Fig. 10.7 Intraoperative photograph showing the excision of the depressor supercilii muscle with Stevens scissors via the upper eyelid blepharoplasty incision after the corrugator superciliaris muscle has been removed. The orbicularis oculi muscle is retracted medially with two lacrimal rakes. The depressor supercilii muscle is pulled from under the orbicularis oculi muscle with a heavy forceps

Fig. 10.8 Intraoperative photograph showing the immediate elevation of the medial and central brow on the right side after excision of the medial brow depressors: corrugators and depressor supercilii muscles

(Fig. 10.9). A tearing type release is felt at the base of the nose (“the sound of beauty”), and can be heard by both the surgeon and the patient, confirming the full release of the procerus muscle.

10.5Lacrimal Gland Prolapse

The preoperative examination of the patient with lacrimal gland prolapse shows fullness in the temporal upper lid, which is firmer to palpation than the adjacent fat (Fig. 10.10). The lacrimal gland prolapse can be made more apparent with retropulsion of the globe and can be easily visualized with eversion of the upper eyelid. The lacrimal secretory complex is composed of the main lacrimal gland and the additional accessory glands of Krause and Wolfring [18–20]. The lacrimal gland proper is further composed of the smaller palpebral lobe and the larger orbital lobe, which normally adheres to the lacrimal gland fossa. Four ligaments suspend the gland in the lacrimal fossa. Anteriorly, bands of fascia connect the

Fig. 10.9 Intraoperative photograph showing the undermining of the procerus muscle. The muscle is elevated from its deep attachments to the glabellar area with Stevens scissors

Fig. 10.10 Photograph of patient at oblique angle (above) and frontal view (below) demonstrating temporal upper lid fullness associated with lacrimal gland prolapse (arrows) (Photo courtesy of Guy G. Massry, MD)