52.4 Complications

The most common complication of epicanthoplasty is formation of hypertrophic Scar (Fig. 52.18). Recurrence due to scar Contracture is also common. Other

complications are undercorrection and overcorrection. In order to reduce complications, appropriate choice of operative method is important and like loupe or microsurgical operative instruments, the choice of operative instruments is also important (Fig. 52.19).

52.5 Conclusions

The normal anatomical structure of an Asian’s eye is quite different from that of a Westerner’s. The eyes of Asians do not have the pretarsal skin attached to the levator palpebrae muscle, so they lack supratarsal folds. While they not only have excessive fat distributed between the orbicularis oculi muscle and the levator muscle, they also have relatively thick palpebral skins and orbicularis oculi muscles. Their orbits are comparatively small so that the orbital margin is more protruded than that of Westerners. Asians also have epicanthic folds that cover up the lacrimal lakes causing the medial canthal area to display fullness.

The methods of epicanthoplasty are various. Most important point is selection of appropriate operative method.

References

1.Joh SH. Clinical study of epicanthoplasty by Y-V advancement flap. J Korean Soc Plast Reconstr Surg. 1996;23:1495.

2.Park JI. Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg. 1996;98(4):602–9.

3.Converse JM, Smith B. Naso-orbital fractures and traumatic deformities of the medial canthus. Plast Reconstr Surg. 1966;38(2):147–62.

4.Spaeth EB. Further consideration of the surgical correction of blepharophimosis (epicanthus). Am J Ophthalmol. 1956; 41(1):61–71.

5.Mustarde JC. Repair and reconstruction in the orbital region. 2nd ed. New York: Churchill Livingstone; 1980. p. 332–44.

6.Yoon KC. Modification of Mustarde technique for correction of epicanthus in Asian patients. Plast Reconstr Surg. 1993;92(6):1182–6.

7.Hughes WL. Surgical treatment of congenital phimosis: the Y-V operation. AMA Arch Ophthalmol. 1955;54(4):586–90.

8.Iliff WJ. Congenital defects. In: Heilmann K, Paton D, editors. Atlas of ophthalmic surgery. Tokyo: Thieme Maruzen; 1985. p. 1103–25.

9.del Campo AF. Surgical treatment of the epicanthal fold. Plast Reconstr Surg. 1984;73(4):566–71.

10.Mulliken JB, Hoopes JE. W-epicanthoplasty. Plast Reconstr Surg. 1975;55(4):435–8.

11.Flowers RS. Surgical treatment of the epicanthal fold (invited essay). Plast Reconstr Surg. 1983;73:571.

12.Park DH. The correction of entropion using skin-tarsal fixation with epicanthoplasty. Korean Aesthetic Plast Reconstr Surg. 1995;1(1):124.

13.Fox SA. Ophthalmic plastic surgery. 5th ed. New York: Grune & Stratton; 1976. p. 223–5.

53.1 Introduction

Volume loss and muscular hyperactivity are two major components of the aging process that contribute to the formation of the folds and wrinkles [1]. In traditional lower eyelid surgery, the focus is removing tissue. The philosophy coupled with this approach is that facial aging is characterized by excess tissue. The fundamental cosmetic goals are to improve the appearance of the midface while maintaining a natural position of the lower eyelid. The creation of harmonious rejuvenation between the midface and lower lid relies on the preservation of the preoperative shape of eyelids.

The pathogenesis of aging within the lower eyelid is multifactorial and varies among patients. Periorbital age-related changes include crow’s feet and lower eyelid rythides, scleral show, infraorbital hollowing, herniated fat pads, excess upper and lower lid skin, festoons, and eyelid hooding. In addition, attenuation of the lateral canthal tendons results in loss of the youthful architecture of the eye secondary to a decrease of the aesthetically pleasing upward tilt [2–6].

However, even with the evolution of these concepts, a problem still affects not only the surgeon, but also the patient himself: the tear trough. The tear trough is a depression centered over the medial inferior orbital rim. It is bounded superiorly by the infraorbital fat protuberance. The inferior border is formed by thick skin of the upper cheek with its abundant subcutaneous fat,

G.A.P. Viana

Member of Brazilian Plastic Surgery, Department of Ophthalmology, Vision Institute, Federal University of São Paulo, São Paulo, Brazil and

Alameda Jauaperi 732, São Paulo, SP 04523-013, Brazil e-mail: info@cliniplast.com

suborbicularis oculi fat, and portions of the malar fat pad. In most individuals, the trough is deeper medially, becoming more shallow laterally. Through aging, further loss of soft tissue and, importantly, a loss of osseous support also cause the tear trough to deepen further [7]. Raul Loeb was one of the first surgeons to preserve adipose tissue during the lower eyelid blepharoplasty in an attempt to improve this region [8].

More recently, there has been interest across many disciplines in a philosophy focusing on the volume loss in facial aging. The surgical options for volume replacement have been traditionally more limited; for instance, autogenous fat grafting requires harvesting and can be unpredictable, and the synthetic fillers that were historically available were either permanent or nonpermanent. The arrival of new generation’s fillers that are acceptably safe and predictable has provided a practical solution to approach facial volume loss [7, 9–11].

The author began using hyaluronic acid gel filler (Restylane®, Q-MED, Rio de Janeiro RJ, Brazil) for periorbital filling in the beginning of 2007. The purpose of this chapter is to review the results of treatment of tear trough deformity and the lessons learned in 150 patients.

53.2 Hyaluronic Acid Gel Filler

The hyaluronic acid (HA) is a molecule naturally occurring in the extracellular matrix found in many human tissues, including connective tissues, interstitial membranes, dermis, joints, and the vitreous body of the eye. HA is a glycosaminoglycan disaccharide composed of alternately repeating units of D-glucuronic acid and N-acetyl-D-glucosamine (Fig. 53.1) [12–14].

HA is a polyanionic polymer at physiologic pH and is therefore highly charged. The highly charged nature