References

42

Lower Eyelid Blepharoplasty:

Procedure Pearls and Pitfalls

John D. Siddens

1. If at all possible, a transconjunctival incision is preferable to a transcutaneous incision, especially if the mid-face is not being addressed.

2. A transconjunctival incision can be performed with a CO2 laser, a radiofrequency unit, a monopolar tip, or even carefully with a hightemperature cautery.

3. Be conservative when removing herniated orbital fat. Draping or repositioning fat over the rim is often preferable to significant fat excision.

4.Meticulous hemostasis is critical in lower eyelid blepharoplasty. We recommend the clamp, cut, and cautery technique using a small hemostat, Westcott scissors, and the bipolar cautery, respectively.

5.If there is excessive skin laxity in an older patient, skin removal can be useful if done conservatively and in conjunction with a horizontal tightening of the lower eyelid. The fat should still be addressed through a transconjunctival incision. We never remove herniated fat through a transcutaneous incision.

6.Beware of creating a “lateral canthal syndrome” (Figure 42.1). This is caused by excessive skin removal and/or orienting the lateral skin too vertically.

7.If the patient is a CO2 laser candidate, this is a preferred way to tighten the lower eyelid skin. Patient selection is critical as this should only be performed on the lighter skin types, and we need to warn the patients of possible persistant erythema or pigment changes.

8.Pretreat CO2 laser patients with an anti-HSV medication, and avoid performing laser to tan patients.

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43

Lower Blepharoplasty:

The Bilamelar Approach

Guy G. Massry

In lower blepharoplasty surgery, the goal is to address skin, muscle, and fat. The order is important: fat-muscle-skin. I call my preferred method “bilamelar blepharoplasty.”

The fat is addressed transconjunctivally through an incision 5 mm below the tarsus inferior to the point of fusion between the eyelid retractors and the orbital septum. The fat can be excised or repositioned or a combination of the two can be performed.

The orbicularis muscle can be tightened with an orbicularis strap technique. A subciliary incision is made across the lateral two-thirds of the lid. Laterally, a strap of orbicularis is created. It is then secured to the lateral orbital rim periosteum with 2–3 buried sutures. The skin, miscle, and septum are thus tightened. Skin excision and closure follows.

If a pinch skin excision is to be performed by itself, a transconjunctival retractor lysis allows the eyelid to elevate and counteracts any downward traction as the skin heals. A temporal intermarginal tarsorrhaphy of 5-0 chromic gut will further oppose downward traction in the first week.

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44

The Skin in Lower Lid

Blepharoplasty: General Principles

Guy Ben Simon and John D. McCann

In cases of fat removal or repositioning or pseudoherniation of orbital fat, enhancement of the deficient suborbital portion of the malar complex is the principal component of modern lower eyelid blepharoplasty. Skin removal is usually unnecessary since there is typically inelasticity rather than actual excess of skin. The widely preferred approach is transconjunctival incision, which results in less eyelid retraction, less scleral show, and less postoperative ectropion than other methods. Some surgeons prefer a transcutaneous approach in patients who have hypertrophy of the orbicularis oculi muscle and therefore require muscle excision.

Wrinkles and excess of vertical skin can be dealt with by skin-resurfac- ing techniques such as chemical peeling and CO2 or erbium—YAG laser resurfacing. These techniques are applicable in patients with Fitzpatrick skin types I–III. Patients with darker skin are at risk of pigmentary changes; these can be managed by the pinch technique. Excess skin is crushed using a straight hemostat 1–2 mm subciliary and excised. Care must be taken to excise as little as possible of the orbicularis muscle. The skin is closed with a running suture. Regardless of the timing of laser treatment, transconjunctival blepharoplasty with adjunctive CO2 laser resurfacing results in improvement of lower eyelid bulging and skin wrinkling.

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45

Incising the Septum over the Nasal, Central, and Lateral Fat Pads in Lower Blepharoplasty

Jemshed A. Khan

The fat pads should be free from any encumbering structures. The overlying orbital septum specifically must be divided for each fat pad before the fat can freely prolapse. The lateral fat pad may be more difficult to mobilize because the overlying septum may be adherent to the inferior lateral orbital rim.

Nasal fat pad:

•Ballote the globe to bring the fat pad forward.

•Make an “X”-shaped incision over the nasal fat pad.

•Deepen the incision until fat prolapses.

Central fat pad:

•Ballotement of the globe to bring the fat pad forward.

•Make a horizontal 10to 12-mm incision over the central fat pad.

•Place the incision 2–3 mm superior to the inferior orbital rim.

•Deepen the incision until fat prolapses. Lateral fat pad:

•Expose the lateral fat pad.

•Divide the fat pad from the underlying lower eyelid retractors.

•Incise the overlying orbital septum.

•Divide the arcuate expansion if necessary (fibrous anterior band separating the central and lateral fat pads).

Reprinted with permission from: Chen WPD, Khan JA, McCord, Jr, CD. Color Atlas of Cosmetic Oculofacial Sugery. Philadelphia: Butterworth Heinemann/ Elsevier, 2004.

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46

Prolapsing the Inferior Fat Pads and

Fornix in Lower Blepharoplasty

Jemshed A. Khan

The successful transconjunctival incision depends on adequate prolapse and exposure of the conjunctival fornix. The lower eyelid margin is retracted by the assistant with two fingers. Retraction of the lower eyelid margin requires that the pads of the assistant’s fingers be placed directly upon the eyelid margin itself in order to exert sufficient inferior traction. At the same time, ballottement of the globe so as to prolapse the fat and conjunctiva anteriorly. When performed successfully, a liberal horizontal roll of prolapsing fat and overlying conjunctiva will present itself reliably and visibly. The use of the titanium Khan-Jaeger plate enables the surgeon to ballottement of the globe posteriorly in order to prolapse the fat anteriorly while also protecting the globe. Ballottement can also be achieved with a cotton-tipped applicator on the metal contact lens.

Key Points

•Begin at the inferior border of the lateral tip of the caruncle.

•Continue laterally.

•Stay 4 mm below the base of the tarsal plate.

•Continue to within 2 mm of the lateral canthal angle.

•Angle the beam towards the inferior the orbital rim.

Reprinted with permission from: Chen WPD, Khan JA, McCord, Jr, CD. Color Atlas of Cosmetic Oculofacial Sugery. Philadelphia: Butterworth Heinemann/ Elsevier, 2004.

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47

Identifying the Inferior Oblique in

Transconjunctival Blepharoplasty

Jemshed A. Khan

Prior to embarking upon transconjunctival blepharoplasty, the inferior oblique muscle should be clearly visualized. The inferior oblique is reliably located in the cleft between the nasal and central fat pads. Using cotton-tipped applicators, the nasal and central fat pads can be easily separated to allow the inferior oblique to come into view. Once identi-

ed, one can safely proceed with excision of the fat pads.

The inferior oblique muscle originates from the periosteum adjacent to the proximal bony nasolacrimal duct and passes inferior to the nasal fat pad and superior to the central fat pad. Arising from the inferior oblique is an expansion of connective tissue that sometimes restrains the contiguous fat of the central and lateral fat pads. This tissue, the arcuate expansion, may be divided if necessary.

Key Points

Recommended Instruments1

•Khan-Jaeger Laser Eyelid Plate

•Castroviejo 0.5 mm toothed platform tying forceps

•Desmarres retractor (dull finish)

•Bipolar cautery, hemostat (fine curved)

•Protective metal scleral contact lens

•The inferior oblique can always be located between the nasal and central fat pads

•If the fat is restrained between the central and lateral fat pads, look

for and divide the anteriorly located brous band of tissue (arcuate expansion)

The lateral fat pad is easier to remove once separated from the underlying lower eyelid retractor

Reprinted with permission from: Chen WPD, Khan JA, McCord, Jr, CD. Color Atlas of Cosmetic Oculofacial Sugery. Philadelphia; Butterworth Heinemann/ Elsevier, 2004.

1 Storz Instrument Company, St Louis, MO

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146 J.A. Khan

Figure 47.1. Inferior oblique muscle is reliably located in the cleft or separation between the nasal and central fat pads.

Figure 47.2. The arcuate expansion sometimes constrains the central and temporal fat pads.