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

REFERENCES

Eremia S, Newman N: Use of an insulated ultrafine-point electrocautery for transconjunctival blepharoplasty of the lower eyelids. Dermatol Surg 27:1052-1054, 2001.

Ghabrial R, Lisman RD, Kane MA, et al: Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg 102:1219-1225, 1998.

Kavouni A, Stanek JJ: Lower eyelid cysts following transconjunctival blepharoplasty. Plast Reconstr Surg 109:400401, 2002.

Seckel BR, Kovanda CJ, Cetrulo CL Jr, et al: Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: A safe and advantageous technique. Plast Reconstr Surg 106:1127-1141, 2000.

Zarem HA, Resnick JI, Stuzin JM: Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg 103:1041-1045, 1999.

As mentioned in Chapter 3, horizontal laxity of the lower eyelid may be addressed with plication of the lateral tarsus or the lateral canthal tendinous complex. This is best approached by means of a transcutaneous approach and is only useful in addressing milder degrees of lower lid laxity. In addition to this limitation, it can produce canthal rounding and anterior displacement of the commissure and lateral lower eyelid, unless stable fixation to orbital periosteum is achieved. Distribution of the lower lid redundancy against a fixed upper lid and canthus becomes difficult and tedious. Therefore, it is only useful in mild degrees of laxity and should be considered in the same category as any procedure that does not mobilize the lateral canthus, such as cephalic lateral orbicularis suspension or transblepharoplasty canthal suspension (canthopexy) without lysis and mobilization of the lateral retinaculum (see Fig. 3-8).

Fat redistribution is a more useful adjuvant procedure in blepharoplasty. This is a powerful technique that addresses the atrophy and ptosis associated with agerelated changes or senescence along the orbital malar junction. Specifically, the malar fat pad becomes ptotic and there is an associated fat atrophy with nasojugal and orbital malar depressions (medial and lateral), resulting in prominence of the orbital rim and visualization of that structure in relief. Although there is associated pseudoherniation of orbital fat owing to septal laxity, simply resecting orbital fat only serves to further accentuate the orbital malar discrepancy instead of rejuvenating the patient's appearance. Some younger individuals present with accentuated atrophy along the orbital malar and nasojugal region without significant orbital fat prominence. These persons have early cheek ptosis and are not yet candidates for midface elevation by facialplasty or other routes, but they may be good candidates for orbital fat repositioning (Fig. 7-1).

ORBITAL FAT REPOSITIONING TECHNIQUE

Orbital fat repositioning requires atraumatic anterior translocation of postseptal orbital fat. Orbital fat is accessed by either the transcutaneous or the transconjunctival route, depending on predetermined factors. Once the orbital septum and orbital rim margin is exposed, supraperiosteal dissection is carried out over the areas for fat deposition. These areas should be delineated with a surgical marking pen while the patient is awake and standing or sitting. Once the orbital rim is exposed, limited soft tissue exposure is preferred so as not to further destabilize malar support and warrant formal suspension. Suborbicularis, subcutaneous, or supraperiosteal dissection is carried out by creating a tunnel with a small scissor or hemostat. The tunnel and pocket that is created should be limited only to the extent of fat that must be passed and the defect that one intends to fill. I prefer the plane of dissection to convert from suborbicularis to supraperiosteal at the arcus marginalis. The septal opening and tunnel should be of adequate size to obviate ischemic necrosis. The orbital fat is teased from its respective compartment (usually the medial and lateral) and by means of a transcutaneous suture engaged and fixed into position. I prefer to place the transcutaneous suture through the skin into the dissection plane where the orbital fat is dissected, engage the desired fat for repositioning, and then pass the suture back through the cutaneous surface to be loosely tied. This technique is similar to cutaneously fixing cartilage grafts, and so on, onto the dorsal nasal surface. The temporary suture is left in place approximately 1 week and then removed. Alternatively, the fat may be fixed to the orbital or malar periosteal surface;

however, more extensive soft tissue dissection is usually necessary and exact positioning of the fat within the area of intended filling is less optimal. Fat may be redistributed in one compartment and selectively removed in another in any combination deemed appropriate for each patient. The incisions are closed as described in

P E A R L S A N D P I T F A L L S

1.The tarsal tuck procedure is only useful in mild lid redundancy and can produce a buckled lower lid. It is, however, readily accessible as a procedure in lower lid transcutaneous blepharoplasty.

2.Orbital fat repositioning can be useful in addressing depressions along the orbit–mid face junction; however, there are volumetric limitations.

3.Various planes for fat repositioning may be chosen, but I prefer the suborbicularis to the supraperiosteal plane, converting at the arcus marginalis.

4.The septal opening and tunnel need to be large enough to obviate ischemic necrosis.

Chapter 5. Skin may be addressed with either a marginal trim or laser procedure, which is another reason for limiting the extent of subcutaneous tunneling or dissection (i.e., devascularization and compromise) (see Fig. 3-8).

REFERENCES

Anderson RL, Jordan DR: The tarsal tuck procedure: Avoiding eyelid retraction after lower blepharoplasty. Plast Reconstr Surg 104:284-285; discussion 286, 1999.

Coleman SR: Structural fat grafts: The ideal filler? Clin Plast Surg 28:111-119, 2001.

Goldberg RA: Transconjunctival orbital fat repositioning: Transposition of orbital fat pedicles into subperiosteal pocket. Plast Reconstr Surg 105:743-748; discussion 749751, 2000.

Turk JB, Goldman A: SOOF lift and lateral retinacular canthoplasty. Facial Plastic Surg 17:37-48, 2001.

Von Heimburg D, Pallua N: Two-year histological outcome of facial lipofilling. Ann Plast Surg 46:644-646, 2001.

The evaluation and management of the patient with eyelid ptosis requires an especially careful history and repeated examinations to corroborate the extent of levator function and the degree of ptosis. One should possess facile knowledge of common conditions that may present as the ptotic eyelid and various methods for addressing them. For the purpose of simplicity and practicality, I will attempt to present the more commonly encountered entities that present as ptosis and a logical way of reliably approaching them. For the purpose of understanding this chapter and logically applying this information to patients, PTOSIS is defined as an abnormal drooping of the upper eyelid so that it lies below the normal anatomic position when secondary compensatory muscular action is not initiated. This may occur as a component of a syndrome or as an isolated finding secondary to a mechanical, neurogenic, or other disorder.

EVALUATION OF THE PATIENT WITH PTOSIS

Eyelid ptosis, when present in syndromes, usually occurs with concomitant neurologic findings, including dysphagia, diplopia, or facial myoneuropathies, such as myasthenia gravis or other conditions. Ptosis associated with pupillary miosis or constricted pupil and anhidrosis suggests a sympathetic lesion associated with Horner’s syndrome. Ptosis associated with mydriasis or a dilated pupil along with diplopia suggests a palsy of the third cranial nerve. Ptosis associated with proptosis of the globe suggests an orbital tumor or infiltrating disease of the orbit. Multiple congenital syndromes, such as the blepharophimosis syndrome, which is asso-

ciated with bilateral ptosis, blepharophimosis, telecanthus, epicanthus inversus, and lower lid ectropion, are rare.

True ptosis as an intrinsic isolated entity should be discriminated from pseudoptosis. The latter is a mechanical condition other than impairment of the upper eyelid retractor complex (levator palpebrae superioris muscle and Müller’s muscle) and can be confused with the former, especially when the patient is examined in a cursory fashion. Conditions that can mimic ptosis but that are mechanical include severe dermatochalasis with or without associated brow ptosis, hypertropia (elevation of the eyeball), blepharospasm or increased hemifacial tone, and enophthalmos, in which the affected eyeball is retrodisplaced with the upper eyelid draping over the anterior corneal surface in a lower position compared with the contralateral side. This is frequently seen in post-traumatic orbital fractures or in erosive lesions of the bony orbit that effectively increase orbital volume. Small degrees of pseudoptosis caused by orbital volume discrepancies may be addressed in a similar fashion to that of isolated true ptosis; however, the surgeon should understand that this is a “masking procedure” and with this approach the underlying pathophysiology is not specifically addressed. In severe cases of enophthalmos, procedures that alter orbital volume are indicated and are described in Chapter 11 (Fig. 8-1).

Once the ptosis is determined to be an isolated intrinsic condition related to impairment of the upper eyelid retractor system, it should then be classified as to whether it is acquired or congenital. It is helpful to obtain a detailed history and view old photographs in making this determination. A history of trauma, a complicated or forceps delivery, an episode or repeated episodes of intense orbital swelling, and even cataract surgery are usually salient and indicate the cause of ptosis to be levator aponeurotic dehiscence.

Figure 8-1 The cause of ptosis of the upper eyelid is frequently ascertained by examination alone. A and B, The signs of levator dehiscence including a superior sulcus deformity, high or absent lid crease, and good levator function are typical in older individuals or those who have sustained trauma. The man shown here underwent a previous left cataract extraction. The woman has left greater than right levator dehiscence with compensatory eyebrow elevation. The etiology is likely age-related attenuation of the levator insertion. Sometimes blepharochalasis and fat herniation can mask the classic signs of levator dehiscence.

C and D, Congenital ptosis usually presents as an absent lid fold and lid lag (lagophthalmos). This 18-month-old boy has moderate left congenital ptosis and no lid fold and on down gaze demonstrates lid lag. E and F, Enophthalmos may cause pseudoptosis. In this case a previous zygoma and orbital fracture has created enophthalmos, with the upper eyelid draping over the eye in a more inferior location. The computed tomographic scan demonstrates a malpositioned left zygoma and disproportionately large orbital volume compared with the contralateral right side. The lower lid on the left is pulled inferiorly by septal attachments to the malpositioned zygoma. Similarly, the left lateral canthus shows inferior dystopia. Appropriate correction of this ptosis requires osteotomies and repositioning of the zygoma. In small degrees of ptosis secondary to enophthalmos, a soft tissue masking procedure may suffice.

A

C

E

B

D

F

Congenital ptosis is caused by poor development of the levator palpebrae superioris muscle. The patient presents with a long-term history of ptosis associated with lid lag on down gaze caused by fibrotic replacement of levator muscle fibers. Acquired ptosis may be mechanical, myopathic, or neurogenic, but by far the most common cause of acquired ptosis is disinsertion or dehiscence of the levator aponeurosis from the tarsal plate. This may occur as a senescent or age-related change or after intense swelling, surgery for cataracts, or blunt or penetrating injuries.

As in all areas of the body, gross observation and careful physical examination are paramount in diagnosing and treating the patient correctly. This can be performed quickly and accurately as time and experience are accrued. Initially, the presence or absence of ptosis should be noted on gross examination. A comparison should be made between each side concerning the upper lid position vis-à-vis the iris and pupillary aperture. Obviously, to properly make this comparison, the pupillary aperture should be the same and pupils should react similarly to light. In third nerve palsies and Horner’s syndrome this is not the case. Several gross but reliable modalities for assessing upper lid ptosis have been described. These include the corneal light reflex distance, which is defined as the distance between the corneal light reflex and the upper lid margin at its mid position. This distance usually is between 3.0 and 4.5 mm. Another useful test is to examine the position of the upper lid vis-à-vis the limbus or corneoscleral junction and the pupillary aperture. A normal upper eyelid should bisect the distance between the limbus and the pupillary aperture. The distance between the upper and lower lids or the vertical interpalpebral distance in the mid position is the least useful tool. This assessment can be influenced by lower lid position and is generally not a true measure of upper lid position. Bear in mind that proper assessment of upper lid position using these tools requires that both eyeballs are in alignment (e.g., absence of hypertropia). Ocular malalignment distorts the pupillary eyelid relationship, which is the backbone of most of these assessment tools.

The key point is to examine the patient and appreciate gross topographic differences or surface deviations from normal before embarking on a detailed and intricate analysis. For instance, look for symmetry or absence of symmetry between the two upper eyelids and the presence and degree of prominence of the lid crease and its relationship to the eyelid margin. The upper eyelid crease is usually 7 to 9 mm above the lash line and an elevated and/or ill-defined eyelid crease usually suggests disinsertion of the levator aponeurosis. A superior sulcus deformity or asymmetry in the lid fold and sulcus usually indicates differences in the position of the preaponeurotic fat pad. This occurs because the preaponeurotic fat pad is loosely but definitively tethered to the anterior surface of the levator aponeurosis. Disinsertion of the levator aponeurosis and retraction from the tarsal plate causes the preaponeurotic fat pad to ride posteriorly within the orbital rim along with the retracted levator aponeurosis. This results in creation of a superior sulcus deformity or diminution in the upper eyelid fold. These findings are characteristic of involutional ptosis or post-traumatic levator dehiscence. The presence of lid lag or lagophthalmos may be noted by having the patient look up and down. Inability to completely cover the globe in down gaze, despite inadequate lid elevation on primary gaze, is associated with congenital ptosis. Unilateral lagophthalmos is more easily discernible than bilateral lid lag on attempted closure. The patient should demonstrate adequate orbicularis motor function by forcibly closing his or her eyes against resistance. Significant weakness in the orbicularis muscle may suggest a myopathic problem and, more importantly, these patients are very poor candidates for ptosis correction because their ptotic eyelid is protective and necessary to achieve adequate corneal coverage and wetting. Any attempt at elevation of their ptotic eyelids may produce severe lagophthalmos or an inability to completely cover their corneas. These patients can develop significant postoperative problems, and the lid lag is difficult to correct. Always have the patient perform ocular versions by looking up, down, left, and right and obliquely up and down. Changes in lid position with extraocular motion suggest

aberrant regeneration of the third cranial nerve. Chronic external ophthalmoplegia presents as limitation of extraocular muscle activity or versions. Have the patient open and close the mouth and sublux the jaw laterally looking for eyelid position. Marcus-Gunn jaw-winking phenomenon or aberrant regeneration of the facial nerve may be discriminated from isolated impairment of the upper eyelid retractor system using this method. A Schirmer test is indicated in all patients in whom a ptosis procedure is planned. A significant compromise in tear production can militate against performing a surgical lid elevation, or a ptosis procedure may have to be modified to obviate excessive evaporative tear loss. Adequate eyeball wetting is not only dependent on tear production and tear quality but also on ambient evaporative loss. The amount of evaporative tear loss will increase with ptosis correction owing to greater ambient eyeball exposure, yet tear production will remain the same. This may tip the patient over into a dry eye syndrome, with its attendant symptoms and complications.

Once a diagnosis in surgically appropriate patients is identified by way of an organized screening process, then a more detailed examination of levator function should be undertaken. I will discuss this in more detail to simplify the evaluation and describe several appropriate procedures that can be logically applied.

MEASUREMENT OF LEVATOR FUNCTION

Once a mechanical or isolated ptosis has been diagnosed then the most important determinant of which procedure to perform depends on two factors: (1) degree of ptosis and (2) amount of levator function. I prefer to evaluate the degree of ptosis based on it being mild, moderate, or severe. Mild ptosis is less than 2 to 3 mm, moderate ptosis is 3 to 5 mm, and ptosis of 5 mm or more is severe. An even more important factor in deciding on the best procedure is the assessment of

levator function. Levator function determines which, if any, upper eyelid retractor complex tightening procedures will work. These include levator advancement, levator tuck, levator resection, müllerectomy, and tarsal conjunctival müllerectomy (Fasanella-Servat procedures). It becomes necessary to utilize exogenous lid elevators such as the frontalis sling procedure when levator function is poor. These procedures incorporate or utilize muscles other than the primary upper eyelid retractor system to serve as upper lid elevators.

ASSESSING LEVATOR FUNCTION

Levator function is the single most important determinant of the likely cause for eyelid ptosis (i.e., neuromuscular vs. involutional or senescent) and the appropriate surgical approach for its correction. Because levator function may vary temporally, based on circulating catecholamines and other factors, it is best to evaluate levator function on at least two separate occasions to corroborate the initial findings. Levator function is established by measuring excursion of the upper eyelid as it moves from down gaze to complete up gaze with the eyebrow fixed by the examiner to prevent any transmission of forces from the frontalis muscle to the upper eyelid. The patient may be asked to look straight ahead with the brow fixed so that primary lid aperture is established. The lid aperture is then measured in extreme up gaze followed by down gaze. The difference in the lid aperture between extreme up gaze and extreme down gaze with the brows fixed is a measure of levator excursion or function and is usually greater than 12 mm in the normal individual. Levator excursion or function can usually be divided into poor, fair, and good categories, with less than 5 mm being poor, 6 to 9 being fair, and 10 to 15 mm being good. Analogously, as already described, the degree of ptosis may be assessed and divided into three categories: mild (1 to 2 mm), moderate (3 to 5 mm), and severe (greater than 5 mm) (Figs. 8-2 and 8-3).