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

Figure 8-12 Continued G, Milder forms of upper lid retraction without a soft tissue deficiency may be passively corrected by weighing down the upper eyelid with a surgically inserted gold weight. Usually these patients have an imbalance between the eyelid elevators (levator, Müller’s) and the eyelid depressors (orbicularis). This patient suffers from a left facial palsy since birth and presents with complaints and a physical examination consistent with corneal exposure from a combination of upper lid retraction, lagophthalmos on closure, and lower lid ptosis. Note his inferior scleral show and cheek ptosis compared with the contralateral right side. H, Here this patient is being assessed for an appropriate-size gold weight preoperatively. The patient’s youth and professional demands required that we achieve maximal corneal coverage but leave him as cosmetically symmetric as possible. As is always the case, the correction of lid retraction should be maximal without interfering with the pupillary axis and functional vision. I find it helpful in an office setting to try various weights that are adhered to the upper lid with a topical adhesive (i.e., Mastisol or Steri-strip). Then the patient can be evaluated through lid excursions. The weight chosen leaves him with some residual scleral, but not corneal, show. The weight should be placed beneath the pretarsal orbicularis muscle and fixed to the tarsal plate. Access is through a standard blepharoplasty incision. I, Here the patient is shown approximately 3 months postoperatively after having undergone an upper eyelid gold weight insertion, a lateral canthoplasty of the lower eyelid, and a midface suspension through the eyelid.

G

H

I

1.True eyelid ptosis must be discriminated from pseudoptosis before one embarks on a treatment plan.

2.Orbital volume discrepancies (enophthalmos or proptosis) can produce pseudoptosis or pseudo retraction of the eyelids.

3.A high lid fold and superior sulcus deformity suggest levator aponeurosis dehiscence.

4.Elevation of the upper eyelid will always cause higher ambient evaporative tear loss and sometimes lid lag. Preoperative evaluation should assess tolerance for these sequelae.

5.The degree of ptosis and the level of levator function are the two most important factors in determining which procedure to perform.

6.The difference in lid aperture between extreme up gaze and down gaze is a measurement of levator function.

7.Congenital ptosis consists of the triad of significant lid malposition, poor-to-absent levator function, and significant lid lag on down gaze. These characteristics are due to an atonic and fibrotic levator muscle.

8.The tarsal conjunctival müllerectomy (TCM) (Fasanella-Servat) is a posterior approach to mild ptosis.

9.In performing the TCM procedure, extreme care must be used in cross-clamping and resection so as to induce a cleansweeping, arched, and not a peaked or retracted eyelid.

10.The levator tuck is an anterior approach to mild or small degrees of moderate ptosis in the setting of good to excellent levator function.

11.The levator advancement procedure is the most powerful

technique for ptosis correction, no matter how severe the ptosis, provided levator function is good.

12.Complete levator advancement requires adequate cephalic dissection along with lysis of the medial and lateral horns of the levator.

13.The central suture in the advanced levator should lie at the vertical meridian of the nasal pupillary margin.

14.A second suture laterally is helpful in avoiding too rapid a decline in the upper eyelid height as it approaches the lateral canthus.

15.Significant levator advancement and resection can be employed in cases of congenital ptosis, provided enough levator function exists.

16.In the absence of adequate levator function, exogenous muscle must be employed to correct the ptosis (i.e., frontalis sling).

17.The upper eyelid should be set at a lower level than normally chosen in the presence of a poor Bell’s reflex or compromised VII cranial nerve or orbicularis function.

18.Upper eyelid retraction must be distinguished from VII cranial nerve or orbicularis muscle dysfunction.

19.A true deficiency in the middle lamella of the upper eyelid requires a spacer for correction, whereas a nerve or muscular compromise requires only a weighing down of the upper eyelid.

20.The dissection for levator recession with interpositional grafting (temporalis fascia) is the same as that for levator advancement.

References

Abdul-Rahim AS: Determination of resting upper eyelid position in patients with ptosis. Ann Ophthalmol 33:298299, 2001.

Bartkowski SB, Zapala J, Wyszynska-Pawelec, G, Krzystkowa KM: Marcus Gunn jaw-winking phenomenon: Management and results of treatment in 19 patients. J Craniomaxillofac Surg 27:25-29, 1999.

Bartley GB, Lowry JC, Hodge DO, et al: Results of levatoradvancement blepharoptosis repair using a standard protocol: Effect of epinephrine-induced eyelid position change. Trans Am Ophthalmol Soc 94:165-177, 1996.

Bradley EA, Bartley GB, Chapman KL, Waller RR: Surgical correction of blepharoptosis in patients with myasthenia gravis. Ophthalmic Plast Reconstr Surg 17:103-110, 2001.

Chen TH, Yang JY, Chen YR: Refined frontalis fascial sling with proper lid crease formation for blepharoptosis. Plast Reconstr Surg 99:34-40, 1997.

Dinces EA, Mauriello JA Jr, Kwartler JA, Franklin M: Complications of gold weight eyelid implants for treatment of fifth and seventh nerve paralysis. Laryngoscope 107(12 pt 1):1617-1622, 1997.

Harris WA, Dortzback RK: Levator tuck: A simplified blepharoptosis procedure. Ann Ophthalmol 7:873-878, 1975.

Khan JA, Garden V, Faghihi M, Parvin M: Surgical method and results of levator aponeurosis transposition for Graves’ eyelid retraction. Ophthalmic Surg Lasers 33:79-82, 2002.

Lim KH, Lee SY, Hwang JM: Primary levator synkinesis associated with eye movement. J Pediatr Ophthalmol Strabismus 38:179-180, 2001.

Mauriello JA Jr: Modified levator aponeurotic advancement with delayed postoperative office revision. Ophthalmic Plast Reconstr Surg 14:266-270, 1998.

Mauriello JA Jr, Abdelsalam A: Modified levator aponeurotic advancement with delayed postoperative office revision. Ophthalmic Plast Reconstr Surg 14:266-270, 1998.

Mercandetti M, Putterman AM, Cohen ME, et al: Internal levator advancement by Müller’s muscle-conjunctival resection: Technique and review. Arch Facial Plast Surg 3:104-110, 2001.

Mulvihill A, O’Keefe M: Classification, assessment, and management of childhood ptosis. Ophthalmol Clin North Am 14:447, 2001.

Saeed M, Usama U, Aziz TM: Recession of levator in the management of retracted upper lid. J Coll Physicians Surg Pakistan 10:451-453, 2000.

Signorini M, Baruffaldi-Preis FW, Campiglio GL, Marsili MT: Treatment of congenital and acquired upper eyelid ptosis: Report of 131 consecutive cases. Eur J Plast Surg 23:349355, 2000.

Tellioglu AT, Saray A, Ergin A: Frontalis sling operation with deep temporal fascial graft in blepharoptosis repair. Plast Reconstr Surg 109:243-248, 2002.

Tezel E, Numanoglu A: Readjustment of the degree of lift following frontalis sling operation in ptosis: A new and simple method. Plast Reconstr Surg 104:587-588, 1999.

Tsa CC, Li TM, La CS, Li SD: Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous frontalis suspension. Br J Plast Surg 53:473-476, 2000.

Tucker SM: Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology 106:517-522, 1999.

Tucker SM, Verhulst SJ: Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology 106:517-522, 1999.

Woog JJ, Hartstein ME, Hoenig J: Adjustable suture technique for levator recession. Arch Ophthalmol 114:620-624, 1996.

ANATOMY AND

PATHOPHYSIOLOGY

There has been an evolution in the conceptualization and the technical approaches to the periocular region and mid face. In the past, surgeons have focused either on the periocular region within the confines of the orbital rim or on the face and brow outside the orbital rim. These two areas were traditionally treated as discrete entities. Classical thinking encouraged surgeons to address either the eyelids alone, the face alone, or the eyelids and face in combination, with the orbital rims being not only a conceptual but also a technical boundary in the amalgamation of a unified concept for addressing anatomic and technical concerns in rejuvenative surgery of the face. As alluded to earlier in this text, the lower eyelid, canthal structures, and mid face or soft tissues overlying the zygoma should be thought of as codependent anatomic and surgical regions. That is, one must consider the lateral canthus, the lower eyelid, and the cheek as three independent variables in the equation we view as the mid face.

Anatomically, the lower eyelid fat pads are held posteriorly and within the orbit by the orbital septum, which effectively links the periosteum and periorbita to the inferior tarsal plate. The arcus marginalis can be viewed as a confluence of the periorbita, periosteum, and orbital septum at or near the orbital rim. The orbital malar ligament extends inferiorly and anteriorly from the arcus marginalis. The orbital malar ligament essentially links the orbital rim confluence or arcus marginalis to the overlying malar soft tissue, including skin. This is accomplished by way of its course through the preorbital orbicularis muscle and malar fat pad. In the youthful and aesthetically pleasing lower eyelid and mid face, the distance between the superior edge of the

lower eyelid and the junction of the cheek is only approximately 10 mm. This transition area is coplanar or even slightly concave in youth. Senescence and attenuation of the lateral canthal tendon allows the lateral canthus to drift inferiorly and medially, shortening the intercommissure distance and changing the normal lateral canthal inclination of 10 to 15 degrees compared with the medial canthal position. Analogously, the orbital malar ligament attenuates with age and the soft tissues of the cheek or mid face undergo an inferior medial ptosis. The distance from the upper margin of the lower eyelid to cheek effectively lengthens, extending well beyond the orbital rim inferiorly, as the orbital malar ligament fails. This usually occurs concomitantly with lateral canthal tendon laxity so that all three elements of the mid face equation are anatomically incorrect and connote the aged periocular look. This consists of an inferior inclination to the lateral canthus, lower lid ptosis with scleral show with or without laxity, midface ptosis, and deepening of the nasolabial fold. Further aging changes associated with soft tissue and fat atrophy produce grooving in the nasojugal region, the tear trough deformity, and depressions along the lateral orbit (Figs. 9-1 and 9-2).

It is therefore important in the more youthful patient, whose only complaint may be confined to cosmetic concerns within the orbital rims, to address cosmetic concerns while keeping in mind the eventual aging changes that will occur at the orbital malar junction. We have all seen patients who have had early aggressive fat resection during blepharoplasty only to have a hollowed out or concave inferior eyelid with malar ptosis and an orbital rim viewed in relief 10 years after the original procedure. It is these more youthful patients in whom conservative resections, repositioning, and support procedures as well as fat conservation, repositioning, and augmentation procedures should be considered and implemented whenever possible and where indicated.

INDICATIONS FOR MIDFACE SUSPENSION

The indications for addressing the mid face specifically are the appearance described earlier in which the lower lid to cheek distance is significantly elongated and the orbital rim is visible with a concavity between the pseudoherniated inferior and medial orbital fat and the ptotic or inferiorly displaced malar fat pad. Other associated abnormalities such as increased or deepening of the nasolabial fold, tear trough deformity, and scleral show may also be present. It is important to note that, as has been previously mentioned, scleral show or lower lid laxity in patients who have moderate or severe midface ptosis are generally not well served by canthopexy or canthoplasty alone. In fact, to reiterate an important point, the lower eyelid cannot support the cheek. Therefore, patients who present with significant midface ptosis and lower eyelid dystopia are candidates for midface suspension along with canthopexy or canthoplasty. At this juncture, clarification of canthopexy versus canthoplasty should be repeated. The canthopexy is a supportive procedure of the canthus in which the lateral canthal crura are not divided, shortened, or interrupted in any way. Generally, the common canthal tendon is fixed cephalad and laterally to provide minimal to moderate support. The canthoplasty should be defined as a canthal support procedure in which the inferior crus of the lateral canthal tendon is usually divided; tarsal elements then serve as a neocanthal tendon, should the lower lid require shortening, and

the lateral canthus is attached to the lateral orbital rim in some fashion, as described in Chapter 3. A commissuroplasty or reconstruction of the lateral canthus is then required; however, most surgeons should not find this learning curve overly steep. There is a third canthal support procedure that does divide the lateral canthal tendon and does not require commissuroplasty. This should be called a canthopexy with disinsertion of the canthal tendon or, more appropriately, a common canthoplasty. This procedure requires mobilization of the entire lateral canthus and lateral retinaculum at the periosteal junction and reinsertion cephalad at an appropriate and desired level. Careful positioning of the suspension suture through the soft tissue avoids distortion and extrusion postoperatively. In my experience it provides the most latitude in repositioning the canthus, and, with correct dissection, the lateral canthus may be positioned as high as the eyebrow. The indication for this procedure should be the patient with severe lateral tendon laxity in whom the entire lateral canthus has drifted inferiorly and medially, presenting with lower lid laxity, scleral show, and a dystopic canthus declined (negatively inclined) by at least 15 to 20 degrees. These patients invariably demonstrate all of the anatomic elements of midface ptosis. They also are not especially well served with a lower lid canthoplasty because shortening the lower eyelid does not serve to reposition the superior crus of the lateral canthal tendon and correct the inferior drift of the upper lateral eyelid. Disinsertion of the lateral canthal tendon with canthopexy is merely a modification and an evolution of procedures familiar to surgeons with backgrounds in craniofacial procedures (Fig. 9-3).

APPROACHES TO THE MID FACE

The midface or malar soft tissues may be addressed in a number of ways, and the choice depends on the patient's age, the degree of deformity, the objectives, and the desires of the patient.

One may choose a transeyelid or canthal approach in a patient who is younger (30s to 40s) and who has early senescent changes and ptosis of the mid face but is not quite ready for a full facialplasty and its associated incision lines. It may also be chosen in the older patient with significant facial aging changes whose complaints are solely focused around the periocular region. These patients are frequently symptomatic from lower lid and canthal laxity but are usually unwilling to undergo a more extensive facelift procedure. The surgeon is forced to utilize a periocular incision to suspend the mid face along with eyelid and canthal procedures, when the preauricular incision is not available as access to suspend the mid face.

The approach to the mid face familiar to most cosmetic surgeons is the preauricular approach, as is typical in a facelift procedure. The facelift incision should extend somewhat into the temporal scalp either at or posterior to the hairline. This should give the surgeon adequate exposure to the deep temporal fascia, orbital rim region, and the body and arch of the zygoma. With the use of a needle-tip cautery, dissection is carried down from the outer one third of the orbit laterally at the level of the orbital rim. The dissection is carried

superiorly as one moves laterally, mimicking the inclination of the orbital rim from medial to lateral. Dissection is carried out over the face and body of the zygoma parallel to the superior aspect of the zygomatic arch. The exposure need only be carried out laterally to the junction of the body and arch of the zygoma, and then inferior dissection is completed lysing the orbital malar ligament and exposing the suborbicularis oculi fat (SOOF) pad. The dissection is carried out superficial to the periosteum throughout the procedure, and the soft tissues can then be fixed cephalad and laterally to the underlying periosteum of the body of the zygoma and zygomatic arch. Laterally along the arch I prefer to plicate the superficial musculoaponeurotic system (SMAS) from medial to lateral approaching the ear. Following this, a canthopexy or canthoplasty may be performed, after the facialplasty flaps have been positioned. It is important for lower eyelid skin to be conserved, and any resection should engender lateral and cephalic tension. I prefer this approach whenever a facelift is part of the planned procedure or in patients who are not amenable to extended eyelid incisions or whose cosmetic concerns far outweigh their functional problems. In my experience, the facialplasty or preauricular approach is a slightly less powerful technique compared with the more direct transeyelid approach; however, it is associated with a notably lessened complication and revision rate. The appropriate lateral cephalic vector is always easier to create by a direct periocular approach to the mid face (Figs. 9-4 and 9-5).