plastic and reconstructive surgery || anesthesia and critical care

AbbreviationsMRD Margin refl ex distanceROOF Retro-orbicularis oculi fatSOOF Suborbicularis oculi fatSMAS Superfi cial muscular aponeurosis system

IntroductionThe eyelids and periorbital area are a common focal point during human interaction.2 This area is also frequently the one that fi rst demonstrates facial aging. Laugh lines, at fi rst, present only with animation but are ultimately visible at rest. This

specifi c manifestation is particularly noted in fair-skinned (Fitzpatrick Type I and II) females. With increasing age, the lateral brows descend more rapidly than the medial brows because of a lack of lateral muscular support. With age, the orbital septum, a distensible anatomical layer of the eyelid, weakens. The orbicularis muscle and the supporting ligaments of the eyelid also lose elasticity. The contents of the orbit produce a downward and anterior displacement of the orbital fat because of the loss of this septal and muscular support of the fat pads.

There is also adjacent loss of fat over the medial and central orbital rim. These changes result in a “dark circle below the eye” commonly referred to as the nasojugal groove or tear trough deformity. Dehiscence or weakness of the levator aponeurosis may also cause an involutional upper eyelid ptosis associated with dermatochalasis (Figure 22.1).

The eyelids themselves act to protect the ante-rior surface of the globe and aid in the regulation of light reaching the eye. Additionally, they dis-tribute the protective and optically important tear fi lm over the cornea during blinking and maintain tear fl ow by a pumping action on the conjunctival and lacrimal sacs. Over-resection of upper eyelid skin may cause the patient with mild or asymptomatic dry eye to become symptom-atic. This may result in discomfort or excessive tearing. Lid malposition, the most common com-plication following lower eyelid surgery may also result in eye irritation or excessive tearing.15

22Eyelid and Periorbital Aesthetic SurgeryColin M. Morrison, Claude-Jean Langevin, and James E. Zins

SummaryThe eyelids and periorbital area are important aesthetic facial subunits as well as sensitive projectors of facial aging. Brow ptosis, eyelid ptosis, dermatochalasis, fat herniation or pro-trusion, tumors and trauma can critically alter the anatomical relationships in this region. Aging may also convey an inaccurate message of tiredness, anger, or sadness, diminishing the overall aesthetic appearance of the face.

This chapter describes the relevant eyelid and periorbital anatomy, techniques, and potential complications resulting from cosmetic surgical procedures performed in this area.

M.Z. Siemionow and M. Eisenmann-Klein (eds.), Plastic and Reconstructive Surgery, 297Springer Specialist Surgery Series, © Springer-Verlag London Limited 2010

PLASTIC AND RECONSTRUCTIVE SURGERY

298

Surgical AnatomySurface Landmarks

The soft tissue cephalometric dimensions of the periorbital area are different in men and women. Typically, male brows are lower and less arched. The medial brow in both sexes begins at the level of the supraorbital rim, and the eyebrow peaks at the lateral two-thirds, going from medial to lat-eral. Ideally, the lateral end of the eyebrow fi n-ishes at a higher level than the medial brow.35

The orbit is a transverse oval shape, with a slight 2–4° upward lateral tilt to the palpebral fi s-sure.1,32 Aesthetically appealing eyes have an almond shape with associated supratarsal full-ness (Figure 22.2). The ideal canthal angle is 2 mm higher than the medial canthus in Europeans and 3 mm higher in Asians.

Globe position (hypoglobus, hyperglobus) and globe protrusion (proptosis, exophthalmos) should be evaluated. Asymmetry of globe position may alter the appearance of the superior sulcus, and surgery alone may not necessarily correct this.

The upper eyelid skin crease is formed by the attachment of the superfi cial insertion of levator aponeurotic fi bers into the dermis. In Caucasian women, the crease is usually 8–11 mm above the lid margin, and in Caucasian men, usually 6–9 mm. Some asymmetry in margin crease distance may result from disinsertion of the levator aponeuro-sis, and this should be noted before surgery.

In contrast, the Asian eyelid has more fullness of the upper eyelid, narrower palpebral fi ssures, and a lower lid crease. The lower lid crease is due to the insertion of orbital septum into the leva-tor at or over the anterior surface of the tarsus and a lower insertion or absence of levator fi ber insertion into the dermis.7 A medial epicanthal fold may also be present.

The lower lid extends below the inferior orbital rim to join the cheek. However, the defi nition of the lid–cheek junction is controversial. It may be defi ned either by the junction of eyelid skin and cheek skin18 or by surface contour change.9,25 In young people, the change at the lower lid cheek junction is at or above the infraorbital rim, whereas it falls below this level with advancing age.

Figure 22.1. Aging eyelids and periorbital region.

EYELID AND PERIORBITAL AESTHETIC SURGERY

299

The nasojugal fold located at the lower lid–cheek junction runs inferiorly and laterally from the medial canthal region, forming the tear trough. The malar fold runs inferiorly and medi-ally from the outer canthus toward the inferior aspect of the nasojugal fold.

In adults, the upper lid margin rests 1.5 mm below the limbus, and the lower eyelid margin rests at the level of the lower limbus.

Structures

The anatomy of the connective tissues of the temporal and periorbital areas has been previ-ously described in detail in several studies. These articles describe the relationship of the connec-tive tissue planes to local nerves and vessels.17,23

The eyelids themselves are composed of skin, orbicularis oculi muscle, the orbital septum, preaponeurotic fat, the tarsi, lid retractors of the upper and lower eyelids, and the conjunctiva.

The upper and lower lids, however, may be con-sidered analogous structures, with differences only in the arrangement of the lid retractors.

In eyelid reconstruction, it is more useful to consider the repair of the anterior and posterior lamellae, with the anterior lamella being the skin and orbicularis and the posterior lamella being the tarsus and conjunctiva. The middle lamella consists of the orbital septum.

Orbicularis Oculi Muscle

The orbicularis oculi muscle is one of the super-fi cial muscles of facial expression. It is invested by the superfi cial musculoaponeurotic system (SMAS), and muscle contraction is translated into movement of the overlying skin by fi brous septa extending from the SMAS into the dermis. The muscle may be divided into an orbital and palpebral part, with the latter being further sub-divided into preseptal and pretarsal components. The orbital portion is used in forced closure, whereas the palpebral portion is used in blink-ing and voluntary winking (Figure 22.3).

Orbicularis muscle fi bers extend superiorly to interdigitate with the frontalis and corruga-tor supercilii muscles. Innervation is from the temporal and zygomatic branches of the facial nerve. The nerves are orientated horizontally and innervate the muscle from its deep surface.

The lateral canthus is the tendinous inser-tion of the orbicularis oculi muscle into the lateral orbital rim. The canthus is composed of an inferior retinaculum that is in continuity with the lower lid and an upper retinaculum that is in continuity with the upper lid. The superior and inferior canthal extensions fuse to form a common band that inserts into Whitnall’s tubercle inside the lateral orbital rim (Figure 22.4).

Submuscular Areolar Tissue

Submuscular areolar tissue consists of variable loose connective tissue below the orbicularis oculi muscle. This submuscular plane continues superiorly and terminates at the retro-orbicu-laris oculi fat (ROOF), which is most pronounced in the eyebrow region. The suborbicularis oculi fat (SOOF) found in the lower lid is the continu-ance of this plane inferiorly.

Figure 22.2. The female brow slopes superiorly from medial to lateral paralleling the palpebral fi ssure. There is at least 1 cm between upper eyelid crease and lower brow lashes.


300

Figure 22.3. Anatomic dissection of the eyelid. The skin and malar fat pad were removed exposing the orbital and palpebral orbicularis oculi muscle. The temporalis and zygomatic branches of the facial nerves innervate this muscle.

Figure 22.4. Lateral canthus. (a) Superior and inferior canthal extensions form a common band that inserts into Whitnall’s tubercle located 1.5–3 mm posterior to the lateral orbital rim. (b) Lower lid distraction test: Distraction greater than 6 mm from the globe indicates lid laxity and is an indication for lid support if lower eyelid surgery is planned.

a b

Lateral Canthus

Eisler'sFat Pad


301

Tarsal Plates

The tarsal plates are responsible for the struc-tural integrity of the eyelids. They are composed of fi brous tissue and sebaceous meibomian glands. Each tarsus is approximately 29 mm long and 1 mm thick. The crescentric superior tarsus is 10 mm high centrally, narrowing medially and laterally. The smaller rectangular inferior tarsus is 3.5–5 mm high. The medial and lateral ends of the tarsi are attached to the orbital rims by the medial and lateral canthal tendons (Figure 22.5).

From an aesthetic and reconstructive view-point, the lateral canthal tendon is a vital struc-ture. It passes deep to the septum orbitale to insert into the lateral orbital tubercle 1.5–3 mm posterior to the orbital rim and 10 mm inferior to the frontozygomatic suture. The Eisler fat pocket lies between the orbital septum and the lateral canthal tendon (Figure 22.4).

Orbital Septum

The orbital septum is a fi broelastic structure that attaches at the periphery of the entire orbital rim. The arcus marginalis represents the confl u-ence of the orbital septum and periosteum. Centrally the orbital septum fuses with the lid retractor structures near the lid margins, acting

as a diaphragm to retain the orbital contents. In the lower lid, the upper septum is reinforced by capsulopalpebral fascia. Conjoined septum and capsulopalpebral fascia then attach to the inferolateral orbital rim as the arcuate expan-sion. The lower part of the orbital septum has no such reinforcement and is consequently weaker.

Upper Lid Retractors

The levator palpebra superioris arises from the under surface of the lesser wing of the sphe-noid bone. It passes anteriorly for 40 mm and then continues as an aponeurosis, changing to a more vertical direction at the superior transverse (Whitnall’s) ligament (Figure 22.6).

The aponeurosis fuses with the orbital septum before reaching the superior border of the tarsal plate. Some aponeurotic fi bers descend to insert into the lower third of the anterior surface of the tarsal plate. An anterior extension from this fusion inserts into the pretarsal orbicularis oculi muscle and over-lying skin, forming the upper lid skin crease.

Müller’s muscle is smooth muscle innervated by the sympathetic nervous system. Fibers originate from the under surface of the levator in the region of the aponeurotic–muscle junction, travel inferiorly between the levator aponeurosis and conjunctiva, and insert into the superior margin of the tarsus.

Figure 22.5. (a) The tarsal plate of the upper eyelid is crescentric in shape and approximately 10 mm in height. (b) The inferior tarsus has a rectangular confi guration and is 3.5–5 mm high. Note the lower lacrimal punctum.

a b


302

Lower Lid Retractors

The lower eyelid retractor is a fascial extension of the inferior rectus muscle. It splits to envelop the inferior oblique muscle and reunites as the inferior transverse (Lockwood’s) ligament. The fascial tissue then passes anterosuperiorly as the capsulopalpebral fascia and inserts into the infe-rior border of the inferior tarsus. The orbital septum fuses with the capsulopalpebral fascia approximately 5 mm below the inferior tarsal border. Sympathetically innervated smooth muscle fi bers are also noted in the lower eyelid and constitute the inferior tarsal muscle.

Fat Pads

In the upper eyelid, preaponeurotic fat is found immediately deep to the orbital septum and anterior to the levator aponeurosis. A central fat pad and a medial fat pad are described.13 The medial fat pad is pale yellow or white, whereas the central fat pad is yellow and broad. A portion of the lateral end of the central fat pad surrounds the medial aspect of the lacrimal gland.

The lacrimal gland has a pinkish lobulated fi rm structure. The gland’s anterior border is normally just behind the orbital margin, but involutional changes may lead to prolapse anteroinferiorly,

Figure 22.6. (a) The levator palpebra superioris muscle with the levator aponeurosis inserting into superior tarsal plate. Note the levator aponeurosis dehiscence between the levator muscle and the superior tarsus. (b) The Whitnall’s ligament forms a fi brous connective tissue sleeve surrounding the levator muscle. It acts as a fulcrum for upper eyelid function.

a

LevatorMuscle

MusculoaponeuroticJunction

LevatorDehiscence

Whitnall’sLigament

SuperiorTarsus

b


303

which is prominent on external lid examination. Three retroseptal fat pads are found in the lower eyelid. The medial and central fat pads are sepa-rated by the inferior oblique muscle. The muscle’s location makes it susceptible to injury during sur-gical dissection of the surrounding fat pads. The middle and lateral fat pads are separated by the arcuate expansion, the conjoined septum, and capsulopalpebral fascia extending to the infero-lateral orbital rim (Figure 22.7).

Clinical ExaminationClinical examination includes visual acuity, ocular motility, visual fi eld testing, and basic tear secre-tion testing using the Schirmer’s test. The Schirmer’s test is performed by placing a strip of fi lter paper over the lateral third of the lower lid conjunctiva and measuring the wetting on the strip after 5 min. If the measurement is less then 10 mm, the patient may have diffi culty producing tears, predicting postoperative dry-eye problems. The value of the Schirmer’s test is, however, controversial.

Examination of the patient should include an evaluation of specifi c landmarks, including palpe-bral fi ssure distance; margin refl ex distance-1 (MRD1), which is the distance between the center of the pupil in primary position and the central margin of the upper eyelid; and margin refl ex dis-tance-2 (MRD2), which is the distance between the center of the pupil in primary position and the central margin of the lower eyelid. Ptosis of the upper eyelid should be suspected when the palpebral distance is less than 10 mm and MRD1 is less than 4 mm (Figure 22.8).

The individual components of the periorbital region are thoroughly assessed before surgery. The relationship of the brow position to the upper lid determines whether an isolated upper lid blepharoplasty is suffi cient or whether brow position adjustment is necessary to achieve the desired results. This is done with the patient in an upright position and with the patient looking in a mirror to help judge how brow position affects the upper eyelid.

Once brow position has been determined, the surgeon assesses the components of excess skin,

Figure 22.7. Upper and lower orbital fat pads.


304

skin laxity, and fat herniation in the eyelids. The most effective means of assessing excess lower eyelid skin is by asking the patient to look upward without moving their head. This stretches the skin and gives the surgeon an idea of how much redundant skin is present. Herniation of all the fat pads is also best tested with the patient’s eyes in an upward gaze. Excess or herniated fat causes a protrusion or convex contour. Finally, careful assessment of lower lid tone is essential in all patients. A lax lower lid is an indication for lateral canthopexy, canthop-lasty or wedge excision in some patients14,16,20 (Figure 22.4).

The patient with a negative vector on clinical examination should be approached with care as such patients are at signifi cant risk for the post-operative complications of scleral show or ectro-pion (Figure 22.9).

Figure 22.8. Margin refl ex distance 1 and 2. An MRD1 less than 4 mm is indicative of upper eyelid ptosis.

Figure 22.9. A negative vector is present when the corner of the globe is anterior to the anterior-most surface of the malar soft tissue prominence.


305

Surgical TechniquesBrowlift

Brow position may be corrected by either endo-scopic or open techniques. The endoscopic fore-head lift has gained signifi cant popularity, because it avoids the long coronal or hairline incision associated with coronal and hairline browlifts, respectively. Although it has many enthusiastic proponents,4,10,24 it has also been criticized by others for its lack of correction and longevity.33,34 There are those who have given up this technique entirely.

Endoscopic Browlift

The endoscopic browlift can be performed in the subperiosteal or the subgaleal plane. Our prefer-ence is to use the subperiosteal plane for both the ease of dissection and the enhanced endo-scopic visualization. Because the skull is light in color, it refl ects light from the endoscope and provides greater illumination during the proce-dure (Figure 22.10).

The operation is begun with a temporal inci-sion made within the hairline approximately 1.5 cm in length. This incision is located on a line from the alar base to the lateral canthus. Once an optical cavity is developed under direct vision, the 5-mm endoscope is introduced, and dissec-tion is continued to the temporalis fascia proper and then either to the intermediate fascia or just deep to the intermediate fascia, to the lateral

orbital rim. Signifi cant subperiosteal release needs to be performed along the lateral orbital rim to the lateral canthus and along the proximal portion of the zygomatic arch. An identical dis-section is performed on the opposite side. Four scalp incisions are then made in the hairline cor-responding to the medial and lateral orbital brow on each side. The subperiosteal dissection is continued to the arcus marginalis and the arcus marginalis is released in its entirety. Care is taken to protect the deep branch of the supraorbital nerve.22 Muscle modifi cation is performed by partial or total resection of the corrugator and, if desired, procerus muscles.

Although the need for bony fi xation is contro-versial, we do fi x the brow through the lateral incisions using a cortical tunnel technique, sutur-ing the under surface of the brow fl ap through the cortical tunnel. Fixation of the temporalis fascia proper on the right and left sides is also performed, suturing superfi cial temporalis fascia superiorly and posteriorly through the temporal incisions on the right and left sides, respectively (Figure 22.11).

Open Browlift

In the case of the high forehead (7 cm or greater), the hairline browlift is preferred, since the brow can be elevated and the forehead lowered simul-taneously. This is done through a hairline inci-sion in the forehead area with extensions into the hair-bearing temporal region. Dissection can be performed in the subgaleal or in the subcuta-neous plane over the non-hair-bearing skin. Subgaleal dissection is carried out in the non-hair-bearing areas. Injury to hair follicles is pos-sible in the subcutaneous plane (Figure 22.12).

Upper Lid Blepharoplasty

TranscutaneousPlanned skin excisions are marked preopera-tively with the patient in the upright position. The lid crease incision is marked fi rst, just below the eyelid crease in the upper lid. The crease is curvilinear, with the arc of the incision peaking just medial to the central point of the eyelid. Nasally, the incision extends no further than an imaginary line projected upward from the medial punctum, to avoid potentially unsatisfactory

Figure 22.10. Endoscopic view of corrugator muscle using a 5-mm, 30° endoscope during endoscopic browlift. CO

2 laser was used to partially

ablate the corrugator.


306

scarring in the medial canthal region. The tem-poral aspect of incision is then curved gently upward in a natural skin crease, being careful not to extend this mark beyond the orbital rim.

Lateral extension may also result in a more prominent and visible scar.

One then gets the patient to gently close the eyelids. A smooth forceps is used to grasp the

a b

Figure 22.11. (a) Preoperative view of 57-year-old female with eyebrow ptosis and facial aging. (b) One-year postoperative view following endo-scopic browlift, facelift with extended SMAS, and fat injections to cheeks.

Figure 22.12. (a) Preoperative view of 63-year-old patient with facial aging, eyebrow ptosis, deep corrugator rhytids, and a high forehead. (b) One-year postoperative view following hairline browlift, lower lid blepharoplasty, and facelift with extended SMAS dissection and autologous fat injec-tions to cheek and infraorbital areas.

a b


307

excess skin above the eyelid crease incision until the eyelashes begin to rotate upward. This point is marked as the maximum amount of skin that may be safely removed. It is important that the superior border of the incision should pass no closer than 1 cm from the inferior border of the brow hairs. This prevents excess skin removal that may cause lagophthalmos and also prevents the blepharoplasty excision from causing down-ward traction on the brow position.

Next, one presses on the globe to observe pro-trusion of the fat pockets. Protrusion or prolapse of the lacrimal glands is also noted. The location and amount of sub-brow fat is assessed and con-sidered for surgical contouring. This is especially relevant in the absence of a browlift procedure.

Upper lid blepharoplasty is performed using a scalpel or by CO

2 laser incisional techniques.5,26

Local infi ltration with lidocaine and adrenaline placed subcutaneously provides suffi cient anes-thesia. In addition, a protective scleral shell may be placed over the surface of the eye after topical administration of tetracaine. The excess skin is removed, either alone or with part of the under-lying orbicularis muscle.

Removal of eyelid skin, sub-brow fat, recon-struction of the eyelid crease, eyelid ptosis cor-rection, brow ptosis correction, modifi cation of the glabellar wrinkles, or resuspension of the lacrimal gland may all be performed through this lid crease incision.36

After exposure or excision of part of the orbic-ularis muscle, one identifi es the orbital septum.

When necessary, the orbital septum is opened to expose the preaponeurotic fat. In the upper eye-lid, two fat pockets are present: one central and the other medial. When gentle pressure is placed on the globe, the fat tends to protrude through the open septum. The medial fat pad has a pale white color, distinct from the deeper yellow of the cen-tral fat pad. Fat is excised as necessary to achieve the desired correction in contour.

If the lacrimal gland is found to be protrud-ing, suturing it back in position inside the orbital rim prevents postoperative fullness in the lateral aspect of the upper eyelid.

To alter or emphasize the eyelid crease, a supratarsal fi xation suturing technique is used to create adherence between the skin and under-lying tissue. This is accomplished by attaching the subcutaneous tissue at the lower aspect of the eyelid crease incision to the levator aponeu-rosis just above the tarsus.

Commonly used materials for skin closure include nonabsorbable sutures, such as 6-0 nylon or 6-0 polypropylene, in a running subcuticular fashion, interrupted fashion, or in an external running fashion. Alternatively, 6-0 plain catgut may be used as an absorbable suture. All sutures are removed in 3–5 days (Figure 22.13).

Lower Lid Blepharoplasty

Lower lid blepharoplasty alone does not eradi-cate fi ne skin wrinkling, regardless of which technique is used. This issue is better addressed

Figure 22.13. (a) Preoperative 56-year-old patient with skin excess of the upper lids and eyebrow ptosis. (b) One year following endoscopic browlift. (c) Two years following endoscopic browlift and 1 year following upper lid blepharoplasty and facelift with extended SMAS dissection.

a b c


308

when the blepharoplasty is combined with either CO

2 laser resurfacing or phenol-croton oil peel-

ing. Numerous publications have described the combined use of CO

2 laser and transconjunctival

blepharoplasty. Although Seckel has described as much as 30% skin contraction with CO

2 laser

resurfacing, our experience is that this skin con-traction is short lived.27 However, the improve-ment in hyperpigmentation can be dramatic and longstanding. The other attractive alternative is the combination of transconjunctival blepharo-plasty and phenol-croton oil peeling, pinch blepharoplasty and phenol-croton oil peeling, or secondary phenol-croton oil peeling after trans-cutaneous lower lid blepharoplasty. This leads to signifi cant effacement of lower lid rhytides and improvement in hyperpigmentation8,39 (Figure 22.14). However, when any of these alternatives are used in the presence of lower lid laxity, lower lid support should be provided in the form of a lateral canthopexy to prevent temporary lower lid malposition.

The presence of excess orbital fat is best assessed by examining the patient preopera-tively, while he or she is in the upright position and by studying preoperative photographs. Once the patient is supine, judgment regarding excess fat is much more diffi cult. Gentle pressure on the

globe with the eyelids closed causes excess fat to bulge anterior to the orbital rim. For bulging lower eyelid fat, the choices are to excise the fat, push the fat back into the orbit, or transfer the fat into the infraorbital rim hollow (tear trough deformity or nasojugular groove). Fat excision may be accomplished using a transcutaneous or transconjunctival approach.

TranscutaneousThe planed incision is marked approximately 2 mm below the ciliary margin in a natural skin crease below the lash line. The incision should not extend laterally past the orbital rim.

A skin only fl ap is elevated by fi rst scoring the incision across the lower lid, taking care to pro-tect the lashes. A No. 15 scalpel blade combined with a small hook for retraction is then used to elevate the fl ap off the underlying orbicularis muscle down to the orbital rim. If a skin muscle fl ap is chosen, the original incision is the same. The fl ap is raised preserving 4 mm of the attach-ment of the pretarsal orbicularis muscle. Once the orbicularis muscle is divided, the retro-orbicular plane is readily identifi able and is again raised down to the orbital rim.

If a skin fl ap is elevated, the orbicularis muscle is opened over the medial, central, and lateral

Figure 22.14. (a) Preoperative view of 69-year-old female with perioral and periocular rhytids and cheek ptosis. (b) Eight months postoperative view following endoscopically assisted cheeklift, periocular, and perioral phenol-croton oil peel.

a b


309

compartments. Using a skin muscle fl ap, the compartments are readily visible. The inferior oblique muscle, separating the medial and cen-tral components, is identifi ed and protected. (Figure 22.7) The orbital fat is teased out with a combination of gentle pressure on the globe and a small cotton-tip applicator.

To complete the procedure, the skin is redraped over the underlying lower lid structures. Skin excision should be performed conservatively, as excess skin removal is the most common cause of lower lid malposition following transcutane-ous lower lid blepharoplasty. If the surgery is under local anesthesia, have the patient look up with the mouth open, to aid in conservative resection. Excess skin is trimmed, and absorb-able or nonabsorbable sutures are used to re-approximate the existing edges.

TransconjunctivalTransconjunctival blepharoplasty is useful in patients with fat excess and fi ne skin wrinkling and in those with fat excess in whom fat excision alone allows for redraping of the lower lid skin.3,37

Transcutaneous blepharoplasty has been associated with the round eye appearance, infe-rior scleral show, and frank ectropion as a con-sequence of overgenerous skin resection.38 Since lower lid malposition is obviated using this technique, the transconjunctival approach can also be used in the elderly patient with signifi -cant lower lid laxity simplifying the lower lid procedure.28,38

To anesthetize the conjunctiva and cornea, drops of tetracaine hydrochloride ophthalmic solution are instilled into the lower fornix of each eye. This is followed by transconjunctival injection of lidocaine with epinephrine injected into the orbital fl oor.

An incision is made on the lower lid conjunc-tiva using the Colorado needle 2–3 mm below the inferior tarsal plate. The incision is taken through conjunctiva and capsulopalpebral fascia exposing the fat pads.30,31 Fat is trimmed judi-ciously as required. The quantity of fat resection is more diffi cult to assess via the transconjuncti-val approach than with a transcutaneous tech-nique. Gentle pressure on the globe provides a guide to the level of fat resection. No sutures are used to close the incisions (Figure 22.15).

Options for pushing fat back into the orbit include septal plication12 or capsulopalpebral fascia and conjunctiva plication to the orbital

rim via a transconjunctival6 or transcutaneous approach.21

Fat transfer has been described by both Loeb19 and Hamra.11 Loeb used suture fi xation of trans-ferred fat to the periosteum and to the origin of levator labii superioris. The septum was not advanced. Hamra’s technique also included pull-ing down the septum with the fat, calling it a “septal inset.” To have a free edge of septum to pull down with the fat, it had to be divided along the length of the orbital rim. Hamra termed this the “arcus marginalis release.”11

Drawing the septum down with the fat (septal inset) has the advantages of creating a smoother layer fi lling in the depression and also tightening the septum, thus inhibiting further bulging of fat from the orbit, into the lower lid.

The planes of dissection for fat transfer into the tear trough deformity include both subpe-riosteal and supraperiosteal. The transferred fat can be sutured down to the periosteum and/or SOOF, sutured up to the underside of the orbicu-laris oculi, or fi xated using transcutaneous bol-ster stitches.

It is important to note that these procedures require extensive dissection in the middle lamella of the lower lid in comparison with sim-ple excisional techniques. These procedures induce more edema and more potential scar than those in simple excisional procedures. Therefore, postoperative support of lower lid position is imperative.

Complications of Blepharoplasty

Bleeding and infection are uncommon but seri-ous complications. To help prevent a hematoma, hypertension is controlled, and medications that predispose to bleeding are discontinued 2 weeks before surgery. Careful hemostasis at the time of the procedure is also vital.

Retro-orbital hemorrhage and visual loss are rare.29 Retro-orbital hemorrhage most frequently occurs following lower eyelid blepharoplasty, with an incidence of 1 per 22,000.

Infections after blepharoplasty are unusual because of the rich vascularity of the eyelids. However, prompt attention and treatment with appropriate antibiotics are required, when they do occur. The wound is opened, drained, and cultured, and any necrotic tissue is debrided.

Diplopia results from extraocular muscle imbal-ance, due to inadvertent damage to the superior or


310

inferior oblique muscles during fat excision. A sound knowledge of eyelid anatomy, adequate hemostasis, and meticulous surgical technique make this complication readily preventable.

Blepharoptosis can occur secondary to inad-vertent levator injury during the procedure. Transitory mechanical ptosis is occasionally found secondary to eyelid edema or hematoma, but if the ptosis persists following complete res-olution of edema and swelling, repair of the leva-tor aponeurosis will be required.

Excessive skin removal may result in lago-phthalmos with exposure keratitis, ectropion, or downward traction of the brow position. Mild lagophthalmos is common in the immediate post-operative period and is treated with reassurance, lubricant eye drops, and ointment. Extension of incisions may lead to a web over the medial can-thal angle or an unsatisfactory visible scar past the lateral orbital rim.

Ectropion is due to tissue defi ciency of the anterior or middle lamellae. If ectropion does occur, the surgeon must determine the location of the pathology and address it. If the anterior lamella is defi cient, skin may be replaced with grafting, but the best treatment is avoiding over-resection. If ectropion is due to early formation of cicatrix in the middle lamella, injection with low-dose steroids may be used. If middle lamellar scarring and lower lid malposition or retraction are persistent, surgical release of middle lamellar scarring and space grafting may be required. Middle lamellar scarring should be suspected if the involved lower lid cannot be manually elevated to the top of the limbus.

Hollowing results from excessive fat removal. However, lower lid malposition and residual excess skin or fat are probably the two most common adverse sequelae following upper or lower eyelid surgery. Asymmetry of eyelid creases is the result of poor preoperative plan-ning or a surgeon’s attempt to alter the crease position. In patients with a preexisting unilat-eral ptosis, the asymmetry may appear more prominent following removal of the overlying skin folds.

References 1. Bartlett SP, Wornom I III, Whitaker LA. Evaluation of

facial skeletal aesthetics and surgical planning. Clin Plast Surg. 1991 Jan;18(1):1–9.

2. Baylis HI, Goldberg RA, Kerivan KM, Jacobs JL. Blepharoplasty and periorbital surgery. Dermatol Clin. 1997 Oct;15(4):635–647.

3. Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty. Technique and complications. Ophthalmology. 1989 July;96(7):1027–1032.

4. Behmand RA, Guyuron B. Endoscopic forehead rejuve-nation: II. Long-term results. Plast Reconstr Surg. 2006 Apr;117(4):1137–1143; discussion 1144.

5. Biesman B. Laser assisted upper lid blepharoplasty. Oper Tech Oculoplasty, Orbital Reconstr Surg. 1998;1:11–18.

6. Camirand A. The surgical correction of aging eyelids. Plast Reconstr Surg. 1999 Apr;103(4):1325–1326.

7. Doxanas MT, Anderson RL. Oriental eyelids. An anatomic study. Arch Ophthalmol. 1984 Aug;102(8):1232–1235.

8. Gatti JE. Eyelid phenol peel – an important adjunct to blepharoplasty. Ann Plast Surg. 2007. In press.

9. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volu-metric analysis of soft-tissue changes in the aging mid-face using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005 Apr;115(4):1143–1152; discussion 1153–1155.

Figure 22.15. (a) Preoperative view of 60-year-old patient with lower lid bags. (b) Six-month postoperative view of the same patient following transconjunctival lower lid blepharoplasty and facelift with extended SMAS. Note the apparent skin tightening of the lower eyelids without worsening of the scleral show.

a b


311

10. Guyuron B. Subcutaneous approach to forehead, brow, and modifi ed temple incision. Clin Plast Surg. 1992 Apr;19(2):461–476.

11. Hamra ST. Arcus marginalis release and orbital fat pres-ervation in midface rejuvenation. Plast Reconstr Surg. 1995 Aug;96(2):354–362.

12. Huang T. Reduction of lower palpebral bulge by plicat-ing attenuated orbital septa: a technical modifi cation in cosmetic blepharoplasty. Plast Reconstr Surg. 2000 June; 105(7):2552–2558; discussion 2559–25560.

13. Januszkiewicz JS, Nahai F. Transconjunctival upper blepharoplasty. Plast Reconstr Surg. 1999 Mar;103(3):1015–1018; discussion 1019.

14. Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg. 1997 Oct;100(5):1262–1270; discussion 1271–1275.

15. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg. 1993 Apr;20(2):417–425.

16. Jordan DR, Anderson RL. The lateral tarsal strip revis-ited. The enhanced tarsal strip. Arch Ophthalmol. 1989 Apr;107(4):604–606.

17. Knize DM. An anatomically based study of the mecha-nism of eyebrow ptosis. PlastReconstr Surg. 1996 June;97(7):1321–1333.

18. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007 Oct;120(5):1367–1376; discussion 1377.

19. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg. 1981 Oct;8(4):757–776.

20. Marsh JL, Edgerton MT. Periosteal pennant lateral can-thoplasty. Plast Reconstr Surg. 1979 July;64(1):24–29.

21. Mendelson B. Fat preservation technique of lower lid blepharoplasty. Aesthet Surg J. 2001;21:450–459.

22. Morrison C, Zins J. An alternative approach to brow lift fi xation: temporoparietal fascia, galeal, and periosteal imbrication. Plast Reconstr Surg. 2007 Oct;120(5):1433–1434; author reply 1434–1435.

23. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and perior-bital regions. Plast Reconstr Surg. 2000 Apr;105(4):1475–1490; discussion 1491–1498.

24. Nahai F. Endoscopic Brow Lift. In: Nahai F, ed. The Art of Aesthetic Surgery Principles and Techniques. St. Louis, MO: Quality Medical Publishing; 2005:551–93.

25. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative maxil-lary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an

integrated model of midfacial aging. Plast Reconstr Surg. 1998 July;102(1):205–212.

26. Roberts E, Holck D. Prospective clinical evaluation of wound healing after carbon dioxide laser upper lid blepharoplasty closed with polypropylene suture or octylcyanoacrylate tissue adhesive tissue. ARVO; 1999; Fort Lauderdale, FL.

27. Seckel BR, Younai S, Wang KK. Skin tightening effects of the ultrapulse CO2 laser. Plast Reconstr Surg. 1998 Sep;102(3):872–877.

28. Silkiss R, Carroll R. Transconjunctival surgery. Ophthal Surg. 1992;23(4):288–291.

29. Teng CC, Reddy S, Wong JJ, Lisman RD. Retrobulbar hem-orrhage nine days after cosmetic blepharoplasty result-ing in permanent visual loss. Ophthal Plast Reconstr Surg. 2006 Sep–Oct;22(5):388–389.

30. Tessier P. The conjunctival approach to the orbital fl oor and maxilla in congenital malformation and trauma. J Maxillofac Surg. 1973 Mar;1(1):3–8.

31. Tomlinson FB, Hovey LM. Transconjunctival lower lid blepharoplasty for removal of fat. Plast Reconstr Surg. 1975 Sep;56(3):314–318.

32. Volpe CR, Ramirez OM. The beautiful eye. Fac Plast Surg Clin N Am. 2005 Nov;13(4):493–504.

33. Walden JL, Brown CC, Klapper AJ, Chia CT, Aston SJ. An anatomical comparison of transpalpebral, endoscopic, and coronal approaches to demonstrate exposure and extent of brow depressor muscle resection. Plast Reconstr Surg. 2005 Oct;116(5):1479–1487; discussion 1488–1489.

34. Walden JL, Orseck MJ, Aston SJ. Current methods for brow fi xation: are they safe? Aesthet Plast Surg. 2006 Sep–Oct;30(5):541–548.

35. Westmore M. Facial Cosmetics in Conjunction with Surgery. Aesthetic Plastic Surgical Society Meeting; May 1975; Vancouver, British Columbia.

36. Zarem HA, Resnick JI, Carr RM, Wootton DG. Browpexy: lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr Surg. 1997 Oct;100(5):1258–1261.

37. Zarem HA, Resnick JI. Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg. 1991 Aug;88(2):215–220; discussion 221.

38. Zarem HA, Resnick JI. Minimizing deformity in lower blepharoplasty. The transconjunctival approach. Clin Plast Surg. 1993 Apr;20(2):317–321.

39. Zins J. Invited discussion: eyelid phenol peel – an important adjunct to blepharoplasty. Ann Plast Surg. 2007. In press.

plastic and reconstructive surgery || anesthesia and critical care

Documents