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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_537_Библиотеки_им_академика_М_И_Перельмана
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The surgeon begins by marking the eyelids at the incision site, which is key
to ensuring precision and optimal aesthetic enhancement. If the patient does
not present with ptosis, the lid is marked along the natural crease or just
above (1mm), the latter of which accounts for skin contracture to optimize
the position of resultant scars. In the presence of ptosis and excess eyelid
skin laxity, Graefe forceps are placed at the crease and grasp excess skin
superiorly until the desired tension is reached (indicated by slight lid
eversion). Calipers are used to precisely mark the area of excess skin to be
removed, leaving at least 20 mm of the eyelid intact, as shown in Fig. 13
[60, 61].
Fig. 13 The image on the left demonstrates precision marking techniques using calipers to determine
the extent of correctable tissue laxity [62]
The incision follows the curve of the eyelid, extending about 2 cm
inferomedially to the punctum and laterally as needed to correct hooding. It
is important for surgeons to palpate the transition between thin eyelid skin
and thicker eyebrow tissues, as this thicker skin should not be avoided [63].
Preexisting bilateral asymmetry of the lid creases can be corrected with
variable incision placement [60, 61].
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Local tumescent anesthesia is injected subcutaneously, using minimal
concentrations whenever possible to reduce its effect on the levator
palpebrae muscles when ptosis correction is indicated. Marked incisions are
followed with a scalpel to cut through the superficial skin layer and/or
underlying orbicularis muscle. A smaller strip of muscle may be removed
with the skin for correction of eyelid skin laxity, as it helps to recreate the
natural eyelid crease. Individuals with orbicularis hypertrophy are indicated
for excision of a larger muscle flap.
After resection of the orbicularis m. and exposure of the orbital septum,
underlying adipose tissue is visible. Patients with pseudoherniation of
orbital fat are indicated for fat removal, which can be accomplished in one
of two ways. Cauterization of the orbital septum allows for tightening of the
tissue, reducing underlying fat herniation from fat compartments below the
upper lid. This septal cauterization technique may be used in lower lid
blepharoplasty [61, 64].
Alternatively, the orbital septum may be opened to expose the
underlying medial and central fat compartments. Gentle globe pressure via
palpation induces extrusion of herniated fat through the opening, which is
gently clamped and removed via cauterization. It is important to remove an
adequate amount of fat for optimal aesthetic results without excessive
removal, using careful technique to avoid aggressive anterior traction and
potential risk of hematoma formation. The subseptal lacrimal gland is
indicated by lateral, firmer, pink-appearing tissues and should be carefully
avoided [66] (Fig. 14).
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Fig. 14 The dissection techniques, muscular attachments, and deeper lacrimal gland are illustrated in
the figure to the left [65]
When ptosis correction is indicated, surgeons will expose the tarsal
plate via dissection of the pretarsal orbicularis medially and laterally. The
pretarsal orbicularis muscle strip is removed, allowing for additional
debulking and exposure of the tarsal segment and underlying inserting
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levator aponeurosis. Surgeons can locate the aponeurosis posterior to the
orbital septum and preaponeurotic fat pad, using gentle dissection with a
cotton-tipped applicator through the fat.
If not already performed, an incision is made into the orbital septum and
medially/laterally extended, through which the levator muscle is grasped.
Retraction of fat can assist with visibility, and the patient can look up while
the muscle is grasped to help confirm the location of the levator muscle.
The aponeurosis is divided from its attachments, and the cut edge is
reattached to the tarsal plate using 6-0 silk horizontal mattress sutures,
placed at mid-tarsal depth to avoid corneal damage (keratopathy).
Placement of additional horizontal mattress sutures can correct the contour
of the eyelid as needed, with a general preference of overcorrection to
account for postoperative tissue descent [67].
After tissue augmentation has been completed, the incision is closed
with single-layer 6-0 gut sutures (fast absorbing or plain) placed into the
skin. Closure should only be performed after careful and thorough
hemostasis to prevent increased risk of postoperative hematoma [60, 61].
3.3.2 Lower Blepharoplasty
Lower eyelid augmentation is performed for a greater variety of conditions,
although correction of the orbitomalar sulcus is quite common and utilizes
augmentation of medial tear trough and lateral lid-cheek junction
deformities. Earlier approaches focused on removal of skin and fat although
the current focus is placed on improving the lid-cheek junction, removing
fat bulges to smooth the lower lid, and adding volume to the tear trough
[66, 68, 69]. The transconjunctival approach is advantageous for its hidden
resultant scar and reduced risk of ectropion (outward turning of the lower
eyelid). A transcutaneous approach is used if orbicularis oculi hypertrophy
is present and muscle excision is indicated [70–72].
With the transconjunctival approach, local anesthetic is injected for
vasoconstriction and pain management, and the conjunctiva is approached
either preseptally or postseptally. With the preseptal approach, the eyelid is
everted using traction on 4-0 silk sutures placed through the margin and
Desmarres retraction. An incision is made into the conjunctiva at the
inferior tarsal margin, through which a surgical plane is dissected between
orbicularis muscle and septum to the orbital rim. Anterior access to the fat
is gained with cauterization of the orbital septum. The postseptal approach
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begins with incision through the conjunctiva and lower eyelid retractors, 4
mm inferior to the lower tarsal margin. Orbital fat is accessed posteriorly
with dissection through the lower eyelid retractors, avoiding the need for
disruption of the septum [71, 72] (Fig. 15).
Fig. 15 Lower blepharoplasty performed with the transconjunctival approach is illustrated in the
figure, along with proper technique for repositioning of orbital fat [73]
Excess fat is removed as discussed with upper blepharoplasty, using
gentle clamping and cautery to avoid orbital hemorrhage. With both
techniques, the inferior oblique muscle should be identified between the
medial and middle fat pads and avoided when incising/cauterizing. When
there is no skin laxity present, the transconjunctival incisions are left open
or closed with loose absorbent suture placement. If skin excision is
indicated, a scalpel is used to remove excess cutaneous tissues and closed
with absorbent sutures [69, 71, 72].
Individuals with significant lower eyelid skin laxity would benefit from
a subciliary approach, in which an incision is made through the skin only
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(“skin pinch” technique) or skin and orbicularis muscle (skin-muscle flap
approach), the latter of which is more invasive [20]. The skin-muscle flap is
lifted in one piece to expose the orbital septum, through which small
openings are made (if necessary) and fat is removed with cauterization.
Orbicularis and cutaneous tissue is excised prior to bilayered closure, which
involves reattaching the orbicularis using 5-0 polydioxanone sutures and
then closing the skin with 6-0 absorbing sutures [61, 74, 75].
3.4 Complications and Outcomes
3.4.1 Functional Complications
With double eyelid surgery, patients may experience resultant functional
complications. Hematoma formation (most common), infection/orbital
cellulitis, dry eyes, hemorrhage, and blepharoptosis have been documented
in the literature [45, 76].
Hemorrhage of vessels in the orbicularis oculi muscle or preaponeurotic
fat (anterior and middle lamella) can result from improper use of
epinephrine, insufficient hemostasis, or poor coagulation. Moderate or
severe hemorrhage can result in the formation of hematomas, the most
common functional complication. Surgeons can potentially lower this risk
by using blunt needles in place of sharp needles to administer local
anesthetic. Patients can minimize risks as well by using ice or cold
compresses, promoting capillary constriction and preventing/controlling
formation of hematomas [77]. Retrobulbar hemorrhage/hematoma is a
serious complication of blepharoplasty with unclear etiology, leading to
visual loss or blindness in severe cases [78].
Infection may occur after blepharoplasty, although it is less prevalent
than hematoma formation. It is thought that the well-distributed vascularity
of the eyelid contributes to infection prevention. Common pathogens
include skin bacteria, but there are documented cases of postoperative
Streptococcus and Mycobacterium infections [79–82]. Orbital cellulitis
(preseptal or postseptal) can result from some infections, potentially
presenting as subperiosteal/orbital abscess or cavernous sinus thrombosis in
severe cases [79, 83].
Dry eyes are a relatively common adverse effect of blepharoplasty,
especially in elderly patients with double eyelid augmentation. Other
disturbances include light sensitivity (photophobia), inflammation of the
conjunctiva, and tingling/burning of the eyes and surrounding tissues [84,
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85]. This can be reduced with conservative technique, as well as
maintenance of at least 20 mm of intact eyelid with upper blepharoplasty.
Generally, these symptoms will reduce or resolve after 3months post
procedure, with the exception of severe cases [86, 87].
Ptosis is diagnosed when more than 2 mm of the cornea is covered by
the upper eyelid, lending to the appearance of tired, droopy eyes. In older
individuals with greater skin laxity, this may be attributed to insufficient
skin removal. Transient ptosis often results from inappropriate disseminated
anesthetic effect, and permanent ptosis may result from damage to levator
or Müller’s muscles [88, 89].
3.4.2 Aesthetic Complications
One of the most common aesthetic complications of blepharoplasty is
asymmetry, usually attributed to unequal bilateral eyelid height. This can
occur if increased unilateral skin laxity or asymmetrical levator palpebrae
muscle strength is not accounted for in the surgery. Multiple creases can
occur even in individuals that have not undergone blepharoplasty, although
excessive dissection of the septum or pretarsal tissue can induce this
outcome as a complication of surgery [45, 90–93]. Disappearance of the
eyelid crease altogether may occur as a result of unstable connection
between the skin and levator aponeurosis. Generally, patients should wait
until the tissues have adequately healed to undergo corrective surgery (up to
1year post surgery) [45].
3.4.3 Outcomes
Assessment of facial focal points indicates greater involvement of the
periorbital area in the overall aesthetic appearance of the face, and the
augmentation of these tissues is highly effective in overall facial
rejuvenation [94, 95]. Overall, patient satisfaction after blepharoplasty is
shown to be very high, and almost all report feeling and looking younger
[94].
Patients are generally pleased with the resultant scarring and overall
aesthetic improvement, as the increased visibility of the tarsal platform has
a positive impact on their appearance. It should be noted that descent of the
eyebrows occurs in many patients, and this could potentially lend to an
unaesthetic appearance. Upper blepharoplasty is determined to produce
similar patient-observed results with or without removal of orbicularis oculi
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muscle. There is a need for additional studies to assess which incision
placement and suture technique produces ideal results [94, 96] (Figs. 16 and
17).
Fig. 16 This image shows the postoperative results after upper eyelid blepharoplasty (lower pane),
compared with the preoperative appearance (upper pane) [97]
Fig. 17 This image illustrates the postoperative results in a younger female patient after lower
blepharoplasty, with a dramatic improvement to under-eye bulging and dark circles [98]
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4 Cheek Augmentation
Many patients pursue cheek augmentation to restore the volume in the
midface and achieve a more youthful and/or aesthetically attractive
appearance. As previously discussed with nonsurgical rejuvenation, aging is
accompanied by resorption of underlying bone structures (zygoma,
inferolateral orbit, maxilla), leading to an overall loss of projection in the
midface. Volume loss in the midfacial fat pads (buccal and deep medial
cheek), as well as loss of tissue elasticity and downward fat migration,
additionally contribute to decreased projection [132].
Injectable therapy such as dermal and soft tissue fillers are well utilized
to replace the lost volume in the midface for some patients. Treatments are
discussed in greater detail with nonsurgical augmentation [132]. Surgical
placement of implants is a more invasive technique to increase projection
and improve midfacial contour [99]. The use of osteotomy has been
documented with male-to-female transgender patients, which is performed
to advance the zygomaticomalar complex and provide a more feminine
facial contour [100]. In general, these augmentations aim to restore or
increase volume of the cheeks.
4.1 Review of Relevant Anatomy
The malar region of the face, a rectangular area that contains the cheeks and
underlying bone structure, largely contributes to the overall perceived
attractiveness of an individual. Studies suggest that high cheekbones are a
culturally universal key contributory trait to an attractive face. The golden
ratio can be used to balance facial contour and volume of the malar
structures in a manner that flatters the nose and other surrounding structures
[101].
In addition to the underlying bone structure, the malar region contains
facial muscles from the superficial musculoaponeurotic system (SMAS)
and fat compartments (both superficial and deep). Nasolabial fat, superficial
medial cheek fat, and infraorbital fat make up the superficial compartments.
Deep fat compartments include medial and lateral subocularis oculi and
deep medial cheek fat, in addition to the medial portion of the buccal fat
pad [102].
4.2 Preoperative Patient Assessment
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Generally, there are two broad categories of implants used for alloplastic
malar augmentation, indicated for various levels of facial deformity:
Malar implants: Used for patients with normal midface soft tissue
volume who specify projection of the zygoma as their chief complaint
Submalar implants: Used for patients with sufficient zygomatic
projection who would benefit from augmentation of the soft tissue near
the malar eminence
Combined/custom implants are used for patients with combined
deficiencies in zygomatic projection and soft tissue volume [103] (Fig. 18).
Fig. 18 Image A shows a submalar implant and its respective placement, while image B illustrates
the placement and appearance of “shell” malar implants, which are placed more superficially for
patients with adequate midface soft tissue volume. A combined implant is shown in Image C [104]
While the relative contraindications remain consistent with previously
discussed patient risk factors, there are absolute contraindications to malar
implant placement. Known allergies to any of the materials contained in
malar implants and/or active periodontal or maxillary sinus infections are
prohibitory for this procedure [104].
Smoking has been discussed in previous sections as a general
contraindication. However, it should be noted that infection, implant loss,
and wound dehiscence can result from the heat and nicotine-related
damage, particularly in malar implant surgery [104].
Before implants can be placed, surgeons must discuss the patient’s goals
and assess their individual anatomy. The malar eminence, or region of
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