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

The levator aponeurosis may be modified at this juncture if so desired. It may be freed from the tarsal plate and advanced as in a formal levator advancement procedure for ptosis. Alternatively, the levator may be plicated or tucked in mild degrees of ptosis (Fig. 4-6). This is described in Chapter 8. Closure is then performed, and I find the preferable method is to utilize an intracuticular suture extending from the medial canthal region to just medial to the lateral canthal region. I prefer a 5-0 nonabsorbable monofilament suture. Laterally, I prefer a 6-0 interrupted monofilament suture. Eversion of skin lateral to the canthus helps in eliminating a depressed incision line, which can be unsightly especially in women. I have seen some longer-lasting absorbable sutures produce unsightly tracts. Suture removal can be performed at 5 to 10 days as deemed appropriate by the treating surgeon. The medial aspect of the intracuticular suture that is transcutaneous tends to be prone to purulent inclusion cysts, and the surgeon may wish to trim this at the level of the skin at surgery or earlier than the scheduled complete suture removal.

Supratarsal fixation refers to creating a controlled adhesion between the levator aponeurosis and the

overlying skin. An endogenous lid fold of variable height, based on ethnic origin and other factors, exists owing to extensions between the levator aponeurosis and the dermal surface of the lid (as previously described). During the blepharoplasty, the surgeon may choose to either more definitely refine the location of an existing endogenous lid crease or he or she may choose to alter its height accordingly. This can be facilitated by passing sutures from the lower margin of the skin incision through the levator aponeurosis and then through the upper margin of the skin incision. The level at which the levator aponeurosis is engaged will determine the level of the upper eyelid fold. This technique is especially useful in creating a lid fold in the patient with congenital ptosis as well as in the typical cosmetic patient. I find it to be a necessity in the Asian patient who desires not to be Occidentalized. I prefer to use three or four interrupted small absorbable sutures such as 5-0 or 6-0 Vicryl or chromic catgut sutures to achieve supertarsal fixation. Cutaneous closure may be performed as described earlier should these fixation sutures not be adequate (see Fig. 4-4).

1.Age and race dictate the position of the upper eyelid fold, with a convergence in anatomy occurring between the aging Caucasian and youthful Asian.

2.Eyebrow and eyelid ptosis are important factors to be noted in planning the upper lid blepharoplasty, and their presence or absence will affect the final procedure of choice.

3.Lateral eyebrow ptosis contributes to lateral upper lid hooding. The surgeon will meet with unacceptable results should he or she attempt to correct either one, using the other.

4.The endogenous or selected position for the upper lid fold is the first key step in designing an upper lid blepharoplasty.

5.When planning a brow elevation procedure, the brow should be digitally suspended prior to delineation of the extent of upper eyelid skin excision.

6.Iatrogenic injury to the levator aponeurosis can be avoided by opening the orbital septum as high as possible where the aponeurosis moves posteriorly.

7.Careful skin eversion lateral to the canthus is important to avoid a depressed incision line.

8.Supratarsal fixation is a potent technique that may be employed in every upper lid blepharoplasty. It allows the creation of an upper lid fold based on skin fixation to the underlying levator aponeurosis.

9.The transconjunctival blepharoplasty and the transcutaneous blepharoplasty are equally effective in approaching fat but the former has some shortcomings vis-a-vis the mid face and in addressing significant skin redundancy.

10.The decision to utilize the transconjunctival versus the transcutaneous route should be predicated on the amount of skin redundancy and whether a canthal tightening procedure is indicated.

11.When fat resection is employed it should be conservative to avoid a hollowed-out appearance.

12.Skin should be redraped, with the line between the nasojugal groove and the lateral canthus kept in mind, that is, inducing a lateral cephalic vector.

REFERENCES

Berman M: Rejuvenation of the upper eyelid complex with autologous fat transplantation. Dermatol Surg 26:11131116, 2000.

Castro E, Foster JA: Upper lid blepharoplasty. Facial Plast Surg 15:173-181, 1999.

Friedland JA, Jacobsen WM, Terkonda S: Safety and efficacy of combined upper blepharoplasties and open coronal browlift: A consecutive series of 600 patients. Aesthetic Plast Surg 20:453-462, 1996.

Guyuron B, Knize DM: Corrugator supercilii resection through blepharoplasty incision. Plastic Reconstr Surg 107:606-607, 2001.

Lee Y, Lee E, Park WJ: Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: Do we have to make an additional scar to correct the Asian epicanthal fold? Plast Reconstr Surg 105:1872-1880, 2000.

Januszkiewicz JS, Nahai F, Zarem HA: Transconjunctival upper blepharoplasty. Plast Reconstr Surg 103:1015-1019, 1999.

Kim JW, Lee JO: Asian blepharoplasty with a short-pulsed contract Nd-YAG laser: Limited-incision resectable laser double fold with internal medial and lateral functional epicanthoplasty. Aesthetic Plast Surg 22:433-438, 1998.

Lee Y, Kwon S, Hwang K: Correction of sunken and/or multiply folded upper eyelid by fascia-fat graft. Plast Reconstr Surg 107:15-19, 2001.

Lee Y, Lee E, Park WJ: Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: Do we have to make an additional scar to correct the Asian epicanthal fold? Plast Reconstr Surg 105:1872-1880, 2000.

Ullmann Y, Levi Y, Ben-Izhak O, et al: The surgical anatomy of the fat in the upper eyelid medial compartment. Plast Reconstr Surg 99:658-661, 1997.

Weber PJ, Wulc AE, Foster J: Transconjunctival upper blepharoplasty. Plast Reconstr Surg 104:2333-2334, 1999.

The lower lid blepharoplasty has been viewed by many, especially the less experienced, as being technically more difficult to perform than the upper lid blepharoplasty. The perception of difficulty likely lies more in the numerous decision-making processes the surgeon and patient are forced to undergo to achieve a satisfactory lower lid result. Once evaluation of the patient is complete, the surgeon has many more choices as to how to approach the lower lid blepharoplasty and less margin for error. In examining the patient, the surgeon is faced with concerns over such things as the degree of horizontal lid laxity, position of the lateral and medial canthal angles, conditions such as scleral show, entropion and ectropion, or other underlying pathologic processes. As in the case of the upper eyelid, the surgeon should obtain a thorough history. I find it is always helpful to have the patient look in a mirror and delineate, articulate, and specifically demonstrate what are his or her cosmetic concerns. Then the surgeon has a plethora of procedures available with which to address these concerns. These include whether to perform a transcutaneous or transconjunctival approach, whether to perform a canthal procedure such as a tarsal tuck or tarsal strip procedure, or even whether to reposition the entire lateral canthus (common canthoplasty). Decisions as to how to address skin and/or fat are equally numerous. The surgeon is faced with whether to address the skin and, if so, whether to perform a skin trim procedure, laser resurface the skin, or address the skin element in some other fashion. Fat can be addressed with resection, redistribution, or both. An appreciation of midface position is as important in lower lid blepharoplasty as is appreciation of brow position in upper lid blepharoplasty. Here with regard to the mid face, the surgeon has a choice as to whether he or she wishes to address it at all, whether to approach it by way of the

lateral extent of the upper or lower lid incision, or whether to approach it by means of a preauricular facelift incision. Of course, the approach depends on the underlying pathologic process and what the patient and surgeon perceive as the underlying cosmetic and/or functional abnormality. The surgeon should be familiar and well versed and comfortable with all techniques and approaches to the lower eyelid and attempt to adjust the operation to the patient and not the other way around.

TRANSCUTANEOUS LOWER LID BLEPHAROPLASTY

The transcutaneous lower lid blepharoplasty is a powerful technique for addressing lower lid cosmetic abnormalities. It allows a number of adjuvant procedures to be performed easily and more accurately than the transconjunctival route. Its disadvantages include greater technical demands, more time, more extensive dissection, and, hence, greater secondary fibrosis; and it has an inherently greater margin for error (i.e., overresection or changes in forces on the lower lid engendering scleral show and/or ectropion). It is, however, more powerful in that one can address fat alone (resect or redistribute), address skin and/or muscle separately, and approach lower lid tightening by way of a direct approach to the lateral lower lid tarsus or inferior crus of the lateral canthal tendon.

Although there have been descriptions of the use of cutaneous flaps as an approach to fine skin rhytids of

the lower eyelid, I do not recommend them. These were originally described as a means of addressing fine rhytids separately from other more gross irregularities. The lower eyelid skin is extremely thin, and any attempt to raise a skin flap independently of the underlying orbicularis muscle likely leads to a poorly vascularized cutaneous segment that is prone to secondary contracture and other complications. In distinction, the myocutaneous flap is extremely hardy and, given the number of other modalities available to the surgeon today for addressing fine rhytids of the lower eyelid, the argument for a cutaneous flap independently of the muscle segment, in my opinion, is tenuous. The decision to use the transcutaneous route versus a transconjunctival route should be predicated on the amount of skin redundancy and whether a canthal tightening procedure is indicated. The transcutaneous or transconjunctival routes are equally effective in addressing fat (resection and/or redistribution). Should one wish to address the mid face (cheek suspension), then an access incision either by way of the lateral lower eyelid, lateral upper eyelid, or facelift approach is usually necessary. The transconjunctival route alone does not in

general provide adequate exposure to the mid face and does not allow appropriate cephalic and lateral elevation of the cheek unit. It may, however, be used to subtly elevate the medial cheek at the nasolabial junction. Midface access by way of a preauricular or lateral upper eyelid incision may force the surgeon to perform a second lower eyelid transcutaneous incision should he or she wish to achieve anything more than a canthopexy or common canthoplasty to the lower eyelid (Fig. 5-1).

The lower eyelid may be delineated for blepharoplasty by drawing an incision line extending from the lateral canthus posteriorly in a natural skinfold. This is usually subtly declined inferiorly to appear more natural and avoid encroaching on the upper lid. As in the upper lid blepharoplasty, one would prefer to minimize the lateral extent of the incision line, and I choose to make a limited incision that is extended if necessary for skin and muscle redraping and/or suspension. The incision line will extend medial to the lateral canthus in a natural fold below the lower eyelid. One would prefer to leave a cuff of pretarsal orbicularis below the lash margin, which is theoretically responsible for eyelash orientation (Riolan's muscle).

Local anesthetic of choice (lidocaine with epinephrine) is infiltrated, and adequate time for hemostasis is allowed to elapse. An incision is made in the lateral extent of the delineated incision through skin and orbicularis muscle. A curved sharp tenotomy or Steven’s scissor is inserted in the postorbicularis/preseptal plane. This is the potential space just anterior to the orbital septum, which has been described in Chapter 1 (see Fig. 1-2). As one enters the potential space from lateral to medially, the scissor is opened gently and a true space is developed extending from the preseptal to the pretarsal suborbicularis regions. The scissor is withdrawn and a fine small sharp scissor (iris scissor) is reinserted with one limb of the scissor in the incision and the other overlying the skin of the lower lid. The marginal aspect of the incision is then made just below the lash line margin of the lid with the scissor beveled inferiorly (lower limb inferior) (Fig. 5-2). The incision should extend up to a point lateral to the medial punctum. The lower eyelid is then placed on cephalic traction with an eyelid hook, and with countertraction on the skin muscle flap the myocutaneous flap is elevated to the level of the orbital rim inferiorly. I recommend that the lower eyelid hook be placed on the conjunctival side of the lower eyelid so as to avoid corneal or eyeball injury should one choose not to use a protective eye shield or contact lens. Once the myocutaneous flap is elevated to the orbital rim, the orbital septum will be easily visualized and may be incised to address orbital fat when appropriate.

I prefer to incise the orbital septum and visualize all three fat pads along with the inferior oblique muscle. The fat may then be resected, preferably with a needle cautery technique. In resecting lower lid fat, conservation is strongly recommended, because overresection usually leads to a concavity or “sickly appearance” to the lower lid and inferior orbital region. Fat redistribution techniques may be used alone or in combination with fat resection depending on which compartment is thought to be prominent or deficient. In general, in approaching resection only, only fat that spontaneously herniates with light digital pressure to the globe should be removed and the amputation point should not extend within the orbital rim. Special care should be taken to directly observe the lateral fat compartment because this is most frequently missed or inappropriately treated (see Fig. 5-2).

Once fat has been addressed and the surgeon suspends the lower lid and/or mid face if appropriate, then

the skin muscle flap is redraped and adjusted. Every attempt should be made to elevate the skin muscle flap cephalad and laterally so as to create a vector force that runs superiorly from the nasojugal groove through the lateral canthal area. This orientation is important in eliminating the line of force that links the lower eyelid directly to the malar tissue in one plane. This technique, however, may be slightly less advantageous in eliminating lower eyelid skin rhytids. The flap may be backcut at the point of insertion to the lateral canthal region, and skin may be trimmed from lateral to medial as a tapered wedge so that very little, if any, skin is resected from the level of the pupillary axis to the medial canthus. The area of skin muscle flap that lies lateral to the lateral canthus can be appropriately resected without tension with the possibility of extending the incision line temporarily depending on the amount of redundancy or dog-ear created. A separate closure of the muscular layer may be performed when a larger amount of myocutaneous resection is employed.

A single absorbable suture through the orbicularis muscle that engenders cephalic lateral suspension forces can be useful in not only eliminating or reducing tension on the skin closure but also further supporting the lower lid against distraction forces. This is especially useful when one performs a formal lower lid tightening procedure whether it be a tarsal tuck, tarsal strip, or other canthopexy procedure. In fact, muscular suspension should be viewed as the simplest but least effective method of increasing lower lid support. Orbicularis repair may be achieved with a small (5-0) absorbable suture (i.e., Vicryl). Before skin closure one may consider resecting a small cuff (2 to 3 mm) of orbicularis muscle from the undersurface of the myocutaneous flap extending from the lateral canthal region medially. Although this usually creates an annoying hemostasis problem near the end of the procedure, it is useful in eliminating or avoiding orbicularis bulge inferior to the lid margin, which in many patients is noted as a preoperative cosmetic concern.

Finally, skin closure is performed and I prefer to utilize a running 6-0 silk suture from medial to the lateral canthus and interrupted 6-0 nylon sutures lateral to that. Only the nylon sutures are tied down (see Fig. 5-2). This enables the silk to be easily removed early in the postoperative period, that is, 3 to 5 days.

D Incised orbital septum

ERemove medial and central fat pads

Central fat pad

FPressure on upper lid causes lateral orbital fat pad to bulge anteriorly

Lateral fat pad

Orbital rim

Medial fat pad

Inferior oblique muscle

Orbital rim