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238 Part VII&Facial Surgery
Answers
ANATOMY
1. A patient is asked to tightly close the eyes against resistance. Which muscle is mainly responsible for this
action?
E. Orbital orbicularis.
The orbicularis oculi muscle forms a sphincter responsible for eyelid closure. The orbicularis has three parts:
pretarsal, preseptal, and orbital. The orbital orbicularis is under voluntary control and is activated during
forceful closure of the eyelids and is innervated by frontal and zygomatic branches of the facial nerve.
The preseptal orbicularis has both voluntary and involuntary functions and is involved in blinking. The pretarsal orbicularis is also involved in blinking and is involuntary.
The corrugator muscles draw the medial brow downward and medially. The procerus muscle lies primar-
ily over the upper third of the nose and its contraction results in transverse rhytids over the nasion.
REFERENCES
1. Nahai F. Aesthetic plastic surgery. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
New York: Thieme Publishers; 2007
2. Zide B, Jelks GW, eds. Surgical Anatomy Around the Orbit. New York: Lippincott Williams & Wilkins; 2007
3. Siegel RJ. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 1984;13:263
ANATOMY
2. The levator palpebrae superioris muscle originates from which of the following bones?
B. Lesser wing of the sphenoid.
The levator palpebrae superioris is innervated by cranial nerve III and originates from the lesser wing of the
sphenoid in the bony orbit.
1,2,3
1,2,3
REFERENCES
1. Nahai F. Aesthetic plastic surgery. In Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
New York: Thieme Publishers; 2007
2. Zide B, Jelks GW, eds. Surgical Anatomy Around the Orbit. New York: Lippincott Williams & Wilkins; 2007
3. Siegel RJ. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 1984;13:263
SURGICAL JUDGMENT
3. A patient presents to clinic 6 days after botulinum toxin A injection to the glabella complaining of left upper
lid ptosis. Which of the following best describes the mechanism of action of apraclonidine, which is used to
help address this issue?
C. Stimulates Müller's muscle via alpha-2 adrenergic agonist effects.
Botulinum toxin A inhibits release of acetylcholine from the pre-synaptic terminal; therefore, answer choice
A is incorrect as this describes the mechanism of action of botulinum toxin A. Apraclonidine is an alpha-2
adrenergic agonist and stimulates sympathetically innervated muscle. Müller's muscle is a sympathetically
innervated involuntary muscle which contributes to 2 to 3 mm of upper eyelid excursion. Apraclonidine,
therefore, stimulates Müller's muscle and can be used to ameliorate lid ptosis due to inadvertent botulinum
toxin effect on the levator palpebrae superioris muscle. Local anesthetics (i.e., lidocaine) are categorized as
class 1 antiarrhythmics and bind/block sodium channel receptors, preventing sodium ion f low and membrane depolarization. Therefore, answer choices D and E are incorrect.
1,2,3
REFERENCES
1. Nahai F. Aesthetic plastic surgery. In Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
New York: Thieme Publishers; 2007
2. Zide B, Jelks GW, eds. Surgical Anatomy Around the Orbit. New York: Lippincott Williams & Wilkins; 2007
3. Siegel RJ. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 1984;13:263
Chapter 34&Upper Blepharoplasty 239
ANATOMY
4. Which of the following correctly describes the function of Whitnall's ligament?
A. It redirects the vector of pull of the levator palpebrae muscle on the superior tarsal plate.
Whitnall's ligament functions as a fulcrum, helping to redirect the vector of pull of the levator palpebrae
superioris muscle on the superior tarsal plate. Whitnall's ligament also contributes fibers to the medial
and lateral canthal tendons. The orbital septum, not W hitnall's ligament, forms the middle lamella of the
eyelid and lies between the orbicularis muscle and orbital fat. In the inferior lid, Lockwood's ligament
functions as a fulcrum to redirect the vector of pull of the capsulopalpebral fascia.
1,2,3
REFERENCES
1. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentousattachmentsin the temple and periorbital
regions. Plast Reconstr Surg 2000;105:1475
2. Muzaffar A, Mendelson BC, Adams WP. Surgical anatomyof the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002;110:873
3. Ghavami A, Pessa JE, Janis JE, et al. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast
Reconstr Surg 2008;121:994
SURGICAL JUDGMENT
5. A 65-year-old female returns to clinic 2 months after upper blepharoplasty complaining of a “tired” appear-
ance of her left upper lid. There is no evidence of lagophthalmos. Examination reveals 10 mm of levator excursion bilaterally, with an MRD-1 of 2 mm on the left and 4 mm on the right. Which of the following is the most
likely reason for this patient's postoperative complaint?
B. Failure to recognize preoperative eyelid ptosis.
The vignette describes a patient with nor mal levator excursion (normal 10–15 mm) but left eyelid ptosis.
Although iatrogenic disruption of levator aponeurosis attachment to the superior tarsal plate can result
in ptosis, it is much more common for postoperative upper lid ptosis to be due to unrecognized preoperative
eyelid ptosis. A browlift would have not addressed this patient's ptosis. Insufficient skin resection would
result in persistent postoperative dermatochalasis. Over-resection of the skin causing lagophthalmos would
have presented differently in a patient who has difficulty closing eyelids due to over-resection.
1,2
REFERENCES
1. Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 1988;15:309
2. Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg
2004;113:32e
SURGICAL MANAGEMENT
6. A 58-year-old female is 9 months post bilateral upper blepharoplasty and complains of right eye irritation and
dryness. Examination reveals 2 mm of right eye lagophthalmos and conjunctival injection without evidence of
ulceration. Which of the following is the most appropriate management?
D. Full-thickness skin graft.
Lagophthalmos is a relatively common complication after upper blepharoplasty and can result from excessive resection of skin. If present in the acute postoperative period, conservative management is appropriate
including hydrating ocular ointment application and downward scar massage on the upper eyelid, as many
cases will resolve over time. However, this patient is 9 months status post upper blepharoplasty with persistent lagophthalmos. A full-thickness skin graft from the contralateral eyelid, cervical, preauricular, or postauricular area is appropriate. A full-thickness skin graft will add additional tissue to the anterior lamella and
is an effective treatment of persistent iatrogenic lagophthalmos. Excising more skin from the upper lid
would cause worsening of her lagophthalmos.
1,2
REFERENCES
1. Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 1988;15:309
2. Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg
2004;113:32e
240 Part VII&Facial Surgery
ANATOMY
7. A 61-year-old woman with significant herniation of upper eyelid orbital fat is to undergo bilateral upper
blepharoplasty with partial excision of orbital fat. The superior oblique muscle is most susceptible to injury
between which of the following structures?
A. Medial and central fat compartments.
The trochlea of the superior oblique muscle separates the medial and central fat compartments of the upper
orbit. Therefore, the superior oblique muscle is most susceptible to injury in this location and can result in
strabismus (i.e., misalignment of the affected eye).
1,2,3
REFERENCES
1. Nahai F. Aesthetic plastic surgery. In Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
New York: Thieme Publishers; 2007
2. Zide B, Jelks GW, eds. Surgical Anatomy Around the Orbit. New York: Lippincott Williams & Wilkins; 2007
3. Siegel RJ. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 1984;13:263
ANATOMY
8. During blinking (i.e., eyelid closure), which of the following best describes the action of the lacrimal sac?
D. It expands due to contraction of the orbicularis oculi muscle.
The lacrimal apparatus is a complex drainage system. The tear film first drains into the punctum, which then
drains into the lacrimal sac via the canaliculus. The lacrimal sac then drains into the nasolacrimal duct,
which drains into the nasal cavity at the inferior turbinate. Jones's muscle (deep head of the preseptal
orbicularis) inserts onto the lacrimal sac. During eyelid closure and orbicularis muscle contraction,
Jones's muscle expands the lacrimal sac. Expansion of the lacrimal sac results in negative pressure, which
draws the tear film into the lacrimal sac. During eyelid opening, the lacr imal sac recoils (i.e., relaxes) down to
its resting size and projects the tear down the nasolacrimal duct.
The lacrimal sac does not contract independently. Expansion and recoil (i.e., relaxation) of the lacrimal
gland is secondary to the action of the orbicularis oculi muscle. Furthermore, the lacrimal sac expands during eyelid closure. The lacrimal sac does not “relax” in the same sense as muscles do. Instead, it participates in
the ongoing drainage process as tears are produced and the eye blinks and moves. The lacrimal sac does
change in size due a variety of factors previously mentioned.
1,2,3
REFERENCES
1. Nahai F. Aesthetic plastic surgery. In Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
New York: Thieme Publishers; 2007
2. Zide B, Jelks GW, eds. Surgical Anatomy Around the Orbit. New York: Lippincott Williams & Wilkins; 2007
3. Siegel RJ. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 1984;13:263
PREOPERATIVE EVALUATION
9. Which of the following is an absolute contraindication to upper blepharoplasty?
A. Coumadin use for a prosthetic heart valve.
Retrobulbar hematoma is a rare, but severe, complication after blepharoplasty which can result in blindness
due to compression of the optic nerve. Patients on therapeutic anticoagulation are not candidates for upper
blepharoplasty due to an increased risk of bleeding.
It is recommended that blepharoplasty should not be performed earlier than 12 months after Lasik procedure. The patient in the above vignette is 14 months after Lasik surgery and therefore blepharoplasty is not
contraindicated. Hypothyroidism, contact lens use, and controlled hypertension are not contraindications to
blepharoplasty.
1
REFERENCE
1. Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 1988;15:309
Chapter 34&Upper Blepharoplasty 241
PREOPERATIVE EVALUATION
10. A 72-year-old female presents to your office requesting a skin-only upper blepharoplasty complaining of
“extra skin” partially occluding her visual fields bilaterally. Physical examination reveals deep transverse
forehead rhytids and pronounced lateral hooding bilaterally. Levator excursion and MRD-1 are 11 and 5 mm
bilaterally, respectively. You counsel the patient and recommend which of the following surgical
interventions?
E. Browlift and upper blepharoplasty.
The clinical vignette describes a patient with concomitant brow ptosis. Deep transverse forehead rhytids
are due to increased frontalis muscle tone. Unconscious frontalis muscle activation can occur to compensate for brow ptosis and/or blepharoptosis. However, the patient has 11 mm (normal) of levator excursion
and an appropriate distance bet ween her corneal light reflex and upper lid margin (i.e., MRD-1 5 mm).
Therefore, this patient is best served by first treating her brow ptosis and a concomitant upper
blepharoplasty.
Isolated upper blepharoplasty is incorrect and would produce a suboptimal aesthetic result. In a patient
with concomitant brow ptosis, isolated blepharoplasty also risks excision of excess tissue.
There is no indication that this patient is not a surgical candidate.
Neurotoxin injection of the frontalis would exacerbate the patient's brow ptosis, and potentially result in
occlusion of her visual fields.
1
REFERENCE
1. Guyuron B. Endoscopic forehead rejuvenation: limitations, flaws, and rewards. Plast Reconstr Surg
2006;117:1121
SURGICAL JUDGMENT
11. The nurse pages you to evaluate a 60-year-old patient who underwent bilateral upper blepharoplasty 2 hours
ago. On examination, the patient complains of severe pain, and proptosis of the left globe is noted along
with decreased visual acuity. Which of the following is the correct next step in management?
E. Emergent lateral canthotomy and cantholysis.
The clinical vignette describes a patient with a retrobulbar hematoma. A retrobulbar hematoma can result
from a bleeding vessel after orbital fat excision. Although emergent ophthalmology consultation and pharmacologic interventions are indicated, visual compromise is an indication for emergent decompression to
prevent permanent blindness. Therefore, a bedside lateral canthotomy and cantholysis under local anesthesia is first indicated, followed by return to the operating room to obtain hemostasis along with ophthalmology consultation and pharmacotherapy.
1
REFERENCE
1. Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 1988;15:309
35. Lower Blepharoplasty
Joseph A. Kelling, Michael R. Lee
See Essentials of Aesthetic Surger y, pp. 451–460
ANATOMY
1. An outward turning of the eyelid margin defines which of the following terms?
A. Entropion.
B. Retraction.
C. Ectropion.
D. Steatoblepharon.
E. Blepharochalasis.
ANATOMY
2. Which of the following options best describes a youthful aesthetic appearance of the lower eyelid?
A. Resting position of the lower eyelid is 2 mm below the level of the limbus with scleral show, fullness of the
pretarsal orbicularis oculi, and a clear transition from the lower eyelid to cheek with a visible inferior orbital
rim.
B. Resting position of the lower eyelid at the level of the limbus without scleral show, fullness of the pretarsal
orbicularis oculi, and a smooth, convex transition from the lower eyelid to cheek.
C. Resting position of the lower eyelid is 1 mm below the level of the limbus with scleral show, lack of fullness of
the pretarsal orbicularis oculi, and a smooth, convex transition from the lower eyelid to cheek.
D. Resting position of the lower eyelid at the level of the limbus without scleral show, fullness of the pretarsal
orbicularis oculi, and concave appearance of the lower eyelid to cheek junction with a defined nasojugal groove.
E. Resting position of the lower eyelid is 2 mm above the level of the limbus, fullness of the pretarsal orbicularis
oculi, and a smooth concave transition from the lower eyelid to cheek.
ANATOMY
3. Understanding the position of the globe relative to the inferior orbital rim is important for predicting which
postoperative outcome?
A. Entropion.
B. Retrobulbar hematoma.
C. Chemosis.
D. Ectropion.
E. Dry eye syndrome.
ANATOMY
4. What is the definition of an abnormal pull-away test and what procedure is indicated to correct the
abnormality?
A. Delayed retur n of the lid margin to native position when retracted downward with finger traction indicates
that a supplemental canthal anchoring procedure should be performed.
B. Greater than 10 mm of la xity of the lid margin when pulled away from the globe indicates that a supplemen-
tal canthal anchoring procedure should be performed.
C. Greater than 6 mm of laxity of the lid margin when pulled away from the globe indicates that skin excision
from the lower eyelid should be performed.
D. Forced closure of the eyelid does not improve the redundant, ptotic appearance of the orbicularis oculi mus-
cle, indicating that a septal reset procedure should be performed.
E. Greater than 8 mm of laxity of the lid margin when pulled away from the globe indicates that a trans-
conjunctival fat removal should be performed.
Chapter 35&Lower Blepharoplasty 243
ANATOMY
5. A 52-year-old man has come to the plastic surgeon's office seeking improvement in the appearance of his
lower eyelids. He expresses concerns about the persistent bags under his eyes that make him look tired and
aged. On examination he has a negative vector, skin elasticity, and poor snap-back test. What is the patient
at risk for and what maneuver may help decrease the possibility of that complication from arising?
A. Entropion–canthopexy.
B. Dry eyes–skin pinch.
C. Dry eyes–fat grafting.
D. Ectropion–canthopexy.
E. Ectropion–skin pinch.
SURGICAL TECHNIQUES
6. A patient with isolated fine lines would best benefit from which type of procedure?
A. Skin resurfacing with a chemical peel or laser resurfacing.
B. Transconjunctival fat removal.
C. Skin-only blepharoplasty.
D. External lower blepharoplasty with orbicularis suspension.
E. External lower blepharoplasty with orbicularis suspension and septal reset.
SURGICAL TECHNIQUES
7. What is the best indication for a skin-only blepharoplasty?
A. Patients with excess fat and no excess skin or orbicularis ptosis.
B. Patients with minimal redundant skin or fullness, the presence of pretarsal and preseptal orbicularis hyper-
trophy, and minimal fat herniation.
C. Patients with minimal redundant skin or fullness, usually isolated to the pretarsal region, and not associated
with fat herniation, lid laxity, or orbicularis ptosis.
D. Patients with the presence of skin excess and orbicularis ptosis, but minimal fat herniation.
E. Patients with significant lid laxity, but minimal redundant skin isolated to the pretarsal region.
SURGICAL TECHNIQUES
8. A patient presents with apparent skin excess of the lower eyelid and a ptotic orbicularis muscle. What is the
key surgical step to address the ptotic orbicularis muscle?
A. Excision of a strip of the orbicularis oculi muscle.
B. Removal of fat from the postseptal compartment.
C. Performing a canthal anchoring procedure.
D. Suspension of a preseptal orbicularis oculi flap to lateral orbital rim.
E. Release of the arcus marginalis to allow extrusion of the lower eyelid fat.
SURGICAL TECHNIQUES
9. Which of the following is an indication to perform a septal reset procedure?
A. Ptosis of the orbicularis oculi muscle.
B. Redundant lower eyelid skin.
C. Ectropion.
D. Isolated fine lines of the periorbital area.
E. Visible nasojugal groove and fat herniation.
SURGICAL TECHNIQUES
10. Which of the following must be considered when determining whether to perform a canthal anchoring pro-
cedure (canthopexy or canthoplasty)?
A. Amount of horizontal lid laxity present.
B. Amount of vertical lid laxity present.
C. Amount of fat resection planned.
D. Presence of a positive vector globe.
E. Past surgical history that includes laser in situ keratomileusis.
244 Part VII&Facial Surgery
COMPLICATIONS
11. You are called about a patient in the postanesthesia care unit who has undergone a lower blepharoplasty.
The patient is complaining of severe pain in the right eye that is not controlled with intravenous pain medication and reports decreased vision in the eye. What is the most appropriate next step in treatment?
A. Recommend head of bed elevation.
B. Recommend applying firm pressure to the right eye.
C. Continued administration of pain medication.
D. Prompt return to the operating room for exploration.
E. Administration of mannitol.
COMPLICATIONS
12. Prevention of dry eye syndrome is largely related to which component of lower blepharoplasty surgery?
A. Performing an appropriate preoperative assessment.
B. Manipulation of the conjunctiva.
C. Performing a canthal anchoring procedure.
D. Removal of fat from the postseptal compartment.
E. Excision of excess lower lid skin.
Chapter 35&Lower Blepharoplasty 245
Answers
ANATOMY
1. An outward turning of the eyelid margin defines which of the following terms?
C. Ectropion.
An ect ropion is defined as an outward turning of the eyelid margin and can be further classified as senile or
cicatricial. Senile ectropion results from age-related laxity of the lower eyelid. Cicatricial ectropion results
from scar-induced retraction of the lower eyelid.
An entropion is a rolling in of the eyelid margin toward the sclera. This can result in irritation of the
cornea or sclera by the individual's eyelashes. Retraction is a downward displacement of the lower eyelid
resulting in inferior scleral show. Steatoblepharon is excess or protruding fat through a lax septum.
Blepharochalasis is thin, excessive eyelid skin secondary to recurrent bouts of painless eyelid edema.
REFERENCE
1. Flowers RS, Du Val C. Blepharoplast y and periorbital aesthetic surgery. In: Aston SJ, Beasley RW, Thorne HM, et al,
eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2007
ANATOMY
2. Which of the following options best describes a youthful aesthetic appearance of the lower eyelid?
B. Resting position of the lower eyelid at the level of the limbus without scleral show, fullness of the pre-
tarsal orbicularis oculi, and a smooth, convex transition from the lower eyelid to cheek.
The lower eyelid should rest at the level of the limbus without scleral show between the limbus and the eyelid margin. The presence of a pretarsal bulge, or pretarsal orbicularis hypertrophy, is considered by many
to be an aesthetic component of the youthful eye. The eyelid–cheek junction should be a smooth, convex,
essentially imperceptible, transition from eyelid to cheek in youthful patients.
1
1
REFERENCE
1. Flowers RS, Du Val C. Blepharoplast y and periorbital aesthetic surgery. In: Aston SJ, Beasley RW, Thorne HM, et al,
eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2007
ANATOMY
3. Understanding the position of the globe relative to the inferior orbital rim is important for predicting which
postoperative outcome?
D. Ectropion.
The orbital vector or position of the globe relative to the inferior orbital rim is useful for predicting postoperative tendencies of lid position. Negative vector orbits have poor lower lid suspension and are at risk for
postoperative ectropion and retraction.
1
REFERENCE
1. Flowers RS, Du Val C. Blepharoplast y and periorbital aesthetic surgery. In: Aston SJ, Beasley RW, Thorne HM, et al,
eds. Grabb and Smith's Plastic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2007
ANATOMY
4. What is the definition of an abnormal pull-away test and what procedure is indicated to correct the
abnormality?
B. Greater than 10 mm of laxity of the lid margin when pulled away from the globe indicates that a sup-
plemental canthal anchoring procedure should be performed.
Both the pull-away test and snap-back test are ways to examine for horizontal lid laxity. The pull-away test
is abnormal when there is greater than 10 mm of lid laxity when the examiner grabs the lid margin with
his or her index finger and thumb and pulls it away from the globe. A snap-back test is abnormal when there
is delayed return of the lid margin to native positive when retracted downward with finger traction. A squinch
246 Part VII&Facial Surgery
(or squint) test can tell you if festoons are caused by ptosis of the orbicularis oculi muscle. The festoon will
improve with forced closure of the eyelids. If either the snap-back or pull-away test is abnormal then the patient
would benefit from a supplemental canthal anchoring procedure if undergoing lower blepharoplasty.
1
REFERENCE
1. Codner MA, Kikkawa DO, Korn BS, et al. Blepharoplasty and brow lift. Plast Reconstr Surg 2010;126:1e
ANATOMY
5. A 52-year-old man has come to the plastic surgeon's office seeking improvement in the appearance of his
lower eyelids. He expresses concerns about the persistent bags under his eyes that make him look tired and
aged. On examination he has a negative vector, skin elasticity, and poor snap-back test. What is the patient
at risk for and what maneuver may help decrease the possibility of that complication from arising?
D. Ectropion–canthopexy.
Given the patient's description and examination findings, he is at risk for developing lower eyelid malposition after undergoing lower blepharoplasty surgery. The combination of a negative vector (where the
lower eyelid is positioned below the level of the eyeball), poor skin elasticity, and a positive snap-back test
(indicating reduced elasticity and poor tissue recoil) can contribute to potential complications involving the
position and contour of the lower eyelid post-surgery.
One possible complication that can arise due to these factors is ectropion. Ectropion is a condition in which
the lower eye lid turns outward, exposing the inner surface of the eyelid and causing discomfort, irritation, and
an unnatural appearance. Given the patient's existing risk factors, there is an increased chance that the lower
eyelid might not heal properly and could become pulled downwar d or have an abnormal position.
To decrease the possibility of ectropion and ensure a successful outcome, the plastic surgeon may employ
a surgical maneuver known as a canthopexy or canthoplasty. These procedures involve tightening and stabilizing the lateral canthal tendon, which is the tissue that holds the outer corner of the eyelid in place. By
reinforcing this structure, the surgeon can help prevent lower eyelid malposition, mitigate the risk of
ectropion, and ensure a more natural and comfortable appearance after the surgery.
1
REFERENCE
1. Trussler AP, Rohrich RJ. MOC-PSSM CME article: blepharoplasty. Plast Reconstr Surg 2008;121(1 Suppl):S1
SURGICAL TECHNIQUES
6. A patient with isolated fine lines would best benefit from which type of procedure?
A. Skin resurfacing with a chemical peel or laser resurfacing.
Patients with isolated fine lines would benefit from an attempt at nonsurgical rejuvenation prior to a surgical procedure. Both nonsurgical and surgical procedures carry risks, but isolated fine lines are not an indication for lower blepharoplasty.
1
REFERENCE
1. Trussler AP, Rohrich RJ. MOC-PSSM CME article: blepharoplasty. Plast Reconstr Surg 2008;121(1 Suppl):S1
SURGICAL TECHNIQUES
7. What is the best indication for a skin-only blepharoplasty?
C. Patients with minimal redundant skin or fullness, usually isolated to the pretarsal region, and not
associated with fat herniation, lid laxity, or orbicularis ptosis.
Skin-only or pinch blepharoplasty is indicated in patients with minimal redundant skin or fullness, usually isolated to the pretarsal region, and not associated with fat herniation, lid laxity, or orbicularis ptosis. If pretarsal
orbicularis hypertrophy is present and contributing to excessive fullness, a strip of pretarsal muscle may be
excised as well. The pinch technique can be combined with other blepharoplasty technique s if indicated.
REFERENCE
1. Kim EM, Bucky LP. Power of the pinch: pinch lower lid blepharoplasty. Ann Plast Surg 2008;60:532
1
Chapter 35&Lower Blepharoplasty 247
SURGICAL TECHNIQUES
8. A patient presents with apparent skin excess of the lower eyelid and a ptotic orbicularis muscle. What is the
key surgical step to address the ptotic orbicularis muscle?
D. Suspension of a preseptal orbicularis oculi flap to lateral orbital rim.
External skin-only techniques do not adequately address orbicularis ptosis even if a strip of orbicularis oculi
muscle is removed. Along with elevating a pennant flap of the preseptal orbicularis muscle, the surgeon
must also release the orbital retaining ligament and lateral orbital thickening in order to adequately suspend
the flap to the lateral orbital rim.
1
REFERENCE
1. Trussler AP, Rohrich RJ. MOC-PSSM CME article: blepharoplasty. Plast Reconstr Surg 2008;121(1 Suppl):S1
SURGICAL TECHNIQUES
9. Which of the following is an indication to perform a septal reset procedure?
E. Visible nasojugal groove and fat herniation.
A visible nasojugal groove and fat herniation along with the presence of the tear trough triad (herniation of
orbital fat, tight attachment of the orbicular along the arcus marginalis, and malar retrusion) are indications
to perform a septal release to allow herniation of the postseptal fat over the inferior orbital rim, or septal
reset. Septal reset procedures should be performed with the eyelid under tension (by temporary Frost
suture) to prevent excessive tightening of the septum and predisposing patients to ectropion.
1
REFERENCE
1. Barton FE, Ha R, Awada M. Fat extrusion and septal reset in patients with the tear trough triad: a critical
appraisal. Plast Reconstr Surg 2004;13:2115
SURGICAL TECHNIQUES
10. Which of the following must be considered when determining whether to perform a canthal anchoring pro-
cedure (canthopexy or canthoplasty)?
A. Amount of horizontal lid laxity present.
The decision to perform canthal anchoring is based upon the amount of horizontal lid laxity (preoperatively determined by the “snap-back test” and “pull-away test”), the prominence of the globe (a negative
vector globe is at considerably higher risk of developing ectropion), the amount of skin/muscle resection
planned, and other ancillary procedures performed (facial rhytidectomy, laser facial resurfacing, chemical
peel, etc.). Whether orbicularis oculi muscle incision leads to paralytic ectropion after blepharoplasty is
controversial. Pretarsal innervation is maintained through medial branches if the incision is only through
the lateral aspect of the muscle. When muscle-splitting techniques are performed it is important to perform proper preoperative risk assessment and routine lateral canthal anchoring procedures for a successful
outcome.
1
REFERENCE
1. Hester RT, Codner MA, McCord CD, et al. Evolution of technique of the direct transblepharoplasty approach for
the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year
experience. Plast Reconstr Surg 2000;105:393
COMPLICATIONS
11. You are called about a patient in the postanesthesia care unit who has undergone a lower blepharoplasty.
The patient is complaining of severe pain in the right eye that is not controlled with intravenous pain medication and reports decreased vision in the eye. What is the most appropriate next step in treatment?
D. Prompt return to the operating room for exploration.
Retrobulbar hematoma is a rare but serious complication with an incidence of 0.04%. A retrobulbar hematoma can compress the neurovascular structures and cause retinal ischemia and optic nerve compression.
Symptoms include severe pain, visual changes, proptosis, and ecchymosis. Any indication of retrobulbar
hematoma should result in prompt return to the operating room for reexploration. If there is any delay,