Fig. 26.1 Sagittal view of the orbit and midface demonstrating a negative vector eyelid as the tip of the globe protrudes more anteriorly than the midface

26.2Anatomic Associations of the Prominent Eye

In addition to increased orbital soft tissue volume, as with TED, eye prominence may be associated with primary exorbitism (shallow orbit), a hypoplastic malar eminence, a congenitally enlarged globe, or other soft tissue and bony lesions. In all instances, a “negative vector eyelid” is present when the cornea protrudes further anteriorly than the malar area (Fig. 26.1). A negative vector eyelid is a set-up for postoperative complications in aesthetic eyelid surgery, as the lower lid must overcome an anatomic predisposition towards abnormal retraction [3]. The lower lid is anchored laterally and medially by canthal ligaments, and supported inferiorly by soft tissues and the bony facial skeleton, as well as the sphincteric action of the orbicularis oculi muscle. This creates a delicate balance that can easily swing toward lid retraction in normal surgical settings, but much more so when globe prominence is present. In this scenario (prominent globe with negate vector eyelid), canthal suspension (an integral part of lower lid blepharoplasty) may lead to “bowstringing” of the globe (Fig. 26.2).

Associated physical findings specific to the periocular area in the setting of globe prominence include eyelid retraction, a high eyelid crease, prominent fat prolapse in the eyelids, and an increased prominence of the tear trough or

Fig. 26.2 The bowstringing effect encountered when tightening an eyelid in a patient with a prominent eye. The arrow demonstrates lid retraction (sclera show) created by the eyelid tightening

nasojugal fold. All of these features may be present in the patient without a prominent globe but tend to be more evident and thus cosmetically worse in the patient with the prominent eye. As such, each finding must be identified, evaluated, and addressed when necessary to appropriately and safely rejuvenate the periorbital area of the cosmetic patient with a prominent globe.

26.3Surgical Treatment of the Prominent Eye

26.3.1 Orbital Decompression Surgery

TED often produces axial proptosis which is directly addressed only with techniques of orbital decompression surgery [4–9]. Orbital decompression surgery expands orbital volume or decreases the volume of orbital contents, which allows recession of orbital contents into the expanded space. Most patients with TED and proptosis want to look more normal. Sometimes, even with no ocular symptoms, the proptosis is severe enough that orbital decompression should be considered. In these instances, a referral to an experienced decompression surgeon is wise if you do not have the expertise needed to perform such a procedure on a cosmetic basis.

Orbital decompression surgery was traditionally performed only in the setting of severe visual loss caused by optic neuropathy or uncontrollable ocular exposure. As surgical techniques have improved, surgeons have been more willing to perform orbital decompression surgery for lesser symptoms or even on a purely cosmetic basis. Clearly, orbital

decompression for only aesthetic reasons requires significant expertise with the surgical procedure, and should be reserved for more severe cases in which eyelid surgery will fail to camouflage the proptosis, or even worsen the cosmetic appearance. If there is no visual or exposure issues and eyelid surgery alone (lid recession and/or blepharoplasty) can mask the globe prominence, this is the patient’s easiest, lowest risk, and often best cosmetic option.

Historically, every orbital wall has been addressed surgically. The transantral decompression technique, which removes the medial wall of the orbit and the orbital floor, is quite effective in reducing axial proptosis but is associated with potentially unattractive globe ptosis, diplopia, and sinus complaints [10, 11]. Many surgeons advocate a balanced approach to decompression by removing the medial and lateral orbital walls [6, 7]. The incidence of postoperative diplopia and globe ptosis is decreased with this approach. The medial orbital wall can be approached via a transnasal endoscopic approach or via a transconjunctival and transcaruncular incision. The lateral wall is often approached via a small canthotomy or temporal upper lid crease incision, although the deeper portions of the lateral wall of the orbit are better exposed via a coronal approach.

As fracturing the walls of the orbit for cosmetic purposes would be objectionable to the majority of patients, orbital fat decompression is a less invasive alternative. Orbital fat decompression techniques, which excise retrobulbar fat, captured the imagination of orbital surgeons when they were introduced by Olivari and Trokel in the early 1990 [4, 9]. Greater familiarity with the internal orbit, aided by highresolution non-invasive imaging and better understanding of orbital soft tissue anatomy, encourages these approaches. These techniques have particular appeal in that they involve purely soft tissue surgery, avoiding special instrumentation and minimizing risks and morbidity. It is possible to combine surgical techniques, performing medial and/or lateral wall decompression in association with a graded amount of orbital fat decompression. The surgical approaches to the

orbital fat readily facilitate simultaneous upper and lower blepharoplasty surgery, arcus marginalis release, various midface lifts, and lower eyelid fat repositioning on a cosmetic basis.

26.3.2 Cheek/Orbital Rim Implants

Orbital rim augmentation, either via osteotomy and bone advancement (Fig. 26.3) or more simply via the placement of an alloplastic implant, moves the orbital rim forward and lessens the prominence of the eye, thereby improving the patient’s cosmetic appearance [12–15]. The association between orbital malar hypoplasia, a negative vector eyelid, and a prominent and cosmetically distracting tear trough deformity is striking.

An osteotomy may be performed with good results on a purely cosmetic patient but is a technique most applicable in patients with a true craniofacial syndrome or severe TED. The use of onlay silicone or porous polyethylene implants to the orbital rim and malar area is well described (Fig. 26.4) and often effective (Fig. 26.5). In some cases, fat repositioning blepharoplasty achieves much of the intended cosmetic improvement associated with these techniques, without the potential risks and complications of an implant.

26.3.3 Repair of Eyelid Retraction

The appearance of a prominent globe is enhanced by retraction of the upper and lower eyelids. Upper eyelid retraction generally relates to TED although it sometimes occurs primarily or in association with other medical conditions. Lower eyelid retraction is a product of globe position, orbital depth, malar projection, and factors innate to the eyelid and cheek soft tissues. Prior surgery may be a serious complicating factor in lower eyelid retraction requiring scar release, full thickness skin grafting, and other treatments. Additionally, surgery for lid retraction is generally undertaken only after

Fig. 26.3 Author’s patient with congenitally shallow orbits, midface hypoplasia, and severe TED. (a) Preoperative; (b) after balanced medial/lateral orbital decompression with C-osteotomy and advance-

ment of the lateral orbital rim; (c) after upper lid recession and lower lid hard palate mucosa spacer grafts

decompression surgery (if it is to be done) is performed. Alteration of the globe position with decompression surgery will alter eyelid position and may change the surgical plan for the treatment of eyelid retraction. Additionally, the shifting of orbital volume that occurs with orbital decompression surgery will often alter the surgical plan for any cosmetic treatment that is to follow.

26.3.4 Upper Lid Retraction

Upper eyelid recession surgery has traditionally relied on anterior approaches to the elevating structures of the eyelid

generally recessing the levator aponeurosis and Mueller’s muscle, and posterior approaches, which release or resect Mueller’s muscle and/or levator aponeurosis [16, 17]. The treatment of upper lid retraction is best performed by surgeons with familiarity and expertise in the treatment of ptosis. The author has enjoyed predictable results for over 20 years using an anterior technique very similar to that described by Harvey et al. [16]. This approach is ideal in treating the cosmetically oriented patient, as concurrent upper blepharoplasty can be performed addressing redundant skin, prominent prolapsing fat, especially the medial fat pad, which is generally hypertrophic in the patient with TED (Fig. 26.6).