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

Blepharoplasty has become one of the more common aesthetic surgical procedures performed today. Preoperative evaluation should include a number of important factors, none the least of which is the patient’s own assessment in a mirror of what he or she finds bothersome. As mentioned in Chapter 2, the preoperative evaluation should include a complete examination including a detailed history concerning dry eyes, recurrent herpes zoster or simplex infections, and thyroid disease. The physical examination should include a Schirmer test, tear film break-up time, visual acuity with and without correction, and so on. Fine examination of the lid margin for chronic blepharitis, evidence for lid retraction or laxity, and signs of associated systemic disease such as thyroid disease or other problems should be assessed. Although the surgical approaches may be the same, an appreciation of the difference between blepharochalasis and dermatochalasis, that is, the etiology for the redundant upper eyelid tissue, should be understood. I like to define blepharochalasis as redundant upper lid tissue secondary to underlying pathophysiology such as recurrent edema as found in renal failure, cardiac disease, or angioneurotic edema. Dermatochalasis is the commonly found redundancy of upper eyelid tissue secondary to

the senescent process with or without ptotic eyebrow changes.

An important concept in appreciating upper eyelid functional and cosmetic surgery is illustrated by contrasting nuances in the anatomy and pathophysiology between racial and age groups. For example, the upper eyelid crease lies 6 to 8 mm from the lid margin in the young Caucasian. The lid fold is created by extensions of the levator to the lid skin. This lid fold is significantly elevated in the deep-set eye or an eyelid in which levator dehiscence has occurred. In both instances, preaponeurotic fat is retracted or located more cephalad. In the senescent or “baggy” Caucasian upper eyelid, septal laxity and tissue relaxation allow preaponeurotic fat to prolapse anteriorly, lowering the eyelid fold and moving it closer to the lid margin. This age-related pathophysiology is analogous to the normal anatomy found in the youthful Asian upper eyelid. Here the eyelid fold is low and variably closer to the lid margin, with fullness created above it owing to prolapsed preaponeurotic fat extending to the insertion of the levator aponeurotic elements on the overriding lid skin. Therefore, the aged Occidental upper lid resembles the youthful Asian lid (Figs. 4-1 and 4-2).

In the patient undergoing upper lid blepharoplasty, it is extremely important to assess eyebrow position and note the presence or absence of ptosis. The eyebrow hairline and sub-brow fat pad should be evaluated in relationship to the upper orbital rim. The surgeon may have to consider direct eyebrow elevation through the upper lid incision or an indirect approach by means of a temporal incision to be included in the facelift, an endoscopic route, or a classic coronal route when significant eyebrow ptosis is present. The surgeon who attempts to correct significant eyebrow ptosis by means of an upper lid blepharoplasty alone will meet with unsatisfactory results and usually have a dissatisfied patient. This approach usually leads to a blending of the very thin eyelid skin with the thicker eyebrow skin and sub-brow fat pad with an appearance of the eyelids being sutured directly to the eyebrows. In my experience, it is the lateral one third of the eyebrow that is most important from a cosmetic standpoint; and this has been corroborated in other studies. Redundancy in the lateral one third of the upper eyelid presents as a hooding that can only be eliminated in two ways. Either the surgeon may elevate the lateral one third of the eyebrow and then perform a more conservative blepharoplasty, or a very aggressive lateral blepharo-

plasty extending beyond the orbital rim is necessary in addressing this hooding. The constraint for the surgeon is that incisions that extend beyond the lateral orbital rim become proportionately more noticeable the more laterally they extend. Therefore, the surgeon must balance the extent of lateral hooding against the desire to minimize lateralization of the upper lid blepharoplasty scar. Based on each patient, the extent of lateralization necessary and other factors, the surgeon and patient may choose to add an adjuvant procedure such as a lateral browlift to the planned blepharoplasty. This becomes an easier decision when a facelift is planned, because the lateral one third of the brow can be elevated in a plane over the deep temporal fascia extending over the lateral orbital rim. This is readily accessed by way of an extension of the facelift incision into the scalp. A direct brow suspension by way of the upper lid is another satisfactory approach that requires a significant amount of dissection, which can result in more postoperative swelling and a prolonged recovery for a blepharoplasty. This latter approach is especially useful in balding men and in limiting surgery and incisions in women. These procedures are described in more detail in Chapter 10.

The amount of horizontal skin laxity of the eyelids themselves, that is with the eyebrow fat pad held in an anatomic position and eliminating its contribution to skin redundancy, is another important factor that should be appreciated preoperatively. The presence or absence of lid lag or lagophthalmos should be noted and measured because asymptomatic lagophthalmos can easily be converted to the symptomatic variety with even small amounts of skin resection. Some patients may not tolerate brow suspension procedures (i.e., along with a skin resection in the upper eyelid, especially in the medial two thirds of the eyebrow). Elevation of the lateral one third of the brow is less likely to produce untoward sequelae even in patients with upper lid skin deficiencies. Therefore, the surgeon should assess “relative” dermatochalasis, that is, skin redundancy as contributed from the eyelid versus the eyebrow. Then the surgeon and patient can choose the appropriate technique based on the pathophysiology and the patient’s desires (Fig. 4-3). Because upper lid blepharoplasty basically involves removal of redundant or excessive skin of the upper eyelids along with excision of some portion of the orbicularis muscle and preaponeurotic fat with violation of the orbital septum, there are a few salient points that predicate a wellexecuted procedure. The first important anatomic location is the upper lid eyelid crease. In Occidentals, this lies 6 to 10 mm above the eyelid margin and is generally higher in females. It is important to remember that one is not bound by a particular eyelid crease height; however, the endogenous lid crease is usually the most appropriate for the patient. In Oriental or Asian eyelids the lid crease may be considerably lower than in Occidentals (see Figs. 4-1 through 4-3). Some Asian patients may request an Occidentalization or elevation of the endogenous upper eyelid fold. One may even encounter patients with asymmetric upper eyelid folds, and the surgeon should be comfortable with adjusting and repositioning eyelid folds as is discussed in Chapter 8 on the technique of supratarsal fixation. Once the upper eyelid fold is defined and marked with a surgical marking pen, the extent of upper eyelid skin excision is determined by a pinch test. The design of the upper and lower limbs of the incision lines should be curvilinear, with the medial aspect being convex superiorly and the lateral aspect being convex inferiorly. Attempts should be made to place the lateral aspect of the lower incision line within a skin crease, and this is upwardly inclined to meet the upper limb of the incision, which is extended laterally. In my mind, the importance of curving the lateral aspect of the upper incision is twofold: (1) to extend the upper eyelid

incision away from any potential lower eyelid incisions and, therefore, obviate a narrow skin bridge that is usually neurovascularly compromised in some fashion and (2) to curve the incision upward, allowing the lower limb to be longer than the upper limb and thereby effectively creating a Burow’s triangle resection of the potential dog-ear. An atraumatic forceps is used to pinch the skin between the delineated upper eyelid fold and the desired excision line superiorly, and I prefer to induce a small amount of upper eyelash eversion as a determinant of the proper amount of skin resection. Remember, brow positioning is important and should a brow elevation procedure be entertained, then suspension of the brow digitally before delineation of the extent of upper eyelid skin excision should be performed. Positioning the brow digitally before marking the upper eyelid allows the surgeon to address the upper eyelid first without risking overresection, independent of which procedure is chosen for brow elevation and independent of the order in which the surgeon chooses to perform the procedures (see Fig. 4-3). I find it very cumbersome to resect skin after the brow is suspended, especially in the transblepharoplasty brow elevation procedure, because this usually results in irregularities in the upper eyelid incision line. Local anesthetic with epinephrine is infiltrated and adequate time for hemostasis is allowed to elapse. Upper and lower lid eyelid incisions are made in a medial to lateral direction through skin and orbicularis muscle (Fig. 4-4). The skin muscle flap is elevated from the lateral to medial direction with digital retraction laterally. The orbital septum is tented with a forceps unroofed from lateral to medial, utilizing a sharp scissor or needle-tip cautery at the level of the upper extent of the eyelid incision. Tentative dissection by some surgeons occurs at this juncture owing to concern over creating iatrogenic damage to underlying structures at or behind the orbital septum (e.g., levator aponeurosis, tarsal plate). This can be obviated by opening the orbital septum as cephalad as possible where the levator aponeurosis lies most posteriorly away from the orbital septum and the buffer of preaponeurotic fat is interposed (Fig. 4-5). In Chapter 1, I pointed out that the levator aponeurosis and orbital septum fuse at the level of the upper tarsal plate and diverge as one moves superiorly, with the levator aponeurosis converting from an inferosuperior to an anteroposterior orientation as one moves cephalad from the tarsal plate (see figures in Chapter 1). Preaponeurotic fat (medial and central fat pads) can then be appropriately resected if desired. It is useful to use a fine hemostat with light digital pressure on the globe to tease the fat free of

septal adhesions and allow it to prolapse spontaneously. Fat may be resected by any technique; however, I find it preferable to use an insulated needle cautery. By using light inferior traction on the upper lid, one should be able to visualize the levator aponeurosis and

Whitnall’s ligament. It is easy to obtain complete access to the anterior one third of the orbit above the levator muscle using these simple technical maneuvers (see Fig. 4-5).

Figure 4-4 In practice the upper lid blepharoplasty can be efficiently performed using a few technical manipulations consistent with the anatomy. Digital traction and light pressure by the surgeon and/or assistant allow smooth quick skin incisions. A, Slightly more pressure must be exerted on the scalpel laterally as the skin thickens around and lateral to the orbital rim. B, The skin may be elevated with the orbicularis muscle in one maneuver using an instrument on the skinmuscle section to be resected and pulling this superonasally while providing digital traction laterally. I find a needle-tipped insulated cautery to be most advantageous in this and other succeeding steps, especially in avoiding any delaying hemostasis problems. The orbital septum is then widely opened, exposing the preaponeurotic space. C, The underlying levator aponeurosis is protected by opening the septum as cephalad as possible, because the levator and septum diverge as one moves superiorly.

UPPER LID BLEPHAROPLASTY

A Incision

Levator aponeurosis

Orbital septum

Pressure on globe causes medial

fat pad to bulge

Figure 4-5 Continued E, Contralateral upper eyelid shows preaponeurotic fat lying lateral to the superior oblique muscle and visualized more anatomically as a thin yellowish fan-shaped layer attached to the levator aponeurosis. The medial fat is separate, isolated between the medial orbit and the superior oblique muscle. After fat resection, closure may be performed as shown in Figure 4-4. F, Close-up photograph of an upper lid blepharoplasty demonstrating some important anatomic and clinical features. Here the lower forceps is indenting the levator aponeurosis and the upper forceps is retracting part of the preaponeurotic fat. Just lateral to the visualized preaponeurotic fat, the orbital septum remains intact. Note that the orbital septum must be violated to gain access to the superior orbit, the levator, and the preaponeurotic fat. Also note that the whiter medial orbital fat is spontaneously prolapsing anteriorly and the more central preaponeurotic fat is loosely attached to the underlying levator mechanism. G, The upper lid is placed on moderate traction, and the preaponeurotic fat is partially divided with a cautery and retracted nasally with forceps. Just above the skin traction hook one can see the tarsal plate with overlying orbicularis muscle (white); above that, a blue band corresponds to a levator dehiscence from the tarsal plate, and superior to that the levator aponeurosis is viewed as a white flat fan. Whitnall’s ligament is seen as a white thin band lateral to the cut end of the preaponeurotic fat. Just above Whitnall’s ligament is the blackened (cauterized) cut end of the orbital septum, and just below Whitnall’s ligament is the levator palpebrae superioris muscle, which is pale yellow and vascularized compared with the white aponeurosis distally. Modifications in the levator or at the levator tarsal junction can be easily performed with this exposure.

F

G