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VI
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CosmetiC surgery
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EVALUATION OF THE AGING FACE
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Faisal A. Quereshy, Sarah Naghibi
1. Can you identify the key elements in the evaluation of the aging face?
The cornerstone to the evaluation of the aging face is the physical assessment. Key elements included in
this assessment are skin quality and bony structures. These are further divided into the evaluation of the
facial thirds: upper, middle, and lower and neck. Although aesthetic surgery will often involve the soft tissue, the underlying bony structures will serve as a critical factor both in the approach and final outcome.
2. What elements of the skin should be evaluated?
The initial evaluation should begin with an analysis of the individual’s skin. Aspects of the aging skin
that warrant attention are skin laxity, skin phototyping, presence or absence of rhytides, persistency of
rhytides against tension, and rhytides from mechanical contraction and gravity.
3. Can you describe skin phototyping and the Fitzpatrick scale?
Skin phototyping is quantified by the Fitzpatrick scale and represents a significant prognostic predictor in
aesthetic facial surgery. The scale classifies the skin’s varying response to UV light in the setting of aesthetic
procedures. The practitioner can deduce from the scale an individual’s response to specific procedures such
as resurfacing and chemical peels. Fitzpatrick I and II patients have lighter skin and heal better; therefore
they are more ideal candidates for laser resurfacing, chemical peels, dermabrasion, and microdermabrasion. Fitzpatrick I, II, and III have a lower risk for complications such as discolorations, burning, and scarring.
However, these types tend to have deeper tension lines, and thus they are less suitable for resurfacing.
Types IV to VI encompass darker skin patients who are not suitable for resurfacing, although they do not
have deep dynamic lines like the former. They are also at a much higher risk for complication.
4. What is Glogau’s classification, and how does treatment strategy change for each
group?
Glogau’s classification of photoaging divides patients into four groups based on the degree of actinic
keratosis, wrinkling, acne scarring, and the amount of makeup worn by the patient. This classification
helps to assess and quantify the degree of sun damage in patients.
5. What is Dedo classification, and how does it help with treatment planning?
Dedo classification helps to categorize cervical deformity based on the deepest tissue later involved in
each: Class I is a normal patient, Class II is related to skin, Class III is fat, Class IV is platysma muscle,
and Class V and VI are related to hyoid bone. Based on the etiology of the defect, treatment will be
different from one group to the other. Submental liposuction alone will be ideal for Class III patients,
whereas Class IV patients will benefit from surgical management of platysma muscle. Class V patients
will require mandibular osteotomy or genioplasty. Class VI patients have low hyoid bone positioning,
which limits the effectiveness of submental surgery.
6. How do you evaluate skin laxity?
The pinch test is used to differentiate between superficial and deep skin laxity. Pinch test interpreta-
tion is as follows: easy lateral and shallow movement of skin is superficial. This superficial laxity
manifests itself as rhytides. The physical exam will identify superficial laxity, while photographic
analysis based on regions of the face will help identify laxity in the upper, middle, and lower and neck
thirds. Specific areas of laxity across the facial thirds include the eyelid fold, nasojugal fold, melolabial
fold, jowls, and platysma bands. Each laxity region is then quantified by severity from Class 0 to 5, 0
being devoid of laxity and 5 being the most severe laxity.
7. What are the common signs found in the aging face?
• Ptotic and wrinkled brow
• Glabellar laxity
• Ptotic eyelid
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• Droopy nasal tip
• Laxity of the cheeks
• Ptotic earlobes
• Perioral wrinkling
• Jowls
• Platysma bands
• Laxity of cervical skin
8. What signs of facial aging are reversible by aesthetic surgery?
• Skin laxity in the cheek and neck region
• Prominence of nasolabial folds
• Jowling
• Rhytides
9. What are the common complaints found in patients with aging upper third of the
face?
A frequent complaint of patients in regard to the aging face in this region is the appearance of a
sustained tired or angry expression that is inconsistent with their actual disposition. When considering
the forehead, aging leads to eyebrow or eyelid ptosis, which results in compensatory contraction of
the frontalis muscle. The end result is forehead wrinkles.
10. How does one evaluate frontalis compensation?
There are two ways to evaluate frontalis compensation: one is with the patient smiling, which
eliminates the compensation. A second is closing eyes tightly and then slowly opening until sight is
first established—compensation appears when eyes are fully open. The depth of existing forehead
wrinkles will determine the surgical method—deep lines benefit from a subcutaneous approach,
whereas laser resurfacing and endoscopic approaches favor finer wrinkles.
11. How does glabellar angle change with age?
The glabellar angle of the forehead is formed by the intersection of the glabella-nasion and nasion-
pronasale. The normal angle is 132 degrees with a 15 degree variation in either direction. Therefore,
this angle can be assessed as excessive, normal, or deficient. Excessive angle indicates frontal bossing, whereas aging causes the normally round and projected glabellar to appear flat or depressed.
12. What changes occur in the eyebrows with age?
Gravity is the primary force in brow position changes with age. The ideal female brow at the medial
aspect coincides with a vertical plane from alar base to the medial canthus, and the lateral end parallels a line from the alar base to the lateral canthus. In females, the medial and lateral aspects of the
brow should lie on the same horizontal plane, and the superior arch of the brow should be at its greatest height above the lateral limbus, with a 1 cm extension above the supraorbital rim. The male brow
rests similarly but at a more level plane than the female arch. Brow correction from aging includes
Botox, which can lift the brow, or surgical lifting involving endoscopic approach or transblepharoplasty.
13. What changes occur in the upper eyelids with age?
The upper eyelid is usually the first feature of the upper face that exhibits signs of aging. These aging
signs are due to skin quality, skin excess, and soft tissue changes. Attention must be given to the
aesthetic areas in the upper eyelid: the lid sulcus, orbital palpebral fold, supratarsal fold, pretarsal
crease, lacrimal gland, pretarsal skin, upper eyelid margin, and orbital fat. Skin laxity can be examined
by gently grabbing pretarsal skin and pulling to create lagophthalmos. Excess skin laxity may result
in the inability to fully close the eye. Redundant orbital fat can be evaluated in a similar fashion, and
excess represents a consequence of aging and indication for correction. Skin laxity and excess can
also lead to the obliteration of the superior palpebral fold in addition to its surrounding anatomy. Thus,
the major goal of blepharoplasty is to reestablish this fold. Furthermore, excision of excess skin, which
diminishes the eyelid’s natural concavity, can restore a more youthful appearance.
14. What are the important factors in evaluating lower eyelid aesthetic surgery?
The lower eyelid differs in its evaluation and surgical approach, depending on the etiology of the
changes. Lower eyelids must be evaluated for lid laxity, fat pseudoherniation, and history of dry
eyes. Ideally, the lower lid is slightly superior to the lower limbus. The lower lid position moves
inferiorly with age, most commonly due to skin laxity and gravity. Excess sclera may be visible.
As part of the physical exam, a snap test should be performed to assess for lid laxity. This entails
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grasping the lower lid and gently pulling inferiorly and laterally. A normal response would be an
instantaneous recoil. Delayed return to its original position signifies increased laxity and tissue
redundancy, which may be an indication for lateral canthal tightening with or without lower
blepharoplasty.
15. Can you describe evaluation of the middle third of the face?
The middle third of the face is punctuated by malar convexity, the depiction of youthful facial features.
This convexity is supported by the zygoma and its associated soft tissue. With aging comes the
descent of the soft tissue due to gravity and atrophy of the supporting subcutaneous tissue resulting in loss of the youthful convexity. The inferior movement of the cheek results in distinct aging
characteristics: a deepening of the nasolabial fold and nasojugal groove and inferior displacement of
the buccal fat pads. This can further result in effacement of the jawline with the now excess displaced
tissue.
16. What are the major causes of aging in the lower third of the face?
Aging of the lower third of the face is predominantly caused by maxillary and mandibular bony resorp-
tion, increased skin laxity, and thinning of the subcutaneous fat.
17. Can you describe the changes with age in the perioral region?
In general, the upper lip tends to thin out more than the lower lip. Gravity contributes to ptosis of the
superficial musculoponeurotic system (SMAS) and fat, both of which are necessary to create a tight,
smooth lower facial appearance. The ptosis causes jowls to develop, which creates a widened lower
facial width. Aging of the lower face can further be evaluated by locating a horizontal line connecting the oral commissures. This line should be parallel to a corresponding horizontal line between the
canthi in young patients. Aging patients will demonstrate a posterior tilt of the oral commissure line.
18. What are the changes that are found in the aging neck?
The aging cervical region is largely dependent on bony structures. Specifically, hyoid position, chin
prominence, and midface vector should all be thoroughly evaluated in the aging patient. The cervicomental angle is formed by the horizontal submandibular plane and vertically by the neck. An angle
between 90 and 100 degrees is considered a youthful aesthetic. Wider angles are often due to a low
and anteriorly positioned hyoid bone. Cervicomental angle is also influenced by chin position. Retrognathia can increase the angle. This creates a dulled transition between face and neck. Furthermore,
the appearance of the neck becomes heavier and blunted.
The aging patient can be evaluated for tissue redundancy in the neck, which will obscure
youthful landmarks and contours. During the physical exam, the practitioner can pull the redundant
tissue upward, just inferior and anterior to the ear, which will cause those landmarks to reappear. If
the tissue is easily displaced it is considered redundant. During this maneuver, the underlying residual
fullness and lipomatosis can be better visualized. The pinch test can also be used to differentiate
between redundant tissue and fat—the redundant being easily pinched. To evaluate skin laxity, the
patient can protrude the mandible forcefully while the clinician assesses for skin laxity.
Evaluate the platysma and its associated lipomatosis via palpation during contraction to observe
midline crossing patterns, which occur at various levels relative to the location of lipomatosis in the
neck. In the aging patient, lipomatosis is commonly found deep to the platysma and midline. This
maneuver also helps the surgeon quantify the amount of subcutaneous fat in addition to its location
relative to the platysma.
19. What differences are noted between men and women in evaluating patients for
aesthetic surgery?
• Position of the eyebrows is different
• Different patterns of hair growth in the scalp
• Presence of a beard in men, which causes an increase the thickness and blood supply in the region
• Psychological differences
BiBliography
Guyuron B, Eriksson E, Persing JA, et al.: Plastic surgery: indications and practice, St Louis, MO, 2008, Saunders.
Kaminer MS, Arndt KA, Dover JS, et al.: Atlas of cosmetic surgery, ed 2, St Louis, MO, 2009, Saunders, pp 37–43.
COSMETIC BLEPHAROPLASTY
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Joe Niamtu III
CHAPTER 55
1. Can you describe the motor and sensory innervation of the eyeball, eyelids,
and associated structures?
• The superior oblique muscle has motor innervation from the trochlear nerve (cranial nerve IV).
• The lateral rectus muscle has motor innervation from the abducens nerve (cranial nerve VI).
• The remainder of the extraocular muscles receive motor innervation from the oculomotor nerve
(cranial nerve III).
• Sensory innervation of the eye is from the trigeminal nerve (cranial nerve 5, V1 branch, mainly
through the ciliary nerve).
• Visual sensory is from the optic nerve (cranial nerve).
• Lid opening is from the levator palpebrae superioris, which is innervated by the oculomotor nerve
(cranial nerve III).
• Lid closing is a result of the orbicularis oculi contraction, which is innervated by the facial nerve
(frontal and zygomatic branches of cranial nerve VII).
• Mueller’s muscle is innervated by the autonomic nervous system and contributes to the last several
mm of eye opening.
2. What are the common anatomic structures in the upper and lower eyelids?
• The upper eyelid has two preaponeurotic fat pads, one medial (also called nasal) and one central.
The medial and central fat pads are separated by the superior oblique muscle. The lacrimal gland
lies in the superior lateral orbit and has been mistaken for fat and inadvertently removed. This obviously is a significant complication.
• The lower eyelids have three fat pads: the medial (nasal), central, and lateral (also called temporal).
The medial and central pads are separated by the inferior oblique muscle, and the central and
lateral fat pads are separated by the arcuate expansion of the inferior oblique muscle.
3. Can you name the anatomic tissue and tissue planes involved with routine
cosmetic upper eyelid blepharoplasty?*
• The skin is the most outer layer.
• The orbicularis oculi muscle is the next layer encountered in cosmetic blepharoplasty.
• The orbital septum is the next layer progressing deeper.
• The periorbital fat pads (preaponeurotic fat) are the next layer encountered in routine cosmetic
upper blepharoplasty.
• The next layer involves the levator palpebrae superioris muscle, and the levator aponeurosis is
the base layer seen when the fat pads are reduced. The levator is not generally addressed in
cosmetic upper lid blepharoplasty, but it may be addressed if simultaneous ptosis surgery was to
be performed.
4. What are the common aging changes seen in the periorbital region?
• There is a descent of the forehead, the eyebrows, and the upper eyelid skin.
• The eyelid skin on both lids becomes atrophic, sun damaged, pigmented, and crinkly. This is known
as dermatochalasis.
• The orbital septum becomes lax, and fat protrusion can occur in both eyelids. This is manifested by
“sausages” of protuberant fat that makes patients look older and tired.
• The nasojugal groove (tear trough) becomes accentuated. This groove deepens and represents soft
tissue changes over the inferior orbital rim. The soft tissue atrophy and descent changes in the
midface also contribute to the “tear trough” deformity.
• The lateral canthal skin develops horizontal lines called “crow’s feet.”
†
* Niamtu J: Cosmetic blepharoplasty. In Naimtu J, editor: Cosmetic facial surgery, St Louis, 2011a, Mosby Elsevier, pp 129–174.
†
Niamtu J: Contemporary blepharoplasty: less can be more, Expert Rev Dermatol 5(4):489–490, 2010a.
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5. How can true dermatochalazia be differentiated from pseudodermatochalazia?
Pseudodermatochalazia occurs when brow ptosis contributes to an appearance of dermatochalazia.
Specific measurements are used to identify the brow location. A female brow should be elevated
above the supraorbital rim 0 to 2 mm medially, 10 mm at the apex, and taper at the tail. A male brow
should lie at the supraorbital rim. If these measurements are not found on the patient, a brow lift may
be indicated.
6. How do you correctly measure lid ptosis?
The palpebral fissure should measure 10 mm. The margin reflex distance-1 (MRD-1) can also be used,
which is the distance between the light reflex in the cornea and the center of the upper lid margin. The
normal MRD-1 is 5 mm. The MRD-2 will measure lower lid ptosis, and it is also 5 mm. The anatomic
points for MRD-2 are also from the light reflex in the cornea down to the center of the lower lid margin.
7. What is the snap test?
This is used to measure lower lid laxity prior to blepharoplasty. The lower lid is pulled away and
allowed to “snap” back. This test can predict postoperative ectropion with moderate to severe lid laxity during the snap test.
8. What is the Schirmer test?
The test evaluates dry eyes. Once the lower fornix is dried, a Schirmer strip is placed into the lateral
aspect and left in place for 5 minutes. Fifteen mm of wetness at 5 minutes is normal. An abnormal test
is not an indicator for surgical treatment.
9. What are common surgical modalities used to remove excess upper eyelid skin,
muscle, and fat?
• Cold steel (scalpel or scissors)
• Microneedle cautery or radio wave surgery
• CO2 laser
• Battery “hot wire” cautery (uncommon)
• Electrosurgery, radiosurgery, or CO2 laser are preferable as they provide a bloodless surgical field,
which reduces complications, lessens bruising and pain, and promotes faster healing.
10. What are the common surgical approaches to the lower eyelid blepharoplasty?
Subciliary and transconjunctival lower blepharoplasty.
11. Can you describe the advantages and disadvantages of the most common surgical approaches to the lower eyelid for cosmetic blepharoplasty and their respective advantages or disadvantages?
• The subciliary approach is the oldest surgical approach for lower eyelid blepharoplasty. This
technique involves making an incision several mm below the lash line that has a downward limb
at the lateral canthus. This incision includes skin and orbicularis oculi muscle, and dissection
proceeds over the orbital septum. The orbital septum is then incised, and the three lower fat pads
are visualized and reduced or recontoured. After the fat is addressed, a controlled amount of eyelid
skin and orbicularis oculi muscle is removed to deal with the dermatochalasis and lower lid skin
excess. Advantages of this technique include that it is a direct vision procedure with easy access to
all tissues. Disadvantages include that this approach violates the orbital septum (middle lamella),
and postoperative septal contraction can result in lower lid malposition where the lower eyelid
is retracted and shows excess sclera at the inferior limbus of the iris. Making the skin incision at
the ciliary margin and making the orbicularis incision several mm lower leaves a small amount of
pretarsal orbicularis, which may aid in preserving normal eyelid position. In the past decade the
subciliary approach has fallen out of favor and is less commonly utilized due to the associated lid
position problems. More contemporary surgeons prefer the transconjunctival approach.
• Transconjunctival lower blepharoplasty has become the favored approach for accessing the lower
eyelid fat pads. An incision is made from the lacrimal punctum to the lateral canthus through the
‡
Niamtu J. Blepharoplasty incisional modalities: 4.0 Radiosurgery vs. CO2 Laser In Pearls and Pitfalls in Cosmetic Oculo-
plastic Surgery. Hartstein ME, Holds JB, Massry GG, (eds.) Springer: NY, 2009,
‡
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conjunctiva and lower eyelid retractors (capsulopalpabral fascia). This incision is made approximately 4 mm inferior to the lower tarsal margin or 9 mm inferior to the ciliary margin. Scalpel,
electrosurgery, radio wave microneedle, or laser are the most common incision modalities. An
advantage of this approach is that it is a retroseptal approach and does not disturb the lower lid
orbital septum (middle lamella) and therefore does not significantly affect lower lid malposition.
Disadvantages of this approach include that the excess skin is not addressed, and the visibility of
the fat pads is harder to access and learn. When using the transconjunctival approach to lower
eyelid blepharoplasty, the lower eyelid skin is addressed by laser skin resurfacing, chemical peel,
skin pinch, or subciliary skin removal with septal preservations.
12. What causes dark circles on the lower eyelids?
Dark circles are multifactorial and can include shadowing from protruding lower lid fat pads, actual
pigmentation in the skin (which can be significant in some racial groups such as people from eastern
Asia). They can also result from underlying blood vessels that show through the thin eyelid skin and
from hemosiderin pigment that extravasates from blood vessels.
13. What are common treatments for dark circles on the lower eyelids?
Treatments include bleaching creams such as hydroquinone 40% to bleach the skin, laser or chemical
peel skin resurfacing to remove the epithelium and create new skin, and direct skin excision.
14. What minimally invasive procedures are used for nonsurgical periorbital
rejuvenation?
Numerous modalities are used to address nonsurgical periorbital rejuvenation. Neurotoxins are used
to treat lateral canthal wrinkles, and injectable fillers can be used to treat the same wrinkles and are
also used to fill the tear trough (nasojugal groove) to mitigate the severe depression seen over the
inferior orbital rim. Latisse (Bimatoprost) is a topical prostaglandin analogue that stimulates the lash
follicles to produce thicker, darker, and longer lashes.
5
15. How is the tear trough deformity treated?
The tear trough can be injected with fillers or autologous fat. This area is vascular, so careful
placement with small-gauge needles and low-pressure injection is essential to avoid intravascular injection, which can lead to tissue necrosis and blindness. Hyaluronic acid fillers are favored
because they are safe, predictable, and can be reversed with hyaluronidase if necessary. The
fillers are not injected in the subcutaneous plane because they can produce a Tyndall effect,
which is a blue tinge or hue visible through the skin. Instead they are injected at the periosteal
plane and more superficially, but still under the orbicularis oculi muscle. The filler, once injected,
can be “walked” across the tear trough from central to medial to fill the area that otherwise
may be difficult or more dangerous to inject. Blunt injection cannulas can also be used in lieu of
6,7
needles.
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16. Can tear trough filler be reversed if the patient does not like result?
The hyaluronic acid fillers (Juvederm, Restylane, Perlane, Voluma, Belotero) can be reversed with hyal-
uronidase. This enzyme will hydrolyze the hyaluronic acid and degrade it in a matter of hours. Generally 50 to 80 units of hyaluronidase injected into the same plane as the unwanted filler will remove
the filler. Nonhyaluronic acid fillers such as Radiesse, silicone oil, Sculptra, Artefil, and autologous fat
cannot be reversed with hyaluronidase or any other substance.
17. Can you name some of the common complications associated with cosmetic
blepharoplasty?
• Edema
• Corneal abrasion
• Lagophthalmos (inability to close the eyes)
• Asymmetry
• Subconjunctival ecchymosis (blood over the white sclera)
• Chemosis (conjunctival edema)
• Ecchymosis of periorbital region
• Retrobulbar hematoma (emergent complication)
• Suture line “cysts” (upper lids)
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18. What is retrobulbar hematoma?
Retrobulbar hematoma (RBH) is a potentially severe complication that can cause blindness. It is a
result of bleeding behind the globe, and since the blood cannot escape, an expanding phenomenon
occurs that can compress the retinal artery and result in permanent vision loss. Any bleeding during
blepharoplasty must be taken seriously for the fear of RBH. RBH can be a result of intraoperative or
postoperative bleeding. After cosmetic blepharoplasty, patients must refrain from any strenuous activity
that may increase blood pressure and produce bleeding in or behind the eye. This includes bending,
lifting, straining during bowel movement, or anything that can produce a Valsalva maneuver or cause
bleeding. Cold compresses are applied immediately after surgery and for 48 hours after surgery. Preoperatively, patients must refrain from any drug or supplement that may affect coagulation. This includes
aspirin, aspirin-containing medications, megadoses of certain vitamins, and certain supplements such
as gingko, ginseng, and fish oil. Any of these products must be discontinued 2 weeks before surgery.
19. What is the purpose of brow and forehead lifting?
As inane as that sounds, the answer is important in that the reason to do a brow lift is to lift the
brow. Many patients develop ptotic brows with aging. This produces an older and tired look and adds
to upper eyelid hooding, which is the condition where the lateral eyelid skin becomes ptotic and
redundant. An additional reason to perform brow and forehead lifting is to improve the vertical and
horizontal forehead wrinkles. Not all patients need a brow and forehead lift as many people never
have elevated or arched brows, and their brows remain in the same position all their life.
20. Why is the option of brow and forehead lifting important?
Contemporary cosmetic surgeons realize the importance in brow and forehead rejuvenation in com-
prehensive upper one-third facial rejuvenation. It is not uncommon to see surgeons who are not skilled
in this procedure, and they do not perform brow and forehead lifting. Instead they perform aggressive
upper eyelid blepharoplasty to remove redundant lid skin. Although this benefits the patient, it does not
address the root of the problem if the brows are ptotic. In addition, if the patient is interested in a brow lift
in the future, it may be impossible if excess upper lid skin has been removed because lifting the brows
and forehead will cause lagophthalmos (inability to close the eyelids). Unfortunately, some patients are
never able to have a rejuvenating brow and forehead lift because they don’t have adequate upper lid skin
because they were treated with blepharoplasty instead of brow lift. Finally, performing aggressive upper
eyelid blepharoplasty on a patient with ptotic brows can actually pull down drooping brows even further.
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21. Can blepharoplasty and brow and forehead lift be performed simultaneously?
Yes, if the patient has sufficient brow ptosis and excess upper lid skin. By performing conservative
blepharoplasty with a brow and forehead lift, the surgeon can improve results with the synergistic
effects. The blepharoplasty can complement the brow lift by making a more sculpted and crisp upper
eyelid complex. The caveat is that when performed in combination, it is critical to be conservative
enough with each procedure to allow normal eyelid closure.
22. What is the function of the musculi frontalis, and what muscles oppose its
function?
The major function of the frontalis is elevating eyebrows. Corrugator supercilii, procerus, and orbicu-
laris oculi muscles are responsible in opposing the brow-lifting activity of the frontalis muscle.
23. What are the main sensory and motor nerves associated with the brow and
forehead lifting procedures?
• The supratrochlear nerve is a bilateral sensory nerve that resides 17 mm lateral to the glabellar
midline and innervates the anterior medial forehead and scalp.
• The supraorbital nerve is a bilateral sensory nerve that resides 27 mm lateral to the glabellar
midline and innervates the anterior and posterior scalp.
• The temporal branch of the facial nerve lies bilaterally between the lateral brow and the temporal
hair tuft and provides motor innervation for the frontalis muscle.
24. What systematic approach should be used to evaluate the contour and position
of the eyebrow?
The ideal location of the brow for a female is approximately 1 cm above the supraorbital rim;
whereas it is only slightly above the rim for a male patient. The contour of the brow is evaluated in
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