorbital region has traditionally been of great concern to plastic surgeons. Operations removing skin and fat from the upper and

Figure 20-16 The midface dissection extends below the malar bone over the surface of the masseter muscle to the level of the buccal space and fat pad.

Figure 20-15 The upper midface suspension secures the midface myocutaneous ﬂap to the temporalis fascia under maximum tension.

Figure 20-17 Highly unattractive and deforming alterations of the lower lid are common with traditional blepharoplasty techniques.

Association of malar and suborbital deﬁciencies

Association of malar and suborbital deﬁciencies Dr. Jelks reported that a recessive orbital rim which he termed a ‘negative vector’ suborbital deﬁciency accentuated the appearance of both the protrusion of fat in the lower eyelid as well as the ocular globe itself, thereby creating a non-attractive and tired/aging appearance.14 Many, if not most patients with a suborbital maxillary deﬁciency have an associated malar zygomatic deﬁciency. This has been deﬁned as a type-1 face.15 A type-1 face has a regional volume deﬁciency in the malar-zygomatic region but has adequate fullness in the submalar lower midface cheek region (Fig. 20-18). This upper malar zygomatic deﬁciency is largely a skeletal deﬁciency, and therefore, augmentation of the entire suborbital malar-zygomatic region with an anatomic alloplastic implant is an obvious solution for resolving this deﬁciency (Fig. 20-19). The natural junction between the thicker skin and subcutaneous fat of the cheek with the thinner lower

Type 1 aesthetic deficiency Malar hypoplasia

A

B

Correction Malar implant on zones 1 and 2

eyelid skin where the subcutaneous fat is sparse creates an abrupt change in the lid–cheek junction along the entire suborbital region. This has been recently described as a tear trough or a suborbital lid–cheek dysjunction.8 The obvious solution is to volume-ﬁll this region and alleviate this cosmetic deﬁciency, while simultaneously providing augmentation to the zygomatic-malar area in the many patients where this is also indicated. The suborbital valley at the junction of the cheek skin and eyelid skin typically occurs 7–10 mm below the orbital rim. Therefore, the goal of a cosmetic surgical intervention is to augment that region permanently. A recent popular two-layer approach is to perform a subperiosteal midface suspension to elevate the thicker subcutaneous tissues and skin into that area, while transposing orbital fat over the infraorbital rim to provide a second deeper layer. These two procedures in combination provide excellent volume ﬁlling and a smooth youthful lid–cheek junction (Fig. 20-20). It must be understood, however, that such surgeries are technically sophisticated and have greater risks of undesirable lower lid sequelae especially in the hands of inexperienced surgeons.

Figure 20-18 A&B, A type-1 face consists of an aesthetic regional volume deﬁciency in the malarzygomatic region combined with adequate fullness in the submalar midface region.

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Figure 20-19 Augmentation of the malar zygomatic region results in signiﬁcant aesthetic improvement for a type-1 face; A, preoperative view; B, postoperative 2 years following malar shell augmentation.

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B

Figure 20-20 Patient (below) is 1 year following a subperioateal midface suspension to elevate the thick subcutaneous cheek layer and transpose the orbital fat over the infraorbital rim to provide a second layer. This obliterates the harsh lid– cheek junction.

Tear trough suborbital implant: technique Placement of tear trough suborbital malar implants can be performed for the correction of: 1. Suborbital aging or post blepharoplasty hollowness (Fig. 20-21). 2. An isolated tear trough sulcus deﬁciency (Figs 20-22, 20–23). 3. A hereditary maxillary, zygomatic, bony deﬁciency (negative vector) (Figs 20-24 to 20-26).

There are four basic approaches. These are: 1. Subciliary incision lower eyelid approach. 2. Transconjunctival lower eyelid approach. 3. An intraoral placement. 4. A combination of intraoral and lower eyelid placement.

Subciliary placement An incision is made 3 mm below the lash line limited in length and never extending beyond the lateral orbital

Tear trough suborbital implant: technique

Figure 20-21 A–C, Left, preoperative view; right, 1 year following suborbital tear trough implant for aging ‘hollow aging fat atrophy.’

A

B

C

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Figure 20-22 A–C, Left, preoperative view; right, and isolated tear trough sulcus deﬁciency is easily corrected by either a tear trough or a suborbital malar tear trough implant.

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B

C

Tear trough suborbital implant: technique

Figure 20-23 A–C, Left, preoperative view; right, postoperative 1 year following correction of a hereditary negative vector suborbital, skeletal deﬁciency.

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B

C

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Figure 20-24 A–C, Left, preoperative view; right, 10 months following improvement of the lid–cheek junction without plastic augmentation for a hereditary negative vector maxillary infraorbital deﬁciency.

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B

C

Tear trough suborbital implant: technique

Figure 20-25 A–C, Left, preoperative view; right, 10 months following suborbital malar tear trough augmentation for severe ‘negative vector’ orbit. Patient also had chin implant and angle of mandible augmentation.

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B

C

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Figure 20-26 A–C, Left, preoperative view; right, 1 year following correction of suborbital sulcus with a volume augmentation using an alloplastic implant.

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B

C

rim. This can be placed (1) only below the eyelid to correct an isolated tear trough; or (2) extended only to the lateral orbital rim for a larger suborbital malar implant placement. A skin muscle ﬂap is elevated preserving 5–7 mm of pretarsal muscle below the tarsal lash line. Dissection is performed using a Freer elevator to facilitate preservation of the orbital septum. This dissection reaches the orbital rim and in its lateral two-thirds continues anteriorly over the orbital rim,

but below the orbicularis muscle into the SOOF layer (Fig. 20-27). An attempt is made to leave an adequate 8 mm cuff of SOOF as well as an intact arcus marginalis orbitomalar ligament. In the medial third, the orbicularis muscle is detached from the bony orbit with a subperiosteal dissection. Once again, an incision is made slightly anterior to the bone to preserve the arcus marginalis tendon for later fat transpositional and implant suturing.

Tear trough suborbital implant: technique

Figure 20-27 A subcilial approach is used by making a 2-cm lateral subcilial incision only to the orbital rim.

Orbitomalar ligament Subperiosteal dissection begins 6–8 mm below the arcus marginalis

The infraorbital nerve trunk is isolated about 5– 8 mm (variable) inferior to the orbital rim. A subperiosteal dissection is done, medial, lateral, and inferior to it. This should be accomplished under direct vision and with small curved elevators (Fig. 20-28). When a suborbital malar tear trough implant is placed, dissection extends laterally over the malar Zone I on the malar bone and down to the inferior border of the malar bone. This is also extended inferior onto the masseter muscle when the implant is planned to augment the submalar Zone 5 space as well. The chosen implant is then placed into the lateral pocket and seated along the infraorbital rim. The medial implant is positioned around the orbital nerve after a keyhole is created using a #11 scalpel blade to permit the infraorbital nerve to comfortably be surrounded by the implant. The slot of the keyhole is cut inferior to the infraorbital trunk (Fig. 20-29). The implant is positioned accurately medial to the tear trough, laterally along the orbital rim, and out onto the malar maxillary bone. Often, medial trimming needs to be accomplished, so that the most nasal portion of the implant is not buckled up into the narrow space of the lateral nasal bone in the medial canthal area. Three 4-0 or 5-0 Vicryl sutures are used to secure the implant to the orbital rim, one medial to the infraorbital nerve and two lateral. Any protruding orbital fat is then secured to the top of the implant with 5-0 Vicryl sutures. This can be done with or without disrupting the orbital septum depending on the laxity of the septum and the degree of protrusion of the fat. Suturing the fat to the implant creates a smooth lid–cheek junction. A standard lower eyelid closure is done and a lateral canthopexy is also routinely performed. The author’s chosen technique is a canthal sling, which incorporates a 4-0 black nylon loop around the canthal tendon two-

A B C

Figure 20-28 A subperiosteal dissection isolates the infraorbital nerve trunk under direct vision to avoid traumatic, symptomatic injury.

thirds of the distance from the orbital rim to the anterior canthal skin surface. This suture is secured just lateral to the tendon into the orbital periosteum or at a precise distance measured by a caliper and marked with methylene blue anywhere from 2–5 mm up on the orbital rim (Fig. 20-30). When the lower eyelid needs special tightening or there is a patient desire to have their palpebral aperture altered to create a more ‘almond-shaped’ elongated appearance, a second skin muscle suture of 4-0 Vicryl is placed into the orbicularis of the skin muscle ﬂap and secured to the level where the lateral canthal tendon has been lifted. This suture is also placed ﬁrmly into the periosteum (Fig. 20-31). Seldom is it necessary to resect more than 3–4 mm of skin and muscle. When the incision is lateral to the

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246 Lateral canthal “sling” suture Orbicularis suture 2 1

3

Figure 20-29 A ‘key hole’ is excised from the tear trough or suborbital or extended suborbital malar tear trough implant to position it around the infraorbital nerve without creating compression injury.

Figure 20-31 The orbicularis oculi muscle of the skin muscle ﬂap is ﬁrmly secured into the lateral orbital periosteum as a secondary support for the canthopexy.

Figure 20-30 Canthal sling lateral canthopexy is performed routinely into the lateral orbital rim periosteum at a precisely measured distance according to the needs of the patient.

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orbital rim this portion is closed with two or three 6-0 black nylon sutures. The subcilial incision is closed with a continuous 6-0 plain catgut suture.

Transconjunctival approach The second approach to placing a suborbital tear trough malar implant is by means of a transconjunctival incision. The incision is made from inside the lower eyelid after adequate inﬁltration with a solution of 0.5 percent lidocaine containing 1 : 200,000 epinephrine. A 27-gauge needle is used to inject while retracting the eyelid with a double hook. Ten minutes is allowed for vasoconstriction. The electrocautery needle is then used to incise the mucosa for a distance of 3 cm starting approximately 3 mm from the lateral canthus and extending to 4 mm from the medial canthus (Fig. 20-

32). This incision is made approximately 8 mm below the lash line just at the lower border of the tarsal plate. Using a blunt tenotomy scissor, the muscles are penetrated in the lateral portion of the incision to avoid the infraorbital nerve. The scissors are aimed to a point several millimeters below the orbital rim and are spread. A retraction suture of 4-0 nylon is placed through the posterior mucosal fornix after penetration. It is pulled up and sutured to the mid forehead to provide better visualization. A blunt scissor or needle holder is placed into the aperture and spread medially and laterally. The depressor muscles are divided with the electrocautery over the scissor. This brings the operating surgeon into the retro-lid space and above the orbital septum. An attempt is made not to disrupt the orbital septum, so that the fat will be contained posteriorly during the dissection. This is necessary to

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Inferior margin of tarsal plate

Orbital septum Periosteum

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Infraorbital nerve

Figure 20-32 A&B, A transconjunctival approach is performed at the lower border of the tarsal plate so that dissection can be performed above the orbital rim.

Figure 20-33 A&B, A lower lid approach can be used for either a malar, a teardrop, or a suborbital extended malar implant placement. Incisions can be subcilial or transconjunctival to access malar zone 1 and 2 and also zone 3, medial to the infraorbital nerve.

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place the implant on the bone. This also facilitates visualization. If the orbital septum is penetrated, retraction of the orbital fat will be necessary using a malleable retractor and the procedure will be more difﬁcult. Globe protectors are used for all transconjunctival surgery. The origins of the orbicularis oculi are incised medially beneath the ‘tear trough’ leaving a cuff of arcus marginalis. Then the dissection is performed later-

ally elevating the orbicularis muscle while leaving an adequate SOOF layer. The subperiosteal portion of the dissection is carried out as previously described for a subcilial incision approach (Fig. 20-33). Placement of either a tear trough implant or a larger suborbital tear trough malar implant has also been previously described. A two or three suture 6-0 plain catgut subcuticular closure is used for the transconjunctival incision.

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Intraoral approach The third approach to suborbital implant placement consists of the intraoral route. Here, after adequate inﬁltration of the malar bone and maxillary buttress, a 1-cm incision is made obliquely through mucosa only at the location of the canine teeth. A second 1–1.5 cm lateral limb is made above the gingival buccal sulcus leaving a cuff of mucosa and muscle. This creates an L-shape incision on the left side and a reverse L on the right side (Fig. 20-34). A small elevator is used to penetrate the inferior portion of the incision directly onto the maxillary bone. An upward outward subperiosteal dissection is performed changing to a larger 1.5 cm spatula elevator going up the buttress of the maxilla and onto the suborbital region. A medial dissection is also made beneath the infraorbital nerve and up to the medial canthal region staying below the periosteum (Fig. 20-35). The lateral

Incision “L” extension

Sulcus

Figure 20-34 Intraoral approach demonstrating an L-shape incision in the buccal region above the canine and incised through mucosa only.

Arcus marginalis

Levator labii superioris alaeque nasi muscle

Dissection extended medial to infraorbital foramen

A Extent of dissection

B

C

Figure 20-35 A–C, An intraoral approach for placement of a tear trough or suborbital tear trough implant can also be used to dissect the proper space and identify and visualize the infraorbital nerve bundle.

Conclusion dissection over the malar bone is done identically as for a malar implant placement. Direct visualization must be accomplished with a ﬁberoptic Aufricht light retractor to see the infraorbital nerve and dissect superiorly along the orbital rim. A tear trough or a suborbital malar implant is inserted with a forceps by ﬁrst placing the lateral portion and then reaching around the inferior orbital nerve superiorly with a small mosquito clamp to pull the medial portion over the top of the infraorbital nerve. Prior to placement, a ‘keyhole’ segment has been removed at the site of the infraorbital nerve to prevent undesirable compression of the main trunk or branches. On occasion, if implant positioning appears too difﬁcult, from either an eyelid or an intraoral approach, a combined approach can be used to manipulate simultaneously from superior and inferior. This is also done in instances where an upper midface suspension is con-

templated and it is necessary to release the entire soft tissues of the midface from the malar bone and down into the submalar space over the masseter muscle.

Conclusion A volume ﬁll 4-mm suborbital implant or an extended suborbital malar tear trough implant, can restore suborbital and malar volume without upper midface suspension or fat translocation techniques (Fig. 20-36). Protruding infraorbital fat which creates tired ‘bags’ can easily be sutured to the external surface of the implant to establish a smooth lid–cheek junction. For this author, this technique has proven successful as a simple solution to the problem of suborbital unattractive aging, which is currently being extensively explored by aesthetic facial surgeons.

Figure 20-36 A–D, Illustration showing how a 4-mm suborbital implant can adequately restore suborbital volume and augment the malar region without upper midface suspension or fat translocation techniques.

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D

C

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References 1. Terino EO: Alloplastic facial contouring: Surgery of the fourth plane. Aesthetic Plast Surg 1992; 16:195–212. 2. Ramirez OM: The subperiosteal rhytidectomy: The third generation face lift. Annual Plast Surg 1992; 28:218. 3. Hamra ST: Frequent facelift sequelae: Hollow eyes and the lateral sweep: Cause and repair. Plast Reconstr Surg 1998; 102:5. 4. Lambros SV: Aging, facial shape and fat injection. In Terino EO, Flowers RS (eds): The Art of Alloplastic Facial Contouring, Chapter 15, pp 221–238. St. Louis, CV Mosby, 2000 5. Coleman SR: Structural Fat Grafting. St Louis, Quality Medical Publishing, 2004. 6. Rees TD: Blepharoplasty, Aesthetic Plastic Surgery, Volume II, pp 457–580. Philadelphia, WB Saunders, 1980. 7. Duke-Elder S: The Anatomy of the Visual Systems. System of Ophthalmology Series, vol 2. St. Louis, CV Mosby, 1961.

8. Flowers RS: Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993; 20–22:403–414. 9. Terino EO: Periorbital Tissue Transplantation. Presentation at Facial Surgery Symposium, San Diego, CA, 1987. 10. Hamra ST: The zygorbicular dissection in composite rhytidectomy: An ideal midface plane. Plast Reconstr Surg 1998; 102:5. 11. Loeb R: Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 1981; 8:4. 12. Hamra ST: The role of orbital fat preservation in facial aesthetic surgery: A new concept. Clin Plast Surg 1996; 23:17–28. 13. Hamra ST: The role of the septal reset in creating a youthful eyelid-cheek complex in facial rejuvenation. Plast Reconstr Surg 2004; 113:2124. 14. Jelks GW, Jelks EB: In Peck GC (ed): Complications and Problems in Aesthetic Plastic Surgery, Chapter 5, p 58. London, Gower Medical Publishing, 1992. 15. Terino EO: Aesthetic facial typing by zonal deﬁciencies and preoperative planning. In The Art of Alloplastic Facial Contouring, Chapter 4, pp 49–63. St. Louis, CV Mosby, 2000.

CHAPTER 21

Chemical Peeling: Independent or in Conjunction with Facial Plastic Surgery Jonathan A. Hoenig, Norman Shorr and David M. Morrow The most skilled seamstress can change the dimensions and draping of a piece of cloth but cannot turn a cotton shirt into a silk blouse. Similarly, a surgeon can lift, resect or reposition skin but cannot change the quality, texture, or elasticity of the skin with surgery alone. This reality is a major limitation of surgery. Fortunately, skin rejuvenation procedures do improve the quality, texture, and elasticity of the skin.1 There are many methods and techniques to rejuvenate the skin including topical cosmeceuticals, dermabrasion, chemical peeling and laser resurfacing. All of these methods are effective in rejuvenating the skin. The most superﬁcial layer, the stratum corneum may be removed with exfoliants, mild alpha hydroxy acids or abrasives. This will give the skin a healthy glow by removing the outer, thickened dead keratin layer and may soften very ﬁne rhytids. Removal of deeper skin layers can be accomplished with dermabrasion, chemical peeling or laser resurfacing. Dermabrasion and chemical peeling are operator dependent for precise control of wound depth. Thus, there is an artistic component to achieving consistent results from these methods. Laser resurfacing, on the other hand, is more precise in regards to wound depth. It is less operator-dependent and theoretically more safe than the other methods. It is extremely important to be well versed in all techniques of skin rejuvenation as well as the basics of wound healing. The authors perform all of the above techniques, individualizing the techniques to the patient’s needs and desires (Fig. 21-1). This chapter will concentrate on chemoexfoliation as the time tested mainstay and still popular method of skin rejuvenation. Jonathan A. Hoenig, Norman Shorr and David M. Morrow

Introduction Chemical peeling or chemoexfoliation, is the process in which the skin is wounded or burned with a chemical agent. The zone of cellular destruction and depth of the wound is dependent on several variables including the peeling agent, the concentration of the agent, skin thickness and skin permeability.1 The immediate reaction of the skin is a second-degree, chemically induced burn. Inﬂammation begins shortly after the peel and extends

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252

A

B

Figure 21-1 (Surgeon: JAH) A 73-year-old woman before (A) and after (B) combination peel, laser and dermabrasion of the eyelids and face. Note the resolution of the dyschromias and the improvement of skin texture. Patient is wearing lipstick and eyebrow pencil only.

variably into the epidermis and dermis. The inﬂammatory response peaks at 48 hours but skin rejuvenation and collagen remodeling may last for weeks or months. Regeneration of the surface epithelium begins almost immediately and is usually complete by 5–14 days. No matter which technique is utilized, if the wounding depth is signiﬁcant there will be some permanent changes to the skin. The papillary dermal collagen changes from a wavy pattern to straight and parallel beneath the epidermal layer. The dermis shows ﬁbroblastic proliferation and replacement of much of the old deformed elastic ﬁbers with new elastic ﬁbers.2 Depending upon the degree of wounding and chemicals used, there may be fewer melanocytes both in the basal layer as well as in the dermis. This accounts for the lightening in color after peeling. This lightening, again, is a spectral change and may be permanent depending again upon the degree and agent of wounding. With fewer melanocytes the ability to tan is diminished accordingly. In terms of texture, the skin itself becomes smoother and more light reﬂective (shinier) which is generally a healthy replacement for the previously sun-damaged skin (Fig. 21-1). The potential increased sun sensitivity due to decreased melanocytes makes sun protective measures very important. In general, the deeper the wound, the deeper the zone of replacement of old, damaged, and disorganized

skin structural elements with new, healthy, and wellorganized elements.3 By the same token, the deeper the wound, the greater the potential for scarring and pigment changes. Chemical peels may be divided into three types, graded by the depth of the wound (Table 21-1). Superﬁcial-depth wounding is to the stratum granulosum, papillary dermis. Medium-depth wounding is to the upper reticular dermis. Deep-depth wounding is to the mid-reticular dermis.

Indications and patient selection Chemical peeling is indicated in any patient whose skin may beneﬁt from greater elasticity, increased smoothness, removal of ﬁne wrinkles, softening or obliteration of deep creases and lessening of pigmentary irregularities. Chemical peeling replaces the sallow, aged appearance of sun-damaged skin with a healthy and youthful glow. Thus, virtually all patients requesting blepharoplasty or any other facial cosmetic procedures have indications for chemical peeling. Chemical peeling is often performed in conjunction with blepharoplasty, endoscopic brow lifting and facelifting. In general, skin that has been surgically undermined is not peeled at the same time as surgery. If the depth of surgical dissection is subcutaneous, it is possible that superﬁcial damage to the skin from the chemical peel may result in full thickness skin necrosis.

Indications and patient selection 253

Table 21-1 Grades of depth of chemical peels

Chemical agent

Indication

Anticipated depth‡

Anatomic depth

TCA* 20–25% 35%

Superﬁcial wrinkling Mild-moderate wrinkling

Superﬁcial-depth Superﬁcial to medium depth

Upper papillary dermis Papillary dermis

Phenol 89% Baker’s†

Moderate wrinkling Deep wrinkling

Medium-depth Deep-depth

Upper reticular dermis Mid-reticular dermis

*TCA, trichloroacetic acid. † Baker’s phenol is also known as Baker-Gordon formula. See Table 21-3. ‡ Clinically anticipated degree of wounding depth.

However, if the depth of dissection preserves the subdermal vasculature, as in subperiosteal facelifting or transconjunctival blepharoplasty procedures, simultaneous peeling is considered safe. Simultaneous transconjunctival blepharoplasty and chemical peeling has been performed since 1989.4 The primary aim of lower blepharoplasty is either the removal or repositioning of fat in order to address the undesirable convexity (bulging) of the lower eyelid and/or central midface concavity. Approximately 70 percent of patients who want to undergo lower blepharoplasty have such a small component of excess skin that the risk of the transcutaneous approach outweighs A the advantage of removing a few millimeters of vertical skin, particularly when the skin problem is mostly due to actinic damage. The authors have been performing only transconjunctival blepharoplasty approaches on these patients for the past 20 years. One of the authors (DMM) developed and has reﬁned the technique of simultaneous transconjunctival blepharoplasty and chemical skin peeling since 1989.4 We now all routinely use this combination procedure (Fig. 21-2). The 70 percent of patients in whom skin removal has too great a potential risk will all potentially beneﬁt from simultaneous transconjuncti- B val blepharoplasty and chemical peel rejuvenation of Figure 21-2 (Surgeon: JAH) A 67-year-old woman before the skin of the lower eyelids; in fact, many of the 30 (A) and after (B) upper blepharoplasty, lower percent in whom the risk of blepharoplasty is accepttransconjunctival blepharoplasty, and simultaneous eyelid able can also signiﬁcantly beneﬁt from this simultanechemical peel and facial laser resurfacing. An improvement ous blepharoplasty and chemical peel without the risk in skin texture is evident. of an infralash incision. Chemical peeling is also performed in conjunction with facelifting procedures. In general, lower facelifting procedures will improve the jowls and tighten the in the glabella and forehead regions. Depending on the neck. It does little to improve the perioral rhytids, degree and depth of these wrinkles, a variety of chemigeneral loss of skin elasticity and dyschromia. Upper cal peels can safely be performed simultaneously in facelifting procedures (forehead lifts) will elevate the areas that have not been surgically undermined. Thus, brows and reduce dynamic wrinkles. It will, however, it is common for us to simultaneously perform an not delete the permanent creases that are often found upper and lower facelift, transconjunctival blepharo-

21

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Chemical Peeling: Independent or in Conjunction with Facial Plastic Surgery plasty along with perioral, forehead and lower eyelid chemical peeling.

may develop areas of hyperpigmentation and hypopigmentation, which cannot be readily camouﬂaged with make-up.

Evaluating the skin5 Hypopigmentation after chemical peel is a concern. Certainly, the issue of skin color change must be thoroughly discussed with the patient preoperatively. The deeper the wounding the more potential for hypopigmentation. In addition, as a chemical, phenol is melanotoxic. Originally it was thought that permanent hypopigmentation presented little or no problem for light-skinned patients (Fitzpatrick’s classiﬁcations I–II6) (Table 21-2). We have come to realize that these very light skinned patients will have signiﬁcant whitening of their skin, especially after deep peels. If a full-faced peel is performed and the edges of the peeling are feathered onto the neck, the hypopigmentation can be easily camouﬂaged. If, however, individual regions are only peeled, the color contrast between the peeled and non-peeled zones can be quite noticeable. This will force the patient to require a base or foundation make-up to blend the peeled and non-peeled regions. Moderately dark patients (Fitzpatrick II–III) have less of an issue with permanent hypopigmentation. These patients often develop splotchy post-inﬂammatory hyperpigmentation during the ﬁrst 3 months after a moderate to deep peel. The hyperpigmentation is usually temporary and easily controlled with bleaching agents. Peeling in darker skinned patients (Fitzpatrick’s classiﬁcation IV–VI) can be fraught with signiﬁcant pigmentation issues. Postoperatively, these patients

Table 21-2 Reaction to sun by skin pigment type

Classiﬁcation (Fitzpatrick)6

Pigment type

Reaction to sun

I

Minimum pigment

Always burns, never tans

II

Blue eyes, red hair

Usually burns, rarely tans

III

Average pigment

Sometimes burns, average tans

IV

More pigment

Rarely burns, usually tans

V

Much pigment

Minimum burns, mostly tans

VI

Most pigment

Never burns, always tans

Contraindications There are few absolute contraindications to chemical peeling. Three groups of patients must be considered cautiously as candidates. First are those with olive or darkly pigmented skin. The peel may permanently remove too much pigment or may result in a blotchy or hyperpigmented appearance. The second group is composed of patients whose skin is fair but has been frequently sun-exposed for many years. These patients now have permanently pigmented skin, and chemical peeling may result in an obvious demarcation between the treated area and the untreated area, even if careful feathering is performed. The third group is made up of the fair skinned and freckled. These patients risk an odd appearance if they lose all their facial freckles in one area while retaining freckles in adjacent areas.

Chemexfoliation and wounding agents Chemical peeling is a commonly performed procedure. The depth (and, therefore, effectiveness) varies with the chemical agent used, its concentration, and the conditions under which it is applied. The wide spectrum of agents and formulas for peeling includes retinoic acid (Retin-A), solid carbon dioxide, sulfur solutions, resorcinol, salicylic acid, alpha-hydroxy acids, trichloroacetic acid (TCA), and phenol and phenol formulas. Table 21-1 lists the most common peeling agents, concentrations, and formulations and the depth to which they can wound. The surgeon must determine the depth to which he or she wishes to wound the skin, since it is wound depth that determines the potential for the ﬁnal result. Unfortunately, depth is not simplistically determined by chemical formulas and concentrations, as implied in Table 21-1. Other major factors that help determine wound depth are skin type (Fitzpatrick’s skin classiﬁcations I–VI), skin condition and thickness, pretreatment with retinoic acid (Retin-A), alpha-hydroxy acids, alpha-keto acids, low dose cis-retinoic acid, epidermabrasive exfoliants, and defatting preparations. These agents alter the permeability of the skin to the wounding agent. Furthermore, the larger the amount of agent applied, the longer and harder the agent is rubbed onto the skin, and the longer the duration of contact between agent and skin, the deeper the wound-

Chemexfoliation and wounding agents ing caused by the same agent. Finally, applying tape over the agent (occlusion) drives the chemical deeper into the skin. Each of the several chemical wounding agents (see Table 21-1) may be used in various strengths. The most common agents, in increasing order of strength, are TCA (15, 20, 25, 35%) and phenol 89 percent. Most wounding agents can be driven deeper into the skin, and thus cause a deeper burn, by occlusion (taping or ointments), wetter applications, multiple applications, or vigorous scrubbing of the agent into the skin. Due to the increased risk of scarring due to uneven penetration, the authors do not use taping as a method of penetration enhancement. Thus, we will not discuss taping in this chapter. The 15 percent and 20 percent dilutions of TCA are used as ‘freshening peels’ and in a single application have a minimal potential for complications and only provide minimal long term improvement. We suggest to participants in our teaching courses that they begin their experience in chemical peeling with these 15–20 percent TCA freshening peels independent of or in conjunction with lower transconjunctival blepharoplasty. Compared to blepharoplasty alone, patient healing time is only minimally increased. Usually the skin is fully re-epithelialized, such that the patient can return to comfortably meeting the public and wearing make-up (or not needing makeup), within 7–10 days – at which time there are still usually telltale signs of surgery after a blepharoplasty anyway. After a great deal of experience has been achieved, we ﬁnd our most commonly used agent is TCA 35 percent for combined simultaneous transconjunctival blepharoplasty and chemical peeling. In our experience, this concentration produces satisfactory results with one application in most patients, assuming that the patient selection, application of the chemical, and aftercare are appropriately carried out. There is still some minimal risk of scarring, textural change, eyelid contracture, or undesirable pigmentary changes. On occasion, and for selected patients, we use phenol 89 percent or Baker’s phenol mixture combined with transconjunctival blepharoplasty. However, these agents are not for the novice. They carry much more risk of complications. Routinely for eyelid skin peeling, other than in conjunction with blepharoplasty, we often use the phenol preparations. Phenol wounds more deeply than trichloroacetic acid and as such is very effective in treating deeper rhytids and creases in the eyelids. It is thought, though still not conclusively proven, that phenol’s ability to wound increases with the dilution. (That is to say, the more dilute the phenol prepa-

ration, the greater the penetration.) Phenol preparations such as Baker-Gordon formula (Table 21-3) dilute the phenol and use additional ingredients. Studies have shown that the most toxic phenol preparation is a phenol and water combination of 2 : 1. Thus, any dilution of full-strength phenol preparation, as occurs when tears run onto the eyelid, may increase the depth of penetration. In choosing the chemical agent, the surgeon must keep in mind differences in wounding agents, the preparation of the skin as well as the anatomic variations in the skin of each area of the face. For example, one may apply Baker-Gordon formula laterally, to the crow’s feet and in the deep rhytids of the glabella and perioral region; 35 percent TCA to the forehead and infrabrow area; 25 percent TCA inferiorly to the upper blepharoplasty incision line, on the medial canthus, and over the bridge of the nose at the radix; and continue with 25 or 35 percent TCA from the lower eyelid lash line inferiorly over the remainder of the face. The solutions should be applied in a feathered fashion to provide a natural look without a demarcation line. It is imperative that the solutions are not applied inferior to the jawline for this may result in scarring. To determine the appropriate depth of wounding in any one area, the surgeon must consider at least the following skin factors: amount of redundancy, thickness, quality, degree of oil production, laxity of the lower eyelid margin, prior upper or lower blepharoplasty or skin peel, actinic damage, rhytids, and pigment and skin color. This customized approach is utilized for all peeling procedures regardless of whether the full face or only speciﬁc anatomic regions are peeled. After consideration of these factors, the appropriate chemical agent is selected. The chemical solutions themselves must be reliably mixed and fresh. TCA solutions are mixed from crystals every 180 days and stored in amber colored bottles. The mixed solution may be purchased from a pharmacy. A 35 percent TCA concentration is obtained by mixing 35 g of TCA (USP) crystals with 100 ml of distilled water. The solution should be stirred before use

Table 21-3 Baker-Gordon chemical peel formula 3 ml 89% liquid phenol (USP) 2 ml tap water 8 drops liquid soap (Septisol) 3 drops croton oil

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Chemical Peeling: Independent or in Conjunction with Facial Plastic Surgery in case some of the crystals may have come out of solution. Evaporation increases the concentration of TCA, therefore, bottles must be securely closed. BakerGordon formulas are mixed fresh daily. Full-strength phenol (89 percent) remains stable on a long-term basis in the manufacturer’s amber glass bottle. Acetone may be purchased from the pharmacy and is used straight out of the bottle on a gauze pad (2 × 2 or 4 × 4 in) to cleanse the skin.

Pretreatment with retinoic acid (retin-A) and bleaching agents Topical retinoic acid (Retin-A) is the acid form of vitamin A. Studies of daily use of retinoic acid for 6 months have demonstrated it to be an effective treatment for wrinkling, actinic and pigmentary changes.7 Pretreatment with retinoic acid for 2 weeks before chemical peeling usually results in a more even uptake and penetration of the chemicals, and a quicker reepithelialization. In addition, this pretreatment may allow for deeper wounding with a given chemical concentration and application technique. Retinoic acid is available in varying concentrations. The most potent and irritating forms, in descending order, are: 0.025 and 0.01 percent gel, and 0.1, 0.05, and 0.025 percent cream. We usually have the patients use the 0.1 percent cream, applied nightly to the affected regions. Retinoic acid commonly causes a retinoid dermatitis, which is a pharmacologic irritation and not an allergy. The potency and frequency of application should be adjusted to minimize excessive irritation, but the patient must recognize that some degree of irritation must be manifest to attain beneﬁt.8 Beginning again 2 weeks after peeling (after resolution of signiﬁcant inﬂammation), regular use of retinoic acid may be continued indeﬁnitely. The use of retinoic acid (just like the chemical peel itself) causes an acceleration in healing and a reduction of blotches, pigmentary changes, and ﬁne wrinkling, with a smoothing of the surface and an improvement in color from the sallow complexion of actinically damaged and intrinsically aged skin to a healthy, rosy glow. All of these results should enhance all types of cosmetic surgery of the face. Since chemoexfoliation induces inﬂammation there is always a risk of post-inﬂammatory hyperpigmentation. All patients are at risk, although the darker the skin the greater the risk. Hydroquinone, kojic acid and azelaic acid are agents that inhibit tyrosinase and decrease the skin’s ability to produce melanin. These bleaching agents come in various strengths and combinations. We prefer to use 4 percent hydroquinone or a combination of 2 percent hydroquinone and kojic acid

(Pigment Gel, Physician’s Choice of Arizona). These bleaching agents should be started along with the retinoic acid two weeks prior to the peel and restarted approximately two weeks after the peel and continued for several months.

Skin cleansing The presence of skin oils or grease on the skin inhibits even and predictable penetration of the wounding agent. The patient’s face and eyelids should be clean, dry, and free of oil before the procedure begins. The patient is therefore asked to wash the face with soap and water the night before and the morning of surgery and to not wear make-up or put skin cream, sunscreen or lotion on the face or eyelids on the day of surgery. Cleansing with soap may be adequate but also may leave soap residue. For these reasons, the already clean face is degreased by the physician with acetone as the ﬁrst step in the procedure. Even the acetone degreasing must be standardized, because more rubbing will disrupt the epidermal barrier and allow for greater penetration. The skin should be stretched during acetone degreasing to assure degreasing at the depth of the rhytids.

Timing relative to surgery Chemical peeling causes a contraction of the skin in both horizontal and vertical meridians, while improving the texture and quality of the skin. Upper and lower eyelid chemical peeling may be performed without surgery or before, in conjunction with, or subsequent to eyelid surgery. Chemical peeling may also be used as an adjunct to endoscopic eyebrow and forehead elevation procedures. As long as the blood supply to the skin has not been disrupted there is no contraindication to perform a chemical peel at the same time of surgery. For example, we commonly perform an endoscopic eyebrow lift and simultaneously peel the skin of the forehead. In contrast, at the time of a facelift we will peel the central portion of the face: The forehead, eyelids, perioral and medial midfacial skin but not the preauricular or skin of the lateral cheeks, since this skin has been undermined and its vascular supply theoretically may be compromised. When chemical peeling is performed simultaneously with upper eyelid surgery (immediately upon completion of the surgical procedure, while still in the operating room), the upper eyelid skin incision and the skin between the upper eyelid incision and the upper eyelid margin are not treated (or, at the surgeon’s discretion, the pretarsal skin may be treated very lightly).

Chemical peeling technique

Anesthesia and patient monitoring The patient is kept comfortable throughout the procedure and during the postoperative course. Some reports state that speciﬁc regional skin anesthesia is not necessary for 35 percent TCA and lighter peels. We have found that many patients do, in fact, have pain with these peels and, thus, we use regional block anesthesia for all chemical peels of 35 percent TCA and the phenol preparations. For greater patient comfort, the regional block anesthesia may be administered along with intravenous sedation. In all cases of simultaneous blepharoplasty and chemical peeling, adequate inﬁltrative anesthesia exists such that regional block using 0.5 ml of 2 percent lidocaine (Xylocaine) with epinephrine and 0.5 ml of 0.25 percent bupivacaine (Marcaine) with epinephrine may be inﬁltrated around the supratrochlear, supraorbital, zygomaticofacial, and infraorbital nerves. For chemical peels performed independent of surgery, the same regional blocks are given provided the wounding agent is TCA 35 percent. The pain from 35 per cent TCA used in eyelid and facial peels seems to last no longer than a few minutes as long as iced compresses are used. Since phenols may burn for several hours after application, a higher percentage (0.5%) bupivacaine (Marcaine) with 1 : 200,000 epinephrine is used. Marcaine provides postoperative anesthesia for 4–6 hours and may be repeated if desired. Cardiac monitoring is standard procedure for full face phenol peels. Phenol is absorbed systemically and is cardiotoxic and may cause arrhythmias. The amount of phenol in the blood stream at any one time is controlled by applying the phenol to segments of the face at 15-minute intervals. If arrhythmias develop, the applications are stopped until the cardiac rate has been regular for 15 minutes. Subsequent phenol applications are applied in smaller surface areas, timed further apart. Lidocaine can be injected intravenously in doses of 5–10 mg to control arrhythmia. The authors have never seen or heard of a localized application of phenol to the eyelids resulting in an arrhythmia. Therefore, the authors do not speciﬁcally use cardiac monitoring for regional applications of phenols. TCA is not absorbed and produces no systemic symptoms other than transient pain. When performing full face peels independent of surgery, many patients will desire intravenous sedation. For those who choose not to have intravenous medication we routinely administer a cocktail of clonidine, which controls acute rises in blood pressure, demerol for pain control and valium which has a sedative and hypnotic effect. The patient is then given regional blocks as described above.

Chemical peeling technique The same techniques of application are used for all chemical peeling agents. As stated earlier, different wounding agents may be used in different areas and in different manners for each area of the face. When eyelid chemical peeling is performed simultaneously with surgery, the method of application differs from that used for eyelid chemical peel performed independent of surgery, because the agent must avoid the suture lines. The independent procedure is described fully ﬁrst, and the modiﬁcations to be used when chemical peel is performed in conjunction with blepharoplasty are then detailed. In all peeling procedures, the skin surface must be adequately prepared. As instructed, the patient has already washed the face before surgery. The surgeon vigorously scrubs the patient’s skin with an acetonemoistened gauze pad.

Application of 35 percent TCA The TCA is applied to the skin using one or two nonsterile, cotton-tipped applicators with wooden sticks. (The use of wooden stick applicators allows the physician to rub the acid vigorously into the skin without breaking the applicator.) The applicator is dipped into the TCA. The cotton tip of the applicator is pressed against the side of the container until excess liquid is removed, so that TCA does not drip onto the skin. The TCA is applied in the desired manner, with one or more applications depending on the depth of wounding desired. The chemical is applied preferably with the patient lying supine. The chemical may be applied to corresponding segments of the eyelids sequentially, that is, to the right lower eyelid, and then to the left lower eyelid, while the amount of chemical and anticipated depth of wounding in the ﬁrst segment is still fresh in the surgeon’s mind. Some surgeons prefer the eyelids to be closed during application as additional protection for the cornea, others prefer the eyelids open to avoid the ‘wick’ phenomenon of pulling the chemical agent along rhytid creases (especially in the canthi) into the eye by capillary attraction. Some surgeons advocate using no bland ointment in the eye for fear it will get onto the skin and cause uneven wounding, and others prefer using ointment to protect the cornea and avoid tearing, which will dilute the chemical agent. We place a drop of topical tetracaine and a small amount of bland ophthalmic ointment in each eye. On the upper eyelid, we prefer to apply the chemical while the patient’s eyelids are closed. We recommend

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one or two cotton-tipped applicators. Wherever the solution is applied, the edges should be feathered to avoid a sharp line of demarcation and objectionable color contrast. When peeling the entire face, the TCA solution is applied with two or three cotton tip applicators. It is best to apply the solution in a methodical manner to each anatomic region so that areas are not skipped. For example, the solution is ﬁrst applied to the right cheek then the left cheek then the right jowl then the left jowl etc. For areas with deeper rhytids the solution can be applied more vigorously, thereby achieving a deeper peel. Once applied, the chemical will produce a white blanching or frosting of the skin. This frosting becomes more prominent over 5–10 minutes, signifying a deeper chemical burn. The extent and speed of frosting are determined by the concentration and amount of TCA applied and by how briskly the applicators are rubbed into the skin (Fig. 21-3). In another 5–10 minutes, the frosting begins to fade, and a deep erythema manifests itself. The surgeon must look through the frosting to see the erythema. With experience, the surgeon can

beginning with the crow’s feet superior to the lateral canthal angle and proceeding across the upper eyelid laterally to medially along the inferior border of the eyebrow, then inferiorly down to the eyelash margin, the inner canthus, and the radix of the nose. This is in contrast to the method of McCollough and Hillman,8 who peel no closer than 2–3 mm from the eyelash margin. The chemical is carried into the eyebrow. There is no damage to the eyebrow cilia from chemical peeling in the eyebrow. (By the same token, the chemical peeling on the forehead is carried into the scalp in a full-face peel.) On the lower eyelid complex, we apply chemicals with the patient’s eyelids open and the patient looking superiorly. The application proceeds from the lateral malar area and orbital rim, across the crow’s feet, moving superiorly and medially to the eyelash margin, in contrast to the method of McCollough and Hillman. The chemical is applied more lightly to the extremely thin skin on the inner canthus and the thin skin over the tarsal plates. The thicker skin of the crow’s feet, infrabrow areas, and upper and lower eyelids can tolerate a stronger application applied with

A

B Figure 21-3 Application of chemical wounding agent. Anatomic segments are peeled. The perioral, glabella and forehead regions have been peeled (A). After application of the TCA the skin turns white (frosting). The deeper the peel the more opaque the color. The remainder of the face is peeled (B). Note that the entire face is frosted with varying degrees of whiteness. Several minutes after the peel regions that have not frosted can be repeeled.

Technique for chemical peel combined with blepharoplasty

Table 21-4 Jessner’s solution formula Resorcinol

14 g

Salicylic acid

14 g

Lactic acid

14 ml

Ethanol (qs)

100 ml

judge the depth of wounding by the relative timing of onset and density of the frosting and the erythema. Generally, the ‘whitening’ of the skin signiﬁes epidermal protein coagulation and is the end point of the application. Deep frosting may last 20–30 minutes before beginning to fade.

Modiﬁcations Just as different depths of wounding are appropriate for different skin thicknesses and different degrees of actinic change, the experienced surgeon can also use differential depth wounding to tailor the results of the procedure. For example, in a patient in whom an increased superior lateral lift or tightening of skin is desired in the lateral canthus, larger amounts of chemical agent may be applied in the lateral canthus to cause further vertical shortening of skin and, thus, a relative ‘lift’ in this area. Deeper penetration of TCA 35 percent can also be achieved by ﬁrst peeling the skin with Jessner’s solution (Table 21-4). The Jessner’s solution destroys the epidermal barrier allowing a more even application and deeper penetration of the TCA 35 percent peel. This peel combination was ﬁrst described by Gary Monheit,9 and is currently the workhorse of peeling in one of our practices (JH). The procedure is similar to that described above. The skin is cleaned with acetone and the Jessner’s solution is applied with cotton-tipped applicators. The frosting achieved from the Jessner’s solution is quite light and splotchy. It is usually not painful and the patient feels a slight increase in heat. After the Jessner’s solution dries (typically 4–5 minutes) the TCA is applied as described above.

Technique for chemical peel combined with blepharoplasty Chemical wounding, performed immediately after the completion of blepharoplasty, is performed in the same way and following the same general scheme just described. If the procedure was an isolated lower transconjunctival blepharoplasty, the upper eyelid and, in

fact, all skin surfaces may be treated exactly as if the peel were being performed entirely independent of the surgical procedure. If the surgical procedure was an upper blepharoplasty and a lower transconjunctival blepharoplasty, the chemicals are applied as described previously, except that a feathering begins 1 or 2 mm superior to the suture line in the upper eyelid and the chemical application becomes denser up to approximately 3–5 mm superior to the suture line, where the wounding depth is the same as it would be without surgery. A very light ‘feathering depth’ application may be applied on the pretarsal skin, beginning several millimeters inferior to the suture line and continuing to within 1 mm of the lash line. The medial canthus and lower eyelid are peeled exactly as if there had been no surgery. In the lateral canthus, care is again taken to stay several millimeters away from the suture line and to feather the edge of the chemical peel adjacent to the suture line to avoid a demarcation line. When a lateral canthal procedure has been performed, the chemical agent is kept away from the suture line as described. Upon completion of the chemical peel, non-sterile gauze pads soaked in ice water are applied immediately to the eyelids and peeled areas. Acid applied to the surface of the skin burns to completion very rapidly. If there is any question as to whether the chemical peeling agent remains on the skin, the skin is immediately dried with the gauze before the application of the cool compresses. The gauze pads are changed frequently to keep them cool. To minimize the discomfort and burning sensation after a chemical peel, many surgeons instruct patients to use continuous cool compresses for the ﬁrst day after application of 35 percent TCA, and two days following phenol applications. A thin coat of petroleum jelly or polymyxin Bbacitracin ointment (Polysporin) is applied to the peeled skin once the patient is comfortable in the recovery room. Patients are instructed to continue cool compresses at home (primarily to offset postoperative swelling) until bedtime and to sleep with the head elevated on two pillows. The theory and techniques for peeling the remainder of the face in conjunction with facial cosmetic surgery are similar to that of the eyelid. When peeling the forehead region we routinely use TCA 35 percent or other agents depending on the desired depth of penetration. In the glabella region, if deep rhytids exist a Baker’s phenol solution can be applied speciﬁcally to those rhytids. The perioral rhytids are often difﬁcult to eradicate and often require a phenol or Baker’s Gordon phenol peel. Peeling of the perioral region can be performed in conjunction with a face lifting procedure.

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Management after chemical peel Management is similar after all chemical peeling procedures, varying only with regard to the total area peeled and the depth of wounding in that area. A partial thickness of the peeled skin dies on the ﬁrst postoperative day. This dark or ashen gray skin begins to spontaneously peel off usually on the third day (Fig. 21-4). Beginning on the ﬁrst day after chemical peel, the patient should institute a regimen of facial cleansing twice a day, followed by application of a thin ﬁlm of ointment. This regimen begins with the cleansing afforded by either cool or warm water compresses, followed by the application of 3 percent hydrogen peroxide applied to the skin peel area with cotton-tipped applicators. After the slough of skin has started, it should be encouraged by light scrubs with the non sterile cottontipped applicators dipped in 3 percent hydrogen peroxide to remove debris and dead skin that comes off easily. (Skin should never be peeled off manually.) Then, with the use of cotton-tipped applicators, a

coating of petroleum jelly or polymyxin B–bacitracin ointment is applied to keep the skin smooth, supple, and lubricated. It should be noted that if a patient doesn’t take off enough dead skin after a large area of skin is peeled with TCA 35 percent or deeper peeling agent, the area may become hot and inﬂamed and the patient may even develop a fever manifesting a cellulitis. This does not happen after peel with less than 35 percent TCA. The patient must be speciﬁcally reminded that showers and scrubs always must be followed by coating the area with petroleum jelly to prevent skin desiccation and to promote re-epithelialization. Mechanical debridement with scissors and forceps should never be performed because it may damage tissue and cause scarring. Following both blepharoplasty and chemical peels, we generally advise the use of cool water compresses on the ﬁrst two postoperative days, and warm water compresses to increase circulation and carry away edema beginning on the third postoperative day. The patient may, of course, add cool water compresses for comfort as needed. Although codeine or hydrocodone (Vicodin) is often prescribed for post blepharoplasty pain, no pain medicine is generally required following TCA skin peels. This regimen of cleansing and compresses is continued until the skin is fully re-epithelialized, which occurs in 7–10 days. When the upper and lower eyelids have been peeled without surgery, the upper eyelids generally heal 1–2 days more slowly than the lower eyelids. This may be due to the fact that the upper eyelid folds in upon itself at the crease, which continually reopens the skin and delays re-epithelialization in this area. Once eyelids are fully re-epithelialized, the patient may again apply make-up. During the ﬁrst 2 weeks after the peel, the patient is instructed not to wipe the eyelids when drying with a towel because this may damage new skin. All drying in the peeled area should be done by patting. Sunscreen should not be applied until 4 weeks after peel, because there is a signiﬁcantly increased likelihood of contact allergy before then. For the ﬁrst postoperative month, the patient is instructed to stay out of the sun and to wear a hat when outside. Sunlight burns the skin and causes hyperpigmentation.

Repeated chemical peels Figure 21-4 Day 5 post full face 35 percent TCA peel. Note the regions that have peeled are pink and healthy. The non-peeled regions are dark brown.

Chemical peeling may be repeated one or more times to achieve the desired result. Whereas some authors encourage deep-depth wounding on the ﬁrst peel, theorizing that the ﬁrst peel has the least risk of scar-

Complications ring and complications, other authors advise the use of repeated medium-depth peels, to lessen the shock of pigment changes and reduce the risk of complications. We discuss the options with the patient and decide on the depth of peeling and considerations for subsequent peeling on the basis of all factors, including how soon afterwards the patient must resume appearing in public. We frequently perform a simultaneous upper blepharoplasty, lower transconjunctival blepharoplasty, and chemical peel with 35 percent TCA. This may be followed as early as 14 days later or at any subsequent time by a repeat peel using TCA 35 percent or 89 percent phenol if so deemed appropriate. If further improvement is desired, a third peeling procedure may be performed after completion of healing of the second peel usually at 4 days or longer. Needless to say, the same basic parameters must be assessed for each repeat chemical peel as though it were the ﬁrst time. These parameters are the amount of redundant skin, the degree of laxity of the lower eyelid margin, the existence of lagophthalmos, the possibility of precipitating corneal exposure, the degree of actinic damage, and skin color. Chemicals may be applied to scar lines from previous blepharoplasties. Peeling over the scar does not cause hypertrophy of the scar and does tend to lighten its color. The repeated application technique with milder chemical solutions also is appropriate for those individuals whose skin is dark (Fitzpatrick’s classiﬁcations IV–VI) and who want to reduce the risk of hypopigmentation as well as for those who want a brief and easy recovery after each application.

Complications Complications include ocular damage, prolonged erythema, unexpected hypopigmentation, splotchy hyperpigmentation, scarring (including textural changes), cicatricial ectropion, eyelid retraction, and lagophthalmos.

Ocular damage Chemical solutions may burn the cornea or conjunctiva. This may occur either when an applicator accidentally strikes the cornea or conjunctiva, or when the welling up of tears along the eyelid margins and canthal areas exerts a wick effect, channeling the chemical to the eye. If the chemical solution strikes the cornea or conjunctiva, it instantly produces a whitish-gray burn on the exposed area. Appropriate management is immediate irrigation with sterile saline or artiﬁcial

tears. Pain is managed with one application of topical 1 percent tetracaine. An antibiotic ointment or antibiotic–steroid ointment is applied. A routine management of a corneal or conjunctival surface burn includes re-evaluation at the end of the procedure with regard to the extent of epithelial damage and existing pain. Consideration for patching or a corneal bandage contact lens, in addition to antibiotic coverage and continuing ophthalmologic care, is appropriate.

Prolonged erythema Deeper wounding causes more pronounced and longerlasting erythema. In general, erythema resulting for 35 percent TCA lasts 2–4 weeks; that from 89 percent phenol, about 3 months; and that from Baker-Gordon formula, 5–8 months. Erythema can usually be camouﬂaged successfully with make-up until it resolves.

Unexpected hypopigmentation The 35 percent TCA usually causes minimal permanent hypopigmentation. There is some permanent hypopigmentation in every case when phenols are used. Thus, it is mandatory that skin color be carefully evaluated and that the edges of the treatment areas be ‘feathered’ to avoid a sharp line of demarcation drawing attention to objectionable color contrast.

Splotchy hyperpigmentation Hyperpigmentation is thought to result from exposure to ultraviolet A light in pigment-prone individuals and those who are pregnant or who are taking birth control pills, exogenous estrogens, or photosensitizing drugs. This complication is easier to avoid than to manage. As mentioned above all patients are primed with bleaching agents prior to and after the peel. Every patient should also wear wraparound ultravioletﬁltering protective sunglasses, which shield the upper and lower eyelids and lateral canthi, including the crow’s feet areas, from light for 4–6 weeks. The patient must wear a wide-brimmed hat for 6 weeks after surgery and must begin using a UV A and UVB sunscreen with a sun protection factor (SPF) of 30 or higher as soon after healing as possible. In patients who are especially susceptible to hyperpigmentation, the physician may advise the use of sunscreen as early as 2 weeks after peel and may insist that it be applied every hour while the patient is outdoors. If splotchy hyperpigmentation occurs, it usually can be successfully treated with a combination of 0.05 percent retinoic acid cream (Retin-A) at bedtime and 4 percent hydroquinone cream in the morning for a few

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Chemical Peeling: Independent or in Conjunction with Facial Plastic Surgery weeks. If this regimen is not successful, the skin may be re-peeled to remove the splotchy hyperpigmentation. Strict avoidance of sunlight on the re-peeled skin should prevent recurrence.

Scarring and other textural changes Scarring and textural changes can and does occur with wounding depths of TCA 35 percent or higher. It may present as ﬂat, shiny (atrophic) areas, as web-type contracture at the inner or outer canthus, or as elevated, thickened areas of skin (hypertrophic). Elevated, thickened types of scarring respond favorably to biweekly injections of approximately 0.1 ml of triamcinolone at a concentration of 10 mg/ml. Additionally, for hypertrophic scarring, topical silicone gels are effective, as well as potent topical steroids. For minor slight elevations of scarring, b.i.d. applications of 1 percent hydrocortisone ointment is also helpful. The authors know of no effective treatments for atrophic scarring.

Cicatricial ectropion, lid retraction, and lagophthalmos One of the beneﬁts of chemical eyelid peeling is a vertical shortening of the skin. If more vertical shortening than is desirable occurs, it will manifest as lagophthalmos with corneal exposure, lower eyelid retraction, or early lower eyelid margin ectropion or frank ectropion.10 Exposure symptoms are far more common in patients with an underlying case of dry eyes. Following a dry eye work-up, management with artiﬁcial tear supplementation and bland ointment at night, consideration for punctal occlusion or bandage contact lenses is appropriate. The lower eyelid is managed with weekly or bimonthly injections of a total of 0.2 to 0.3 ml of triamcinolone (10 mg/ml) combined with 5ﬂurouracil (50 mg/ml) injected into the skin in a horizontal line just inferior to the lower eyelash margin. Further help can be achieved by support of the lower eyelid with sterile gauze strips (Steri-strips) or tape, as is standard for management of post-blepharoplasty eyelid retraction or ectropion. These methods, combined with time, can be expected to resolve the majority of such problems related to chemical peeling.

Infections Bacterial infections, usually secondary to Staphalococcos aureus can occur. We routinely have patients take oral antibiotics for a week following a full facial peel of TCA 35 percent or deeper. Yeast infections can occur after any type of peel. Since patients are on antibiotics the normal ﬂoral balance is disrupted, allowing

yeast cells to proliferate. Yeast infections are characterized by erythema, itching and sometimes white plaque-like lesions. Treatment with oral ketoconazole (Nizoral) 200 mg per day is highly effective against candidal infections. Wet to dry saline compresses is also beneﬁcial since it creates an environment less conducive to the growth of yeast organisms. The most feared infection is that due to the herpes simplex virus. Since most of the population has been exposed to the virus all patients are at risk of infection. The infection usually occurs between 7 and 10 days after a peel. The patient may develop fever, pain, erythema and sometimes vesicles which are seen as punched out ulcerations. All patients who are undergoing one of the more major full face peels are started on oral antiviral agents on the day of the peel and continue for 2 weeks. Patients who are undergoing just periorbital peels usually do not require prophylactic antivirals.

Authors’ collective experience with complications The authors have performed over 10,000 chemical peels over the past 25 years. In general the procedure has been extremely safe and effective. In our combined experience we have not had any complications with peels of TCA 25 percent or less. The complications that have occurred were in TCA 35 percent and the phenol peels. There were two cases of herpetic infections after full face phenol peels that resulted in scarring. Both of these patients were on prophylactic acyclovir and had breakthrough infections. At that time acyclovir was the only antiviral available. Currently, patients are placed on valcyclovir 500 mg twice a day for 7 days. Our recommendation is that if a patient develops a herpetic infection despite being on valcyclovir, a second antiviral agent should be added to the medical regimen. Approximately 1 percent of patients who underwent perioral phenol peels developed mild hypertrophic scarring. We have been able to reduce these scars with a combination of silicone gels, pulse dye laser, and intralesional steroid/5-ﬂuorouracil injections. Many patients developed mild textural skin changes even after a 35 percent TCA peel. In general these changes are mild but problematic to the patient, since make-up will not adhere well to these areas to provide camouﬂage. We recommend if textural changes are noticed early on in the postoperative period, that the patient should start using a mild topical steroid. Two of us (NS and JH) have performed lateral canthal resuspension with a SOOF and cheek lift11–15 with satisfactory ﬁnal results in seven patients referred

References with lower eyelid retraction after chemical peel. The use of a hard palate graft, which is successful for lower eyelid retraction following transcutaneous blepharoplasty, is usually not necessary after chemical peel, because the mid-lamella has not been manipulated and therefore is not scarred.

Conclusion Chemical peeling alone or in conjunction with surgery can vastly improve the quality of the skin. The procedure is safe and effective but does require a knowledge of skin pathology, wounding and its management, and proper patient selection. The potential for improvement by adding chemical peeling to blepharoplasty or facelifting is signiﬁcant. The risk of signiﬁcant complications in properly selected patients is relatively small. With the above in mind, we routinely perform upper blepharoplasty and lower transconjunctival blepharoplasty, facelifting and endoscopic browlifting combined with simultaneous chemical peeling.

References 1. Morrow DM: Chemical peeling of the eyelids and periorbital area. J Dermatol Surg Oncol 1992; 18: 102–110. 2. Brody HJ: The art of chemical peeling. J Dermatol Surg Oncol 1989; 15:918–921. 3. Stegman SJ, Tromovitch TA: Cosmetic Dermatologic Surgery, pp 27–46. Chicago, Year Book Medical Publishers, 1984.

4. Morrow DM: Presentation: ‘Simultaneous CO2 Transconjunctival Lower Lid Blepharoplasty and Chemical Skin Peeling,’ Third International Congress of Aesthetic Surgery, Paris, France, May 20, 21, 22, 1989. 5. Hoenig JA, Morrow D: Patient Evaluation. In Carniol PJ (ed): Laser Skin Rejuvenation. Philadelphia, Lippincott, 1997. 6. Fitzpatrick TB: The validity and practicality of sunreactive skin types I through VI. Arch Dermatol 1988; 124:869–871. 7. Kligman AM, Grove GL, Hirose R, Leyden JJ: Topical tretinoin for photoaged skin. Am Acad Dermatol 1986; 15:836–859. 8. McCollough EG, Hillman RA: Chemical face peel. Otolaryngol Clin North Am 1980; 13:353–365. 9. Monheit GD: Advances in chemical peeling. Facial Plast Surg Clin North Am 1994; 2:5–9. 10. Wojno T, Tenzel R: Lower eyelid ectropion following chemical face peeling. Ophthalmic Surg 1984; 13:596–597. 11. Shorr N, Fallor MK: Repair of post blepharoplasty ‘round eye’ and lower eyelid retraction, combined cheek lift and lateral canthal resuspension. In Ward PH, Berman WE (eds): Plastic and Reconstructive Surgery of the Head and Neck, Vol 1, Aesthetic Surgery, pp 279–290. St Louis, CV Mosby, 1984. 12. Shorr N, Fallor MK: ‘Madame Butterﬂy’ procedure: Combined with cheek and lateral canthal suspension procedure for post blepharoplasty ‘round eye’ and lower eyelid retraction. Ophthalmic Plast Reconstr Surg 1985; 1:229–235. 13. Shorr N, Goldberg RA: Lower eyelid reconstruction following blepharoplasty. J Cosmet Surg 1989; 6:77–82. 14. Hoenig JA, Shorr NS: The suborbicularis oculi fat in aesthetic and reconstructive surgery. Inter Ophthal Clin 1997; 37:179–191. 15. Hoenig JA, Shorr NS, Goldberg R: The Verstaile SOOF Lift in oculoplastic surgery. Fac Plast Clin 1998; 6:205–219.

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Eyelid and Facial Laser Skin Resurfacing Sterling Baker and Erin L. Holloman

Skin rejuvenation has long been a goal of medical practitioners. Time-honored remedies have included a wide range of chemical and mechanical agents, but the results were often much ado about little improvement, which might also be an apt description for many modern efforts! Perhaps the major difference between current practitioners and their predecessors is an understanding, albeit an imperfect one, of the treatment goals and of the methods to achieve them. The epidermis is tightly bound to the papillary dermis with an intervening basement membrane. The papillary dermis is about equal thickness to the epidermis and it blends into the much thicker reticular dermis. In a simpliﬁed understanding of skin anatomy, the appearance of the skin is largely a product of the regularity, or lack thereof, of the external layers of the skin. The most superﬁcial layer is the epidermis. The major structural and elastic components of the papillary and reticular dermis are collagen bundles and elastin ﬁbers. The collagen in skin is a dynamic tissue component formed by ﬁbroblasts. Skin starts life as ‘baby smooth’ largely because the collagen in the skin is formed as long and tightly cross linked bundles which impart a uniform pattern. As life progresses, skin experiences the degrading inﬂuences of sun, age and environmental pollutants such as smoke. Even though the body’s extensive reparative processes attempt to restore normal architecture, the pattern of the collagen bundles breaks into disjoined and fragmented bundles. This loss of regularity is reﬂected on the epidermal surface by the appearance of lines and wrinkles, also known as rhytids. Of special interest for facial skin anatomy is the presence of generous numbers of appendages which include hair follicles, sebaceous glands, and sweat glands. These structures arise within the deeper reticular dermis and subdermis. They each are connected to the skin surface by duct like structures which are lined with epithelium. During ablative resurfacing, the surface epithelium is completely removed. The epithelium from these glands provides the reservoir from which much of the re-epithelialization occurs. In contrast, the neck and especially the anterior chest wall have a paucity of these structures. This skin is a poor choice for resurfacing because the healing process is slow and prone to scarring. The goal of resurfacing is to induce signiﬁcant improvement in the surface appearance of the skin. Alteration of the collagen in the papillary and upper reticular dermis is the method to achieve the goal. Before the advent of lasers,

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266 those changes were produced by a variety of topically applied chemical agents or by mechanical appliances such as dermabraiders. The expectation for both modalities was reformation of the papillary and upper reticular dermis with new, tightly cross linked, collagen bundles followed by re-epithelialization. By the late 1980s and early 1990s, carbon dioxide (CO2) laser vaporization was added to these modalities. Erbium laser vaporization was available by the mid 1990s. Both the CO2 and the erbium lasers ablate or remove the epidermis and the papillary and upper reticular dermis with precision and predictability. Their successful use requires an understanding of lasers, skin anatomy, and laser tissue interaction. Common to all ablative modalities including chemical peels, dermabrasion and laser ablation is production of a partial thickness wound in the skin which requires a ‘down time’ to heal. By the late 1990s another group of lasers, light sources and radiofrequency devices were introduced with the goal of inducing change in the collagen of the papillary and reticular dermis without damaging the epidermis. This group can collectively be grouped together as non-ablative devices. The number of wavelengths in this group and the variable parameters used to induce collagen neogenesis offer mute testimony to the fact that this technology is still developmental. Sterling Baker and Erin L. Holloman

Laser physics Lasers are devices that generate light energy. A substance or medium is ‘pumped’ by an external energy source which moves electrons from a stable to an ‘excited’ state. Some of these excited electrons will spontaneously decay to a lower energy state. In the case of lasers, the excited molecule returns to a stable, lower energy state by emitting the extra energy as light in the form of a photon. A photon is a discrete bundle of energy with no mass. Once released, this photon cruises along in a population of like molecules which are also excited. When it strikes another excited molecule, the process of ampliﬁcation occurs because the excited molecule is stimulated to release its extra energy as another photon of exactly the same wavelength and precisely in phase with the ﬁrst. When all of this activity occurs in a tube with mirrors at both ends, the energy builds up as the light waves bounce back and forth. If one of the mirrors has a small central aperture, it can be opened in such a way as to release laser light. Why ‘laser’? It’s an acronym formed from the ﬁrst letters of the process described above; namely, Light Ampliﬁcation by Stimulated Emission of Radiation. The concept of radiation in the form of wavelengths is derived from the dual nature of our understanding of

light as being characterized by both photons and electromagnetic waves. There are unique features of laser light that make it useful for a variety of applications including medical ones. Laser light is collimated or highly directional which keeps the energy of the beam from dissipating over distance. Laser light is coherent with the peaks and troughs of the sinusoidal wave traveling through space in phase with one another. Coherence allows the energy within the beam to be concentrated with precision. Finally, the light is monochromatic or emitted at a narrow band of the electromagnetic spectrum. It is this monochromatic property that is used in medicine to achieve speciﬁc goals in tissue. Once this laser light has been formed in the generator, it can be manipulated in several useful ways. The release can be controlled by a variety of gating mechanisms ranging from simple shutters to complex pulse generators. For medical uses, the beam is either released as a continuous beam or as a pulsed one. The power output is measured in watts or joules per second. The beam can be focused which is a useful property when cutting or resurfacing by scanning. It can be transmitted through mirrored conduction tubes, wave guides or ﬁber conductors. If the beam is released in a pulse with the intent to conduct it to the target without signiﬁcantly modifying its physical characteristics, the power of the laser must

Laser physics 267

105 104 Absorption coefficient (1/cm)

be high enough to produce an appropriate effect when it reaches the target. Once this emitted laser light strikes tissue, it can be reﬂected, scattered, absorbed or transmitted. While reﬂection is not a very useful property in medicine, there are some applications where scattering can be employed to achieve therapeutic goals. The most useful current medical applications are absorption and transmission. Our current concept of what happens when laser light and tissue interact was articulated by Anderson and Parrish1 in 1984 in their landmark paper describing selective photothermolysis. Speciﬁc components in tissue absorb light more intensely at some wavelengths than at others. These components are known as chromophores. For example, absorption by water peaks at 2900 nm and at 10600 nm. The erbium laser emits at 2940 nm and the carbon dioxide laser emits at 10600 nm. The incident energy from both of these lasers is rapidly absorbed by water in the most superﬁcial layers of skin where it is converted to thermal energy. If the laser energy is sufﬁciently high, it will vaporize the water and in doing so will thereby remove or ablate the tissue. By controlling the incident energy and the duration of application, precise amounts of skin can be removed with limited collateral thermal damage. Another example of this concept of absorption can be seen in the choice of an argon laser emitting at 514 nm (in the green part of the visible spectrum) where water absorption is very low and melanin absorption is relatively high. Energy emitted from this laser passes through the ﬂuid medium of the eye to be absorbed by the chromophore melanin in the retinal pigment epithelium. The thermal energy generated by this effort can be useful in treating some pathology such as diabetic retinopathy. Figure 22-1 shows the different chromophores and their wavelengths of absorption. The goal of laser skin resurfacing is to vaporize or ablate surface tissue while minimizing thermal damage adjacent to the site of application. The obvious ﬁrst step is to build the laser with enough power to reach the heat of vaporization, which in the case of water is 100ºC. How efﬁciently this process of vaporizing tissue proceeds will be determined largely by the shape of the laser beam and the time of application. Since most medical lasers emit in either a true Gaussian shape or something similar to it, the most useful bell-shaped conﬁguration will have the energy of the beam highly concentrated in the central portion of the beam. The objective in ablative resurfacing lasers is to exceed the energy of vaporization for the broadest area of the beam possible and to minimize the undesirable formation of thermally devitalized but intact skin on the margins of the beam. In prosaic

Water

103 Melanin

102 Hemoglobin

101 100

Protein

10-1 10-2

Scatter

10-3 10-4

-1

1 Wavelength (microns)

10

Figure 22-1 Chromophores and absorption wavelengths.

terms, a beam conﬁguration that looks more like a ‘high top hat’ than a ‘beret’ is desirable. Duration of application of the laser beam can be a confusing parameter to understand. Conduction of any energy away from the site of origin/application requires time. When the water in tissue is the chromophore or target in tissue, the light energy is converted to thermal energy. If the laser energy is applied for a short enough time, thermal energy will be largely dissipated at the site. However if the energy is applied long enough, then the thermal energy will be conducted to the adjacent tissues. If this phenomenon occurs over a long enough time, signiﬁcant thermal devitalization of the surrounding tissue is possible.2 Thermal burns can be produced that can dramatically alter the healing process, to the extent of scarring. This period of time before signiﬁcant conduction occurs is deﬁned as the thermal relaxation time of tissue. For skin, that time is about 400 microseconds (400 µsec). The challenge is to build a laser with enough power to treat a fairly large area of skin with a ‘short burst.’ An alternative to a single pulse is a scanner that will trace a small focused beam over the target rapidly enough to produce a desirable effect and still not expose the target area for longer than the thermal relaxation time of the tissue. Of course at the sides and depths of the beam, some subablative energy will exist which will produce a residual of thermally devitalized tissue beyond the area of application. Actually, this thermal residual can be helpful because it produces cauterization of small vessels which otherwise might bleed thereby obscuring the ﬁeld.3 The effect of ablative laser applications can be predicted. The common denominator, at least among lasers of the same wavelength, is ﬂuence which is the amount of

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Eyelid and Facial Laser Skin Resurfacing energy applied per unit area. Fluence is measured in joules/cm2. For the purpose of comparing lasers, both the carbon dioxide and the erbium laser can be considered to ablate 4 microns (µm) of skin/joule of ﬂuence. Therefore, if the laser beam is applied at 20 J/cm2, about 80 µm of skin will be ablated in one pass. 80 µm is about the thickness of eyelid skin. Remembering that the thickness of the papillary dermis is about that of the epidermis, a second pass at 20 J/cm2 would place the thermal residual well within the reticular dermis. Thus, two passes over the eyelids at a ﬂuence of 20 J/ cm2 would be aggressive treatment. For non-ablative devices, the laser or light energy is relatively poorly absorbed by chromophores in the skin. Therefore most of the energy from these devices will pass through the epidermis to be scattered by encounters with molecular structures deeper in the skin before being absorbed by the targeted chromophore. While thermal energy generated by this process is not sufﬁcient to vaporize the tissue, there is enough thermal energy to devitalize the collagen and initiate a reparative process that will ‘renew’ the collagen in the papillary and upper reticular dermis. The entire process can be signiﬁcantly enhanced by passive and dynamic cooling methods that are mainly designed to protect the epidermis. The choice of wavelengths, duration of application and modiﬁcation of effect by superﬁcial cooling can be confusing. There are no simple guides. Furthermore, the results tend to vary considerably among patients, often in unpredictable ways. Perhaps the best approach is skepticism. Use conservative guidelines to gain familiarity. Most importantly, progress must be documented with pre- and postoperative photographs that can be readily accessed. We can all see what is, but our recollection of what was is poor. Remember, the improvement induced by non-ablative devices can take months to reach a maximum effect and that effect can be subtle.

Laser safety Laser safety is a requirement for all physicians. There are many regulatory levels in laser medicine: federal, state, local, departmental, and institutional. Before offering laser resurfacing or using any laser tool in practice, be sure to check with each level for safety standards. Federal regulations are outlined by the Occupational Safety Health & Administration (OSHA, www.osha.gov) in the form of general industry standards, directives, and compliance letters. Laser safety standards are speciﬁcally further delineated by the American National Standards Institute (ANSI). ANSI

Z136.1-2000 document covers the general safe use of lasers. ANSI Z136.3-1996 document provides standards for the safe use of lasers in health care facilities. This document is most often used by regulatory groups and in litigation. Most states also maintain regulations as adjuncts to OSHA and ANSI standards, which may be even more rigorous. While engineering controls are built into laser systems by the manufacturer, each practice must be proactive in pursuing the highest level of safety for both the patients and the staff. ANSI recommends that physicians develop and maintain safety procedures and training policies. Each practice should appoint a Laser Safety Ofﬁcer, whose duty lies in risk management and all laser safety oversight. Hazards and their control measures must be identiﬁed. Protective environmental controls are required including protective eyewear, non-ﬂammable drapes (aluminum foil is common), smoke evacuators, ﬁre extinguishers, and masks. Procedural controls include limited access to the treatment room and regulated laser warning signs at entrances. A paramount concern is always for protection of the eye. The eye is very sensitive to the effects caused by the inadvertent application of laser energy. Ocular tissue damage can occur at different sites depending upon the laser wavelength. The retina and its pigmented cells are potential targets for laser light in the visible and near infrared spectrum (400–1400 nm). The lens and or cornea can be damaged by the ultraviolet (290–400 nm) or the far infrared (1400–10600 nm) spectrum. Maximum Permissible Exposure (MPE) is deﬁned for speciﬁc wavelengths and exposure durations. The Nominal Hazard Zone (NHZ) is the space in which direct, reﬂected, or scattered laser radiation exceeds the MPE. Appropriate protective eyewear according to wavelength and optical density should be worn by all persons in the treatment room and NHZ. For any laser treatment not involving the eye, the patient must wear protective shields that shield the entire globe. Therefore, corneal shields alone are inadequate. Much has been written about plumes from lasers and cautery devices that contain viral and potentially mutagenic materials, hazardous gases, and bloodborne pathogens.4 Avoidance of such contaminants is obviously important. These plume hazards can be mitigated by laser speciﬁc surgical masks and smoke evacuators. The evacuator should be positioned within 2 cm of the smoke production for its highest efﬁciency. Speciﬁc laser masks should also be employed. The standard surgical mask has a 5 micron ﬁlter. Laser surgical masks have ﬁltering capacity of 0.1 microns or less.

Preoperative evaluation and patient selection

Table 22-1 Clinical laser safety checklist for intraoperative ablative facial laser resurfacing

Preoperative evaluation and patient selection

Prevent oxygen from pooling under drapes during the case (wet towels are helpful)

Facial resurfacing is an elective cosmetic procedure. Counseling patients about realistic expectations and postoperative care is critical before undertaking any such procedure. Special care should be taken to understand which areas of the face are of concern to the patient. Indications for facial laser resurfacing include facial rhytids, skin laxity (Fig. 22-2), dyschromia, atrophic acne scarring, rhinophyma (Fig. 22-3) and scar revision (Fig. 22-4). Benign skin growths may also be ablated; however, all suspicious skin lesions must be biopsied ﬁrst. Education of the patient before the procedure is crucial. Show the prospective patient a photo album of pictures taken daily of actual patients who have undergone laser skin resurfacing during their ﬁrst two postoperative weeks. This review can be most helpful in preparing the patient for what can be a challenging postoperative recuperation.

Smoke/plume evacuator Metal eye shields for patient, protective lenses for staff Anodized Laser safe instruments (e.g. David-Baker lid clamp, Jaeger plate, Desmarres lid retractor) Test laser on wet tongue blade before applying to skin to conﬁrm it is co-axial with the aiming beam

A

B Figure 22-2 59-year-old man who underwent full face resurfacing along with adjunctive endoscopic brow lift and upper eyelid blepharoplasty. A, Preoperative; B, 6 weeks postoperative.

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A

B Figure 22-3 Rhinophyma signiﬁcantly improved after resurfacing. A, Preoperative; B, postoperative.

Complications and how they will be treated should also be discussed. Photographs must be taken to document preoperative anatomy. Both the patient and practitioner must have appropriate expectations of results. Emphasize that the goal is to modify and not erase. Laser facial resurfacing can usually improve severely photoaged skin to a moderate level, and a moderately photoaged skin to a minimal level and so on.5 Laser resurfacing is also a ﬁne complementary procedure to other surgical modalities. Figures 22-5 and 22-6 show a patient who underwent full face resurfacing combined with a brow lift, midface lift, and four-lid blepharoplasty. A routine medical and dermatologic history should be obtained. The skin type must be noted as part of the normal physical exam. Fitzpatrick Class IV or darker has an increased risk of pigmentation change and scarring. Oral retinoids within the previous 1 to 2 years may have depleted the density of pilosebaceous appendages. These structures provide the reservoir for reepithelialization. Active acne should be treated with

oral antibiotics before resurfacing. Tobacco abuse may cause delayed healing which could lead to hypertrophic scarring. Table 22-2 shows contraindications to resurfacing. A pretreatment consultation should include providing prescriptions for complication prophylaxis. A common protocol includes an anti-herpetic, beginning 1 day preoperatively and continued until fully epithelialized (7–10 days).6 Most experienced surgeons also prescribe an oral antibiotic. More controversial are topical retinols or alphahydroxy acids in the immediate preoperative period which may prime the skin for healing, and the routine use of hydroquinones postoperatively to decrease possibility of hyperpigmentation. A documented, preoperative consultation with informed consent including potential complications is paramount. Risks of the procedure as well as anesthesia complications must be documented. Photographs must also be performed preoperatively for the medical record.

Operative techniques for ablative facial resurfacing

Figure 22-4 Scar modiﬁcation, another application of resurfacing. A, Preoperative; B, postoperative.

A

B

Operative techniques for ablative facial resurfacing Laser selection Ablative resurfacing lasers are limited to two wavelengths. The erbium-YAG (Erb) laser emits at 29400 nm and the carbon dioxide laser (CO2) emits at 10600 nm. The beam from the CO2 laser can be a continuous beam or a pulsed one. The Erb laser emits only as a pulsed beam. By including two erbium laser tubes in the same delivery unit, the pulses can be emitted sequentially which effectively lengthens the pulse duration. Both lasers target water as their chromophore. The skin has a high water content which makes both

wavelengths effective for ablation. The key to extending the treatment into the vascularized papillary and reticular dermis is to control bleeding. The CO2 laser can create enough thermal residual at subablative ﬂuences and can be applied long enough at the treatment site to cause effective hemostasis by thermally cauterizing small vessels. The same hemostatic effect can be achieved with the erbium laser by immediately following the ﬁrst ablative pulse with a second non-ablative pulse. The second pulse creates thermal energy that cauterizes. The major difference between the two wavelengths involves the absorption coefﬁcient which is the physical property that determines the efﬁciency with which the incident energy is absorbed by water.

271

A

B

A

B Figures 22-5 and 22-6 78-year-old woman with severely photoaged skin. She underwent full face resurfacing along with endoscopic brow and midface lift, and CO2 laser assisted 4-lid blepharoplasty. Also note some expected mild erythema of skin at postop week 6. A, Preoperative; B, postoperative.

Operative techniques for ablative facial resurfacing

Table 22-2 Contraindications to resurfacing Unrealistic expectations Oral retinoids (accutane) within previous 1 year (reduces reservoir from which re-epithelialization occurs) Vitiligo – relative contraindication Active skin infection Ectropions – avoid vigorous lower lid treatment Non-facial skin – especially neck or chest, because of paucity of appendages decreases the speed of reepithelialization and increases possibility of scarring History of deep peels – relative contraindication History of hypertrophic scarring – relative contraindication History of keloids – relative contraindication History of skin radiation (may have caused decrease in appendages) Pregnancy

The energy emitted by the CO2 laser is not as completely absorbed as that from the erbium laser. The practical result is the existence of non-ablative ﬂuences at the depths and edges of the application. The laser energy at these margins is largely absorbed by collagen. In this process, collagen visibly contracts or tightens which seems to provide a scaffold for new collagen development.7,8 The ‘long pulse’ erbium lasers can create a similar effect by following the ﬁrst ablative pulse sequentially with a second non ablative pulse that leaves a signiﬁcant thermal residual.9 Some machines (e.g. Derma-K) have combined the two wavelengths to accomplish the same objective of hemostasis and collagen shrinkage. The beam from both lasers can be focused. This manipulation allows a lower powered laser to achieve higher ﬂuences (remember: ﬂuence = Joules/cm2). A negative feature of a focused application is the necessity to hold the delivery hand piece at precisely the proscribed focal distance to deliver the desired ﬂuence. Since the topography of the face is not planar, this feature becomes relatively critical when the beam is delivered through a pattern generator. The speed with which the laser energy is delivered can be increased by coupling the beam to a pattern generator. The generator either scans a continuous beam or moves a pulsed beam over a large target area more rapidly and reliably than can be accomplished with a manual deliv-

ery. The energy from pattern generators must be delivered from a stable platform to an immovable target to avoid undesirable overlapping. Generators that deliver pulsed and collimated beams are more ‘user friendly’ than those that deliver focused and continuous beams because delivery position is not as critical. A reasonable choice for applied ﬂuence with both the long pulsed erbium and CO2 lasers is 15–20 joules/ cm2. At this level about 80 µm of tissue will be ablated per pass. The number of passes over speciﬁc areas must be individualized for each patient. General, conservative guidelines are: forehead = 2–3 passes; intraorbital eyelids = 1 pass; cheeks = 2–3 passes; perioral lips = 2–3 passes with only 1 pass crossing the vermillion border; angle of the mandible = 2 passes; and the upper neck 1 pass. The areas adjacent to these treatment zones should be treated with reduced ﬂuence and density to avoid demarcation lines by blending or feathering.

Anesthesia For a full face resurfacing, laryngeal mask anesthesia is commonly used. Other options include nerve blocks, regional inﬁltration, IV sedation or topical agents. An anesthesiologist experienced in laser resurfacing is quite helpful. Avoid potential ﬁre hazards caused by free-ﬂowing oxygen in the treatment area.

Prepare patient Most practitioners recommend prepping the skin with a non-ﬂammable cleanser such as 10 percent povidone solution. A drop of topical anesthesia should be placed in the conjunctival cul-de-sac, and laser safe metal shields are placed over the corneas.

Drapes The patient should be draped in a ﬁreproof manner. Wet towels are a good alternative to aluminum foil.

Skin marking (zones) Divide the face into cosmetic zones. The brow, periorbital lids, the midface, and the perioral/lower face zones are useful anatomical boundaries to describe cosmetic units. One must not treat just an individual rhytid, but rather an entire zone, with ‘blending’ into adjacent areas for an optimal aesthetic result.

Safety reminders All surgical personnel must wear protective eyewear. Surgical instruments must be laser impermeable and non-reﬂective to avoid possible ricochets. Free ﬂowing

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Eyelid and Facial Laser Skin Resurfacing oxygen should be avoided to prevent risk of a ﬂash ﬁre.

Treatment/application of laser First, a member of the surgical team must be able to operate the laser turning it from standby to ready mode at the surgeon’s vocal request. Next, a test ﬁre on a wet tongue blade ensures that the aiming beam is in line. Most machines have a pattern generator for resurfacing. Hold the delivery system perpendicular to the surface of area to be treated. Tilting the delivery system changes the shape of the laser beam from a circle to an oval which can dramatically alter the power density of the beam. The surface of the face is rather angular and not planar. For practical purposes, patterns smaller than 1 cm2 will facilitate adjusting to the changing topography of the face. If the delivery system is focused, the exact focal distance must be maintained to deliver predictable energy densities. Conversely, a collimated system is not focused which allows a greater degree of freedom in positioning the hand piece. After each pass of the laser, the ablated tissue residue should be gently wiped away with ‘sopping’ wet, saline soaked gauze. Next, the area is gently patted dry, avoiding vigorous debridement, which may lead to dermal abrasion and scarring. Treat to the base of a wrinkle or to the appearance of a soft ‘chamois’ color. Avoid overlapping applications. A good rule of thumb for the maximum number of passes on the forehead, cheeks, and non-vermillion lips is three. Limit passes on the dry vermillion lips and eyelids to one pass and then reassess intraoperatively. Another pass may be added in these areas carefully to reach treatment endpoints. If treatment is limited to a single cosmetic zone, blend or feather from the treated to untreated zones to avoid demarcation lines. After the last pass, do not hydrate or remove the desiccated skin. Place occlusive dressings at the end of the case. Always record treatment areas and parameters in the medical record.

Postoperative care for ablative laser resurfacing Immediately after surgery, an occlusive or semiocclusive wound environment must be initiated. One possibility is a biosynthetic dressing10 (e.g. Flexzan) (Fig. 22-7). As an alternative, petrolatum ointment may be applied. Topical antibiotics should be avoided, especially during the early phases of wound healing, because the epithelium has been removed by the surgical procedure thereby reducing the barrier effect of the epidermis. If a biosynthetic dressing is used, it is usually removed on postoperative day 1–3 by ‘soaking it off’

Figure 22-7 Postoperative patient with bio-occlusive dressings.

in a long shower. Once the dressing is removed, vigorous open wound care is begun using soaks and ointments. Aquaphor is a common choice although many other healing balms have been advocated including Crisco and Vaseline. The most important objective is keeping the wound moist which promotes rapid reepithelialization. Soaks containing a weak acid (1 teaspoon of white vinegar/cup of tap water produces a concentration of about 0.25% acetic acid) will ‘cut’ the residual ointment and be a weak antibacterial. The soaks should be applied as ‘sopping wet’ 6–8 times/ day. Using clean paper towels provides an alternative to the accumulation of soiled hand towels. After soaking for 15–30 minutes, reapply the barrier ointment. The treated skin should not be allowed to ‘dry out.’ A yellowish serous transudate will be prominent on the treated dermal surface for 3–5 days. Keeping the wounds clean will help to prevent accumulation of a nutrient bed for fungal or bacterial infection. Expect moderate erythema and some edema, especially in periorbital and perioral zones. Pain is usually minimal. Many patients need only over-the-counter medicines. Most physicians prescribe

Complications of ablative laser resurfacing

Figure 22-8 Contact dermatitis after laser resurfacing.

an anti-herpetic for prophylaxis because the trauma of the surgery may reactivate dormant herpes simplex virus which could lead to a herpetic infection. Oral antibiotics may also be prescribed. The patient should be seen frequently in the ﬁrst 10 days to monitor for infection or other complications. It is important to assess how meticulous the patient is with their postoperative skin care. Since this early recovery period is a vulnerable one for the patient, emotional support and encouragement are important during this time. Complete re-epithelialization should occur around day 7 to 10 and will be manifested by smooth pink skin. It will take a month for the epithelium to regain its full thickness. Make-up and other cosmetics can be slowly introduced, usually one at a time to facilitate identiﬁcation of potential irritants. Inform patients that contact dermatitis (Fig. 22-8) can occur even to topicals that they have successfully used in the past. Sun block of at least SPF 30 should be used. Acne and milia can also occur after the epidermis has been re-established. The new epidermis is thin, so avoid unnecessary chemicals, perfumes, or abrasive scrubs for the ﬁrst few weeks. The skin is usually pink for 8–12 weeks (Figs 22-5, 22-6). New collagen and elastin ﬁber production may continue for up to 12 months after resurfacing. Figure 22-9 represents one year post-op follow-up results. As with other anti-aging procedures, most results should be longstanding.

Complications of ablative laser resurfacing Postoperative care and complication recognition are perhaps the most difﬁcult part of laser facial resurfacing. A preceptorship or formally arranged partnership

with an experienced surgeon will be invaluable to the beginning laser surgeon. Complication avoidance is the goal of appropriate postoperative care as outlined above. However, complications do occur and most can be overcome with patience and treatment. Bacterial cellulitis can occur in the ﬁrst 1–2 weeks following resurfacing.11 Typical signs are redness, pain, infectious exudates, and even foul odor. Gram stain, cultures, and sensitivities are necessary in all cases. IV antibiotics may be needed depending on severity. If bacterial infection does occur, polymicrobial infections are not uncommon. Staph, strep, and pseudomonas are the typical pathogens. Some surgeons advocate pretreatment prophylaxis with antibiotics such as cephalosporin. Herpetic and fungal infections can be seen in the same time frame. It can be difﬁcult to properly identify herpetic infection in the early postoperative stage because herpetic dermatitis usually presents with epithelial signs. The typical vesicular stage is not seen when the epidermis is gone. A row or crop of raw, red lesions may be observed instead. Signiﬁcant scarring can occur if untreated. Figure 22-10 represents a severe herpetic infection following perioral resurfacing. Fungal infections, usually candida, appear as soft white plaques with erythema and satellite lesions. Diagnostic evidence with KOH prep can be vital to identiﬁcation and differentiation. Prophylaxis with a single dose of ﬂuconazole may be prudent. Pruritis is a common side effect of the healing response. Symptoms can be strong, but thankfully are transient. The mandibular border and the forehead are the most affected areas. An oral antihistamine, topical mild steroid, ice pack or cool pack should give relief. Acne may occur after resurfacing. An oral tetracycline, such as Minocin, may be prescribed. Milia are

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Figure 22-9 Lasting results, one year postoperative A, Preoperative; B, 1 year postoperative.

A

B

Figure 22-10 Severe herpetic infection after perioral resurfacing.

often present in the ﬁrst 3–4 weeks postoperative (Fig. 22-11). Treatment with low concentrations of retinoic acid, alphahydroxy acids, or glycolic peels is usually beneﬁcial. Post-inﬂammatory hyperpigmentation occurs transiently in about 30 percent of resurfacing patients (Fig. 22-12). It typically presents in the ﬁrst 3–4 weeks. It is more common in Fitzpatrick Type III to VI skin types.12 Melanin builds up in macrophages and production is increased during the postoperative period. There are many treatment options, including observation (resolves usually within 6 months), topical bleaching agents (i.e. hydroquinones), topical steroids, sun avoidance and sun block (SPF 30 and higher). Some surgeons pretreat those at risk for hyperpigmentation with hydroquinones and possibly topical steroids. Hypopigmentation occurs in less than 1 percent of treated patients. It is thought to be caused by an overall

Complications of ablative laser resurfacing

Figure 22-11 Milia are possible sequelae of resurfacing.

Table 22-3 Advantages and disadvantages of ablative laser resurfacing

Advantages Most aggressive modality for improving texture and laxity of aging skin Can be tailored to patient needs Unlike non-ablative applications, the ‘bottom’ of the treatment area can be seen, providing for more predictable yet safer efforts Relatively quick procedure

Disadvantages Healing period of epidermal regrowth with true downtime Risk of scarring Redness for several weeks Risk of altered pigmentation Risk of infection Procedural discomfort

Figure 22-12 Post-inﬂammatory hyperpigmentation may present in patients with Fitzpatrick skin types III to VI.

reduction in melanocytes following resurfacing. Patients who have undergone previous deep chemical peels or dermabrasion are most at risk. Unfortunately, there is no simple or reliable treatment. Cosmetic camouﬂage may be the most practical answer. Erythema is normal during the ﬁrst 12 weeks. It should gradually lessen. After 3 or more months of persistent erythema, mild topical steroids may be necessary to hasten improvement. Most of the redness can be neutralized after re-epithelialization by using makeup with a yellow or green color because these colors are complimentary to red. Scarring may result as a rare complication in the resurfaced face.13 It is probably the most signiﬁcant

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Eyelid and Facial Laser Skin Resurfacing iatrogenic complication, but is preventable with proper technique. The resurfacing must not be performed too vigorously. Stay within the superﬁcial reticular dermis. In addition, careful cleaning of the residual desiccated tissue during the resurfacing will avoid char.14 Char is formed by the carbonization of residual treated tissues. Char then becomes the chromophore for additional passes of the ablative resurfacing laser. When char becomes the target, there is a change in thermal dynamics from the temperature needed to vaporize water (100ºC) to a much higher temperature. This additional thermal energy has the potential to produce side effects that may result in scars. Scarring can present unpredictably in certain skin types. The surgeon must be aware of previous unfavorable healing and or keloids. Treatment of scarring may consist of topical steroids, intralesional steroids, 585 nm pulse dye laser, or surgical excision. The risk of scarring can be best reduced by appropriate preoperative evaluation, safe surgical technique, close follow up of the patient after surgery, and good compliance with aftercare instructions. Cicatricial ectropion secondary to anterior lamellae scarring or shrinkage with or without punctal ectropion can also occur. This is not to be confused with the early, likely lower lid eyelid edema and skin tightening, which will spontaneously resolve. True cicatricial ectropion may be seen in the later postoperative period. Again, carefully examine the patient in the preoperative period looking for other potential factors in ectropion: gravitational cheek descent, excessive lid laxity, and canthal tendon dehiscence. Some surgeons incorporate a lateral tarsal strip procedure into the operation in those at risk. Facial laser resurfacing is an effective tool in skin rejuvenation. It may seem daunting at ﬁrst to the laser inexperienced. However, once implemented, it can be a very satisfying and valuable procedure for the oculoplastic surgery practice.

References 1. Anderson RR, Parrish JA: Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220:524. 2. Ross EV, Domankevitz Y, Skrobal M, et al: Effects of CO2 laser pulse duration in ablation and residual thermal damage. Lasers Surg Med 1996; 19:123–129. 3. Kirschner RA: Cutaneous laser surgery with the CO2 laser. Surg Clin North Am 1992; 64:871–883. 4. Gloster HM Jr, Roenigk RK: Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol 1995; 32(3): 436–441. 5. Biesman BS: Cutaneous facial resurfacing with the carbon dioxide laser. Ophthal Surg Lasers 1996; 27:685–698. 6. Lowe NJ, Lask G, Grifﬁn ME: Laser skin resurfacing: pre and posttreatment guidelines. Dermatol Surg 1995; 21(12):1017–1019. 7. Bass LS, Aston SJ: Shrinkage and thermal injury in human skin in vitro after resurfacing with carbon dioxide and erbium : YAG lasers. Lasers Surg Med 1997; (Suppl): 30 pp. 8. Cotton J, Hood AF, Gonin R, et al: Histologic evaluation of preauricular and postauricular human skin after high energy, short-pulse carbon dioxide laser. Arch Dermatol 1996; 132(4): 425–428. 9. Gardner E, Reinisch L, Stricklin GP, et al: In vitro changes in non-facial human skin following CO2 laser resurfacing. Lasers Surg Med 1996; 19:379–387. 10. Pozner JN, Ramirez OM, Weinstein C: Experience with the use of semipermeable dressing following laser resurfacing. Lasers Surg Med 1997 (Suppl): 60 pp. 11. Goldman MP, Fitzpatrick RE, Smith SR, et al: Infections complicating pulsed CO2 laser resurfacing for photoaged facial skin. Laser Surg Med 1997; (Suppl): 43 pp. 12. Ho C, Nguyen Q, Lowe NJ, et al: Laser resurfacing in pigmented skin. Dermatol Surg 1995; 21(12):1035–1037. 13. Nanni CA, Alster TS: Complications of CO2 laser resurfacing. Laser Surg Med 1997; (Suppl): 53 pp. 14. Ross EV, Glatter RD, Duke D, et al: Effects of pulse and scan stacking in CO2 laser skin resurfacing. Laser Surg Med 1997; (Suppl): 61 pp.

uded on DVD

CHAPTER 23

Injectable Agents for Dermal Soft-Tissue Augmentation of the Face: Options and Decision Making Steven Fagien, Jean Carruthers and Alastair Carruthers Facial aesthetic enhancement to restore youth, beauty, and vitality has seen a rapid increase in popularity over the past few decades. The higher level of understanding of the components of facial aging has led us to the appreciation that volume restoration is integral to rejuvenation as surgical repositioning (the ‘lift’). Signiﬁcant advances and reﬁned techniques have allowed minimally invasive procedures and solutions to volume loss to ﬂourish. Patients can now have these procedures performed in the comfort of a consulting room setting and a swift return to normal activity. Of these, dermal soft-tissue augmentation is unarguably one of the most popular due to its convenience and pleasing results. In addition to smoothing facial rhytids, injectable ﬁlling agents are often used in combination to improve the appearance of the periorbita, mid- and lower face, restoring a more youthful appearance with little inconvenience and few complications. In this chapter, we will discuss many of the currently available ﬁlling agents, their unique characteristics, and speciﬁc procedures most often requested. Steven Fagien, Jean Carruthers and Alastair Carruthers

Fillers: restoring the aging face The aging face undergoes many alterations (Fig. 23-1), including changes to skin texture and color, wrinkles and furrows (due to overactive muscles and loss of elasticity), and sagging (in part, due to loss of underlying fat – see Chapter 2, and accompanying DVD clip). There are a number of options for the experienced clinician when choosing a ﬁller for volume replacement, facial contouring, or simply to correct wrinkles and subtly restore the face to a more youthful appearance. With efﬁcient procedures, little downtime, and few complications, ﬁllers may herald the future of facial rejuvenation.

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A

Figure 23-1 This artist’s rendition of the split image changes from youth (right side of face) to aged (left side of face) depicts the noted changes of the periorbita that include, in part, volume loss, reduced skin elasticity and rhytid formation, and eventual soft tissue ptosis related to loss of underlying supporting structures.

Injectable soft tissue options available Collagen Non-permanent biodegradable ﬁllers:

· · ·

Zyderm/Zyplast CosmoDerm/CosmoPlast Others

Widely available and easy to use, bovine ‘collagen’ represents an excellent affordable option for temporary augmentation and is indicated for the correction of facial rhytids and scars, as well as lip augmentation. Although these agents are typically included in the long list of soft tissue ﬁllers used for volume augmentation, their role (with the exception of lip augmentation) is primarily for line reduction/eradication. Zyderm and Zyplast (Allergan Inc, Irvine, CA). These agents were the ﬁrst widely used commercially available products,1 whose names have become synonymous with the word ‘collagen’ despite the fact that there have been dozens of collagen-based injectable products commercially available worldwide since their introduction. These are composed of puriﬁed fragments of heterologous animal collagen ﬁbrils derived from processed bovine skin, in a suspension of phosphate-buffered physiologic saline with 0.3 percent lidocaine. Supplied in preﬁlled syringes and stored at a temperature of 4ºC, the dispersed collagen ﬁbrils remain small and ﬂuid. When implanted, the product rises in temperature, forming a more cohesive gel. Zyderm 1 was approved by the Food and Drug Administration (FDA) in 1981, con-

B Figure 23-2 A, Pre-collagen. B, Post-collagen.

tains a collagen concentration of 35 mg/ml, and is rapidly reabsorbed. Zyderm 2, approved in 1983, contains 65 mg/ml of collagen; reabsorption is consequently slower than with Zyderm 1. Zyplast, approved in 1985, is similar to Zyderm 1 and 2 but the fragmented collagen ﬁbrils are chemically modiﬁed and stabilized via crosslinkage with glutaraldehyde. Zyplast is the most viscous of the three products, lasts longer than Zyderm, and although is theoretically less immunogenic than its predecessors has shown a similar rate of allergic reactions. While early reports of bovine collagen were enthusiastic, claiming a duration of effect as long as 8–12 months, our experience has shown otherwise. Typically, bovine collagen requires two initial treatment sessions to produce the desired effect, which persists from 2–6 months, after which time maintenance treatments are required at least every 6 months or at times more often (Fig. 23-2). Single treatment sessions have been reported in some to last less than 6 weeks despite adequate technique. Good results with bovine collagen (as with all of the injectable ﬁlling agents) demand the injection of sufﬁcient volume of product in the appropriate tissue plane; an overly conservative approach (injecting too little) will produce suboptimal effects of short duration. In addition, using sufﬁcient volume ensures simpler maintenance, and less correction at follow-up. Deeper placement (i.e. sub- or deep dermal) produces more transient and less satisfactory effects as resorption with most dermal ﬁlling agents appears to be expedited when closer to the subcutaneous space.

Injectable soft tissue options available 281

A Figure 23-3 Although a host of injection techniques have been described including serial puncture, serial threading, etc., the key point is not which technique is used, rather the best technique to deliver the product with precision and the comfort and experience of the physician injector.

It has been suggested that the aesthetic improvement of facial lines rests more in the low-grade inﬂammation afforded by the heterologous (bovine) collagen2 rather than as a direct result of true augmentation of the dermis, but there is also a concern that may relate to potential complications arising from their use. Injection technique is highly variable, but the preferred method is generally regionally dependent. The B serial puncture technique is most commonly prescribed Figure 23-4 A, This patient presented for treatment of lip (Fig. 23-3) for use of CosmoDerm (for ﬁne lines) and rhytids. Laser skin resurfacing had been done 2 years prior CosmoPlast (for deeper wrinkles and folds) (Allergan and she states the ‘wrinkles returned’ in a very short period Inc, Irvine, CA). These are new bioengineered human of time. B, One month after 2 ml of CosmoDerm was used collagen-replacement products approved for cosmetic for the treatment of upper and lower lip and chin rhytids. The result lasted 3 months. use in Canada and the United States that contain human collagen puriﬁed from dermal tissue grown in the laboratory.3 These particular products are processed identically to their bovine counterparts (Zyderm/ The ‘collagens’ enjoyed the majority market-share Zyplast). Although their use has been relatively limited, of agents for injectable soft tissue augmentation for no allergic responses were observed in a study of 428 many years, primarily due to lack of availability of patients,4 and a great advantage is that a skin test is other agents and ease of administration. Additionally, not required prior to treatment. Anecdotal reports they were available at a time when there was a lesser with experienced injectors however, suggest that the appreciation of the value of injectable soft tissue augpersistence of these agents in some individuals might mentation. Most patients expected that they would actually be even less than for bovine collagen. It is sugreceive treatment and have positive effects that would gested that there is less antigenic stimulation, which last for a predictable, albeit abbreviated, time period may reduce the inﬂammatory effect and subsequent (Figs 23-4 & 23-5). The standards had been set, and edema required to further reduce the appearance of most individuals expected aesthetic improvement of rhytids.2 One advantage of all of these ‘collagen’ prodthe order of magnitude of several months at best. Other ucts is that the agents can mostly be delivered without more labor-intensive agents introduced in the early the need for local anesthetic (already contained in each 1990s were met with some resistance when they of the product mixtures) and minimal edema and required multiple injection sessions to achieve optimal bruising that allows for quicker return to normal activcorrection (Silicon, Fat, Dermalogen). Despite the ity and appearance. introduction of new injectable ﬁlling agents with Techniques for these agents are identical as those improved characteristics, these agents are still used by for Zyderm/Zyplast (Fig. 23-3). many for a host of reasons including lack of better

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A Figure 23-6 An acute ulcerative reaction to Zyplast. This eventually resolved spontaneously by about 6 months.

B Figure 23-5 A, This patient presented for treatment of a deep oral commissure on her right side. She was not interested or in need of any treatment to the left side and feared asymmetry or irregularities associated with treatment to just one side. B, One month after 1 ml of CosmoPlast was injected into the mid-dermis via a serial puncture technique. The result lasted, however, just over 2 months.

options for particular applications (including the treatment of ﬁne rhytids) and cost. Complications The transient nature of its clinical effect and the need for repeated treatments are injectable collagen’s main drawbacks. In addition, at least 3–5 percent of patients will experience an allergic reaction to bovine collagen5 (Fig. 23-6), necessitating double skin testing prior to treatment. Allergic responses, although rare, can also occur despite negative double skin testing and can be severe and/or long-lasting (Fig. 23-7). Adverse reactions to bovine collagen injection in the lips are less common and transient. Redness at the injection site nearly always disappears within hours, and bruising will usually resolve within 3–7 days. The patient’s greatest dissatisfaction with ‘collagen’ relates mostly to its rapid resorption. The residence time, however, seems to be correlated with the depth of placement into the dermis, and superﬁcial nodules (as a result of a

Figure 23-7 This patient suffered from a chronic episodic inﬂammatory granulomatous reaction to Zyderm. Treatment involved the use of intra-lesional corticosteroids, also administered elsewhere, that resulted in focal dermal atrophy.

bolus of products in the superﬁcial dermis) or visible whitish particulate can last for months and even years. These are commonly seen in individuals who have received collagen on multiple occasions for the treatment of superﬁcial rhytids. Another common ﬁnding in individuals who had received bovine collagen products to the lips (particularly the vermilion border) on multiple occasions is a progressive difﬁculty in ﬁnding the ‘vermilion plane’ that can usually (in the naïve patient) be easily found (and injected) by placing the needle in the subdermal plane parallel to the lip margin. In many patients, injection of product at the lateral lip margin with this technique can ‘roll’ the material sometimes clear across the midline to the contralateral side. It has been postulated, as well, that the obliteration of this plane is related to chronic inﬂammation and eventual scarring.2

Other ‘collagen’ products

Other ‘collagen’ products Dermalogen With all of the reported and anecdotal concerns relating to injectable bovine collagen, ophthalmologic pioneer, Charles D. Kelman, MD and collaborator biochemist Dale P. DeVore, Ph.D. began exploring the options and possibilities of using autologous human collagen as an injectable agent for facial soft tissue augmentation. This could potentially address the problems relating to allergy and inﬂammation, avoid a skin A test prior to treatment, and hopefully would yield greater performance compared with the heterologous options. The concept essentially evolved into a process whereby patients undergoing cosmetic surgery (where skin was to be removed) would have their typically discarded skin ‘excess’ saved and transported via express overnight carrier to a central processing facility (Autogenesis Technologies, Acton, MA) where the collagen/dermal matrix could be extracted from the skin. The proprietary process from procurement to the ﬁnal product delivered intact collagen ﬁbers along with other constituents of the normal dermal matrix in an B injectable form called Autologen.6–9 The approximate Figure 23-8 A, This patient presented for treatment of a 3–5 percent sterile dispersion of dermal matrix was deep glabellar furrow. She had prior treatment with sent back to the injecting physician in 1 ml syringes ‘Collagen’ with very transient results. B, After treatment that could be used at a deﬁned period after receipt for with Autologen. Less than 0.5 ml was injected in three the correction of dermal contour defects (Fig. 23-8). sessions over a period of several months. The result lasted The process was a bit laborious and costly; however several years. with appropriate injection technique persistence of wrinkle correction rivaled the bovine collagen experiences that essentially ‘owned’ the ﬁller market at that created on a larger and more economical commercialtime. The initial resistance to its use related to the ized scale. Dermalogen (allogeneic human dermal limited applicability for only those individuals undermatrix) was a result of this concept.2,8–10 The biologic going cosmetic procedures where skin was to be behavior was identical to Autologen, but was far less removed; at times poor yield and consistency (concencostly and readily available, also without the requiretration) of the injectable product; requisite of more ment of skin testing (Figs 23-9 & 23-11). than one injection session for full correction in many; The cost and time delay of procurement and custom and the need for local anesthetic to improve patient processing, although ideal, could thereby be elimicomfort as the product contained no local anesthetic nated. Factors contributing to the resistance to its use within. Shortly thereafter other human tissue products also related to (as with Autologen) the need to use local (such as Alloderm) were becoming accepted as care anesthetic for comfort, as clinicians had only the bovine standards in other areas of cosmetic and reconstructive collagen experience (containing Xylocaine 0.3%). The plastic surgery with a much reduced concern of the product became unavailable after a few years of steady possibility of communicating disease with such prodsales and satisfactory results by experienced injectors ucts from a human donor source. There was also an as a result of the demise of the parent company; improved understanding of rigorous donor tissue however it will again become available (Collagen testing, cleansing, and sterilization/decontamination Matrix Technologies, Boca Raton, FL). As the product performed to insure safety. The idea of creating an is highly biocompatible, it elicits almost no inﬂammaallogeneic variety of human tissue collagen matrix was tory response and the effects are mostly dependent on born whereby skin was obtained from approved tissue precision injection technique with delivery of product banks (like all other donor organs) that were certiﬁed into the mid to superﬁcial dermis. As we have all by the American Association of Tissue Banks (AATB) become more comfortable with the requirement for and injectable human tissue collagen matrix could be

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B Figure 23-9 A, This patient presented for treatment of (mostly) upper lip rhytids. B, 2 months after ﬁnal treatment with Dermalogen with 1 ml administered in three sessions. The result lasted approximately 6 months.

the use of local anesthetic and regional nerve blocks with our recent wealth of experiences with a host of hyaluronic acid products, its acceptance is now even greater. The advantages over the hyaluronic acid products, as with the other ‘collagens’ is its superiority speciﬁc for the treatment of ﬁner and more superﬁcial rhytids. Its advantage over the use of bovine is the lack of need for skin testing and the advantage over CosmoDerm/CosmoPlast also relates to persistence, lack of inﬂammatory reactions, and cost. As with most of the injectable agents, preferred injection technique is highly variable and region dependent. Enhanced patient comfort is facilitated by local anesthesia. Once anesthetized a slow and deliberate application whether by serial puncture or threading can deliver excellent results with satisfactory persistence (Fig. 23-11). Protocols for optimal treatment vary slightly from the Zyderm/CosmoDerm experiences whereby patients are treated initially and a second treatment is administered within 3–6 weeks to a satisfactory visual endpoint. Patients are seen again within the next 3–6 weeks to evaluate and consideration of a third treatment. In

Figure 23-10 A, This patient presented for lip augmentation. B, After Dermalogen treatment. 1 ml was divided to the upper and lower lip vermilion and lower lip proper.

Figure 23-11 Dermalogen administered to the lip vermilion via a threading technique into the subdermal plane. This plane can usually be easily found (with the exception of individuals who have had multiple prior injections with bovine collagen) and a single injection through the lateral aspect of the lip can administer material (‘ﬂow’) to past the central lip margin.

Other ‘collagen’ products either scenario of a third (or even fourth) treatment or not, the experiences with skilled injectors is that the result can be up to 6 months. Complications As with other collagens and some of the hyaluronates, the transient nature of these products are also the major drawbacks. Inappropriate injection technique and protocol can yield disappointing results (deep injections dramatically reduce residence time). Complications relating to ‘allergy’ or other illness have not been reported. As with other ‘collagens’ these agents are best used for the treatment of facial lines and are less effective for volume enhancement.

More ‘collagens’ Over the past 20 years, a host of other collagen-like products have come and gone. The high level of interest in producing a collagen-based product for distribution has persisted since the introduction of bovine collagen in the early 1980s. Fascian, Cymetra, and a long list of other products have emerged after the introduction of Dermalogen, as a result of the demand for a collagen-based product for soft tissue augmentation that would not require skin testing. The nature of some of these agents however, yield suboptimal persistence, hence their waning popularity. A porcine collagen derivative, Evolence, will be introduced into the US market in the next couple of years.11 The theoretic advantages over the bovine collagens (beyond the growing European resistance to bovine products) relate to their proprietary cross-linking process that is supposed to aid against rapid degradation and resorption. A skin test, however, may also be required for this product.

Some believe autologous fat grafting to represent the ideal replacement for soft-tissue atrophy, replacing volume and contours lost in the aging process.14 Injections are delivered through large-bore needles requiring local or even general anesthesia. Techniques, handling, and instrumentation vary signiﬁcantly and consensus has yet to be arrived upon. In 1997, Coleman promoted LipoStructure® – the placement of small amounts of autologous fat in multiple tunnels – for a safe, long-lasting method of recontouring the face.15 The fat autograft muscle injection (FAMI) technique, developed by Amar, involves the injection of adipose tissue within the muscles of facial expression in intricate layers of autologous fatty tissue with anatomic patented microcanulas and has shown improved longterm, aesthetic results for facial rejuvenation.16,17 In ‘fat rebalancing,’ fat is harvested from the patient, frozen, and transferred in less than 0.1 cc aliquots under low injection pressures, weaving fat in a crosshatched 3D design through the muscle to the subdermis or, when injected periorbitally, placed conservatively deep to the periocular musculature.18a,18b,19 Despite improvements in technique, however, the fact remains that autologous fat grafting demonstrates unpredictable and sometimes temporary results.20,21 Relating to the use of injectable autologous fat for facial rejuvenation, possibly the largest ‘epidemic’ of disappointment by patients regarding their treatment is the indiscriminant use of fat as a tool for improving the volume depletion and hollowness of the lower periorbita (Fig. 23-12). Unfortunately, the attempts of ‘simple’ replacement of volume of the lower eyelid and cheek are met with several obstacles including the irregular fat survival after injection compounded by

Autologous fat The oldest available ﬁller and reportedly ﬁrst used by Neuber in 1893,12 fat has the advantage of being autologous and abundant in the body,13 enabling the correction of contour defects without risk of allergy. The indications are most often for the correction of larger subcutaneous defects such as the nasolabial folds and senescent facial volume loss. However, the success of fat procedures depends on the method of harvesting, the type of fat used, and the injector’s level of experience, and disadvantages include donor site morbidity, calciﬁcation of the injected fat, and unpredictable resorption.13 Since the variable longevity of contour correction depends on technique, amount of fat injected, and location, improvements in harvesting, handling, and the injection process may have an impact on positive patient outcomes.14,15

Figure 23-12 This patient presented with desire for removal of autologous fat injected to the periorbita (elsewhere). The fat is located at various depths (subdermal, intramuscular, and submuscular). Surgical removal required a skin ﬂap and separate orbicularis ﬂap, and transconjunctival access to the variously located autologous fat.

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B Figure 23-13 A, This 28-year-old patient presented after receiving autologous fat injections to the lower periorbita. B, After surgical excision that required a transconjunctival, skin ﬂap, and orbicularis ﬂap to full excision.

the atrophy of the lower periorbital structures that reveal the imperfect solution, and is not only distressful for the patient but at times difﬁcult if not impossible to correct. Similar to experiences in the other facial regions, results also have been highly variable and somewhat unpredictable, often with gross visibility of the irregularity of fat survival through the thin periorbital skin. Surgical efforts to reverse these iatrogenic problems are difﬁcult at best (Fig. 23-13). Complications Harvesting and reinjecting fat are both signiﬁcant procedures that are associated with downtime and the possibility of serious complications. The main problems associated with autologous fat are its variable resorption rate and unpredictability.13 Although largely technique-dependent, potential complications of autologous fat grafting include prolonged edema, bruising, undercorrection, overcorrection, clumping, irregularities, fat necrosis, migration, and infection, in addition to the other risks associated with surgical procedures.13

Hyaluronic acid Acting as a space-ﬁlling and stabilizing molecule, natural hyaluronic acid is a key structural component of the skin. In gel form, hyaluronic acid binds to water and

provides volume to easily ﬁll in larger folds of skin around the mouth and cheeks. There are a number of hyaluronic acid derivatives from which to choose, including Restylane, Restylane Fine Lines, Perlane, and Perlane Plus (Q-Med, Uppsala, Sweden), Hylaform, Hylaform Plus, and Captique (Allergan Inc, Irvine, CA), and Juvéderm family of products (Allergan Inc, Irvine, CA). These stabilized hyaluronic acid (NASHA) gels appear to provide superior durability and aesthetic improvement than bovine collagen,22 may be useful adjuncts in facial cosmetic procedures,23,24 and rarely cause an allergic reaction. The differences in each of the hyaluronic acid gel products relate to cross-linking methods, concentration, and particle size that translates into the variable ﬂow characteristics, injectability, gel hardness, and persistence. These differences also suggest selection of the most appropriate product that matches the region to be treated and the patient’s expectations. There are a number of advantages associated with hyaluronans, including longer duration of effect requiring less frequent touch-ups than collagen, and a lack of hypersensitivity (ideal for patients who are allergic to bovine collagen). In addition, some patients may resist using animal-derived products, such as Zyderm and Zyplast, and may perceive greater safety with a non-animal product. As with collagen injections, treatment with hyaluronans is easy and quick and can be performed in as little as 30 minutes. In contrast, patient experience and possibly results25 may be signiﬁcantly improved with the use of local or regional anesthetic (with epinephrine). The effects are immediate, there is little or no recovery time in most facial regions, and the clinical effects persist for 4–6 months, depending on the product, technique, volume, and density of the hyaluronic acid used. While hyaluronans provide greater persistence of effect, they are still similar to natural components of the skin and, as such, elements of the ﬁller gradually break down and are absorbed, necessitating periodic touch-up treatments to maintain the desired outcome. Most treatment protocols involve the application of the hyalurons to slight overcorrection with the anticipated variable initial resorption or effect loss due to dissipation of the initial edema (that can be profound in some patients and facial regions [lips]). Occasionally, patients will require a second treatment session 2–4 weeks after the initial treatment to rebuild the tissue to the desired degree (Figs 23-14 to 24-16). Complications Transient adverse effects include pain on injection, and intermittent swelling, edema, and erythema at the injection site.3 Injection-related adverse effects, namely, bruising, erythema, pruritis, and discoloration are

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B Figure 23-14 A, This 38-year-old patient presented for treatment of mid and lower facial furrows. B, After 2 ml of Restylane to the nasolabial folds, oral commissures, and perimental hollows.

A

B Figure 23-15 A, this patient presented for treatment of nasolabial folds and lower facial aging. B, After 2 ml of Restylane to the nasolabial fold, lips, and perimental hollows.

A

B Figure 23-16 A, This 40-year-old female presented for facial rejuvenation including treatment of deepening nasolabial folds and lower facial volume loss. B, She returned 4 months later, shown here, after receiving Botox to the periorbita and (a total of 1.6 mL) Juvederm Ultra to the nasolabial folds and oral commissures. As is typical, it was an appropriate time for retreatment with Botox yet she noted at that time that the nasolabial fold correction had persisted.

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body reaction.30 Granulomas often respond to injected corticosteroids, topical antihistamines, and digital pressure or manipulation.27

common, and delayed skin reactions (albeit rare) have been reported post-injection.26 Routine intramuscular or subperiosteal injections are not recommended for most regions, as much of the ﬁller will be absorbed. Likewise, injections into dynamic areas associated with a great amount of movement, such as around the mouth, may lead to less satisfactory results, as the motion will encourage absorption and displacement.27 Enhanced effects can be achieved in mobile areas such as the lips with the adjuvant use of botulinum toxin in sufﬁcient dosages to reduce movement yet maintain function.28 Residence time should also be considered when injecting in multiple planes as with most nonpermanent injectable agents, persistence is greater in the more superﬁcial layers of the dermis. If signiﬁcant amounts of product are injected in the superﬁcial dermis, the result may initially look quite satisfactory and this phenomenon may not be evident until the deeper product dissipates25 (Fig. 23-17). Recent publications have documented intermittent swelling and granulomatous reactions,27,29 and the use of impure or contaminated material can result in infection or foreign

Calcium hydroxylapatite beads Radiesse (formerly Radiance) is an admixture of calcium hydroxylapatite beads in a carboxy-methylcellulose (CMC) vehicle (BioForm, Inc., Franksville, WI). It is now approved in the United States for the correction of moderate to severe facial folds and wrinkles around the nose and mouth, including nasolabial folds.31 Preliminary data suggest that with good technique and adequate volume of material that the persistence in most areas is of the order of magnitude of one year or greater.32 Once injected, the gel is absorbed; what remains is a matrix of material that will take on characteristics of the cells that populate it, requiring precise placement of the ﬁller in order for the permanent correction to occur. Since the collagen produced is native and the material injected is inert, the ﬁller formed has the potential to be stable and permanent. Skin

A

B

C

D Figure 23-17 This patient was thrilled with her initial injection of 2 ml Restylane to her deep nasolabial folds. (A) Before; (B) After. The injection technique utilized a multi-plane approach with serial threading to the deep dermis and also to the superﬁcial dermis for the ‘etched line’ component to the contour defect. (C) Before; (D) 5 months after injection you can see that the deep component has mostly dissipated, as expected, however there is persistence of the HA product in the superﬁcial layer. This must be considered with treatment.

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Figure 23-18 A, This 60-year-old male presented for improvement of the appearance of lower facial aging and was not interested in surgery at that time. B, Six months after lower facial soft tissue augmentation with Radiesse (total of 3 ml administered on one occasion) to cheek and peri-mental hollows, nasolabial folds, oral commissures and mental creases.

testing is not required prior to use. Similar to other particulate ﬁllers, this agent is less forgiving in areas of signiﬁcant mobility, such as the lips, and is best reserved for injectors who have had great experience with its use with excellent injection technique (Fig. 23-18). Complications There is little data on the potential complications of Radiance when used in cosmetic procedures. To date, there have been no reports of antibody formation or hypersensitivity. Bruising and swelling are common. Pain associated with the injection is mild and can be treated with acetaminophen in most cases. Complications that are the most troubling to patients are persistence of palpable areas in the skin and nodule formation. Nodule formation can relate to an over-abundance of products placed in one region, superﬁcial placement, and has also been implicated as a reaction to the carboxymethylcellulose. Placement in the mid- or superﬁcial dermis (especially in light- or thin-skinned patients) will result in visible material. Nodule formation that is mild and self-limited occurs in a small percentage of patients injected, and some of these patients will have nodules that require treatment with either intralesional steroids or incision and drainage.32–34

Injectable poly-L-lactic acid Sculptra (previously Nu-Fill; poly-L-lactic acid) has been used extensively in Europe especially for the treatment of facial volume loss as in patients with HIVassociated facial lipoatrophy. Due to its tremendous success in facial volume restoration in difﬁcult situations such as HIV, the applications were readily extended to facial volume loss due to a variety of causes and speciﬁcally, age-related. Sculptra was FDA ap-proved for use in HIV-related facial lipoatrophy in August, 2004. It has been used ‘off label’ in the US for aesthetic purposes

with good results in selected patients. The agent is provided in glass vials as a sterile lyophilized cake of microparticles of poly-L-lactic acid (PLLA, similar to the constitution of Vicryl suture) with the average particle size (diameter) of approximately 50 microns. Carboxymethylcellulose and mannitol are two of the non-active ingredients. Most injectors now reconstitute the material in 5–8 ml of sterile water. Saline suspension is not recommended, because changing osmolality might interfere with the solution’s characteristics and hence the performance of PLLA. Biodegradation is by hydrolysis of the material to lactic acid monomers that are then metabolized via normal lactate metabolism. Injection techniques vary; however the premise is to disperse the suspension in the plane of the deep dermis/subcutaneous space by serial threading or fanning to actually deposit the material diffusely into the region to be affected. The attempt is not to achieve full correction with a single treatment, rather to cause a reaction which yields collagen production at the deep dermal layer. This actually increases dermal thickness while enhancing the appearance of regional volume. The immediate effect is simply mechanical, and related to the volume of ﬂuid injected. The action is in the delayed effect that suggests the formation of new collagen despite the resorption of the PLLA particles. Most regions require two to three treatment sessions, spaced approximately one month (or greater) apart. Local anesthetic is not universally used; however some injectors prefer to give regional blocks while others use a small volume of anesthetic in the injectant itself. For aesthetic uses, after a series of treatments that vary in volume and in number, the results appear to last in the order of magnitude of at least one year35,36 (Figs 23-19 & 23-20). Late granuloma formation is now seen less than the prior European experience, as a more dilute suspension appears to be more forgiving, whereas an attempt to ‘overcorrect’ and/or use a higher concentration in pre-

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Figure 23-19 A, This 75-year-old female presented with complaints of hollowness in her cheeks that she felt added to her aged appearance. She has had a myriad of treatments (surgery, lasers, injectables, etc.) for facial aesthetic enhancement over the years and was looking for a solution to her complaint and was unwilling to undergo autologous fat injections. B, Six months after her ﬁnal of 3 treatments of Sculptra (1/2 vial to each cheek) administered 6 weeks apart.

vious years is believed be a leading cause for this complication.

Permanent, non-biodegradable ﬁllers Polymethylmethacrylate (PMMA) microspheres Arteﬁll (previously Artecoll; Artes Medical Inc., San Diego, CA) is a suspension of 50 micron uniform, polished, polymethylmethacrylate (PMMA) microspheres in 3.5 percent bovine collagen solution. After implantation, the collagen vehicle eventually dissipates, leaving behind the non-biodegradable PMMA microspheres.37–39 Although the volume injected depends on the depth and size of the wrinkle, usually at least two injection sessions are required. Since the product is permanent, it is important to select patients carefully and treat cautiously. Partial correction, followed by reinjection after a few months, will produce a smoother, more natural appearance than overcorrection. Applied by a skilled clinician, Artecoll is a powerful and effective ﬁlling agent that yields excellent results and may not require repeated touch-up treatments (Fig. 23-21). However, its permanence demands that great care be taken in choosing the appropriate patients who are comfortable with the risks associated with permanent facial augmentation. Disadvantages to the current formula is that due to the bovine collagen carrier, a skin test is still required. Complications Injections are not recommended for areas of thin skin (e.g. lower eyelid) and with lip augmentation, or in any

other areas of repetitive movement. Injudicious use of this agent may result in beading, palpability, and visibility of the implant. Artecoll facial injections have been reported to cause the delayed development of granulomatous reactions,40,41 and improper placement intradermally (rather than into the upper levels of the subdermis) or too aggressive injections can lead to beading, ridging, and nodule formation. This can cause disﬁgurement reversible only by surgical excision.27 Conservative amounts of Artecoll and a long interval between injections are recommended.42 Even with a conservative approach, granulomas can appear long after treatment. Fortunately with proper patient/region selection combined with good technique the incidence is low, and responds well to intralesional triamcinolone injections.27,41,43 Bovine collagen allergy has also been reported with the use of this product. As with most products, Arteﬁll has evolved with a variety of product improvements that with careful patient selection and good injection technique can achieve satisfactory long-term results.

Acrylic hydrogel DermaLive and DermaDeep (Euromedical Systems, Ltd., Nottingham, UK) are semi-permanent soft-tissue ﬁller substances composed of acrylic hydrogel in a hyaluronic acid vehicle. After injection, the hyaluronic acid component is resorbed, while the nonbiodegradable acrylic hydrogel particles are left behind and induce a tissue response to yield long-lasting results of at least 12 months.44,45 DermaLive consists of smaller acrylic hydrogel particles and is injected less deeply into the tissue to ﬁll medium to deep skin depressions, such as the nasolabial folds, glabellar lines, marionette

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B Figure 23-21 A, This 51-year-old female presented for treatment of deep nasolabial folds, oral commissures, and lip rhytids. B, After serial treatments with Artecoll. Photographs courtesy of Alastair Carruthers, MD.

C Figure 23-20 Sculptra: A, Before; B, After 3 months; C, After 6 months.

lines, and facial scars; with its larger acrylic hydrogel particles, DermaDeep is reserved for pronounced tissue defects, such as deep nasolabial folds and sunken cheeks. Because of its longer duration of effect, DermaLive/DermaDeep may be an acceptable alternative to hyaluronic acid or collagen in the carefully selected patient. Our experience with this product (JC, AC) is limited. More than one injection of Derma-Live/ DermaDeep is often needed, with a maximum of three

or four sessions spaced at least 3 months apart. Marketed in Europe primarily for long-term correction of facial lines and creating volume since 1998, Derma-Live/DermaDeep is currently not approved for cosmetic use in the United States. DermaLive/DermaDeep should not be implanted in the mucosal part of the lips, the periorbital zone, horizontal lines across the forehead, or in vertical wrinkles on the upper lip. Contraindications include a history of hypertrophic scarring, immunotherapy, autoimmune or inﬂammatory diseases, multiple allergies, and (rarely) known allergy to sodium hyaluronate or hyaluronic acid. Since DermaLive/DermaDeep has no elements of animal origin and is generally non-allergenic, skin testing is not required.

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Injectable Agents for Dermal Soft-Tissue Augmentation of the Face: Options and Decision Making Complications Short-term side effects include pain on injection, itching, discoloration, tenderness, palpable lumpiness, redness, and edema, most of which resolve within 1–2 days or, in the case of lip injections, a week. The majority of complications seen with DermaLive/DermaDeep are considered due to improper injection techniques or use in the presence of contraindications.44 Long-term side effects include nodules, swelling or redness at the point of injection appearing an average of 6 months after injection. Serious complications, such as granuloma, superﬁcial necrosis, and urticaria, are generally reported to be rare, although a few reports have suggested a much greater A incidence of granuloma formation in a larger series of patients with longer (greater than 2 years) follow-up.27 At the ﬁrst sign of a nodule or other complication, a series of corticosteroid injections with an interval of 1–3 weeks between each is usually effective. Surgical excision is a last resort and rarely necessary.

Silicone oil Although injections of silicone oil are not approved by the FDA for cosmetic use (the approved indication is for its use in the repair of retinal detachments), their off-label use as a permanent soft-tissue ﬁller for facial rejuvenation persists, despite the history of contro- B versy. Injected through a special 30-gauge needle (RJ Figure 23-22 A, Pre-silicone. B, Post-silicone. MaxFlo, Richard James Inc, Boston, MA) in microdroPhotographs courtesy of Drs Alastair and Jean Carruthers. plets of 0.01 ml into the subdermis, each microdroplet induces its own ﬁbroblastic response.13 Since ﬁbrous capsules form around each silicone particle over several which dips and sags due to a host of factors19 including weeks, conservative injections with follow-up correcanimation, environmental and hereditable factors, and tions 6 weeks apart are recommended to achieve adevolume loss.2,9,15 Recent research and clinical experiquate augmentation. This microdroplet serial puncture ence has supported the hypothesis that this sagging is technique is believed responsible for dramatically caused not by gravity, as long believed, but by the lowering the risks previously associated with liquid 45 atrophy of subcutaneous fat, suggesting that a redissilicone. Silicone oil is used most commonly in tribution of fat or volume replacement may restore the perioral region (Fig. 23-22). vitality (see Chapter 2).18,19,21,49,50 With atrophy of subcutaneous soft-tissues, unsupported skin falls into Complications wrinkles and folds, and often exaggerates the illusion Minor adverse reactions are similar to those seen with of true soft tissue descent, which traditionally necessiother injectable augmenting agents, including pain upon tated the surgical ‘lift’. Loss of volume, particularly 45 injection, edema, and discoloration. Although some around the eyes and cheeks, cannot always be adebelieve complications of silicone oil to be largely due to quately improved or corrected by traditional surgical improper injection technique or the quality of the siliprocedures, which carry a variety of potential compli46 cone, reported complications include inﬂammation, cations.51 A number of techniques aimed at restoring 47 discoloration, ulceration, migration, and granulomas. lost fat volume through the use of ﬁllers have demonMore disconcertingly, there are reported complications strated that replacing volume to youthful proportions 48 arising as long as 20 years after injection. can restore the harmonious aesthetic of the face. Our early experiences with ‘ﬁllers’ (primarily ‘collagen’) for the most part limited our application of these products Fillers: aesthetic facial applications to line reduction. With the establishment of the next A youthful face is associated with smooth, even distrigeneration of ‘off the shelf’ ﬁllers that were useful for bution of ample fat, in sharp contrast to the aging face, both line eradication and volume replacement, our

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ability to restore facial volume in an outpatient/ consulting room setting has escalated to dramatic proportions. Fillers that have the capacity to enhance and restore volume can improve the appearance of brow, cheek and lower facial ptosis in selected patients.

Non-invasive ‘lifts’ Traditional surgical procedures in facial rejuvenation focus on identifying and correcting the signs of A aging by tightening and lifting the soft tissue, with the underlying concept of gravitational aging in the brow and midface. However, there are a variety of complications associated with forehead and brow-lifting procedures, as with any surgery.51 In addition, in many the results can be either unsatisfactory or not longlasting. Alternatively, volume replacement with ﬁllers in the brow and midface subtly restores the face to a more youthful aesthetic, and is particularly useful in those individuals who either are not quite ready for surgery, or already have embarked upon the surgical journey. B

Temporal brow lift

Figure 23-23 A, This patient presented after being unhappy with the ‘hollow’ appearance after upper and lower blepharoplasty performed elsewhere. B, 2 ml of Restylane was injected to the lower tear trough and bony lower periorbital prominences and the lateral infrabrow region for a ‘brow lift’ effect.

While brow ptosis has traditionally been approached via a surgical solution, experience has shown that a purely surgical lift cannot restore the same youthful appearance to the anterior projection of the lateral brow. Adequate pain management can be achieved either by anesthetizing the skin with topical ElaMax 5 percent or Betacaine ointment, or direct inﬁltrative anesthesia. For the ﬁrst treatment, Restylane, Juvederm, and Hylaform Plus are ideal ﬁller products; alternately, Artecoll may be used in patients with previous experience with a biodegradeable ﬁller and a negative skin test. Using a marking pen to delineate the area to be treated, the product is injected using the ‘push-ahead’ technique (allowing the ﬁlling agent to A dissect ahead of the needle) through a 30-gauge needle. The initial injection is placed at the temporal end of the lateral brow cilia (injection volume of approximately 0.2 cc), followed by a reinjection 7–10+ mm medial to the ﬁrst at the lateral aspect of the supraorbital notch (injection volume is 0.1–0.2 cc). After injection, the ﬁller is molded gently to form the natural projection previously created by the brow fat pad, and B ice is applied. An instantaneous lateral brow lift effect Figure 23-24 ‘Brow lift’ effect with hyaluronic acid. is observed (Figs 23-23, 23-24).

Photographs courtesy of Drs Alastair and Jean Carruthers.

‘Tear trough deformity’ The causes of volume loss and skeletonization of the medial lower periorbita are multifold. This can be

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observed with overzealous fat excision after lower blepharoplasty, but is more commonly seen with age (in those who have never had surgery) and relates to soft tissue (fat) atrophy, skin-thinning, a mild degree of soft tissue descent and even fat herniation cephalad to this region. As the process is complex, simple monotherapy solutions, including soft tissue augmentation via injection, have been tried with varying success. The problems relating to injectables in this region is that the atrophy and thinning is unforgiving to the inevitable visibility of these products (Fig. 23-25). Nonetheless, with careful application using a variety of these agents in the appropriately selected patients, pleasing results and improvement can be achieved (see DVD). Treatment is best directed in a deeper, supraperiosteal plane to reduce visibility of the product bolus. The most forgiving are the hyaluronates; with this application, due to the common atrophy of the local soft tissue and thinning of the skin, a conservative application will yield subtle aesthetic improvement while lumpiness can be minimized (Fig. 23-26). The collagens are too rapidly

resorbed to enhance the low risk/reward ratio. Arteﬁll has shown satisfactory results with precision application and proceeding with utmost caution and conservatism. Fat can also gives good effects, but due to the variable resorption, yields surface contour irregularities even with experienced injectors (see pp. 283–284). Local anesthetic with epinephrine may be required for comfort and to minimize the inevitable bruising with injection to this highly vascular area. Deep plane injection bypassing the needle to periosteum will avoid intravascular injection in almost all situations (see DVD).

Midface ‘lift’ Hypoplasia of the zygoma or midface fat descent and atrophy robs the female face of the normal heartshaped contour. Using a marking pen, the treatment area is demarcated. An evaluation to detect for facial asymmetry may indicate an individualized treatment on each side of the same individual to maximize results.

A A

B Figure 23-25 A, This patient had multiple lower blepharoplasty procedures performed elsewhere and presents for unhappiness with the ‘hollow’ appearance of the lower eyelid region. B, 1 month after Restylane was injected to the lower periorbita via serial puncture applied supra-periosteal at the orbital rim using 0.4 ml per side.

B Figure 23-26 A, This young male presented with ‘a hollow appearance’ after undergoing lower transconjunctival fat removal performed elsewhere. B, 0.5 ml of Restylane was injected to the lower periorbita and ‘tear trough.’ This result lasted over 6 months.

Fillers: aesthetic facial applications Local or topical anesthetic is optional. Restylane, Juvederm, Hylaform Plus, and Perlane all work well in this region. Artecoll and Radiesse also work well, but clinicians should take care to inject a smaller volume and follow-up with a ‘touch-up’ treatment in approximately 8 weeks. After the chosen ﬁller has been injected into the subdermal space in each treatment site, the patient can immediately inspect the aesthetic beneﬁt (Fig. 23-27).

Lip augmentation The use of soft-tissue augmentation agents to enhance the lips and improve the shape of the mouth is extremely popular in both younger and older patients, since lip procedures can be performed during a short visit

A

B Figure 23-27 A, This patient presented for midfacial aging. B, After Restylane injections to the midfacial hollows and nasolabial folds. Photographs courtesy of Drs Alastair and Jean Carruthers.

(usually less than an hour). In addition, recovery time is minimal, and side effects and complications are rare and generally transient. The lips and mouth are associated with sensuality, and procedures to enhance the fullness of the lips often impart a dramatic improvement to the overall appearance of the face. In patients seeking a more temporary augmentation of the lips, we use Zyderm 1, the least viscous of the bovine collagen injectables, for preliminary injections in the lips to deﬁne the area of treatment and to create a channel for subsequent Zyplast injection. We start in the outer corner and work our way across the length of each lip, just inside the vermilion border, with a total of ﬁve to six injections per lip and 1 cc of Zyderm 1. The lips should be gently massaged after injection to ensure that the ﬁller is evenly distributed. Once Zyderm 1 has been injected, we may implant Zyplast in the channel formed by the Zyderm 1 injections beginning at the corner of the mouth and placing the injections at even intervals across the lips inside the vermilion border. Massage follows to break up any irregularities and to establish a smooth texture and appearance. Zyplast is then injected precisely along the vermilion border in the upper lip and directly into the upper lip just above the corners of the mouth, enhancing lip border deﬁnition, producing an aesthetically pleasing ‘ski-jump’ proﬁle to the lips, and creating a slight upturn to the corners of the mouth (Fig. 23-2). The injection technique used with hyaluronans is similar to that used for collagen, with injections placed along the length of the lips within the vermilion border. We use Hylaform Plus, Perlane, and Reviderm for their extended duration of effect and effectiveness in imparting dramatic improvement to the shape and texture of the lips. Restylane, Juvederm or Hylaform Fineline injected more superﬁcially along the vermilion border will create a line of ﬁrmness that will deﬁne the lip border and resist wrinkling. Juvederm and Restylane products are also superb for treating lip volume by direct injection into orbicularis and enhancing persistence by injecting low-dose Botox to the vermilion border (see Chapter 24) (Figs 23-28, 23-29). In February 2003, the FDA recommended avoiding Artecoll for perioral injections due to reports of lumpiness. However, injection into the lips is possible, with some precautions. Ideally the orbicularis oris should be relaxed with botulinum toxin prior to injection to prevent ﬁller migration and aggregation with movement of the lips. Since Artecoll is permanent, it is important to avoid overcorrection; instead, it is more prudent to use smaller volumes and assess the result before augmenting further. In addition, cautious and gradual treatment results in the most natural and pleasing effect. After injection, massage the lip gently and apply pressure to any perceptible lumps to ensure

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A A

B B Figure 23-28 A, This young female desired lip augmentation. B, After 1 ml of Restylane to upper and lower lips. This result lasted 4 months.

proper distribution of the ﬁller. However, too-vigorous massage can cause diffusion, diminishing the effect of the product. A settling period occurs after treatment, as the collagen in Artecoll dissipates and is replaced by the body’s own collagen. To minimize the changes in appearance that take place during this period, we have found that the adjunctive use of a hyaluronan, placed more superﬁcially, overlaying the Artecoll, produces an immediate cosmetic result (Fig. 23-30). Radiance should also be used with great caution for lip augmentation, as the constant motion of the mouth tends to cause migration of the ﬁller. Additional potential problems include lumps and bumps that can occur in this area with frequency. Lip augmentation with Radiance should be done gradually and with caution, and prior clinician and patient experience with other ﬁllers is imperative. To increase lip volume or deﬁnition, a serial puncture technique is recommended, with small injections (0.01 cc) used to deposit material along

Figure 23-29 A, This 35-year-old female presented for lip augmentation and aesthetic enhancement of her perioral region noting mostly that her lip size had seemed to diminish more recently. B, After 1.6 ml (total) of Juvederm Ultra to the lip and oral commissures.

the vermillion border above the orbicularis and in the dermal–subcutaneous junction. Most patients will require no more than 0.5 cc of Radiance to treat both the upper and lower lips. Unlike other ﬁllers, Radiance does not require overcorrection.

Chin ‘implant’ augmentation After photographing the face in primary position, as well as right and left lateral gaze, we inject the ﬁller (typically, 0.2–0.4 cc) subdermally into the region superior to the mentum, producing a fuller chin that projects forward to line up with the lower lip when the face is in the Frankfort horizontal (Fig. 23-31).

Peri-mental hollows The signs of lower facial aging are commonly associated with ‘jowling’ along with the appearance of

Fillers: aesthetic facial applications 297

A A

B Figure 23-30 A, This patient presented for a ‘permanent’ lip augmentation. B, After Artecol injection to the upper and lower lips. Photographs courtesy of Drs Alastair and Jean Carruthers.

A

B Figure 23-31 A, This patient presented with a signiﬁcant depression along the central chin region and lower facial aging. B, After 2 ml of Restylane to mentum, upper and lower lips and perimental hollows.

B Figure 23-32 A, This elderly patient presented for improvement of lower facial aging and was not a candidate for a surgical facelift. B, After 3 ml of Restylane to oral commissures, and perimental hollows.

depressions or ‘hollows’ lateral to the chin (mentum) (Figs 23-32 & 23-33).The partial illusion of descent posterior to this depression is caused and exaggerated by the magnitude of this depression related to volume loss caused by life-long mobility of the lower lip/facial depressors (i.e. depressor anguli oris, etc.). In selected

individuals improvement of this appearance can be afforded by applying injectable soft tissue augmentation agents along the jaw line overlying this depression. Agents commonly used are those that have more capacity for volume ﬁlling including the hyaluronics, Radiesse, and fat (see DVD).

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A

B Figure 23-33 A, This patient presented for facial rejuvenation. B, after Botox injections to the upper face and Restylane injections to the lips, nasolabial folds, and perimental hollows. Botox was also injected to the lip vermilion and the depressor anguli oris muscle on each side. See Chapter 24.

Combination therapy: botulinum toxin and ﬁllers The combination of botulinum toxin type A (BTX-A; BOTOX, BOTOX Cosmetic; Allergan Inc., Irvine, CA) and soft-tissue augmentation is a highly synergistic approach used routinely to achieve more effective, longer lasting results, especially in the mid- and lower face, by simultaneously treating static and dynamic aspects of rhytids. Early anecdotal reports28,52,53 corroborated with clinical study54 found that BTX-A in patients undergoing soft-tissue augmentation in certain facial areas (i.e. deep glabellar furrows or lip augmentation) eliminated or reduced the muscular activity responsible for the wrinkles and increased the longevity of the ﬁlling agent.28,54 Preceding the injection of ﬁlling agents by approximately 1 week, BTX-A may work on several levels, reducing the dynamic component of rhytid formation in newly remodeled skin and allowing more permanent eradication of wrinkles23,24,52 (Figs 23-28 to 23-33). For practical pur-

poses, most combination therapy is given at the same ofﬁce visit. Several studies have also documented the synergistic effect of adjunctive BTX-A and ﬁllers.55 In a study evaluating 65 patients with moderate-to-severe glabellar rhytids who received BTX-A, Zyderm II collagen, or a combination of both therapies55: after 1 month, patients who received combination therapy showed signiﬁcantly greater improvement in furrows (79% vs. 56% and 50% in the BTX-A and Zyderm arms, respectively; p < 0.05). In addition, clinical effects were longer in duration and patient satisfaction higher in patients who received both BTX-A and collagen (Figs 23-34, 23-35). Likewise, in another study, patients with moderate-to-severe glabellar rhytids injected with both BTX-A and hylan B responded better than those treated with BTX-A alone.23 After injection of combination therapy, 6 percent had only moderate rhytids, while the rest (94%) had mild rhytids; of patients who received BTX-A alone, none (0%) had achieved no or mild rhytids. In a prospective, randomized study of 38 patients with moderate-to-severe glabellar rhytids,

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A

B Figure 23-34 A, This patient presented after unsatisfactory resolution of glabellar and forehead furrows with Botox alone performed elsewhere. B, After CosmoDerm injections to the glabella and forehead furrows combined with Botox to these regions. See Chapter 24.

B

A

Figure 23-35 A, Before and B, after a combination of CosmoDerm and BTX to the glabella and forehead.

BTX-A plus NASHA (Restylane) led to a better response both at rest and on maximum frown than NASHA alone.24 In addition, combination therapy led to a longer duration of response: the median time for return to preinjection furrow status occurred at 18 weeks in the NASHA alone or BTX-A alone groups,

compared to 32 weeks in patients treated with BTX-A plus NASHA. Combinations therapy is also advantageous in all other areas where BTX-A can be applied safely and effectively, such as the lips and perimental hollows,28,52,53 forehead and chin (Figs 23-32, 23-33, 23-36).

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B

A

Figure 23-36 A, This patient presented for upper and lower facial rejuvenation. She had undergone upper/lower blepharoplasty and face lift 10 years prior performed elsewhere. B, After secondary upper and lower blepharoplasty with ptosis repair, Botox to the periorbita and Restylane to the nasolabial folds, lips, and perimental hollows.

Conclusion The recent surge in available injectables has shifted the focus of rejuvenation from traditional surgical procedures to those that are more convenient and associated with fewer complications and little or no downtime. Soft-tissue ﬁller injections can be performed using only topical or local anesthetic agents and, in marked contrast to surgical procedures, give an instant result with no downtime. In addition to their beneﬁts in correcting rhytids and folds, ﬁllers can be used to restore fullness that is naturally lost as fat diminishes from the face with aging, creating a more harmonious and aesthetically pleasing appearance. Although the more traditional ﬁllers are still used widely, newer agents – particularly hyaluronic acid and particulate microspheres – have gained popularity and achieved wider accessibility, their space-occupying properties used to replace lost subdermal fat and provide brow or midface lifts almost instantly enhancing the projection and proﬁle of the injected area. Unlike traditional surgical procedures, soft-tissue augmentation addresses the increasing demand for less invasive treatments and may prove to be the ideal rejuvenation agents, producing a more natural and youthful countenance.

References 1. Knapp TR, Kaplan EN, Daniels JR: Injectable collagen for soft tissue augmentation. Plast Reconstr Surg 1977; 60;398–405. 2. Fagien S: Facial soft tissue augmentation with injectable autologous and allogeneic human tissue collagen matrix (Autologen and Dermalogen). Plast Reconst Surg 2000; 105:362. 3. Jordan DR: Soft-tissue ﬁllers for wrinkles, folds and volume augmentation. Can J Ophthamol 2003; 38:285–288. 4. INAMED Esthetics. URL: www.inamed.com (accessed August 2004). 5. Klein AW: In favor of double testing. J Dermatol Surg Oncol 1988; 14(Suppl. 1):27. 6. 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. Philadelphia, WB Saunders, 1993. 7. Fagien S: Autologous collagen injections to treat deep glabellar furrows. Letter to the Editor. Plastic Reconst Surg 1994; 93:642. 8. Fagien S: Facial soft tissue augmentation with autologous and homologous injectable collagen (Autologen and Dermalogen). In Klein AW (ed): Tissue Augmentation in Clinical Practice, Procedures and Techniques, pp 87–124. New York, Marcel Dekker, 1998. 9. Fagien S: Facial soft tissue augmentation with autologous injectable collagen. In Putterman AM (ed): Cosmetic

References Oculoplastic Surgery: Eyelid, Forehead, and Facial Techniques, Third Edition, Chapter 32, pp 367–375. Philadelphia, WB Saunders, 1998. 10. Fagien S, Elson ML: Facial soft tissue augmentation with allogeneic human tissue collagen matrix (Dermalogen and Dermaplant). In Matarasso A, Matarasso SL (eds): Clinics in Plastic Surgery, pp 63–81. Philadelphia, WB Saunders, 2000. 11. Monstrey SJ, Pitaru S, Hamdi M et al: A two-stage phase I trial of EVOLENCE Collagen for soft tissue contour correction. Plast Reconstr Surg 2007; 120:303–311. 12. Neuber G: Fettransplantation. Bericht uber die Verhandlungen der Dt Ges f Chir Zentralblatt fur Chirurgie 1893; 22:66. 13. Cheng JT, Perkins SW, Hamilton MM: Collagen and injectable ﬁllers. Otolaryngol Clin North Am 2002; 35:73–85. 14. Kanchwala SK, Bucky LP: Facial fat grafting: The search for predictable results. Facial Plast Surg 2003; 19:137–144. 15. Coleman SR: Facial recontouring with lipostructure. Clin Plast Surg 1997; 24:347–367. 16. Amar RE: [Adipocyte microinﬁltration in the face or tissue restructuration with fat tissue graft]. Ann Chir Plast Esthet 1999; 44:593–608. 17. Butterwick KJ, Lack EA: Facial volume restoration with the fat autograft muscle injection technique. Dermatol Surg 2003; 29:1019–1026. 18a. Donofrio LM: Fat distribution: A morphologic study of the aging face. Dermatol Surg 2000; 26:1107–1112. 18b. Donofrio LM: Structural autologous lipoaugmentation: A pan-facial technique. Dermatol Surg 2000; 26:1129–1134. 19. Donofrio LM: Fat rebalancing: The new ‘facelift.’ Skin Therapy Lett 2002; 7:7–9. 20. Chajchir A, Benzaquen I: Fat-grafting injections for soft tissue augmentation. Plast Reconstr Surg 1989; 84:921. 21. Coleman SR: Long-term survival of fat transplants: Controlled demonstrations. Aesthet Plast Surg 1995; 19:421. 22. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, Smith S: A randomized, double-blind, multicenter comparison of the efﬁcacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg 2003; 29:588–595. 23. Carruthers J, Carruthers A, Maberley D: Deep resting glabellar rhytids respond to BTX-A and Hylan B. Dermatol Surg 2003; 29:539–544. 24. Carruthers J, Carruthers A: A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytids in adult female subjects: Treatment of severe glabellar rhytids with a hyaluronic acid derivative compared with the derivative BTX-A. Dermatol Surg 2003; 29:802–809. 25. Fagien, S: Injection and anesthetic techniques with Restylane. Focus on ﬁllers. Inaugural Meeting of the International Filler Board and Faculty Training. The Brown Palace Hotel, Denver, Colorado, July 13, 2003. 26. Lowe NJ, Maxwell CA, Lowe P, Duick MG, Shah K: Hyaluronic acid skin ﬁllers: Adverse reactions and skin testing. J Am Acad Dermatol 2001; 45:930–933. 27. Saylan Z: Facial ﬁllers and their complications. Aesthetic Surg J 2003; 23:221–224. 28. Fagien S: Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: Adjunctive use in

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facial aesthetic surgery. Plast Reconstr Surg 2003; 112:40S–52S. Hoenig JF, Brink U, Korabiowska M: Severe granulomatous allergic tissue reaction after hyaluronic acid injection in the treatment of facial lines and its surgical correction. J Craniofac Surg 2003; 14:197–200. Toy BR, Frank PJ: Outbreak of Mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg 2003; 29:971–973. Sklar JA, White SM, Radiance FN: A new soft tissue ﬁller. Dermatol Surg 2004; 30:764–768. Jansen D, Graivier M: Soft tissue substitutes in perioral augmentation. Semin Plast Surg 2003; 17:181–197. Gladstone HB, Morganroth GS: Evaluating calcium hydroxylapatite for facial augmentation. Presented at the Annual American Society for Dermatologic Surgery Meeting, New Orleans, LA, 2003. McGrath MH, Nahai F, Airan L, Born T, Cohen SR, Coleman SR, Fagien S, Graivier M: Tissue ﬁllers in plastic surgery. Roundtables in Plastic Surgery; Part II. Roundtable Discussion with the Experts. St. Louis, MO, Quality Medical Publishing, 2004. Vleggaar D, Bauer U: Facial enhancement and the European experience with Sculptra (poly-L-lactic acid). J Drugs Dermatol 2004; 3:542–547. Moyle GJ, Lysakova L, Brown S, et al: A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection. HIV Med 2004; 5:82–87. Lemperle G, Gauthier-Hazan N, Lemperle M: PMMA microspheres (Artecoll) for long lasting correction of wrinkles: Reﬁnements and statistical results. Aesthetic Plast Surg 1998; 22:365. 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 2004; 114:964. 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. Alcalay J, Alkalay R, Gat A, Yorav S: Late-onset granulomatous reaction to Artecoll. Dermatol Surg 2003; 29:859–862. Lemperle G, Morhenn V, Charrier U: Human histology and persistence of various ﬁller substances for soft tissue augmentation. Aesthetic Plast Surg 2003; 27:354. Pollack S: Some new injectable dermal ﬁller materials: Hylaform, Restylane, and Artecoll. J Cutan Med Surg 1999; 3(Suppl 4):S27–S35. Lemperle G, Gauthier-Hazan N, Lemperle M: PMMAmicrospheres (Artecoll) for long-lasting correction of wrinkles: Reﬁnements and statistical results. Aesthetic Plast Surg 1998; 22:356–365. Bergeret-Galley C, Latouche X, Illouz Y-G: The value of a new ﬁller material in corrective and cosmetic surgery: DermaLive and DermaDeep. Aesthetic Plast Surg 2001; 25:249–255. Brown LH, Frank PJ: What’s new in ﬁllers? J Drugs Dermatol 2003; 2:250–253. Clark D, Hanke W, Swanson N: Dermal implants: Safety of products injected for soft tissue augmentation. J Am Acad Dermatol 1989; 21:992–998.

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Injectable Agents for Dermal Soft-Tissue Augmentation of the Face: Options and Decision Making 47. Spira M, Rosen T: Injectable soft tissue substitutes. Clin Plast Surg 1993; 20:181–188. 48. Rappaport MJ, Vinnik C, Zarem H: Injectable silicone: Cause of facial nodules, cellulites, ulceration and migration. Aesth Plast Surg 1996; 20:267–276. 49. Berman M: Rejuvenation of the upper eyelid complex with autologous fat transplantation. Dermatol Surg 2000; 26:1113–1116. 50. Lambros V: Facial aging. Presentation at the annual meeting of the American Society of Aesthetic Plastic Surgeons, April 30, 2005. 51. Tardy ME, Alex J, Hendrick D: Rejuvenation of the aging brow and forehead. In Putterman AM, Warren LA, Lampert R (eds): Cosmetic Oculoplastic Surgery: Eyelid,

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Forehead, and Facial Techniques. Philadelphia, WB Saunders, 1999. Fagien S, Brandt FS: Primary and adjunctive use of botox in facial aesthetic surgery: Beyond the glabella. In Matarasso A, Matarasso SL (eds): Clinics in Plastic Surgery, pp 127–148. Philadelphia, WB Saunders, 2000. Fagien S: Extended use of botulinum toxin A in facial aesthetic surgery. Aesthet Surg J May/June; 1998; 18:215–219. Carruthers J, Carruthers A: The adjunctive usage of botulinum toxin. Dermatol Surg 1998; 24;1244–1247. Patel MP, Talmor M, Nolan WB: Botox and collagen for glabellar furrows: Advantages of combination therapy. Ann Plast Surg 2004; 52:442–447.

uded on DVD

CHAPTER 24

Expanded Uses of BTX-A for Facial Aesthetic Enhancement Steven Fagien, Alastair Carruthers and Jean Carruthers First described in the medical literature in 1992,1 the cosmetic use of botulinum toxin (BTX) has widened to include many previously inconceivable applications. Prior to this discovery, clinical experience with the use of the toxin was primarily limited to an option for the treatment of strabismus and a variety of disorders of chronically increased skeletal muscle tone2 (Fig. 24-1). The application of the toxin for aesthetic improvement was derived from keen observation of the appearance of facial soft tissue in patients who received the drug for a spectrum of disorders related to facial dystonia (Fig. 24-2). The toxin has become not only the gold standard in non-surgical facial rejuvenation, for eradicating dynamic rhytides in the forehead, glabella, around the eyes, and in the lower face and neck, but it has also become a viable alternative, as well as partner to surgery, for facial shaping and contouring.3,4 With essentially no downtime and few complications or adverse effects, the application of BTX in the environment of a comfortable clinical setting, represents the most modern form of cosmetic enhancement that is timesensitive, safe, and effective (Fig. 24-3). Steven Fagien, Alastair Carruthers and Jean Carruthers

Although the primary mechanism of action of BTX is known to be a result of a temporary focal chemodenervation of the target muscle(s) with reduction or elimination of muscular tone to produce the aesthetic desired effect (facial line or shape improvement), the exact mechanism is not so well understood. This also holds true for the processes that lead to eventual recovery and the possibilities for long-term improvement and other effects including recruitment. Moreover, other inﬂuences that might suggest longterm beneﬁt including ‘collagen remodeling’ and atrophy of the injected muscles are more complicated and variable. They are strongly inﬂuenced by the dosage given. In the ever-growing spectrum of uses in facial aesthetic enhancement, the effects are very predictable. Optimal results, however, are achieved only with the highest level of understanding of the causes of the variety of facial aging changes and facial muscular anatomy, precise injection technique, and appreciation of the aesthetic result desired by the subject.

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Treatment of the upper face and periorbita A number of clinicians, impressed by the toxin’s obvious beneﬁts and high level of safety, experimented with BTX for facial rejuvenation in the late 1980s, prior to the ﬁrst reports published in the early 1990s.5,6 Although it appears obvious now that cosmetic improvement can be easily afforded by precision application of this agent for dozens of applications, initial enthusiasm was quelled by a lesser understanding of the various causes of facial aging and the possibilities for the use of this drug. Initially used primarily for the treatment of glabellar rhytides, BTX is now a ﬁrst-line treatment for a number of cosmetic concerns, particularly in the upper face.7–21 To date, the three most common areas treated are the glabella, forehead, and lateral canthus for the treatment of rhytids in the respective regions. Treatment can be applied in various combinations to achieve the desired effect.

Figure 24-1 70-year-old female with benign essential blepharospasm.

A

B Figure 24-2 A, This patient developed ‘Bell’s palsy’ of her right face that had a long recovery several years prior. Facial nerve/function appeared to recover to a reasonable extent with relative symmetry in repose. B, With any movement of the mouth, however, the patient develops variable dyskinesis of the upper and lower eyelid orbicularis oculi, zygomaticus, and corrugator muscle resulting in right periorbital ‘spasm.’ This patient is a good candidate for low-dose botulinum toxin type A.

Treatment of the upper face and periorbita 305

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B Figure 24-3 A, This young female presented for improvement of her facial appearance. She was bothered by dynamic glabellar furrows (seen mostly with animation) and the new onset of ‘crow’s feet’ and horizontal furrows of her central forehead. B, After Botox treatment to the glabellar region, lateral canthus and high central forehead. Note the enhanced smoothness of these regions, minimal induction of brow ptosis, and retention of native features due to proper placement and dosing (discussed later).

Glabellar rhytides Historically, the ‘glabella’ was the area ﬁrst and most described as a potential treatment site with BTX for aesthetic enhancement. Currently (at the date of publication) it is still the only facial site with FDA approval for the cosmetic use of BTX, speciﬁcally Botox Cosmetic. All other areas for which the toxin is used for cosmetic enhancement are considered ‘off-label.’ This means that under the physician’s discretion it is lawful to apply the drug in other areas with, of course, the appropriate patient consent. The glabella is loosely deﬁned as the region depicted by the smooth elevation of the frontal region just above the bridge of the nose that extends laterally to each side onto and just above and lateral to the medial (head of) the eyebrow. The ‘glabellar complex’ often refers to a group of browassociated muscles (mostly depressors in action) that function primarily for facial expression (Fig. 24-4). Muscles of the glabellar complex include the corruga-

tor supercilii, procerus, depressor supercilii, and orbicularis oculi. Vertical glabellar frown lines arise naturally from the repeated activity of the corrugator supercilii and medial orbital orbicularis oculi muscles (plus depressor supercilii muscles) that not only induce vertical descent of the medial eye brow but cause adduction and depression of the surrounding soft tissue (Fig. 24-5). Horizontal lines at the proximal nasal bridge typically located at the most caudal aspect of the glabellar complex are a manifestation of the muscular activity of the procerus and depressor supercilii muscles (Fig. 24-6). In 1992, Carruthers et al injected 18 patients with BTX-A for the treatment of glabellar frown lines.1 Sixteen of 17 patients followed showed improvement for varying lengths of time with few side effects. This initial paper sparked a frenzy of interest across the globe. Following a number of publications, two randomized, placebo-controlled studies involving 537

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Procerus Corrugator supercili

Frontalis

Orbicularis oculi

A

Zygomaticus minor Zygomaticus major

Levator labii superioris Orbicularis oris

Platysma

B Figure 24-4 The greater understanding of the muscular facial anatomy facilitates a higher level of injection latitude and reduces complications.

patients conﬁrmed the impressive safety and efﬁcacy of the injection on the glabella. This led to the Food and Drug Administration (FDA) approval of BTX-A for the treatment of glabellar lines in 2002.22–24 This region has still been the most readily adopted area for the use of BTX for a variety of reasons mentioned previously, as well as a lack of consistent prior effective treatment options. Dosing The strength and size of the muscles of the glabellar complex varies signiﬁcantly from patient to patient. More importantly, despite similar anatomic components in most of us, a greater variable is the individual dynamics (i.e. the way we use our muscles). Although the most common treatment pattern utilizes two injections to each corrugator and one centrally to reduce procerus function (Fig. 24-7), individualizing treatment sites and doses to each patient will optimize clinical beneﬁts. In addition, the exact effect desired may vary as well. In women, recent studies also suggest that higher doses may be longer lasting and give greater aesthetic beneﬁt. A prospective, randomized, doseranging study of 80 women showed the greatest

Figure 24-5 A, Young female with deep glabellar frown line with animation on command. The frown pattern can vary signiﬁcantly in individuals. Demonstrated here are obvious deep vertical ‘frown’ lines that repeat laterally toward the central eyebrow as well as extend cephalad toward the hairline. B, Shown again here in animation after Botox treatment to the glabella region with 5 ‘standard’ injections, four units per injection site.

responses with the longest duration on glabellar lines with 30 and 40 U BTX-A, compared to the responses seen with only 10 or 20 U.25,26 Moreover, higher doses (20–40 U) produce an additional beneﬁt of eyebrow lift.27 The likely cause for this effect resides primarily in the fact that with higher doses to the glabella region, there is enhancement of diffusion to the adjacent frontalis muscle.28 With this phenomenon, attenuation of the central frontalis activity by BTX induces a secondary hyperdynamic contraction/recruitment of the untreated lateral and superior frontalis that yields this effect (Fig. 24-8). In addition, the desired effects will vary from individual to individual as well. For instance, some individuals might have a more elevated medial eyebrow and prefer a greater lateral arch (Fig. 24-9). Precise and isolated injection placement of toxin to the corrugators and secondary brow depressors (typically a more caudal placement of the injection at or about

Treatment of the upper face and periorbita 307

A A

B Figure 24-6 A, This patient exhibits the common ﬁnding of a combination of furrows relating to the brow depressors, speciﬁcally the corrugator supercilii and procerus muscles. The vertical furrows are primarily due to the actions of the corrugator muscles and the horizontal furrow at the bridge of the nose is mostly related to the depressor supracilii and procerus muscles. B, After treatment to the corrugator muscles, depressor supracilii and the procerus, there is a dramatic reduction in these furrows.

Figure 24-7 Standard sites for treatment to the glabellar region.

the brow cilia) could further elevate the medial eyebrow reducing any chance of enhancing the desired brow contour. In these individuals, a ‘high-glabellar’ technique (Fig. 24-10 and DVD) might be preferable. This will affect both the brow depressors and adjacent frontalis muscle, and will reduce the glabellar vertical

B Figure 24-8 This patient was treated with Botox to the glabella region only (4 units per site; 2 into each corrugator muscle and one to the central procerus muscle). No injections were given anywhere else. Note the brow position and arch with medial descent and lateral elevation.

frown lines as well as induce a varying degree of medial brow descent. This will also be inﬂuenced by additional injections (or not) to the more cephalad portions of the forehead and dose (discussed below) (Fig. 24-11). In general, men have a larger glabellar muscle mass compared with women. Studies comparing the efﬁcacy and safety of the ranges of 20 to 80 U of BTX-A in men suggest that patients injected with doses as high as 80 U achieved a ‘better’ response rate than those injected with lower doses, without experiencing an increase in adverse effects.29 This high level dosing produces enhanced efﬁcacy as well as persistence of effect which are not only required due to the greater muscle mass in males, but are also better suited to the male’s gender aesthetics and attitude. As in all treated areas, the most effective applications are delivered with precise injection techniques. The most effective format of application and technique to this region has generated healthy debate. As in

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B Figure 24-9 A, This patient presented for improvement of upper facial lines and shaping of her eyebrows. Note the elevated medial eyebrow position associated with more centrally located forehead furrows. B, Precise placement of toxin accomplishes both line reduction and eyebrow shaping.

A

B Figure 24-10 A, This patient exhibited minimal glabellar furrows but desired improvement of the upper face. B, After treatment to the lateral canthus and a ‘high glabella’ technique inducing medial brow height accentuating the arch of the eyebrow.

Treatment of the upper face and periorbita 309

Figure 24-12 Injection technique to the glabella region. The non-dominant hand is used to stabilize and elevate the eyebrow over the superior orbital rim. The thumb can be placed, as shown here, in the supraorbital notch, while the dominant hand injects toxin with precision.

A

B Figure 24-11 A, Patient with asymmetric brows who desires enhancement of symmetry and a more arching lateral eyebrow. B, After treatment with Botox with precise injection that improves the appearance of furrows yet also causes more of a medial brow depression and induces a lateral arch to the eyebrows left greater than right.

most facial regions, precision (i.e. targeting the recipient muscle with exactitude) will yield the most predictable responses. Understanding underlying facial muscle anatomy allows precision as to how much toxin is injected and where it is injected. The corrugator muscles lie deep to the insertion of the frontalis muscle in this region and just superﬁcial to the periosteum of the supraorbital rim. Superﬁcial injections (intradermal, subdermal/subcutaneous) will very likely equally (if not more) affect the frontalis muscle and will depend on diffusion to arrive at the corrugator muscles. Deeper injections (into the belly of this large muscle) will more accurately affect the corrugators in isolation. However, it should be mentioned that two of the authors (AC and JC) performed an objective study on 24 women with asymmetric medial eyebrows using an asymmetric

injection technique as described above. On objective photographs taken at rest (Canﬁeld system) there was no differential change in eyebrow height demonstrated. The techniques of one of the authors (SF) to this region is as follows (Fig. 24-12 and see DVD): The injector uses the non-dominant hand to stabilize the eyebrow between the thumb and foreﬁnger and can also easily distract the medial eyebrow above the orbital rim. At the same time the injector can place the thumb into the supraorbital notch to protect against toxin migration posteriorly into the orbit. The injecting hand then orients the syringe at 90 degrees to the skin surface and with a swift motion attempts placement of the needle tip into the mid-aspect of the muscle in two places (the lateral and medial components of the corrugators). This maneuver is then repeated on the opposite side. Care is also taken to avoid unnecessarily puncturing periosteum (as happened with techniques described in the past, which aimed to pass the needle to the periosteum, then withdraw slightly to the muscle) as this can be a cause of headache and post-injection pain, probably due to periosteal inﬂammation. Finally, this section would be incomplete if there were not a mention of our aesthetic goals that include what constitutes a satisfactory endpoint and outcome with effective dosing. Unfortunately, the concept of ‘immobility’ has become, in the mind of some consumers, synonymous with ‘effective’ treatment. Patients will return to your ofﬁce to display their ability to ‘frown’ with the most unusual and noble efforts that produce the vaguest glimmer of a vertical frown line (Fig. 24-13). As in most situations, educating your patients on what they should expect and what constitutes an aesthetic satisfactory result that might not include immobility will avoid

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A

Figure 24-14 Where is the muscle location that causes these furrows? At times furrows can be seen clearly beyond (cephalad) to the hairline, however the induction of these lines can be caused by the action of the frontalis far caudal to them. This is best detected by palpating the forehead while the patient animates and will lead to a better result with fewer injections and reduced eyebrow descent. B Figure 24-13 A, This patient presented for treatment of glabellar furrows. Shown here in animation on command. B, 3 weeks after treatment to the glabellar region, only she feels there is a ‘slight’ furrow (that no one else could see), with this dramatic voluntary attempt at frowning.

many phone calls and return visits and ultimately a happier and well-informed patient.

Horizontal forehead rhytides The frontalis is a large, quadrilateral muscle that originates in the galea aponeurotica. It inserts inferiorly into the procerus, orbicularis oculi, depressor supercilii muscles and anteriorly over the corrugator supercilii muscle, and terminates beneath the skin of the eyebrow. Although most ﬁgures (Fig. 24-4) depict the frontalis in two sections, it usually spans the forehead from one temporal fusion line to the other and may be thicker in certain portions of the forehead. The frontalis raises the eyebrows and skin over the root of the nose and also draws the scalp forward. Contraction of the frontalis primarily produces a series of horizontal forehead wrinkles and furrows. The most active portion of the frontalis muscle in most individuals is the 2 or 3 cm immediately above the brow. Activity in this portion produces horizontal rhytids that can appear as cephalad as the anterior hairline (Fig. 24-14). This ﬁnding is

important when deciding at what locations BTX will be injected for a particular individual. Also, the effects of inducing brow ptosis will be greater if the lower portion of the forehead is injected (Fig. 24-15). In many individuals, a single row of treatment sites in the midforehead is effective in reducing or eliminating rhytids while preserving brow position (Fig. 24-16). Finally, as with most areas of the face, individual unique habitual animation and the desired aesthetic effects will dictate where the drug is applied. The lateral extent of the forehead injection sites will be inﬂuenced by a combination of aesthetic desires and the functional anatomy. BTX-A injected across the forehead lessens undesirable horizontal forehead lines for a period of 4–6 months.30 Although treatment is individualized for each patient, in most individuals injections should be placed 2.5–3 cm above the brow proper to avoid brow ptosis or a lack of natural expressiveness. In general, narrow brows receive fewer injections and lower doses than broader higher brows. The exact site and dosage will depend on each individual presentation and the desired effects. Dosing As in the glabella, prior research suggested that higher doses of BTX-A may be more effective than lower doses in the forehead. A randomized, double-blind, dose-ranging study examined 60 women injected with either 16, 32, or 48 U BTX-A in eight sites and found

Treatment of the upper face and periorbita 311

A Figure 24-16 This is an example of a pattern of injection for an individual who presents for improvement of the appearance of mild to moderate horizontal forehead furrows. Note that although in many patients the frontalis muscle is two distinct (paired) quadrilateral muscles, the central injection allows for improvement either by diffusion to each side, or if the patient has a frontalis muscle that spans across the entire forehead region.

B Figure 24-15 A, This patient presented with desire for complete eradication of the horizontal forehead furrows that were accentuated with animation as shown here. Pan injection of the forehead with injections to the frontalis muscle within 2 cm of the eyebrow will induce signiﬁcant brow ptosis (as seen in B) that may be acceptable in some males however objectionable for many others. B, After treatment. This patient, like some, will demand treatment as such rather than demonstrate any signiﬁcant furrows with animation.

the greatest improvement and duration of response with 48 U.31 However, adverse effects (headache, eyelid swelling, and brow ptosis), though uncommon, were more frequently associated with the higher doses. For reasons less clear that might relate to muscle mass, the number of active neuromuscular junctions is less in the frontalis muscle,32 BTX-A effects in this region (for any combination of the postulated causes), usually last longer than any other facial area. Therefore despite a slight reduction in regional efﬁcacy, lower dosages (and few injection sites) may allow for a more harmonious onset and dissipation of effects. Retained animation, reduction in the degree of induced brow ptosis and greater aesthetic beneﬁts also result from more conservative dosing (Fig. 24-17). As mentioned, the frontalis is unusually ‘sensitive’ to even seemingly low doses of drug. The placement (whether intradermal, immediately subcutaneous, deep subcutaneous, or intramuscular) has less bearing on the result. Although a direct intramuscular injection usually gives the most effective treatment, the authors advocate a more superﬁcial injection that helps avoid bleeding, bruising, signiﬁcant pain, or hematoma that can ‘spoil’ an otherwise perfect application in selected individuals.

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A

A

B

B Figure 24-17 A, This patient presented for improvement of forehead furrows but did not desire a signiﬁcant induction of brow ptosis. B, By placing the injections higher in this individual (greater than 2 cm above the eyebrow) induction of brow ptosis is minimized, while improvement of forehead lines is dramatic as desired.

Brow lift and contouring As previously mentioned, treating glabellar rhytides can also result in a pleasing brow lift. Adept clinicians can now predictably produce elevations in the medial, central, and temporal eyebrow. Varying treatments to the brow depressors have been shown to be effective in elevating the eyebrow through a host of techniques. Isolating treatment to the procerus, depressor supracilii, and lateral orbital orbicularis oculi muscle alone will elevate the brow but preserve its natural arc. Injecting 7 to 10 U BTX-A in the procerus at the midline, followed by one injection on each side (5 U) into the superolateral eyebrow at the temporal fusion line21 has been shown to be effective. This technique is especially useful in those individuals who exhibit brow

Figure 24-18 A, This patient presented with complaints of periorbital rhytids including ‘crow’s feet’ and the horizontal furrows at the nasal bridge. She also wanted to improve the shape of her brows. She had received Botox elsewhere in the past and stated that despite avoiding the forehead and some obvious improvement, she always appeared a bit angry and had an exaggerated ‘arch’ to her eyebrow with ‘heaviness’ on the medial upper eyelid area. B, After Botox treatment to the lateral canthus and depressors of the central glabellar region, with particular avoidance of treatment to the lateral corrugator muscles (that might affect adjacent frontalis by diffusion).

ptosis and whose vertical glabellar frown lines are less of a concern (Fig. 24-18). This dramatically reduces the possibility of further brow depression (with any diffusion to the adjacent frontalis). By ignoring the variations in eyebrow shape presentation and the potential effects of treating the brow depressors in isolation, we fall short of delivering the optimum aesthetics (Fig. 24-19). Other techniques described demonstrate isolated injection of the lateral brow depressors13,14 by injection of 7–10 U into the superolateral orbicularis oculi at three sites below the lateral third of the brow, superior and lateral to the orbital rim, and produced signiﬁcantly variable mid-pupillary and lateral brow elevations ranging from 1 to nearly 5 mm.13,14 The cause for such variability, while at ﬁrst appearing confusing, might be more explainable than previously

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Figure 24-19 This patient presented for upper blepharoplasty with complaints of the feeling of heaviness of the upper eyelids exacerbated by recent injections of BTX-A to her forehead performed elsewhere to eliminate regional rhytids. Over-treatment to the forehead, especially to the central portion, does not always result in profound brow ptosis, but can result in an unhappy patient that experiences discomfort with the inability to satisfactorily animate the forehead (shown here using great effort to raise her eyebrows) and the worsening of upper eyelid dermatochalasis and overall aesthetic appearance.

thought. Such variability has also been shown with surgical brow lifts, whereby the identical technique performed on various individuals can produce dramatically different results. The explanation most likely lies in the fact that precise application to the brow depressors can cause their dense chemo-denervation. The ‘lift’ ultimately will also depend on increased tone in frontalis.15 Signiﬁcant brow elevation will be achieved after treatment to the brow depressors if the technique is precise. It is important to avoid injections ‘too high’ that may produce diffusion to the lateral frontalis (Fig. 24-20). The potential effects and the ability to manipulate brow shape was a prelude to the recognition of the use of BTX for both the eradication of facial lines and as an agent for facial reshaping.4 Some patients experience eyebrow asymmetry, for which BTX-A has also been beneﬁcial. There are many causes of eyebrow asymmetry, including facial nerve trauma following surgical brow lift or other surgically induced facial paralysis, ipsilateral eyelid ptosis, and asymmetric non-pathologic facial expression.9 BTX-A injections into the brow depressors on the lower brow side can reset the balance (Fig. 24-11). Extreme care must be taken when treating non-pathologic facial asymmetry, both for the treatment of rhytids and brow position. Patients may look aesthetically improved in repose, but they might appear unusual with even casual

Figure 24-20 Technique of injection of lateral brow depressors (lateral orbital/infrabrow orbicularis oculi muscle) for a ‘brow lift’ effect. A ‘wheel’ of ﬂuid (containing 2–6 U of BTX) is injected beneath the lateral brow cilia.

animation when mobility (i.e. of the forehead) is only seen on the untreated side (Fig. 24-21).

‘Crow’s feet’: treatment of the lateral periorbita and canthal region The palpebral portion of the orbicularis oculi – the sphincter-like muscle of the eyelids – is thin and close to the skin, regulating the palpebral opening and acting largely involuntarily during blinking (pretarsal). The orbital portion is thicker, with mostly horizontal and oblique ﬁbers. Contraction of the orbicularis oculi, whose ﬁbers run vertically under the skin at the lateral angles of the eyelids, accentuates the lateral canthal rhytides or ‘crow’s feet.’ Dosing BTX-A injections of 12–15 U per side (in two to four injection sites) placed subdermally or intradermally relax the muscle of the lateral periorbita without completely inactivating the orbicularis oculi, which could affect both voluntary and involuntary eyelid function (discussed in ‘Complications with treatment to the periorbita’) and the ability to fully close the eye.7 Results usually last in the range of 3–6 months with few adverse effects (Fig. 24-22). Although historically the use of BTX-A was mostly considered an effective tool for the eradication or improvement of facial rhytids, a higher level of understanding and vision of improved aesthetics and rejuvenation has revealed that it is equally if not more effective in the improvement of facial shape.4 Precise application of the drug, with strong consideration of both direct and indirect effects with the ability to augment results by applying the drug in a variety of ways in multiple facial regions in coordination, has

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A

B Figure 24-21 A, This patient is happy with her BTX injection only while in repose. BTX had been injected differentially to the forehead and infrabrow region to treat a marked asymmetry of the eyebrow position. B, When the patient animates and attempts to raise her brows, the areas of treatment are far more obvious. Care must be taken to consider asymmetric treatment effects on animation and aesthetics.

A

B Figure 24-22 A, This young female presented for treatment of ‘crow’s feet’ noted mostly with animation (smiling, squinting, etc.). B, After injections as noted, complete eradication of crow’s feet is achieved. Routine scheduled treatment sessions at 4-month intervals have prevented, in her, the onset of static rhytids.

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A

Figure 24-24 Typical injection sites for treatment of the lateral canthus. Injections may be as high as the infra-brow cilia and as low as the lateral malar region depending on the patient presentation and the desired effects.

B Figure 24-23 A, This patient presented for ‘crow’s feet’ treatment and ‘any other improvement of her eye appearance’ with BTX. B, After extended treatment to the infrabrow region and to the inferior aspect of the orbicularis oculi muscle that extends onto the malar process, the extended lateral canthal and lower eyelid lines are improved as well as the position of the tail of the eyebrow.

Figure 24-25 Common areas for treatment of the lateral canthus. 3–5 injections are given depending on the patient presentation and desired effects.

Hypertrophic orbicularis facilitated the next level of aesthetic results. Similarly, the treatment of ‘crow’s feet’ in most situations should not be considered as an isolated therapy for canthal rhytids, rather a coordinated treatment for improvement of these lines and contouring of both the lateral eyebrow, midface, as well as improvement of lower eyelid lines, and orbicularis muscle hypertrophy (next section). The extended application of injection sites while treating the lateral periorbita will depend on the patient’s presentation and aesthetic desires and will vary from individual to individual (Fig. 24-23). The preferred plane of injection is immediately subdermal, whereby a signiﬁcant wheal is observed with each dermal puncture (Fig. 24-24, and DVD). This can reduce bruising, bleeding and discomfort, but additionally places the toxin most distant (superﬁcial plane) from the orbit, allowing for safe and effective treatment. The sites of treatment for the lateral periorbita and canthal rhytids are usually lateral to the lateral orbital rim (Figs 24-24 & 24-25).

In some patients, particularly but not limited to individuals of Asian descent, the perceived size of the palpebral aperture diminishes noticeably while smiling, and they request ‘larger’ eyes as a component of aesthetic improvement. Other related phenomena include those who develop signiﬁcant pretarsal ‘bulging’ in association with ‘smaller’ eyes (Fig. 24-26) from either chronic squinting (more common in those who either work or play outdoors in sunlight) or even those individuals who aesthetically desire a larger vertical palpebral aperture to improve appearance (see p. 317). Increasing the size of the palpebral aperture with carefully placed injections is another part of the new ‘art’ of BTX-A, and experience has shown that injections of 2 U into the lower pretarsal orbicularis will relax the palpebral aperture at rest and while smiling.7,15 One study describes the injection of 2 U subdermally, 3 mm inferior to the lower pretarsal orbicularis and, on one side only, three injections of 4 U placed 1.5 cm from the lateral canthus, each 1 cm apart, in 15 women.19 Mean palpebral aperture

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A

A

B Figure 24-26 A, This patient presented for treatment of lateral canthal rhytids, brow position, extended lateral lower eyelid and cheek lines, and ‘bulging’ of the lower eyelid ‘pretarsal’ region upon smiling. B, After treatment in the areas shown, lower eyelid, canthal, and cheek rhytids, lateral brow position, and lower eyelid ‘orbicularis hypertrophy’ is improved. Note that the vertical eyelid aperture is invariably affected by the treatment to the lower eyelid orbicularis muscle.

increase in 86% of patients was 1.8 mm at rest and 2.9 mm at full smile, with the most dramatic results seen in the Asian eye. However, it is important to select patients with good lid tone and proceed with particular caution in those who have had previous lower eyelid ablative resurfacing or transcutaneous blepharoplasties, so that the lateral canthal support is not affected. Better candidates for this application are typically younger females, without prior surgery, and no history or symptoms consistent with dry eye syndrome. At times, onset or worsening of lower eyelid/cheek festoons can also be seen in particular individuals with these treatments to the lower eyelid.33 This approach can also be used with caution in those individuals who experience and/or complain of worsening of the lower eyelid rhytids or ‘pretarsal bulge’ after traditional treatment to the lateral canthus. As with all applications of BTX-A, the facial regions in proximity to the injection sites can experience secondary effects from toxin diffusion. Unwanted and exaggerated ‘over-elevation’ of the lateral eyebrow can

B Figure 24-27 A, This patient was unhappy with her BTX treatment performed elsewhere. She realized a deﬁnite improvement in line reduction, especially in repose, but claimed that she thought she looked ‘strange’ at times but could not be more speciﬁc. B, With animation, there is an exaggerated effect of the lateral brow arch with complete immobility of the medial brow. These effects are often seen for a variety of reasons that include glabella injections given too high that affect the central frontalis muscles, as well as injections given to the lateral brow depressors. This can be easily improved with low-dose BTX to the lateral frontalis as shown, but are best avoided by accurate preinjection assessments and precise localization of drug. In these situations, recruitment of the more lateral and cephalad portion of frontalis can also sometimes be seen, with treatment to adjacent muscle. This can also be treated in various ways depending upon presentation.

result from toxin injected too high at the lateral commissure (Fig. 24-27). Midface ptosis can be the result of toxin being injected in the region of the zygomatic notch (Fig. 24-28). Diffusion effects can inﬂuence the cheek elevators (zygomaticus complex). In addition, those individuals with the early notation of ‘malar

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A A

B

B Figure 24-28 A, This patient desired ‘extended’ treatment of the lateral canthus to improve brow position, reduce the appearance of upper eyelid ‘excessive’ skin, and reduce lower eyelid/canthal lines. B, After treatment as shown, the canthal rhytids, lower eyelid lines and lateral upper eyelid hooding is corrected. The position of the malar ‘bag’ however is directed caudally in a more visible position.

bags,’ lower eyelid lymphedema, or even lower eyelid bags can experience a worsening of the appearance of these conditions (even with treatments limited to the lateral canthus) (Fig. 24-29). Reduction of the effect of the lymphatic pump and reduction of muscle tone to the preseptal orbicularis muscle can lead to a periorbital edema that can last up to 4 weeks in rare individuals (Fig. 24-30).

Complications with treatments to the periorbita Many patients will say, especially prior to their initial treatment, that the complication that they most fear

Figure 24-29 A, This patient presented for improvement of lower eyelid and canthal rhytids and was treated with BTX. B, After treatment lines were only modestly improved at the cost of undesirable worsening of her ‘lower eyelid bags’ that is from weakening of the orbicularis oculi hammock of the injected regions.

is the development of upper eyelid ptosis. Although this is a relatively uncommon occurrence, it can be the cause of patients’ reluctance to undergo treatment. The effects of undesirable or unexpected soft tissue position changes are common (brow, lower eyelid, cheek, lip etc.). In most other facial areas treated however, no other complication is as obvious and disconcerting. The effect can occur from any of the periorbital regions discussed above including the forehead (Fig. 24-31), that is usually an unmasking of a compensated upper eyelid ptosis, or the glabellar (Fig. 24-32) or lateral canthal regions (Fig. 24-33). The cause in the later regions is usually due to diffusion effects that can occur from high dosing or improper placement. Fortunately, in many mild to moderate cases, the effects can be counteracted by the pharmacological effects of topical agents that causes the contraction of Müller’s muscle. Topical anti-histamine eye drops, such as naphazoline or antazoline, or drugs such as apraclonidine that also have a secondary effect of contraction of Müller’s muscle (without pupillary dilation) all can be effective in improving the upper eyelid

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A

B Figure 24-30 A, This patient presented for improvement of lateral canthal rhytids. She has had two prior lower blepharoplasty procedures (performed elsewhere) with resulting lower eyelid retraction. The risk and limited beneﬁts were discussed; however she elected to undergo treatment. B, After treatment with Botox, lines are partially effaced; however the lower eyelid ‘bags’ and lower eyelid retraction are worsened. This might have been avoided by limiting injections to the extreme lateral canthus distant from the lower eyelid.

A

B Figure 24-31 A, This patient presented for treatment of periorbital and eyebrow asymmetry. B, After treatment, forehead lines are improved and eyebrow reshaping is accomplished at the cost of manifesting a mild relative right upper eyelid ptosis that was being compensated for by action of the frontalis over the right eye. This can be avoided by reducing the forehead injections or injecting the right upper eyelid pretarsal segment with low-dose BTX for the treatment of upper eyelid ptosis (see section on Treatment of mild upper eyelid ptosis and lid malposition and asymmetry, p. 317).

Treatment of mild upper eyelid ptosis and lid malposition and asymmetry 319

A

Figure 24-33 Right upper eyelid ptosis resulting from an attempt to elevate severely ptosic brows by injecting into the infrabrow region toward the central aspect of each eyebrow.

B Figure 24-32 A, This patient presented for evaluation and treatment of a recent onset right upper eyelid ptosis several weeks prior that caused hospitalization and entire neurological work-up that was subsequently ‘negative’ for any pathology. After noting the smooth forehead, she was questioned regarding the possibility of receiving recent BTX injections that she for the ﬁrst time recalled/admitted to receiving in the glabellar and forehead region. B, Five minutes after instillation of Naphcon A eyedrops. She was instructed to use the eyedrops (BID) until the ptosis resolved one month later.

posture if such an effect is experienced (Fig. 24-32B). Adrenergic agents such as neosynephrine should be avoided because of secondary cardiac effects. The persistence and longevity of the occurrence of upper eyelid ptosis is, as always, dose-dependent (i.e. a large dose to the levator muscle can have a rather rapid onset and can persist for months). Additionally, if dosages to the upper eyelid and orbit are sufﬁciently large the effect of these kinds of remedy therapy are less if at all effective, especially if the lid ptosis is profound. A common, but more easily treated undesirable effect is the over-elevated lateral eyebrow with treatment to the lateral canthus commonly called the ‘Mr Spock’ eyebrow (Fig. 24-27). This can most often be predicted if one evaluates how the patient animates, even during the consultation and examination. For

instance, individuals who furrow clearly to the lateral forehead will more often experience this over-elevation if the brow depressors are effectively weakened and the forehead is also treated less effectively (lack of concurrent treatment to the lateral forehead). Treatment is also easily afforded in this situation by treating the previously untreated forehead area in the appropriate manner (Fig. 24-34). Interestingly, in many cases, these situations of over-elevation of the lateral eyebrow will ‘settle down’ even without treatment, possibly due to some sort of adaptation that is often observed yet poorly understood. Finally, on a related issue, these secondary adaptational effects (i.e. enhanced ‘bunny lines’ after the treatment of the glabella in isolation, over-elevated eyebrow with treatment of the lateral canthus etc.) that have been called ‘recruitment’ or ‘complications’ can be avoided by accurate pretreatment assessment. Predicting what areas may ‘recruit’ becomes part of the art of planning the most effective and aesthetic results.

Treatment of mild upper eyelid ptosis and lid malposition and asymmetry The physiologic mechanisms whereby eyelid ﬁssure symmetry is achieved in the blepharospastic patient (Fig. 24-1) is by reducing the musculospastic effect of the protagonist (orbicularis muscle) while allowing the antagonist (Müller’s muscle and the levator muscle) to stand relatively less opposed. The result is a precise reduction or elimination of focal blepharospasm with

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B

A

Figure 24-34 A, This young female presented for treatment of horizontal forehead furrows and for eyebrow shaping. Standard treatment was administered that involved mostly the glabellar region and central midforehead. B, This was her result and although she was happy with the forehead ‘smoothness,’ she was unhappy with the exaggerated brow peaking (right greater than left). This was treated by the injection sites as shown. C, Final result.

C

the secondary effect of enhancing the vertical palpebral aperture. Often those patients with even mild true upper eyelid ptosis, induced by unilateral chronic facial spasm, appear to have complete resolution of the upper eyelid malposition (Fig. 24-2). A similar phenomenon exists in the lower eyelid; patients who have been treated for lower eyelid lines, orbicularis muscle hypertrophy, or spastic involutional entropion with focal injections of Botox to the various regions of the lower eyelid (Fig. 24-26) commonly exhibit a variable degree of lower eyelid retraction and scleral show. As it is apparent that the upper eyelid position can be affected by manipulation of the protagonistic/antagonistic effects of the lid elevators and depressors in conditions

of blepharospasm, it stands to reason that upper (and lower) eyelid position can also be inﬂuenced even in the non-spastic state. This hypothesis prompted further study for the use of botulinum toxin type A for aesthetic improvement of upper and lower eyelid position for a variety of conditions.15 Although the standard of care for these conditions has traditionally been a surgical solution, there are some patients for whom surgery is not a clear option. These may include those simply unwilling to undergo a surgical procedure, individuals who for medical reasons are unable to have surgery (surgical ‘risk’ or are unable to discontinue blood ‘thinning’ agents etc.), or those who have had much prior surgery and a satisfactory endpoint would be difﬁcult at best.

Treatment of mild upper eyelid ptosis and lid malposition and asymmetry 321

Figure 24-35 Mild to moderate upper eyelid ptosis can be treated with ‘low-dose’ BTX to the pretarsal orbicularis oculi as shown.

A

Dosing Lower dosages, in the order of magnitude of 1–2 units per injection site are typical for these applications. Higher dosages (as in other facial regions where function may be affected such as the lips) can cause signiﬁcant morbidity such as exposure keratopathy, or B epiphora, as well as lack of aesthetic improvement. For Figure 24-36 A, This patient presented for BTX treatment mild to moderate upper eyelid ptosis, the starting in the most common areas (glabella and lateral canthus) dosages are usually around 1 unit applied to the prefor the ﬁrst time after multiple sessions performed at tarsal orbicularis (in the subdermal plane) at the several other physicians’ clinics in the past. The left upper extreme medial and lateral aspect (Fig. 24-35). Results eyelid ptosis was noted on examination and she was can be dramatic (Fig. 24-36). Due to lower dosing, the questioned if she had ever noted this and/or inquired effects are less long-lasting and usually are in the 2–3 about treatment. She was aware of this, but felt that the month range. only treatment option was surgery for which she was not Complications can be mild and include differential interested. B, After glabella and canthal treatment with blink rate or more signiﬁcant with lagophthalmos and Botox as well as 1.5 U BTX to the pretarsal region as shown in ‘A.’ exposure keratopathy that can be temporarily treated with topical emollients in most situations until the effects subside. Higher dosages can also yield diffusion effects to both Müller’s muscle and the levator muscle and worsen the lid ptosis. This can be avoided by starting with lower dosages and injection in the immediate a small subset of individuals with mild to moderate subdermal plane, with sites as far medial and lateral as upper eyelid retraction (interestingly, these patients possible. Avoidance of injury to the globe must be commonly wear vision corrective contact lenses) who cautioned and is also best facilitated by injecting as demonstrate this enhancement of the vertical palpebral parallel to the skin surface as possible (much as with aperture and do not raise their forehead for this effect, treatment in this region for ‘blepharospastic’ condiwill show a reduction of the upper eyelid retraction tions). This is a safer technique, especially in the ‘new’ when Botox is applied to raise the eyebrow (Fig. patient who has no prior experience with BTX-A or 24-37). even your routine ‘jumpy’ patient. Treatment to the lower eyelid can be applied to Upper eyelid position has been shown to be inﬂuasymmetries that result from congenital effects, aging enced by manipulation of the eyebrow in several changes, prior surgery, stroke, and a host of other ways.15 As shown previously (Fig. 24-31), those indiregions including bilateral lower eyelid treatment to viduals with compensated upper eyelid ptosis (i.e. ‘enlarge’ the eyes (enhance the vertical dimension of those patients who raise their eyebrow to elevate the the palpebral aperture). Higher dosages to the lower upper eyelid to the slightest degree when a mild upper eyelid region should also be avoided and the usual lid ptosis exists) will negate this effect if Botox is used starting dose is 1–2 units per injection site. The locato counter the associated forehead furrows. Similarly,

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Figure 24-38 Lower eyelid position asymmetries can be treated in selected patients by reducing lower eyelid orbicularis tone by injection with BTX.

A

with upper face injections and a thorough understanding of anatomy and vasculature are strongly recommended (Fig. 24-28).

Nasalis ‘bunny lines’ B Figure 24-37 A, This patient presented for treatment of brow ptosis as well as glabellar and canthal rhytids. Mild upper eyelid retraction was noted on examination. B, After treatment in the sites shown, note the reduction of rhytids as well as the improvement of brow shape/position and reduced upper eyelid retraction (not as a cause from drug diffusion to the lid elevators).

tion will depend on the effects desired (Figs 24-38 to 24-40).

Treatment of the mid- and lower face Clinicians must take care when injecting BTX-A into the mid- and lower face; incorrect placement of the toxin can have devastating effect (albeit temporary) on function and expression, particularly in the perioral region. Attempts at treatment of the proximal nasolabial fold and also to reduce the ‘gummy smile’ (discussed later) can, at times, achieve signiﬁcant improvement for the appropriate patient. The nasolabial fold, for instance, can be completely effaced with BTX. This unfortunately can mimic the effects seen after facial paralysis or weakness (i.e. Bell’s palsy or stroke). Any attempts to signiﬁcantly improve the nasolabial fold by chemodenervation alone will usually yield such a ‘paralytic’ appearance. Prior experience

Frequent contraction of the upper nasalis, which runs from the bony dorsum of the nose inferiorly, contributes to the development of fanning, radial rhytides obliquely across the radix of the nose called ‘bunny lines.’ Treatment allows the underlying mimetic musculature to relax, softening the lines. Inject anterior to the nasojugal groove on the lateral wall of the nose and well above the angular vein, and massage gently after injection to help diffuse the toxin. The lower nasalis ﬁbers drape over the lateral nasal ala and can lead to repeated nasal ﬂare, in which nostrils dilate involuntarily in social situations and give patients the embarrassing appearance of a race horse. Injection into the lower nasalis ﬁbers will weaken this involuntary action (Fig. 24-41). Higher dose injections (5 units per side) or those administered caudal to these locations may affect the levator labii superioris aleque nasi and can be effective in further reducing the ‘bunny lines.’ Higher dosages to this region injected with precision can reduce the ‘gummy smile’ and soften the proximal nasolabial fold in the appropriate patient. Care should be taken to avoid or reduce the effects to the primary lip elevators (i.e. levator labii superioris) in most situations.

Lower face Perioral lip rhytides (‘smokers’ lines’) The orbicularis oris is the sphincter-like muscle that encircles the mouth, lying between the skin and mucous membranes of the lips and extending upward to the nose and down to the region between the lower lip and chin. Sometimes called the ‘kissing’ muscle, it causes

Lower face 323

A

B Figure 24-39 A, This patient presented for ‘standard’ BTX treatments to the glabella and crow’s feet. Eyelid ﬁssure asymmetry was noted that related mostly to a disparate position of the lower eyelid. B, After treatment to the glabella, lateral canthus, and right lower eyelid. Note the improvement of eyebrow shape and eyelid ﬁssure symmetry in addition to the reduction of periorbital rhytids.

the lips to close and pucker. Overactive orbicularis oris causes vertical perioral rhytides (which are referred to as smokers’ or lipstick lines but often have numerous causes, such as heredity, photodamage, playing musical instruments that require embouchure, whistling, and other personal habits). Very small amounts of BTX-A (1 to 2 U per lip quadrant) are usually sufﬁcient to result in localized microparesis of the orbicularis oris and can be used as a primary agent for the treatment of dynamic lip rhytids3,4,9–11,30 (Fig. 24-42). Similar to treatment in the other facial areas, at these dosages the dynamic component is mostly satisfactorily affected, while deep static rhytids may have at best a modest improvement. In addition, the lower dosages are necessary to avoid lip dysfunction, while typically effects last in the range of 6–8 weeks. This application (using lower dosing) is especially useful when used adjunctively with a soft-tissue augmenting agent, and can greatly improve persistence of the ﬁlling agent by

reducing the dynamic local activity that may be responsible for dissolution of the injected implant (Fig. 2443). Symmetric injections (unless otherwise indicated) and careful placement of the injection sites to balance either side of the columella or the lateral nasal ala will help alleviate difﬁculty with post-injection asymmetry, lip proprioception, and aesthetics experienced with some patients. Patients who play a wind instrument or who are professional singers/speakers may not be ideal candidates.

Midfacial asymmetry Correction of midfacial asymmetry is another ‘artistic’ indication for BTX-A that requires a thorough knowledge of muscular anatomy and function. Physicians not comfortable with facial anatomy may beneﬁt from the aid of an electromyograph (EMG) system for accurate placement of injections.

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A

B Figure 24-40 A, This young female model presented for BTX treatment. She exhibited no upper facial rhytids and requested an improved and more provocative appearance to the periorbita by making her ‘eyes look bigger.’ A high corrugator technique combined with treatment to the lateral brow depressors (as shown) was used to enhance the appearance of an arched brow while ‘splaying’ the brow head that gives an illusion of ‘widening’ the eyes horizontally (B). Lateral canthal injections were also extended to the lateral lower eyelid to widen the vertical palpebral aperture.

Although midfacial asymmetry may have multiple etiologies, asymmetry with innervational or muscular causes can be minimized or alleviated with BTX-A. In hemifacial spasm, for example, repeated clonic and tonic movements draw the facial midline toward the hyperfunctional side. BTX-A injections into the hyperfunctional zygomaticus, risorius, and masseter relax the muscles and allow the face to fall back into a centered position at rest. Likewise, hypofunctional asymmetry, such as Bell’s palsy, can be alleviated by small injections of 1–2 U into the zygomaticus, risorius, and orbicularis, and 5–10 U in the masseter on the normofunctional side.8 In patients with asymmetric jaw movements, intraoral injections of 10–15 U BTX-A in the internal pterygoid on the hyperfunctional side will relax the jaw and relieve discomfort. Surgical cutting

or trauma to the orbicularis oris or the risorius muscle can result in an off-centered mouth caused by the unopposed action of the partner muscles in the normally innervated side. Correction can be achieved by treatment of the risorius immediately lateral to the corner of the mouth on the normally innervated side. In patients with congenital or acquired unilateral weakness, who cannot depress the corner of one side of the mouth, BTX-A injected into the partner depressor anguli oris will restore functional balance.

Depressor anguli oris The depressor anguli oris (DAO) extends inferiorly from the modiolus to attach into the inferior margin of the mandible on the lateral aspect of the chin. DAO

Lower face 325

A

B Figure 24-41 A, This patient presented for her standard BTX treatments and desired to reduce the appearance of her ‘bunny lines’ that seemed to be exaggerated after treatment to the glabella. B, After treatment to the glabella and to the lateral portions of the nasalis muscle (as shown). Note the medial brow elevation with precise treatment to the corrugator muscles and the softening of the ‘bunny lines’ with this additional treatment. Photos courtesy of Rod Rohrich, MD.

A

B Figure 24-42 A, This patient presented for improvement of upper lip rhytids with BTX. B, after asymmetric treatment for more numerous and deeper lines on the left portion of her upper lip and decentration of cupid’s bow (as shown). Note the improvement of rhytids and also the appearance of enhanced upper lip fullness and more central position of cupid’s bow.

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Figure 24-43 This patient received injectable soft tissue A augmentation just a few minutes prior to this photo. Local and regional anesthetic was administered prior to injections to eliminate pain and bruising. 1.5 units of BTX was administered to each of the four sites indicated by the blue dot at the vermilion border of the upper and lower lip after the injection of ﬁller product. This effect allowed for greater persistence of the implant for volume augmentation as well as a longer lasting reduction of lip rhytids.

contraction causes a downward turn to the corner of the mouth, resulting in a negative, bitter appearance. Repetitive contraction over many years likely has a dramatic inﬂuence on volume loss to this region and B the appearance of ‘perimental hollows’ and ‘jowling.’ Figure 24-44 A, this patient presented for treatment of Since direct injection of the DAO can cause intolerable oral commissures, ﬁne upper lip rhytids, and her ‘pebbly’ paresis of the depressor labii, BTX-A injections are chin. B, After BTX treatment to the DAO, upper lip rhytids placed instead at the level of the mandible but at its and mentalis. Note the improvement of the position of the posterior margin, close to the anterior margin of the lateral oral commissure, reduction of lip rhytids and masseter (easily felt when patients are directed to improved lip shape and reduced chin ‘dimpling.’ clench their teeth). The aim of treatment is to weaken, not paralyze, the DAO; doses of 3–5 U are usually sufﬁcient to achieve the desired result (Fig. 24-44). In addition, the simultaneous injection of the DAO with collagen unmasks the mentalis and depressor labii injectable soft tissue augmentation to this region will muscle attachments. A combination of BTX-A into the enhance the result. mentalis plus soft-tissue augmentation leads to optimal results, although some patients fare well with BTX-A Mental crease alone (Figs 24-44, 24-45). The mental crease can be softened by injecting 3–5 U BTX-A into the mentalis just anterior to the mentum Coordinated treatment of the mouth (Fig. 24-45). Injection higher at the level of the mental corners and chin crease will also weaken the lower lip depressors and The opposing actions off the DAO (downward) and orbicularis oris, causing serious perioral weakness mentalis (upward) cause permanent downward angulalasting 6 months or more. As in the perioral area, weaktion of the lateral corners of the mouth. When treating ening, rather than paralysis, is the aim of treatment. mouth frown with BTX-A, it is important to remember that treatment of a single muscle may positively or negaPeau d’orange chin tively affect adjacent muscles. Weakening the DAO or A dimpled or ‘peau d’orange’ appearance in the aging mentalis alone, while appropriate in some individuals, chin occurs when a loss of subcutaneous fat and dermal may be associated with unacceptable side effects in

Lower face 327

A A

B Figure 24-45 A, This male patient presented for treatment of nasolabial folds and for any improvement to the appearance of his chin region. B, After treatment to the nasolabial folds with Restylane and treatment to the mentalis to reduce chin ‘dimpling’ and reduce the mental crease.

others. However, lower doses of BTX-A injected simultaneously into both muscles (3 U into each DAO and mentalis, for a total of 12 U) results in a synergistic and subtle effect that is safe and does not interfere with elocution or pursing of the lips (Fig. 24-46).

Lower facial asymmetry Some patients experience surgical or traumatic cutting of the orbicularis oris or risorius, resulting in decentration of the mouth from the unopposed action of the partner muscles in the normally innervated side. BTXA injected in the overdynamic risorius, immediately lateral to the lateral corner of the mouth will help to recenter the mouth when the face is in repose. Patients may have congenital or acquired (even iatrogenic) weakness of the DAO, resulting in inability to depress the corner of one side of the mouth; chemodenervation of the contralateral synergistic muscle will restore functional and aesthetic symmetry (Fig. 24-47).

B Figure 24-46 A, This is the same patient as shown in Figure 24-44. Also note the improvement of the ‘downturn’ to the lateral oral commissure and depressions in that region as well as a smoother appearance to her chin as shown in ‘B.’

Masseteric hypertrophy Contouring the lateral muscular jaw prominence – a relatively common aesthetic procedure especially among Asian patients – is yet another use for BTX-A. Park et al injected 25–30 U BTX-A per side in ﬁve to six sites evenly at the prominent portions of the mandibular angle in 45 Asian patients for aesthetic improvement and found a gradual reduction in masseter thickness during the ﬁrst 3 months following injection.34 The average change in masseter thickness, 1.5– 2.9 mm, was equivalent to 17 to 19 percent of the original muscle thickness, as measured by ultrasound and computerized tomography. The response lasted 6–7 months before the muscle thickness retreated to its initial size; at 10 months, 36 patients expressed satisfaction with the results. Masseter hypertrophy is also a common byproduct of bruxism. This application in these individuals is not only an aesthetic enhancement, but also a dramatically effective cure for the sometimes

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will avoid both the deeper venous perforators that can bleed and the underlying muscles of deglutition that can be affected. This application is limited in those with severe static rhytids in this region.

Vertical platysmal bands

Figure 24-47 Treatment of the asymmetry caused by a weakened or paralyzed depressor anguli oris (due to a variety of causes) as shown on this patient’s left side can be readily performed by focally treating the DAO on the contralateral side.

signiﬁcant focal pain associated with these disorders (Fig. 24-48). Local side effects, including mastication difﬁculty, transient muscle pain, and verbal difﬁculty during speech, were uncommon.

Cervical indications The platysma is a large muscle arising from upper parts of pectoralis major and deltoid that slants upward along the full length of the neck. Some platysmal ﬁbers extend to the mandible, while others insert into the skin and subcutaneous tissue of the lower part of the face or blend into the muscles of expression above the angle and lower corner of the mouth and lower lip. As with all facial muscles, there can be some anatomic variation in some, but most often an enormous variability of function from one individual to another. Two types of line can be produced from the platysma: horizontal ‘necklace’ lines – transverse lines in the neck that run perpendicular to the contraction of the platysma – and vertical platysmal bands.

Horizontal necklace lines Horizontal necklace lines of skin indentation, caused by the superﬁcial musculoaponeurotic system attachments in the neck, often grace the chubbier neck and can be treated in selected individuals by ‘dancing’ along the lines, injecting small doses over multiple sites, for a total of 15–20 U per treatment session. Gentle massage following treatment will help alleviate potential bruising. Deep dermal, rather than subcutaneous, injections

When cervical skin loses its elasticity, the anatomy of the submental space changes: more submental fat becomes visible, and the platysma separates into two diverging vertical bands that tighten and become prominent during speech or other animation. Early banding can be seen in younger individuals that may reﬂect a hyperdynamic nature of the platysma. BTX-A injections can soften vertical platysmal bands in some patients27,35; however, careful patient selection of those with obvious platysmal bands, good cervical skin elasticity, and minimal fat descent, is essential.36 Younger patients with signiﬁcant banding may require larger dosages in lieu of the hyperdynamic activity that is able to distract the cervical soft tissue, despite adequate skin elasticity and tone. On the other hand, in the elderly who exhibit a signiﬁcant degree of descent and jowl formation, treatment with BTX-A may be entirely ineffective or actually worsen the appearance of the bands. Used as an adjunct to rhytidectomy, BTX-A can reduce the residual muscular banding that becomes apparent in the postoperative phase. In addition, some patients may prefer to use BTX as a kind of ‘rehearsal’ for the surgical alternative. Also, BTX-A into the platysma muscle may reduce the undesirable inferior pull of the platysma muscle on the facelift incision, thus resulting in a thinner and ﬁner scar.37 Since the platysma is external to the muscles of deglutition and neck ﬂexion, large doses of BTX-A (i.e. 75 or 100+ U) have been known to cause profound dysphagia,30 and must be used cautiously. Decreased phonation, difﬁculty with head posture, and worsening of dry mouth have also been reported with ‘overdosing.’ Injecting 5 U with as few as three sites for each band (with sites that are 1–1.5 cm apart) and no more than 25–30 U over multiple sites per treatment session is typical. The safest effective plane is more superﬁcial and the least likely to induce unwanted effects. It is far better to under-treat; additional ‘touch-up’ treatments can always be given if necessary during a subsequent treatment session (Fig. 24-49).

Adjunctive use in facial aesthetic enhancement The adjunctive use of BTX-A with a host of other methods used for aesthetic facial enhancement has demonstrated a clear synergy when the appropriate

Conclusion 329

A

B Figure 24-48 A, this patient had previously undergone surgical resection of the right masseter for severe bruxism and chronic pain a few years prior with complete return of the massive muscle enlargement and pain. B, After BTX treatment in three areas (total 15 U) only to the right masseter that not only eliminated his pain but reduced masseter size to near symmetry to the left side.

combination of therapeutic modalities are applied. Improved and longer lasting results with a variety of energy/laser applications, injectable soft tissue agents, wound healing, brow lifts, canthopexy/plasty, suture suspension techniques, have been demonstrated3,9–11,38 while this is only a shortlist of the potential adjunctive beneﬁts (Figs 24-50 to 24-54).

Documentation of pretreatment status and procedural reporting Although an accurate history and examination of the patient will detect the pretreatment status of most individuals, the documentation of this is best accomplished by photography. Not infrequently patients will notice things after treatment of any sort that they claim were not present prior to your care. This occurs for many reasons that include, but are not limited to, their increasing awareness and curiosity to detect changes after your treatment while their observations prior to your procedures were less keen.

A clear diagrammatic operative note is also essential for both an explanation and documentation of treatment details and for your own record of treatment that might be amended in future sessions based on response (Figs 24-55, 24-56). This record should include lot number, dilution, site, number of units per site, and any other notations including unusual blemishes, bleeding, etc.

Conclusion As with many discoveries in science and medicine, it is often the accidental discoveries that have the most profound effects. Our collective experiences with BTX have not only expanded the applications of this useful primary tool for facial rejuvenation and a vital adjunctive agent to improve other methods, but has also enlightened us to the complicated causes of facial aging and the explanation for failure of various previous treatment methods. Although initial applications were

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A

B Figure 24-49 A, This patient presented for treatment of residual neck ‘bands’ after undergoing a lower face/neck lift several years prior. B, After BTX treatment in the areas indicated.

A

B Figure 24-50 A, This male presented for improvement of deep forehead lines. B, After a combination of 2 mL CosmoDerm applied to the superﬁcial to mid dermis of the forehead lines and BTX to the brow depressors combined with lower-dose BTX (2 units given at 4 sites in the mid-forehead) facilitated the improvement of forehead rhytids while adequately maintaining eyebrow position.

Conclusion 331

A

B Figure 24-51 A, This male patient presented for improvement of the deep glabellar furrows as well as the horizontal forehead furrows. Here using BTX alone would likely not completely eradicate the facial lines and would induce a signiﬁcant degree of eyebrow ptosis. B, After treatment using CosmoDerm to the glabellar and forehead furrows, 30 units of BTX (total) to the glabella with direct injections to the belly of the corrugators, procerus, and superciliaris muscles, and low dose injection to the mid forehead (4 injection sites of 2 U each).

A

B Figure 24-52 A, This patient presented for periorbital rejuvenation. B, After upper/lower blepharoplasty utilizing CO2 laser skin resurfacing and lateral retinacular suspension canthopexy. BTX was administered at 2 weeks after surgery and requires this treatment three times per year to maintain this effect/result.

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A

A

B

B Figure 24-53 A, This patient had undergone upper blepharoplasty and endoscopic brow lift (elsewhere) and was disappointed when the brow elevation did not persist. B, After BTX to the areas shown for brow lift and shaping, reduction of lower eyelid and canthal rhytids as well as lower eyelid orbicularis muscle hypertrophy.

Figure 24-54 A, This patient presented for upper/lower eyelid rejuvenation and was most concerned with lower eyelid and canthal lines. B, After upper and lower blepharoplasty and CO2 laser skin resurfacing to the lower eyelid and lateral canthus with lateral retinacular suspension canthopexy. BTX was administered at 2 weeks after surgery and at 4–6 month intervals to maintain the result that included the canthal re-suspension that can (with suture canthopexy alone) easily fail in patients with such active orbicularis muscle. Figure 24-55 A facial drawing is most useful with individualized coding that will indicate the site and amount of drug injected for future reference.

o

x x

o

x

x x

x x x x

x x

x = 4u o = 2u

Conclusion 333 BOTULINUM TOXIN TYPE A OPERATIVE REPORT Date....................................................................

Patient.................................................................

• History of recent NSAID:.................................. • Significant medical history:...............................

• Current medications.......................................... • Pregnant YES NO

1st Botox injection YES

NO

Off label consent given.......................................

Date of last Botox injection.............................

Informed consent given.......................................

LOCATION MAP OF INJECTIONS Clinical Analysis Upper Face ________ Forehead frown lines ________ Brow asymmetry (R / L lower) ________ Glabellar rhytids ________ Procerus lines Eyelid ________ Aperture width (R / L larger) ________ Crows feet Lips/Mouth ________ Lateral ________ Central ________ Commissures ________ Rhytids Neck ________ Medial bands ________ Lateral bands 100 units of Botox used in 4 cc of PFNS (2.5U / 0.1 cc) Amount Used..............................

Lot Number..............................

Exp Date..............................

Complications:............................................................................................................................................. Instructions Given Follow-up appointment ________ 2 weeks

________ 3 months

________ Other

Comments:.................................................................................................................................................. Physician Signature:..................................................................................................................................... Provided courtesy of R. J. Rohrich MD, FACS. Used with permission.

Figure 24-56 An operative report might contain a drawing as shown here or in Figure 24-55, and can be more detailed as shown here. A brief history is contained here that is a review of medical history and medication that might have changed from the prior visits, as well as other information indicating the speciﬁc treatment and follow-up, lot number, total dose, etc. Original ﬁgure courtesy of RJ Rohrich, MD, FACS. Used with permission.

Chapter 334

24

Expanded uses of BTX-A for Facial Aesthetic Enhancement used primarily for the improvement or correction of facial rhytids it has been shown to be useful in the enhancement of facial shape. The greatest aesthetic results with this agent are achieved through a higher level of understanding of the multitude of potential beneﬁcial effects, an accurate and comprehensive patient assessment, detailed knowledge of facial anatomy, and a precise application to achieve maximal beneﬁts while avoiding complications.

References 1. Carruthers JD, Carruthers JA: Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 1992; 18:17–21. 2. Scott AB: Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. Ophthalmology 1980; 87:1044–1099. 3. Fagien S: Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: Adjunctive use in facial aesthetic surgery. Plast Reconstr Surg 2003; 112;40S–52S. 4. Fagien S: Botulinum toxin type A for facial aesthetic enhancement: role in facial shaping. Plastic Reconstr Surg 2003; 112 (Suppl.):6S. 5. Carruthers JDA, Stubbs HA: Botulinum toxin for benign essential blepharospasm, hemifacial spasm and agerelated lower eyelid entropion. Can J Neurol Sci 1987; 14:42–25. 6. Fagien S: Cosmetic improvement of dyskinetic eyelid and facial asymmetry with botulinum toxin type A. Abstract submitted to the annual meeting of the American Society of Ophthalmic Plastic and Reconstructive Surgeons, Summer, 1991. 7. Carruthers A, Carruthers J: Botulinum toxin type A: History and current cosmetic use in the upper face. Semin Cutan Med Surg 2001; 20:71–84. 8. Carruthers JDA, Carruthers JA: Botulinum toxin in clinical ophthalmology. Can Ophthalmol 1996; 31:389–400. 9. Fagien S, Brandt FS: Primary and adjunctive use of botulinum toxin type A (Botox) in facial aesthetic surgery: Beyond the glabella. Clin Plast Surg 2001; 28:127–148. 10. Fagien S: Extended use of botulinum toxin A in facial aesthetic surgery. Aesthet Surg Journal May/June; 1998; 18:215–219. 11. Fagien S: Treatment of hyperkinetic facial lines with botulinum toxin. In Putterman AM (ed): Cosmetic Oculoplastic Surgery: Eyelid, Forehead, and Facial Techniques. Third Edition. Chapter 33, pp 377–388. Philadelphia, W.B. Saunders, 1998. 12. Carruthers A, Carruthers J: Dose dilution and duration of effect of botulinum toxin type A (BTX-A) for the treatment of glabellar rhytids. Presented at the American Academy of Dermatology 2002 Winter Meeting, 2002 February 22–27, New Orleans, LA. 13. Ahn MS, Catten M, Maas CS: Temporal brow lift using botulinum toxin A. Plast Reconstruct Surg 2000; 105:1129–1135. 14. Fagien S: Temporal browlift using botulinum toxin A: an update by Kim EJ, Maas CS. Plast Reconstr Surg [Discussion]; 2003; 112 (Suppl.):105S,

15. Fagien S: Temporary management of upper lid ptosis, lid malposition, and eyelid ﬁssure asymmetry with botulinum toxin. Plast Reconstr Surg 2004; 114:1892. 16. Rohrich RJ, Janis JE, Fagien S, Stuzin JM: Botulinum toxin: expanding role in medicine. Plast Reconstr Surg 2003; 112 (Suppl.):1S. 17. Rohrich RJ, Janis JE, Fagien S, Stuzin JM: The cosmetic use of botulinum toxin. Plast Reconstr Surg 2003; 112 (Suppl.):177S. 18. 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. 19. Flynn TC, Carruthers JA, Carruthers JA: Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye. Dermatol Surg 2001; 27:703–708. 20. Huang W, Rogachefsky AS, Foster JA: Brow lift with botulinum toxin. Dermatol Surg 2000; 26:55–60. 21. Huilgol SC, Carruthers A, Carruthers JDA: Raising eyebrows with botulinum toxin. Dermatol Surg 2000; 25:373–376. 22. Carruthers JA, Lowe NJ, Menter MA, et al: A multicentre, double-blind, randomized, placebo-controlled study of efﬁcacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol 2002; 46:840–849. 23. Carruthers JA, Lowe NJ, Menter MA, et al: A multicentre, double-blind, randomized, placebo-controlled study of efﬁcacy and safety of botulinum toxin type A in treatment of glabellar lines. J Plast Reconstr Surg 2003; 112(Suppl.): 5S. 24. Fagien S: Double blind, placebo-controlled: study of the safety and efﬁcacy of botulinum toxin type a in patients with glabellar lines by Carruthers JD, Lowe NJ, Menter A, Gibson J, Eadie N. Plast Reconstr Surg [Discussion] 2003; 112(Suppl.):31S. 25. Carruthers A, Carruthers J: Glabella BTX-A injection and eyebrow height: A further photographic analysis. Presented at the Annual Meeting of the American Academy of Dermatology, March 21–26 2003, San Francisco, CA. 26. Carruthers A, Carruthers J, Said S: Dose-ranging study of botulinum toxin type A in the treatment of glabellar lines. Presented at the 20th World Congress of Dermatology, July 1–5 2002, Paris, France. 27. Carruthers A, Carruthers J: Botulinum toxin type A (BTXA) in the treatment of glabellar rhytids: An objective analysis of treatment response. Presented at the American Academy of Dermatology 2002 Winter Meeting, February 22–27 2002, New Orleans, LA. 28. Fagien S: Multiple causes for brow lift effect from glabellar injections. The First Annual Meeting of the National Education Faculty Training sponsored by Allergan, Inc. The Westin Hotel, Denver, Colorado. July 26, 2003. 29. Carruthers A, Carruthers J: Botulinum toxin type A for treating glabellar lines in men: A dose-ranging study. Presented at the 20th World Congress of Dermatology, July 1–5 2002, Paris, France. 30. Carruthers J, Carruthers A, Cohen J: A prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in female subjects with horizontal forehead rhytides. Dermatol Surg 2003; 29: 461–467. 31. Carruthers A, Carruthers J, Cohen J: Dose dependence, duration of response and efﬁcacy and safety of botulinum

References toxin type A for the treatment of horizontal forehead rhytids. Presented at the American Academy of Dermatology 2002 Winter Meeting, February 22–27, 2002, New Orleans, LA. 32. Happak W, Liu J, Burggasser G, et al: Human facial muscles: Dimensions, motor endplate distribution, and presence of muscle ﬁbers with multiple motor endplates. Anat Rec 1997; 249:276–284. 33. Goldman MP: Festoon formation after infraorbital botulinum-A toxin: A case report. Dermatol Surg 2003; 29:560–561. 34. Park MY, Ahn KY, Jung DS: Botulinum toxin type A treatment for contouring of the lower face. Dermatol Surg 2003; 29:477–478.

35. Matarasso A, Matarasso SL, Brandt FS, Bellman B: Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg 1999; 103:643–652. 36. Fagien S: Botulinum A Exotoxin for the Management of Platysma Bands by Matarasso A, Matarasso SL, Brandt FS, Bellman B. Plast Reconst Surg [Discussion] 1999; 103:653. 37. Carruthers A, Carruthers J: Using Botulinum Toxins Cosmetically, p 59. London & New York: Martin Dunitz, Taylor & Francis Group, 2003. 38. Carruthers JDA, Carruthers A: The adjunctive use of BOTOX. Dermatol Surg 1998; 24(11):1244– 1247.

335

Index Note: Page numbers in italics refer to ﬁgures. Page numbers in bold refer to tables.

A Abnormal contour after brow lift, 76 Acne after laser resurfacing, 275–6 Acrylic hydrogel, 290–2 Adipose body, orbital, 51 Aging cheek bags and depressions, 27 comparative anatomy and aesthetics of blepharoptosis and, 91, 91–2, 92 current observations of periorbital, 15–20, 17–19 enophthalmos and, 16–17 excess eyelid skin associated with, 5 eye size and, 16 eyebrow position and, 17, 17 facial changes in, 59, 60, 228, 279, 280 ﬁllers for restoring the face, 279 globe and, 16 levator aponeurosis and, 17 lid-cheek junction and, 17, 18, 59, 60, 228 nasojugal groove, 59 orbital rim, 59, 60 palpebromalar groove, 59 photography, comparative, 16 ptosis and, 16 skin changes in, 17 suborbicularis oculi fat and, 18 upper eyelids and, 17 Ali ibn Isa, 4 Allergies collagen ﬁllers, 282, 282 history taking, 32 Allogenic dermal matrix spacer grafts, 205–16 sizing, 211 suturing to lower eyelid retractors, 212, 212 Alloplastic contouring, 227–49 alloplastic solution, 232–3

association of malar and suborbital deﬁciencies, 237, 237–8 conclusion, 249, 249 facial balance, 233–5, 235 historical background, 228 implant designs, 229, 232–3 malar suborbital deﬁciencies, 228–32 periorbital region, 236, 236 suborbital maxillary volume, 228–32 tear trough suborbital implant, 238–49, 239–48 upper midface suspension, 236, 236 Alloplastic materials, 232–3 Alopecia after brow lift, 76, 77 Alpha-hydroxy acids, 254 Ancient medicine, 4, 4 Anesthesia cheek-midface lift, 188 chemical peels, 257 hard palate grafting, 207 laser skin resurfacing, 273 local see Local anesthesia lower blepharoplasty, 167 Müller’s muscle-conjunctival resection, 125, 126 skin-muscle ﬂap approach, 182 transconjunctival approach to lower eyelid orbital fat, 156 upper eyelid crease creation, 109 upper eyelid retraction, 146, 147 Angular artery, 53, 54 Anterior hairline lift, 72, 73, 73 Apocrine sweat glands, 46 Arcuate expansion, 50, 50 Arcus marginalis, 50, 50, 218, 218, 220 Artecoll, 290, 295, 297 Arteﬁll, 11, 289–90, 291 Arteries, eyelid, 53–4 Asian patients epicanthal folds, 112

ethnic differences, 106 eyelid shape in, 17, 18 facial anatomy, 107 preoperative counseling, 107 psychological and aesthetic needs of, 106 surgical techniques, 107–10 upper blepharoplasty in, 105–12 complications, 110 postoperative care, 110 upper eyelid anatomy, 106–7, 107 upper eyelid crease/fold complex, 7, 108 aesthetics, 105, 106 anatomy, 107 creating, 107–10 by conjunctival suturing, 107, 108–9 by external excision, 107, 109–10, 111, 112 Asymmetry after brow lift, 76 assessment and management of, 43 eyelid, 319–22, 319–22 lower facial, 327, 329 measuring device, 22–3, 23 midfacial, 323–4 physical examination, 33 Auricular cartilage grafts, 230, 231 Autologen, 283, 283 Autologous fat facial ﬁller, 285, 285–6, 286 Autologous tissue transplantation, 230–2, 231, 232 Axial myopia, 34, 37 Azelaic acid, 256

B Bacterial infections, 262, 275 Baker-Gordon formula see Baker’s phenol Baker’s phenol, 253, 255, 255 Barbed suture technology, 10

Index 338

Bell’s palsy, 303, 304, 324 Bell’s phenomenon, 29 Bettman, Adabert, 5 Beveled lift incision, 73, 73 Bleaching agents, chemical peels, 256 Blepharochalasis, 5 Blepharopigmentation, 8 Blepharoplasty chemical peel with, 253, 259–60 extended, 9–10 history of, 4–8, 6 laser carbon dioxide (CO2), 9 scalpel-YAG, 8–9 lower eyelid, 9–10, 161–79, 167–73 anesthesia, 167 fat repositioning in, 217–22, 218–22 results, 174–9 transconjunctival fat maintenance, 167–79, 167–79 transconjunctival, 9, 167–79, 167–79 upper eyelid, 87–103 advanced rejuvenative, 92–7, 93–7 in the Asian patient, 105–12 combined with levator aponeurosis repair, 115– 22, 118–19 combined with Müller’s muscleconjunctival resection see Müller’s muscleconjunctival resection comparative anatomy and aesthetics of ptosis and aging, 91–2 conclusion, 102–3 consultation, 87–9 crease and fold of upper eyelid, 90–1 discussion, 101–2 early technique, 4, 4 eyebrow position and volume, 90, 90 results, 97, 98–101 technique, 95–7, 96, 97 Blepharoptosis comparative anatomy and aesthetics of aging and, 91, 91–2, 92

complication of botulinum toxin injection, 317, 319 and dermatochalasis, 120 evaluation of, 24–5, 25, 26, 38 Müller’s muscle-conjunctival resection, 125 treatment with botulinum toxin, 319–22, 319–22 Blepharospasm, 303, 304, 319–20 Blood supply eyelids, 53–4, 54 forehead, 69 midcheek, 59–60 Bones, facial, 55, 55 Botox see Botulinum toxin A Botulinum toxin A, 10, 298, 298–9, 299, 300 brow lift and contouring, 312–13, 312–14 cervical indications, 328–9 conclusion, 329–34 crow’s feet, 116, 313–15, 314–15 depressor anguli oris, 324–6, 326 documentation of pretreatment status and procedural reporting, 329, 332–3 expanded uses of, 303–34 facial aesthetic enhancement, 328–9, 330–2 forehead rhytides, horizontal, 310–11, 310–12 glabellar rhytides, 305–10, 306–10 hypertrophic orbicularis, 315–17, 316–18 lid malposition and asymmetry, 319–22, 319–22 lower face treatment, 322–8, 325–6, 327, 328 masseteric hypertrophy, 327–8, 329 mental crease, 326, 327 mid-face treatment, 322, 323–4 mouth corners and chin, 326–7, 328 nasalis bunny lines, 322, 325 necklace lines, horizontal, 328 peau d’orange chin, 326, 327 perioral lip rhytides, 322–3, 325–6 periorbita, 304–17 complications, 317–19, 318–20 platysmal bands, vertical, 328, 330 upper eyelid ptosis, 319–22, 319–22

upper face, 304–17 Bourguet, Julian, 5 Bovine collagen, 10 Brow fat pad, 135–6 removal, 137–8, 139 Brow inferior limbus (BIL), 22 Brow lift, 67–77 aesthetics, 67, 68 algorithmic approach to surgical rejuvenation of the brow, 71, 72 anatomy, 67–9, 68–70 anterior hairline lift, 72, 73, 73 botulinum toxin, 312–13, 312–14 brow deformities, 70, 71 complications of, 76, 77 coronal, 7, 71–3, 72 direct, 72, 73–4 endoscopic, 75–6, 76 internal, 135–44 anatomic considerations, 135–6 complications, 139–42 indications, 136–7 results, 142, 143, 144 surgical technique, 137–9 limited incision, 72, 74, 74–5 postoperative care, 76–7 procedure, 72 temporal, 7 ﬁllers, 293, 293 Brow-to-fold distance (BFD), 94, 94 Brow upper lid (BUL), 22 Browpexy, 135 complications, 142 indications, 136–7 results, 142 technique, 138–9, 140–1 Browplasty, 135 complications, 142 indications, 136–7 results, 142, 143 technique, 137–8, 138, 139 Bunny lines, 322, 325 Bupivacaine, 125

C Calcium hydroxylapatite beads, 288–9, 289 Calvarial thickness, 68 Canthal sling, 245, 246 Cantholytic canthoplasty, 9–10 Canthopexy, 10, 245, 246

Index suture, 163, 164, 165 Canthoplasty, 9–10 Canthus see Lateral canthus; Medial canthus Capsulopalpebral fascia, 50, 50, 52 detachment of the septum from, 7 Carbon dioxide (CO2) laser, 271–3, 272 blepharoplasty, 9, 116 Cardiac monitoring, chemical peels, 257 Carotid arteries, 60, 61 Caruncle, 19 Celcus, Aulus Cornelius, 4 Cellulitis after laser resurfacing, 275 Cervical indications of botulinum toxin injections, 328–9 Char after laser resurfacing, 278 Cheek-midface lift, 10, 187–203 anesthesia, 188 complications, 200–1 conjunctival closure, 196, 196 dissection of cheek periosteum, 190–4, 191–3 fat repositioning completion, 199–200, 200 nasal and lower eyelid fat pads repositioning, 195, 196 orbicularis ﬂap formation, 196–8, 197–8 postoperative care, 200 preparation for surgery, 187 results, 201, 201–3 skin closure, 199, 200 skin dissection, 198–9, 198–200 surgical technique, 188–200, 188–200 tarsal strip procedure, 194–5, 194–5 Cheek(s) bags, 27, 41, 316–17 contour abnormalities, 7 examination in patient evaluation, 27 lift see Cheek-midface lift periosteum dissection, 190–4, 191–3 see also Malar; Midcheek anatomy Chemexfoliation see Chemical peel Chemical peel, 8, 251–63 agents for, 254–6 anesthesia, 257

combined with blepharoplasty, 259–60 complications, 261–3 contraindications, 254 crow’s feet, 116 grades of depth of, 252, 253 indications, 252–4 management after, 260, 260 patient monitoring, 257 patient selection, 252–4 pretreatment with retinoic acid and bleaching agents, 256 repeated, 260–1 skin cleansing, 256 skin evaluation, 254 technique, 257–9, 258 timing relative to surgery, 256 Chief complaint, 31–2 Chin botulinum toxin A, 326–7, 328 implant augmentation, 296, 297 peau d’orange, 326 Chromophores, 267, 267 Collagen, skin, 265 Collagen as a facial ﬁller, 10–11 bovine, 280, 280–2 complications, 282, 282 human, 283, 283–5, 284 porcine, 285 Colorado needle, 156, 156 Conjoined fascia, 50 Conjunctiva, 52 closure, cheek-midface lift, 196, 196, 197 dissection in upper eyelid retraction, 146–7, 147 reattachment, 149, 150 resection see Müller’s muscleconjunctival resection suturing, 107, 108–9, 128 Conjunctival goblet cells, 52 Consultation, 30 see also speciﬁc procedure Contact dermatitis after laser resurfacing, 275, 275 Cornea evaluation of the, 29–30 sensation, 29 staining, 29–30 Coronal brow lift, 7, 71–3, 72 Corrugator muscle, 47 botulinum toxin injection, 309 forehead lift, 7

resection and/or interruption of, 10 Corrugator supercilii, 69 Cosmetic Surgery: The Correction of Featural Imperfections, 5 CosmoDerm, 281 CosmoPlast, 281, 282 Counseling, preoperative, 107 Craniofacial soft tissue, 55–6 Crow’s feet, 116 botulinum toxin A, 116, 313–15, 314–15 patient evaluation, 40–1 resurfacing, 9

D Dacryoadenopexy, 7 De re Medica, 4 Depressor anguli oris, 324–6, 326 Depressor supercilii, 69 DermaDeep, 290–2 Dermal matrix grafts, 205–16 sizing, 211 DermaLive, 290–2 Dermalogen, 283, 283–5, 284 Dermatochalasis, 5, 25 after transconjunctival approach to lower eyelid orbital fat, 157 and blepharoptosis, 120 internal brow lift, 136 skin-muscle ﬂap approach, 181–5 upper eyelid, 79–85 eyelid crease reconstruction, 82–3, 83 isolation and excision of orbital fat, 81–2, 82 postoperative care, 84 postoperative complications, 84–5 preparation for surgery, 79–83 results, 85 sequelae, 84 skin marking, 79–80, 80, 81 skin-muscle excision, 80–1, 81, 82 surgical technique, 79–83 Dermis, 265 Desmarres retractor, 126–8, 127 Diazepam, 109 Diplopia, 28 Direct brow lift, 72, 73–4 Dissatisfaction after brow lift, 76

339

Index 340

Drug history, 22, 32 Dry eye symptoms, 8, 33, 43–4

E Ear cartilage grafts, 230, 231 Ecchymosis after upper eyelid dermatochalasis, 84 Eccrine sweat glands, 46 Ectropion after lower eyelid retraction, 213 cicatrical, 262, 278 iatrogenic, 9 involutional, 9 lower eyelid, 184–5 prevention of, 6 Edema after upper eyelid dermatochalasis, 84 idiopathic, 5 lower eyelid, 26 Eisler’s fat pad, 51–2 Electrons, 266 Endoscopic brow lift, 75–6, 76 Endotine Forehead 3.5, 76 Enophthalmos aging and, 16–17 progressive, 19 Entropion after lower eyelid retraction, 213 nasal, 213 Epicanthal folds in Asian patients, 112 Epicanthus palpebralis, 112 Epicanthus tarsalis, 112 Epidermis, 265 Epinephrine hard palate grafting, 207 Müller’s muscle-conjunctival resection, 125, 126 skin-muscle ﬂap approach, 182 transconjunctival approach to lower eyelid orbital fat, 156 upper blepharoplasty, 96, 96 upper eyelid crease creation, 109 upper eyelid retraction, 146 Erbium laser, 9, 271–3 Erythema after laser resurfacing, 277 prolonged after chemical peel, 261 Evolence, 285

Expectations, patient, 110 Exposure keratopathy, 321 External carotid artery, 60, 61 Eyebrow(s) aging and position of, 17, 17 comprehensive assessment, 34, 34, 35 deformities, 70, 71 examination in patient evaluation, 22–3, 23 position and volume, 90 posterior ﬁxation, 8 ptosis see Ptosis, eyebrow spatial relationships of the ideal, 67, 68 Eyelash(es) fullness and position, 38 loss of, 185 Eyelid crease reconstruction, 82–3, 83 see also Asian patients, upper eyelid crease/fold complex; Upper eyelid(s), crease Eyelid creaser, 24 Eyelid(s) anatomy of, 45–54, 46 asymmetry treatment, 319–22, 319–22 blood supply, 53–4, 54 contour abnormalities, 7 excision of excess skin see Blepharoplasty fat, 50–2, 51 indurated, 5 innervation, 53–4 laser skin resurfacing see Laser skin resurfacing lower see Lower eyelid(s) lymphatics, 53–4 malposition treatment, 319–22, 319–22 modern cosmetic surgery, 4–8 relaxed, 4 retraction after chemical peel, 262 retractors, 52, 53 support, 48 thickened, 5 upper see Upper eyelid(s) Eyeliner, tattooed, 8 Eye(s) appearance, 45 care after lower eyelid retraction, 213 differing size of, 43

dry see Dry eye symptoms gel masks, 76–7 protection from lasers, 268 size with aging, 16

F Face aging changes, 59, 60, 228, 279, 280 anatomy, 54–62 Asian patients, 107 dyskinesis, 33 examination in patient evaluation4, 27 fascial layers, 55, 56 general assessment of upper, 33–7, 34–7 laser skin resurfacing see Laser skin resurfacing skin, 56 weakness, 33 see also Cheek(s); Midcheek anatomy Facelift with chemical peel, 253 non-invasive, 293 see also Cheek-midface lift; Forehead lift; Midface lift with ﬁllers; Midfacial suspension Facial artery, 60 Facial balance, 233–5, 235 Facial contouring alloplastic see Alloplastic contouring botulinum toxin, 312–13, 312–14 Facial nerve, 54, 60–1, 61, 62, 70 Facial zones, 227, 228 Fasanella-Servat procedure, 131 Fascial layers of the face, 55, 56 Fat autologous as a facial ﬁller, 285, 285–6, 286 compartments of upper and lower orbit, 7 disappearance of, 230 eyelid, 50–2, 51 herniated orbital see Orbital fat, herniated lower eyelid, maintenance, 167– 73, 167–73 lower eyelid examination, 25–6 orbital see Orbital fat pad sculpting, 8

Index repositioning in lower blepharoplasty, 217–22, 218–22 retro-orbicularis oculi (ROOF), 10, 51, 94 suborbicularis oculi (SOOF), 10, 18, 51, 58 transplantation of, 230, 230 upper eyelid examination, 23 see also speciﬁc fat pads Fat autograft muscle injection (FAMI) technique, 285 Fat bags, 230–1 Fat pedicles, 219 Fat rebalancing, 285 Fillers, facial acrylic hydrogel, 290–2 aesthetic applications, 292–7 autologous fat, 285, 285–6, 286 and botulinum toxin A, 298–9 chin implant augmentation, 296, 297 collagen see Collagen as a facial ﬁller hyaluronic acid, 286–8, 287, 288 lip augmentation, 295–6, 296, 297 midface lift, 294–5, 295 non-permanent biodegradable, 280–2 peri-mental hollows, 296–7, 297 permanent, non-biodegradable, 289–92 poly-L-lactic acid, 289, 290, 291 polymethylmethacrylate (PMMA) microspheres, 289–90, 291 restoring the aging face, 279 silicone oil, 292, 292 tear trough deformity, 293–4, 294 temporal brow lift, 293, 293 Fitzpatrick classiﬁcation of skin, 254, 254 Focal granulomas, 213 Forehead aesthetics, 67, 68 examination in patient evaluation, 22–3, 23 structures of the, 69 wrinkles, 70, 72, 310–11, 310–12 Forehead lift, 7, 67–77 aesthetics, 67, 68 algorithmic approach to surgical rejuvenation of the brow, 71, 72

anatomy, 67–9, 68–70 anterior hairline lift, 72, 73, 73 brow deformities, 70, 71 complications of, 76, 77 coronal, 71–3, 72 direct, 72, 73–4 endoscopic, 75–6, 76 limited incision, 72, 74, 74–5 postoperative care, 76–7 procedure, 72 Frontalis muscle, 69, 70 botulinum toxin injection, 307, 310 brow ptosis, 70 effect on eyebrow shape, 136 forehead lift, 7 Frown lines, 10, 305, 306 see also Forehead, wrinkles Fuchs, Ernest, 4–5 Fungal infections after laser resurfacing, 275

G Gel eye masks, 76–7 Glabellar rhytides, 305–10, 306–10 Globe aging and the, 16 prominence, 34–7 Grafts allogenic dermal matrix spacer, 205–16, 212 autologous fat, 285, 285–6, 286 ear cartilage, 230, 231 hard palate see Hard palate grafting Granulomas, focal, 213

H Hard palate grafting, 205–16 anesthesia, 207 harvesting and grafting, 206–7, 210 obtaining, 211 postoperative care, 213 preparation for, 206 suturing to lower eyelid retractors, 210, 211–12 Hematoma after brow lift, 76 Hemorrhage, retrobulbar, 84, 85 Herniated orbital fat see Orbital fat, herniated Herpes simplex virus, 262

Herpetic infections after laser resurfacing, 275, 276 Hertel exophthalmometry, 34 Hindus, 4 History taking, 21–2, 31–3 Hooding, 37, 42 Horner’s muscle, 48 Horner’s syndrome, 52 Hotz trichiasis procedure, 7 Hyaluronic acid, 10–11, 286–8, 287, 288, 293 Hyaluronidase upper blepharoplasty with levator aponeurosis repair, 116 in upper eyelid crease creation, 109 Hydrocodone, 109 Hydroquinone, 256 Hyperpigmentation, 256, 261–2 after chemical peels, 254 after laser resurfacing, 276, 277 Hypopigmentation, 261 after chemical peels, 254 after laser resurfacing, 276–7

I Idiopathic edema, 5 Infection after brow lift, 76 after chemical peel, 262 bacterial, 262, 275 fungal, 275 herpetic, 276, 375 yeast, 262 Inferior orbital rim hollowing, 27 Inferior rectus muscle, 52 Inferior temporal fusion line (ITL), 69 Infraorbital artery, 53, 54, 60 Infraorbital nerve, 245, 245 Injectable agents for dermal soft-tissue augmentation, 279–300 acrylic hydrogel, 290–2 aesthetic facial application, 292–7 autologous fat, 285, 285–6, 286 calcium hydroxylapatite beads, 288–9, 289 chin implant augmentation, 296, 297 collagen, 280–2, 280–3 combination therapy, 298, 298–9, 299, 300 conclusion, 300 Dermalogen, 283–5, 284

341

Index 342

ﬁllers aesthetic facial application, 292–7 botulinum toxin and, 298, 298– 9, 299, 300 permanent, non-biodegradable, 289–92 restoring the aging face, 279 hyaluronic acid, 286–8, 287–8 lip augmentation, 295–6, 296 midface lift, 294–5, 295 non invasive lifts, 293 options available, 280–9 peri-mental hollows, 296–7, 297 poly-L-lactic acid, 289, 290, 291 polymethylmethacrylate (PMMA) microspheres, 289–90, 291 silicone oil, 292, 292 tear trough deformity, 293–4, 294 temporal brow lift, 293, 293 Innervation eyelids, 53–4 midcheek, 60–1 Internal brow lift see Brow lift, internal Internal carotid artery, 60 Internal maxillary artery, 60 Intra-ocular lenses, 10–11 Intraoral approach, tear trough implants, 248, 248–9

J Jessner’s solution formula, 259, 259 Juvederm, 295, 296

K Keratitis, exposure, 121 Keratopathy, exposure, 321 Kojic acid, 256 Kolle, Frederick, 5

L Lacrimal artery, 53, 54 Lacrimal gland, 52–3, 53 prolapsed, 7, 25, 117 secretory evaluation, 43–4 Lacrimal tubercle, 50 Lactosorb polymer, 76 Lagophthalmos, 28, 102 after brow lift, 76, 77

after chemical peel, 262 after upper blepharoplasty with levator aponeurosis repair, 121 botulinum toxin injection complications, 321 Laser skin resurfacing, 265–78 advantages and disadvantages, 277 anesthesia, 273 canthal support after, 164 complications of, 275–8 contraindications to, 273 drapes, 273 laser physics, 266–8, 267 laser safety, 268, 269 laser selection, 271–3 operative techniques, 271–4 patient preparation, 273 patient selection, 269–70 postoperative care, 274, 274–5 preoperative evaluation, 269–70 safety reminders, 273–4 skin marking, 273 treatment/application of laser, 274 Laser surgery carbon dioxide (CO2) laser, 9, 116, 271–3, 272 resurfacing, 9 scalpel-YAG laser blepharoplasty, 8–9 Lateral canthal raphe, 49 Lateral canthal tendon, 49 laxity, 26, 27 medialization of, 16 release of, 167 Lateral canthus, 9–10 anatomy of, 49, 49–50 dystopia, 43 support, 162 suspension suture, 8 Lateral orbital thickening, 49 Lateral palpebral artery, 53, 54 Lateral retinacular suspension, 163–4, 164, 165, 167–73 Levator aponeurosis, 7, 38, 52 aging and, 17 in blepharoptosis, 92 disinsertion of, 24 ethnic differences, 106 identiﬁcation of, 117 repair, 115–22 adjunctive procedures, 120 complications, 121 evaluation, 115–16

overcorrection treatment, 121 postoperative care, 120–1 results, 121–2, 121–2 surgical technique, 116–20, 118–19 undercorrection treatment, 121 upper eyelid crease, 116 separation of Müller’s muscle from, 125–6, 127 stripping, 149, 149 Levator labii superioris, 61, 62 Levator palpebrae superioris, 52 Lid-cheek junction (LCJ) aging and, 17, 18, 59, 60, 228 blending with orbicularis muscle, 161–79 Lid cheek segment, 58, 58 Lidocaine hard palate grafting, 207 Müller’s muscle-conjunctival resection, 125, 126 skin-muscle ﬂap approach, 182 transconjunctival approach to lower eyelid orbital fat, 156 in upper eyelid crease creation, 109 upper eyelid retraction, 146 Limbal goblet cells, 52 Limited incision brow lift, 72, 74, 74–5 Lipolytic diathermy, 8 LipoStructure®, 285 Lips augmentation, 295–6, 296, 297 depressors, 55 elevators, 55, 58, 59 rhytides, 322–3, 325–6 Local anesthesia Müller’s muscle-conjunctival resection, 125 in upper blepharoplasty, 96, 96 Lockwood’s ligament, 52 Lower eyelid(s) blepharoplasty see Blepharoplasty, lower eyelid examination of, 25–6, 27, 39–41, 40–2 excision of excess skin see Blepharoplasty fat examination, 25–6 herniated orbital resection, 155–60

Index maintenance, 167–73, 167–73 pads repositioning, 195, 196 transposition, 217–22, 218–22 herniation, 40 history of surgery on, 5–6, 6 laxity, 8, 26, 27, 41 malposition, 9 retraction, 184–5 after fat repositioning, 220 evaluation, 26, 27 treatment with recession of retractors, 205–16 complications, 213 postoperative care, 213 preparation for, 206 results, 213, 214–16 technique, 206–13, 208–10 retractors recession, 207 suturing allogenic dermal graft to, 212, 212 suturing hard palate graft to, 210, 211–12 skin-fat examination, 25–6 Lymphatics, eyelid, 53–4

M Malar augmentation, 10 Malar bags, 41, 316–17 Malar deﬁciencies, 237, 237 Malar mound, 58, 58 Malar region, 227 Malar suborbital deﬁciencies, 228–32 Margin crease distance (MCD), 24, 24 Margin reﬂex distance-1 (MRD1), 24, 26 after Müller’s muscle-conjunctival resection, 130 comprehensive assessment, 34 test, 124 upper eyelid retraction, 146 Margin reﬂex distance-2 (MRD2), 26, 27, 206 Margin reﬂex distance (MRD), 38 Margin to fold measurement (MFD), 38 Masseteric hypertrophy, 327–8, 329 Masseteric ligaments, 62 Maxillary hypoplasia, 34, 36, 41 Maxillofacial deformities, 232 Maximum permissible exposure (MPE), 268

Medial canthal tendon, 48–9, 49 attenuation, 26 Medial canthus anatomy of, 48, 48–9 in Asian patients, 112 Medial palpebral artery, 53, 54 Meibomian glands, 45–6, 52 Melanin, 267 Melanocytes, 252 Mental crease, 326 Microdroplet serial puncture technique, 292 Midcheek anatomy, 54–62 basic arrangement, 55–6 surface anatomy, 57–62 surgical applications of, 62 Midcheek furrow, 57, 58 Midface lift with ﬁllers, 294–5, 295 Midfacial suspension, 10, 232, 233, 234, 236, 236 Milia after laser resurfacing, 275–6, 277 Miller, Conrad, 5 Modern cosmetic eyelid surgery, 4–8 Moll’s glands, 46, 52 Motility restriction after fat repositioning, 220 after transconjunctival approach to lower eyelid orbital fat, 157–8 Motor deﬁciency after brow lift, 76 Mouth care after hard palate graft, 213 corners treatment, 326–7, 328 Mr Spock eyebrow, 316, 319 Müller’s muscle, 52 botulinum toxin injection complications, 321 contraction of, 317–19 dissection, 147–9, 148 excision, 149, 150 lower eyelid retraction, 207, 209 separation from levator aponeurosis, 125–6, 127 upper blepharoplasty with levator aponeurosis repair, 117 upper eyelid retraction, 146, 146 Müller’s muscle-conjunctival resection, 123–33 alternative techniques, 131 anesthesia, 125, 126 clamp application, 126–8, 127, 129 diagnosis and preoperative evaluation, 124

goals, 125 indications, 125 postoperative care, 128–30 results, 130, 131–3 securing and resection of conjunctiva and Müller’s muscle, 128, 129 separation of Müller’s muscle from levator aponeurosis, 125–6 skin marking, 125, 126 surgical technique, 125–8, 126–7, 129, 130 upper blepharoplasty, 128 Muscularis malaris, 47

N Nasal entropion, 213 Nasal fat pads repositioning, 195, 196, 199–200, 200 upper eyelid dermatochalasis, 81, 82 Nasalis bunny lines, 322, 325 Nasojugal groove, 19, 47, 57, 58 aging effects, 59 Nasojugal sulcus see Tear trough Nasolabial fold segment, 58, 58 Nasolacrimal duct, 53 Necklace lines, 328 Neosynephrine, 124 Neuromuscular junctions, 47 Newer Methods of Ophthalmic Plastic Surgery, 5 Noel, Suzanne, 6–7 Nominal hazard zone (NHZ), 268 Non-invasive lifts, 293

O Ocular asymmetry measuring device, 22–3, 23 Ocular damage after chemical peel, 261 Oculomotor motility testing, 28 Oculomotor nerve, 52 Ophthalmic artery, 53 Orbicularis ﬂap formation, 196–7, 197–8 Orbicularis oculi muscle, 47, 69 anatomy of, 46–7 blending the lid-cheek junction (LCJ) with, 161–79

343

Index 344

blepharoplasty, 7 crow’s feet, 313 debulking of, 94 evaluation, 41 excision, 102 exposure, 164 hypertrophic, 26, 315–17, 316–18 skin-muscle ﬂap approach, 181–5 incision and dissection, 169–70, 170 innervation, 61 manipulation of, 167 preservation of, 93, 94 suspension, 164, 171 upper eyelid dermatochalasis, 81, 81, 82 Orbicularis oris, 322–3, 324 Orbicularis retaining ligament, 47, 47, 58, 62 Orbit, adipose body of, 51 Orbital fat herniated, 4, 5, 26 excision in lower eyelid retraction, 207–11, 209, 210 skin-muscle ﬂap approach, 181–5 transconjunctival approach to resection of, 155–60 isolation and excision in upper eyelid dermatochalasis, 81–2, 82 repositioning, 195, 196, 199–200, 200 in lower blepharoplasty, 217– 22, 218–22 Orbital rim aging effects, 59, 60 inferior, 27 superior, 17, 67 Orbital septum see Septum orbitale

P Palpebral aperture, 315–16 Palpebral arteries, 53, 54 Palpebral ﬁssure shape, 45 width, 24–5, 25 comprehensive assessment, 34 evaluation of blepharoptosis, 38

Palpebral ligaments see Lateral canthal tendon; Medial canthal tendon Palpebromalar groove, 47, 57, 58 aging effects, 59 Pars lacrimalis, 48 Pars orbitalis, 46, 47, 47, 58 Pars palpebarum, 46–7, 47 Patient evaluation, 21–30 cheek and face examination, 27 comprehensive, 31–44 asymmetry assessment, 43 general upper facial assessment, 33–7, 34–7 history, 31–3 lacrimal secretory evaluation, 43–4 lower eyelid examination, 39–41, 40–2 photographic assessment, 44 upper eyelid examination, 37–9, 38–9 visual ﬁeld testing, 44 consultation, 30 cornea evaluation, 29–30 forehead and eyebrow examination, 22–3, 23 history taking, 21–2 lower eyelid examination, 25–6, 27 ocular motility testing, 28 photographic assessment, 29 skin evaluation, 27 tear secretion evaluation, 28, 28 upper eyelid examination, 23–5, 24, 25, 26 visual acuity determination, 28 visual ﬁeld evaluation, 28–9, 29 Peau d’orange chin, 326 Peri-mental hollows, 296–7, 297 Perioral lip rhytides, 322–3, 325–6 Periosteum, cheek see Cheek(s), periosteum dissection Phenol, 253, 254, 255, 257 Phenylephrine test, 124 Phorias, 28 Photography comparisons for aging observations, 16 patient evaluation, 29, 44 Photons, 266 Physical examination, 33 Pinch technique, 96, 96 Platysma, 328 Platysmal bands, vertical, 328, 330

Poly-L-lactic acid, 289, 290, 291 Polymethylmethacrylate (PMMA), 10–11 microspheres, facial ﬁller, 289–90, 291 Polypropylene sutures, 11 Postoperative care brow lift, 76–7 cheek-midface lift, 200 hard palate graft, 213 laser skin resurfacing, 274, 274–5 lower eyelid retraction, 213 Müller’s muscle-conjunctival resection, 128–30 skin-muscle ﬂap approach, 184 transconjunctival approach to lower eyelid orbital fat, 157 upper blepharoplasty with levator aponeurosis repair, 120–1 upper eyelid crease creation, 110 Postseptal fat, 50–2, 51 Preaponeurotic fat pads, 51, 102 in Asian patients, 106–7, 110 sculpting, 117 Precanthal web, 49 Premedication for upper eyelid crease creation, 109 Preoperative counseling in Asian patients, 107 Preoperative evaluation Müller’s muscle-conjunctival resection, 124 upper blepharoplasty, 115–16 Preseptal fat, 50–2 Preseptal skin, 46, 46 Pretarsal extension of the levator, 50 Pretarsal skin, 46, 46 Prezygomatic space, 56, 57, 58 Procerus muscle, 47, 69 forehead lift, 7 resection and/or interruption of, 10 Proparacaine, 109 Pruritis after laser resurfacing, 275 Psychological implications of cosmetic surgery, 7 Ptosis aging and, 16 brow, 6 eyebrow assessment, 67 asymmetry, 136, 136

Index description of, 90 development of, 70, 71 frontal illustration of, 137 patient evaluation, 22, 23 supraciliary brow incision, 6 upper lid arc, 17, 17 face, 27 postoperative, 84, 85 preoperative recognition, 115 upper eyelid see Blepharoptosis see also Müller’s muscleconjunctival resection Ptosis adiposa, 4–5 Ptosis atonica, 5

R Radiance, 296 Radiesse, 288–9, 289 Relaxed eyelid, 4 Resorcinol, 254 Restylane, 295, 296, 297 Retaining ligaments, 56, 57 see also speciﬁc ligament Retinoic acid (Retin-A), 254, 256 Retractors, eyelid, 52, 53 see also Lower eyelid(s), retraction; Lower eyelid(s), retractors; Upper eyelid(s), retraction Retro-orbicularis oculi fat (ROOF), 51 excision of, 94 resection, 10 Retrobulbar hemorrhage, 84, 85 Rhytides forehead, 9, 10–11, 70, 72, 310– 11, 310–12 glabellar, 305–10, 306–10 perioral lip, 322–3, 325–6 temporal see Crow’s feet Risorius muscle, 324, 327

S Salicylic acid, 254 Scalp numbness after brow lift, 77 Scalpel-YAG laser blepharoplasty, 8–9 ScanlanTM, 116 Scarring after brow lift, 76, 77 after chemical peel, 262 after laser resurfacing, 277–8 Schirmer tear test, 8, 28, 28 Sculptra, 289, 290, 291

Sebaceous glands, 46 Sensory loss after brow lift, 76 Septum orbitale anatomy of, 50, 50 in Asian patients, 110 in blepharoptosis, 92 ethnic differences, 106 identiﬁcation of, 117 penetration of, 139 upper eyelid dermatochalasis, 81, 82 Silicone oil, 292, 292 SILVERGlideTM bayonet electrocautery forceps, 117 Skeleton, facial, 55, 55 Skin aging changes in, 17 cleansing, chemical peels, 256 closure, cheek-midface lift, 199, 200 dissection, cheek-midface lift, 198–9, 198–200 evaluation of, 27 for chemical peels, 254, 254 eyelid anatomy, 45–6, 46 facial, 56 lower eyelid examination, 25–6 preseptal, 46, 46 pretarsal, 46, 46 upper eyelid examination, 23 Skin-muscle ﬂap approach complications, 184–5 herniated orbital fat, 181–5 hypertrophic orbicularis muscle, 181–5 lower eyelid dermatochalasis, 181–5 postoperative care, 184 preparation for surgery, 181 results, 185, 185 surgical technique, 182–4, 182–4 upper eyelid dermatochalasis, 79–85 eyelid crease reconstruction, 82–3, 83 isolation and excision of orbital fat, 81–2, 82 postoperative care, 84 postoperative complications, 84–5 preparation for surgery, 79–83 results, 85 sequelae, 84

skin marking, 79–80, 80, 81 skin-muscle excision, 80–1, 81, 82 surgical technique, 79–83 Skull, bony landmarks of, 68, 68 Smoker’s lines, 322–3, 325–6 Soft tissue augmentation, 10–11 layers of the face, 55–6 midcheek, 58–9 see also Injectable agents for dermal soft-tissue augmentation Solid carbon dioxide, 254 Spacer grafts, 205–16 sizing, 211 Spaeth, Edmund, 5 Splotchy hyperpigmentation, 261–2 Subciliary approach, tear trough implants, 238–46, 245, 246 Suborbicularis fascia penetration of, 139 upper eyelid dermatochalasis, 81, 82 Suborbicularis ﬁbrosis, 93 Suborbicularis oculi fat (SOOF), 10, 51, 58 aging and, 18 Suborbicularis plane, 218 Suborbital deﬁciencies, 237 Suborbital maxillary volume, 228–32 Suborbital region, 227 Suborbital sulcus, 230, 232 Subperiosteal plane, 218, 220 Sulfur solutions, 254 Superﬁcial leaf of the lateral canthal tendon, 49 Superﬁcial musculoaponeurotic (SMAS) layer, 47, 55, 56, 61 Superﬁcial temporal artery, 53, 60, 69 Superﬁcial temporal fascia (STF), 69, 70 Superior orbital rim brow ptosis assessment, 67 loss of soft tissue volume, 17 Superior temporal fusion line (STL), 69 Supraciliary brow incision, 6 Supraorbital artery, 136 Supraorbital nerve, 69, 74, 74, 136, 138

345

Index 346

Supraorbital notch, 137, 138 Supraorbital vessel, 69 Supraperiosteal plane, 220 Supratarsal ﬁxation, 102 Supratarsal skin crease, 46 Supratrochlear nerve, 69 Supratrochlear vessel, 69 Suture canthopexy, 163, 164, 165 Suture cysts, 85, 185 Suture tarsorrhaphy, 173, 173 Sutures barbed, 10 browpexy, 138–9 lateral canthal suspension, 8 Müller’s muscle-conjunctival resection, 128 polypropylene, 11 rapid-absorbing gut, 9 skin-muscle ﬂap approach in upper eyelid dermatochalasis, 83, 83 upper eyelid crease creation, 110 Sweat glands, 46 Swiss Eye Therapy masks, 76–7

T Tarsal goblet cells, 52 Tarsal strip procedure, 8, 9, 167 cheek-midface lift, 194–5, 194–5 Tarsorrhaphy, 173, 173 Tarsus anatomy of, 50 suturing allogenic dermal graft to, 212, 212 suturing hard palate graft to, 210, 211–12 Tattooed eyeliner see Blepharopigmentation TCA see Trichloroacetic acid (TCA) Tear trough, 8 deformity, 217–18 ﬁllers, 293–4, 294 description of, 228 implants, 232, 234, 235 intraoral approach, 248, 248–9 subciliary approach, 238–46, 245, 246 technique, 239–48 transconjunctival approach, 246–7, 247

Tear(s) function after blepharoplasty, 8 secretion test, 28, 28 see also Lacrimal gland Temporal artery, 61 Temporal fossa, 68, 69 Temporal fusion line (TL), 69 Temporal lift, 7 Temporal ridge, 67–8 Temporalis fascia (TF), 69, 70 grafts, 230, 230 Temporalis muscle grafts, 230, 230 Tetracaine, 146–7 Thermal burns, 267 Thyroid disease, 21–2 cheek bags and depressions, 27 lower eyelid retraction, 26, 213, 214, 216 transconjunctival approach to lower eyelid orbital fat, 159 upper eyelid retraction, 149, 150, 151 Titanium screws, 76 Transconjunctival approach blepharoplasty, 9 lower eyelid orbital fat, 155–60, 167–73, 167–73 anesthesia, 156 complications, 157 postoperative care, 157 results, 158–60, 159 surgical technique, 156, 156–7, 157, 158 tear trough implants, 246–7, 247 Transverse facial artery, 60 Trichloroacetic acid (TCA), 254, 255 application of 35%, 257–9 chemical peels, 253 exfoliation, 8 Tropias, 28

U Upper eyelid creaser, 24, 25 Upper eyelid(s) aging changes in, 17 anatomy, 106, 106–7, 107 in Asian patients, 106–7 blepharoplasty see Blepharoplasty, upper eyelid crease, 90–1

in Asian patients see Asian patients, upper eyelid crease/fold complex in blepharoplasty with levator aponeurosis repair, 116 examination, 23–4, 24, 25 crease-fold complex, 7 dermatochalasis see Dermatochalasis, upper eyelid examination, 37–9, 38–9 excess fold, 4 excess skin see Dermatochalasis excision of excess skin see Blepharoplasty fold, 90–1 history of surgery on, 5, 6 loss of soft tissue volume, 17 patient evaluation, 23–5, 24, 25, 26 ptosis see Blepharoptosis retraction evaluation, 25 internal approach to, 145–51 anatomy, 146, 146 anesthesia, 146, 147 comments, 149–51 conjunctival dissection, 146–7, 147 conjunctival reattachment, 149, 150 levator stripping, 149, 149 margin reﬂex distance-1 (MRD1), 146 Müller’s muscle dissection, 147, 147–8, 148 Müller’s muscle excision, 149, 150 results, 150–1, 151 surgical technique, 146–9, 146–9 skin-fat examination, 23 soft tissue herniation, 37

V Veins, eyelid, 54 Vermilion plane, 282 Visual acuity, determination of, 28 Visual ﬁelds evaluation, 28–9, 29, 44

W Whitnall’s ligament, 49, 52 Whitnall’s tubercle, 49, 52

Index Wounding agents, 254–6 Wrinkles see Rhytides

Y Yeast infections, 262

Z Zeis’ glands, 46, 52 Zone of ﬁxation, 68, 68 Zyderm, 280–1, 282, 286 lip augmentation, 295 Zygoma, 58

Zygomatic ligaments, 62 Zygomaticus major, 62 Zygomaticus minor, 62 Zygomaticus muscles, 55, 62 Zyplast, 280–1, 282, 286 lip augmentation, 295

347