Ординатура / Офтальмология / Английские материалы / Atlas of Aesthetic Eyelid and Periocular Surgery_Spinelli, Lewis, Elahi_2004

When Elsevier approached me concerning writing a text on eyelid and periocular surgery I tried to determine which books were popular and why they maintained popularity. Given the incredibly busy schedule that most surgeons and medical practitioners maintain in every specialty, the texts that seem to be the most popular are those that are quick and easy to read and review, are well illustrated, and serve as small atlases in that they serve as “how-to-tackle” books. Books of single authorship or limited authorship appear to be the most popular because these are well-organized and cohesive texts that flow with a distinct beginning, middle, and end. In my opinion these texts are usually purposefully drafted and directed. We noted anatomy and physiology to be fundamental and everlasting in their applicability. After all, the foundation of any surgical procedure is solidly grounded in the concepts of a basic understanding of anatomy, physiology, and pathophysiology. Additionally, excellent practical drawings, illustrations, and photographs of actual procedures, when organized and crossreferenced, appear to provide the most salient teaching tool in any text. These, combined with succinctly summarized legends, enable the reader to quickly browse through a chapter, gleaning its most important aspects.

A summary of each chapter, which delineates salient positive and negative points, technical aspects, and trouble spots within the concepts covered in each chapter, appears to be extremely useful in capsulating the topics covered and serves as a quick reference and refresher for the reader.

With this in mind, I have compiled an atlas that combines a directed practical narrative by a single author with both illustrations, photographs, and a summary in each chapter, which I have entitled Pearls and Pitfalls. I hope I have created a text that may find itself on the shelf of every practitioner of surgery and treatment in the periocular and facial regions. These

include plastic surgeons, ophthalmologists (oculoplastic surgeons), and otolaryngologists, as well as other practitioners. I also believe that this text will be useful to the cosmetic as well as the reconstructive surgeon in its reliance on important principles and concepts. This would make the text a long-lasting addition to the library of the experienced and well-versed surgeon, as well as of the resident and student.

In structuring the text I relied heavily on anatomy and physiology, as well as pathophysiology. Within the context of these basic science areas, I built on them practical options and techniques for the treatment of both functional and aesthetic problems. The single authorship and strong illustrations should make for a very directed and organized text; however, it is obviously biased toward the techniques and concepts that I find most acceptable.

In the areas of eyelid, periocular, and orbital surgery, there is considerable overlap in interest by multiple specialties and there appears to be a drive on the part of some practitioners to make this region esoteric and especially complex.

I have made every effort in this text to demystify this area through a fundamental understanding of anatomy, physiology, pathophysiology, and good basic clinical thinking. The “technical wizardry” is minor and within the grasp of most practitioners. The concept of identifying the pathophysiology and then how to tackle it is a much more important principle for all of us to understand and apply so that our patients may benefit. I have attempted to compile an atlas that is easy to read and reference and that unifies many of the principles and techniques I have incorporated and taught. It should enable most surgeons to feel more confident in assessing and treating patients with cosmetic and/or symptomatic periocular problems. I hope that you, the reader, will agree.

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

Bibliography

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Hughes SM: The history of lacrimal surgery. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:139–168, 1986.

Katzen LB: The history of cosmetic blepharoplasty. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:89–96, 1986.

Mikamo M: Mikamo’s double-eyelid operation: The advent of Japanese aesthetic surgery. Plastic & Reconstructive Surgery 99(3):664–669, 1997.

Miller CC: The excision of bag-like folds of skin from the region about the eyes. By Charles C. Miller, 1906. Aesthetic Plastic Surgery 12(3):155–156, 1988.

Miller CC, Miller F: Folds, bags and wrinkles of the skin about the eyes and their eradication by simple surgical methods. By Charles C. Miller and Florence Miller, 1907. Aesthetic Plastic Surgery 12(3):157–158, 1988.

processes and experiences. Without any of the individuals I have mentioned, this text would not be possible.

Henry M. Spinelli, MD, FACS

Patel BC, Anderson RL: History of oculoplastic surgery (1986–1996). Ophthalmology 103(8 Suppl):S74–95, 1996.

Reifler DM: The tarsectomy operation of A.P.L. Gillet de Grandmont (1837–1984) and its periodic rediscovery. Ophthalmologica 89(1–2):153–162, 1995.

Rogers BO: History of oculoplastic surgery: The contributions of plastic surgery. Aesthetic Plastic Surgery 12(3):129–152, 1988.

Safian J: A late report on an early operation for “baggy eyelids.” Plastic & Reconstructive Surgery 48(4):347–348, 1971.

Servat J, Mantilla M: The history of ptosis surgery. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:133–137, 1986.

Silverstone P: History of surgery for involutional ectropion. Advances in Ophthalmic, Plastic, & Reconstructive Surgery 5:97–123, 1986.

Watts MT: The history of oculoplastic surgery. Facial Plastic Surgery 9(2):151–156, 1993.

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

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

The tarsal plate is especially important for vertical support and rigidity of the eyelid. If one were to eliminate it, an eyelid would conceivably flop or flutter like a sail on a boat in changing or slack winds. This vertical supportive task is important and fundamental in maintaining the lower eyelid position 1 or 2 mm above the corneoscleral junction or limbus. The internal lining of the eyelid is mucosa. This layer reflects off the eyeball and onto the back surface of the eyelids, including the posterior surfaces of the medial and lateral canthal tendinous structures. This reflection in itself is analogous to the visceral and parietal pericardium or pleura. The conjunctival surface provides a near frictionless surface for the lids and eyeball to move against themselves and each other. The conjunctival surface is rich in secretory cells and glands and includes mucin and goblet cells and minor salivary glands. The upper lateral fornix is especially rich in minor lacrimal glands, including the glands of Kraus and Wolfring.

One should view the upper and lower lids as analogous or similar, with a few specialized differences, rather than the traditional fashion in which some anatomy and surgical texts treat the upper and lower lids as disparate anatomic and functional structures.

A sagittal section through the orbit viewing the upper and lower eyelids and eyeball demonstrates how the upper and lower eyelids and periocular structures are quite similar (see Fig. 1-2B). First, there is an anterior layer of skin followed by a middle structural support layer or the tarsal plates. The tarsal plate is a little wider on the upper lid than on the lower, and both upper and lower lids enjoy a mucous membrane lining that is applied to the visceral and parietal surfaces, namely, the eyeball and posterior eyelids. The upper and lower eyelids have a cul-de-sac that is the junction between the parietal and visceral conjunctiva. Upper and lower lids are surrounded by orbicularis muscle that is contiguous with the superficial musculoaponeurotic system (SMAS), platysma, and frontalis muscles. The orbicularis functions as a sphincter, despite the possession of a medial and lateral raphe. The orbicularis muscle is traditionally divided into subdivisions depending on where it lies, and these include the pretarsal, preseptal, and preorbital areas. The orbicularis muscle is innervated by the seventh nerve and, hence, with facial nerve paralysis, the cornea and globe are typically exposed, owing to an atonic eyelid left without the protractor action of the orbicularis and with the overaction of the unopposed retractors. The retractors of the eyelids are analogous as well, with the upper lids possessing a voluntary or primary retractor, namely, the levator palpebrae superioris muscle and a secondary sympatho-

mimetically innervated muscle called Müller’s muscle. Müller’s muscle is the so-called fright/flight response muscle and is responsible for approximately 2 mm of lid elevation as occurs in sexual excitation or being chased by a ferocious dog. The levator palpebrae superioris is responsible for the remainder of lid elevation and is elective or voluntary. The levator palpebrae measures approximately 37 mm in length and is only 4 mm in width at the apex of the orbit. It gradually widens anteriorly until it fans out into an approximately 20-mm long aponeurosis that expands from 6 mm at the distal end of the levator muscle to a width of 30 mm where it inserts onto the tarsal plate. The levator muscle sends some fibers to the dermal surface of the upper lid skin, creating an upper lid fold. The exact fashion in which fibers insert onto the skin and create this lid fold has not been clearly elucidated. Surgical manipulation of the levator aponeurosis is a very powerful tool for altering upper lid height. This can be achieved by plication, advancement, or recession. A normal upper eyelid lies midway between the upper aspect of the pupillary aperture and the upper corneal scleral junction or limbus. The apex of this arch lies just medial to the pupil, and this is an important landmark in any ptosis correction.

The lower lid retractors are intimately linked to the inferior extraocular muscles. The inferior rectus and inferior oblique muscles send out extensions by way of the capsulopalpebral fascia, and these insert onto the inferior edge of the tarsal plate of the lower eyelid. This is analogous to the levator aponeurosis of the upper lid. The capsulopalpebral fascia is a “voluntary” retractor of the lower eyelid and is understandably linked to the depressors of the eyeball so that in electively looking down the lower eyelid gets out of the way. The capsulopalpebral fascia is an important structure that is always divided at some level in the transconjunctival blepharoplasty or in any transconjunctival route to the orbit. Retractors of the upper and lower eyelids share a reorientation of their direction of pull within the orbit as one follows them anteriorly. The levator palpebrae superioris muscle has a significant change in direction from anterior to posterior to cephalad to caudad just as in the case of the inferior lid retractors. In the upper lid the levator aponeurosis reorients directions, and in the lower lid the capsulopalpebral fascia does the reorienting. In the case of the upper eyelid, this occurs by way of an interesting and clinically relevant mechanism. The levator palpebrae superioris muscle moves from its insertion in the apex of the orbit, from the lesser wing of the sphenoid bone, and runs in a horizontal direction anteriorly in the orbit until it changes to a vertical direction by way of a pulley system. It is this

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

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