Secondary Upper Eyelid Blepharoplasty

Transcription

1 Editor s Note: My thanks to the moderator, Peter McKinney, MD (board-certified plastic surgeon and ASAPS member, Chicago, IL), and to panelists Andre Camirand, MD (board-certified plastic surgeon, Montreal, Quebec, Canada), James H. Carraway, MD (board-certified plastic surgeon and ASAPS member, Virginia Beach, VA), and Steven Fagien, MD (board-certified ophthalmologist, oculoplastic surgeon, and associate member of ASAPS, Boca Raton, FL), for sharing their opinions and clinical experience. Dr. McKinney: The first patient is a 41-year-old woman who had a bilateral upper-eyelid blepharoplasty 3 months ago. She is unhappy with pigment changes in her upper lid and complains that her scar is too high (Figure 1). Dr. Fagien, how do you control scar height in the upper lid, and what scar level is best for a patient such as this one? Peter McKinney, MD James H. Carraway, MD Dr. Fagien: With good incision planning, you can often avoid these obvious color changes and an overly high visible scar. This scar appears to be positioned at about 14 mm, suggesting that the planned incision was at least at 10 mm or higher and was possibly placed at or near the patient s natural crease at the time of surgery a common mistake. I design the crease incision much lower, typically at 7 to 9 mm, which begins the process of regaining the youthful upper-eyelid configuration and includes both a lower-positioned upper-eyelid crease and fold, along with more supratarsal volume and fullness. 1 I consider many factors with this design, including the height of the incision, the location of the eventual crease, the contour of the crease, the contour of the ellipse that I design, and the ultimate distance of the eyebrow from the eventual crease. You can notice, even in the medial aspect of her upper eyelid, that the incision is very close to her brow, even more so on the left side. It starts off low, but it has a curvilinear arch that approaches the brow. My incision planning would be far lower. And you can see, on the left, there is a much larger space from the scar to the brow, laterally, where the scar more closely follows the eyebrow contour. Andre Camirand, MD Dr. McKinney: Dr. Fagien, do you think that the skin of the lid stretches? For example, if the surgeon set the lower part of the incision right in the crease, could that have happened in this patient? Dr. Fagien: I do think that the eyelid stretches, but I am not Steven Fagien, MD sure that this is all that has happened in this patient. I usually do not follow the natural crease. Instead, I ignore the natural crease and place my incision or design the crease demarcations where I believe the crease would work best for each patient. If you stretch the skin, you will find that the natural crease may be as high as 12, 13, or 14 mm. Therefore I will ignore that crease and usually lower it. Also, your measurements of the distance of your markings from the eyelid margin will also depend on how much you physically distract the upper eyelid skin while making your determinations. Dr. McKinney: Dr. Carraway, do you measure from the gray line of the upper lid or from the eyelashes? When I use the caliper, sometimes there is a 1- or 2-mm difference in measurement. In other words, do you place the caliper A ESTHETIC S URGERY J OURNAL ~ january/february

2 Figure 1. This 41-year-old woman is unhappy with color changes in her upper lid and complains that the scar is too high 3 months after upper eyelid blepharoplasty. right at the lower edge of the lid or where the lashes extend, at least 1.5 mm higher? Dr. Carraway: I never use a ruler; I decide how much skin to leave in the pretarsal segment, and that is where I make my mark and then I decide how much skin to leave in the subbrow area. In this patient, it is likely that the surgeon put the crease at 8 or 10 mm, making the upper segment short, which would stretch the skin several millimeters. I avoid that situation by maintaining the upper lid skin at the width I choose. In terms of treating this patient, you cannot move the crease down because that upper skin is too thick and resistant. I think the laser would be the best way to remove the discoloration. Dr. McKinney: Dr. Camirand, what do you think about the height of the crease? Dr. Camirand: I do feel that we have been taught to place the incision a little too high. But this patient has her eyes closed, and she has a lack of tissue because she has had a very aggressive blepharoplasty, which stretches the pretarsal skin and also lowers the brow. Dr. McKinney: How would you have prevented this color change? Dr. Camirand: We know that the pretarsal skin and the skin below the brow are entirely different in color, pigment, texture, and thickness. When I decide where to place incisions, I always consider this. The attempt to avoid this contrast would influence my choice of incision location. I also make sure to achieve a low infrasupratarsal fold. Dr. McKinney: What height do you use? Dr. Camirand: Generally about 8 or 9 mm, and sometimes even a little lower to achieve a very low supratarsal fold, which is an obvious sign of youth. And I certainly avoid excising too much skin. Dr. McKinney: Do you consider fullness in the upper lid youthful? Dr. Camirand: I think it is very youthful and beautiful. Dr. McKinney: But you cannot prevent the color change? Dr. Camirand: In some patients, I may make an incision a little higher, when the lower part of the pretarsal skin is very different from the infrabrow skin. My resections are much more conservative than they used to be, and I would not get this tremendous contrast. Dr. McKinney: When you perform an upper lid blepharoplasty, do you remove both skin and muscle? Dr. Camirand: Usually, to retain a youthful fullness, I try not to remove muscle or fat. But in some patients who want a more pronounced supratarsal sulcus or hollowness, I might remove some muscle and even some fat to get the desired effect. I certainly do not remove as much skin as I used to, and I try to avoid muscle and fat excision. Dr. McKinney: How do you determine whether the patient has adequate skin for a brow lift? Are there measurements you use? Dr. Camirand: It is very subjective. I have the patient stand in front of the mirror while I relocate the brow manually to determine whether the patient likes the effect. When the answer is yes, I try to relocate the brow at that level. Dr. McKinney: Can you control it that accurately? Dr. Camirand: Yes, if you elevate more laterally than medially, the brow will be higher laterally. I do take measurements; I follow the Bruce Connell method. 2 I remove one-and-a-half times the amount of skin to raise the brow by the amount I need. Then I perform a hairline incision, and it gives me pretty much 52 A ESTHETIC S URGERY J OURNAL ~ january/february 2004 Volume 24, Number 1

3 what I want. Dr. McKinney: So you always perform an open brow lift? Dr. Camirand: Yes, I always perform an open hairline-incision brow lift. It reduces the width of the forehead, a most obvious sign of age. If the forehead is narrow, my incision is behind the hairline, which will avoid making it narrower. Dr. Fagien: Dr. McKinney, I would like to add a couple of comments. First, we are seeing this patient 3 months after surgery. The erythema and pigmentation are very obvious at 3 months, but when you see these patients 6 months to a year after surgery, these conditions are not as obvious, not as angry-looking. Also, we often have similar problems in patients who are initially happy with surgery but come in for secondary blepharoplasty 5 or more years later, when the crease has migrated significantly. This patient s crease appears to be at 15 or 16 mm. If a patient exhibits the appearance of significant upper lid excess, I actually place my incision much lower, remove the old scar, or bring down the new upper scar into a more favorable, less visible, location. In this woman, I would wait. I would have her return in 6 months to a year and see whether things have changed, or improved, and then make a better treatment plan. Figure 2. This 51-year-old woman complains of ptosis of the right eye 6 months after undergoing upper eyelid blepharoplasty and a 6-mm levator resection on the left eye. Dr. McKinney: The next patient, a 51-year-old woman, is shown 6 months after undergoing upper blepharoplasty; she had ptosis on the left that was repaired with a 6-mm levator resection. She now complains of a droop on the right side, which she says she did not have before the surgery on the left side (Figure 2). Dr. Carraway, what do you think happened? Dr. Carraway: She is a little overcorrected on the left; the arch of the lid is not normal. There is a little peaking of the lid, and she does have ptosis on the right. The procedure I would choose is to drop the left eyelid and raise the right with a levator aponeurosis reinsertion technique, under monitored conditions, which can produce absolute symmetry. Dr. McKinney: What do you mean by monitored? Dr. Carraway: With the patient awake, I sit the patient up and observe the lid levels. Having the patient lie down, sedated, does not provide accurate lid levels. Dr. McKinney: How do you decide between Müller s and levator resection? Dr. Carraway: I think that the levator aponeurosis reinsertion to the tarsus is accurate within the 95th percentile. I do not choose to do the Müllerectomy because, if you operate from the conjunctival side, once in awhile the patient gets a red eye. I want be able to treat everything that may occur after surgery, and, as a plastic surgeon, red eye is not a condition I like to treat. In the end, I usually send those patients to an ophthalmologist, and I prefer to avoid that. Dr. McKinney: Dr. Camirand, what do you think happened here? Dr. Camirand: I have never seen a more classic case of Herring s Law unexpected contralateral ptosis after ptotic repair. We do not understand the mechanism, whether or not it is related to the oculomotor nerve. The only management is to treat the contralateral ptosis. I agree with Dr. Carraway that the left side is overcorrected. Dr. McKinney: Can you predict this occurrence? Dr. Camirand: You can try to predict this by raising the ptotic lid before surgery; you would probably get a reflex in which the eyelid on the opposite side would unexpectedly droop. A ESTHETIC S URGERY J OURNAL ~ january/february

4 Müller s muscle raises the eyelid that you plan to treat. Dr. Carraway: Another way to predict this is that when you cover the left eye, the right eyelid level should come up. Dr. Fagien: It would have been nice to know what her preoperative margin reflex distance measurements were. There is a good chance that she was bilaterally, but asymmetrically, ptotic before surgery, simply with more upper lid ptosis on her left side. One way to avoid this error is by performing a preoperative Neosynephrine (Sanofi Pharmaceuticals, New York, NY) test. Instill Neosynephrine ophthalmic solution in the patient s (apparently) ptotic eye and see what happens to the position of the upper eyelid on that side and the other side. The lid effects of Herrings Law are demonstrated with this simple maneuver and more often can predict this problem. The real question now is how do we manage this problem when it occurs? Dr. McKinney: Can you define ptosis for our readers? Illustration by William M. Winn, Atlanta, GA. Figure 3. The distance from the midpupil (the light reflex will locate this point) to the lower margin of the upper lid is the margin-reflex distance. (Normal margin-reflex distance is 3 to 4 mm.) Dr. Fagien: True upper eyelid ptosis, from a physical standpoint, is a drooping or inferiorly displaced upper lid margin relative to the pupil. Some grade ptosis as mild, moderate, or severe, whether it is 1, 2, or 3 mm. I find the diagnosis of ptosis somewhat subjective. In my opinion, some people actually look good with a little bit of ptosis, and not all upper-eyelid ptosis requires correction from an aesthetic standpoint. Here we are talking about acquired involutional ptosis, which is traditionally described as a mechanical disinsertion or a stretching of the levator aponeurosis. Some people consider anything greater than 3 to 3.5 mm from the midpupil a normal upper lid margin position and believe that anything less than this falls into the category of upper lid ptosis (Figure 3). Topical ophthalmic Neosynephrine stimulates Müller s muscle to contract and, in doing so, raises the upper eyelid margin. Even if you do not plan to use a Müller s muscle conjunctival resection posterior approach for repair, Neosynephrine will also demonstrate how the other upper eyelid will react when contraction of Dr. Carraway: I think we should also consider the level of the brow. This woman had left brow ptosis and a right-side dynamic brow elevation; this condition may have been longstanding and the reason for ptosis repair of the left upper lid. Dr. Fagien: The brow elevation on the right side may be a direct response to her induced lid ptosis. My guess, again, is that she had bilateral, asymmetrical lid ptosis, which could have been predicted with the use of Neosynephrine in her left eye before surgery. I would choose a posterior approach repair in this patient because although she is raising her brow, which tends to deepen the supratarsal sulcus on the right side, she also has an overlying fold and crease disparity that typically is suspicious for an involutional upper lid ptosis on the right. A Müller s muscle posterior approach procedure, predictably, will lower the lid crease on that side. That should be a consideration in choosing the best ptosis repair procedure. Dr. McKinney: Can you explain how a Müller s resection lowers the supratarsal crease on the right side? Dr. Fagien: Anatomically, the effects of the Müller s muscle conjunctival resection are likely not just a result of the shortening of this muscle but are caused by the advancement of the recessed and atrophic soft tissue layers of the posterior upper eyelid, including the levator aponeurosis. When you advance the posterior upper eyelid lamellae to the supratarsal border, you tend to not only raise the upper 54 A ESTHETIC S URGERY J OURNAL ~ january/february 2004 Volume 24, Number 1

5 eyelid margin but also add more volume and lower the eyelid crease and fold. With levator aponeurosis surgery, on the other hand, in some individuals you may have a little more flexibility to place the crease where you choose, especially if the aesthetic goal is to raise the upper eyelid crease. So if you did not, for instance, want to lower the crease on the ptotic side, you might choose not to do a posterior approach because that would predictably lower the crease. Her left upper lid retraction may also be a direct response to the right upper lid ptosis, in accordance with Herring s Law. I would now place Neosynephrine in the right eye and see how that affects the left eye. Raising the right upper lid slightly, even 1 mm, will probably cause as much as 1 mm of compensating descent of the upper eyelid position on the left. I would be hesitant to perform a levator recession on the left eye. I would simply ask her which eye she thinks looks better. If she is adamant about lowering the left upper lid, that may be what you need to do. But consider Herring s Law no matter what approach you choose; raising the right upper lid and testing it first with Neosynephrine will tell you how the left upper eyelid will respond. Dr. McKinney: The third patient is a 68-year-old woman who underwent upper lid blepharoplasty 1 year ago (Figure 4). She complains of hollowing in her lid. She looks sleepy, and you can see a medial fullness. Dr. Camirand, how do you prevent hollowing and, if it is present, how do you correct it? Dr. Camirand: Well, it may be involutionary (atrophy with time). If you Figure 4. This 68-year-old woman complains of looking hollow eyed and sleepy 1 year after an upper eyelid blepharoplasty procedure. perform an upper blepharoplasty and you remove a lot of skin, muscle, and fat, you will aggravate the enophthalmia of aging and get a hollow upper eyelid. In this patient there is no visible supratarsal fold, although there is one far behind, or hidden, within the orbit. The ptosis is involutional because the eyelid drops down and the supratarsal fold has risen (detachment of the levator aponeurosis), remaining attached to the skin and the orbicularis. To correct this, I would advance the levator aponeurosis. I am not that successful in fat grafting in this area. Dr. McKinney: I have not been successful performing open grafts; taking a strip of fat and putting it in the upper lid does not seem to correct very much. Dr. Carraway, have you ever performed fat grafts in these patients? Dr. Carraway: In thinking about repair of ptosis, first consider the individual patient. Young people like a low lid appearance. In Seventeen magazine, most of the eyelids appear low, but as one ages this low lid level causes a sleepy, older appearance. This woman probably has involutional ptosis. To correct this problem, advance and suture the levator aponeurosis to the tarsal plate, which will lower the crease. You do not need a fat graft because the tissue bunches up and fills in the space. In fact, sometimes you have to resect extra skin when you perform this procedure. Levator aponeurosis repair is indicated bilaterally. My concern is whether she had the hollow area before her blepharoplasty. If she did, maybe some fat grafting would be indicated later if there is still hollowing. When performing upper blepharoplasty, if you are not careful resecting skin and muscle, you can actually cut the insertion of the aponeurosis easily. Most of the postoperative ptosis that we see is probably a result of that inadvertent injury. Frequently there is already a little dehiscence or weakness of the aponeurosis insertion, which predisposes the patient even more to injury during blepharoplasty. Yes, I do inject fat grafts to improve the hollow lid problem, but only after I first place an ellipse of fat dermis graft in the area behind the septum. That is the only way that I can get it to remain in that area. Subdermal fat graft injections are effective in the subbrow area. A supratarsal crease hollow will not A ESTHETIC S URGERY J OURNAL ~ january/february

6 Figure 5. This 60-year-old woman underwent upper eyelid blepharoplasty 10 years ago. During an open coronal brow lift, significant lagophthalmus developed. take fat graft very well by injection, which is why you should use an ellipse of fat and dermis graft. Dr. McKinney: Dr. Fagien, can you comment on the medial fullness? Dr. Fagien: This is clearly medial orbital fat, which is far more evident because she has a deep sulcus centrally that makes everything next to it relatively more obvious. Her medial fullness might not bother her as much if she were not so deep centrally. I agree with the previous comments that involutional patients with such atrophic soft tissue, presenting with marked upper lid excess, need skin-only blepharoplasty. Removing muscle has no advantage. She is raising her brows because she has lid ptosis, which tends to further deepen the supratarsal sulcus. She would be an ideal candidate for a Müller s muscle conjunctival resection to lower the upper lid crease. It would not only lower the crease mechanically but would also stop her from raising her brows. She may indeed become brow ptotic and need a secondary brow procedure. I would certainly like to see what Neosynephrine does in terms of lid position and how it affects the brows. Her deep hollowness has many causes, including involution, overresection, and her chronic raising of the brows to compensate for lid ptosis. Dr. McKinney: After you have taken out the appropriate amount of medial fat, do you ever take out some muscle medially to allow the lid skin to lie down more into the sulcus? Dr. Fagien: Typically my upper lid blepharoplasties involve skin excision only, and I actually perform a limited myectomy medially to get through the orbicularis and septum to reach the medial orbital fat. So I probably do resect it without even meaning to debulk the area. It has been said that to get the skin to lie into the sulcus, you need to debulk the medial canthus of the upper lid incision. If there is bunching or heaviness, it is probably a result of inadequate incision design or retained soft tissue, including fat. Dr. McKinney: The next patient is a 60-year-old woman who underwent upper lid blepharoplasty 10 years ago. Significant lagophthalmus became apparent during an open coronal brow lift (Figure 5). Dr. Carraway, what would be your approach if you saw this problem during surgery? Dr. Carraway: If the surgeon had already closed the coronal incision, I would advise him or her to perform an intermarginal tarsorrhaphy with the suture placed about one-third of the way from the lateral canthus. After several days had passed, I would see whether the patient was able to close her eyes and loosen up the tissue. The coronal lift does not pull that much on the lids, although it can appear frightening during surgery. If the surgeon had already resected skin from the coronal lift and closed the wound and the patient had unilateral or bilateral lagophthalmus, I would advise him or her to make an incision in the lid crease, like a blepharoplasty incision, through the skin and orbicularis muscle, and bring the lid down to where it should be. I would then have the patient massage the lid several times daily with an ointment such as bacitracin. The open wound will epithelialize with the lid in a stretched-down position. 3 Dr. McKinney: Some surgeons will not perform an upper lid blepharoplasty and a coronal lift at the same time. Dr. Fagien, would you comment on that? Dr. Fagien: I do not have major concerns about performing an upper lid blepharoplasty in conjunction with a brow lift in most patients. During surgery we can be misled, but these concerns should be alleviated by a good presurgical assessment. Before surgery, if you elevate the brows significantly and the patient can close his or her eyes without difficulty, you can be sure that intraoperative lagophthalmus is not going to be a long-standing problem, assuming that the brow is raised to the appropriate position. Postoperative or intraoperative 56 A ESTHETIC S URGERY J OURNAL ~ january/february 2004 Volume 24, Number 1

7 swelling can cause lagophthalmus. Obviously, as evidenced by the volume of lubrication on the patient s eyes, this surgeon was concerned. Here you are likely seeing intraoperative lagophthalmus resulting from reduced orbicularis tone caused by anesthesia combined with edema, which should not result in a long-term postoperative problem. Dr. McKinney: In the 1960s we were trained to perform skin-only blepharoplasty. We made great efforts to take only skin, avoiding the muscle, and we used stab wounds to extract fat. Dr. Allan Putterman described the suborbicularis fascia in 1968 and Dr. Julius Few discussed this structure and its clinical importance in ptosis at The Aesthetic Meeting 2003 (Annual Meeting of ASAPS and ASERF, May 15-21, Boston, MA). Dr. Fagien, I know that you perform skin-only blepharoplasty, but you take out more skin than I am accustomed to and your patients do not get lagophthalmus. Do you think resection of the suborbicularis fascia causes lagophthalmus more than does resection of skin, muscle, or both? Figure 6. This 52-year-old woman underwent a coronal brow lift and upper lid blepharoplasty 3 years ago. Her chief complaint is heavy brows. Dr. Fagien: Whether it does or does not, I agree that a subdermal cicatrix causes problems more than does the skin tension. When I perform a skinonly blepharoplasty, even during a secondary procedure, it is surprising how much skin I can remove as long as it is safely and aesthetically planned. Whether it is the suborbicularis fascia or the orbital septum, the cicatrization, I believe, is caused primarily by violation of the orbicularis, orbital septum, or both. If you keep the orbicularis intact, lagophthalmos, even with secondary blepharoplasty, is far less likely. Dr. Camirand: I fully agree that if the patient could raise her eyebrows and close her eyes properly before surgery, I would not be concerned. This patient is recumbent, and her eyelid position is not the same as if she were upright. Also, the epinephrine will stimulate the Müller s muscle and the Xylocaine (Astra Pharmaceuticals, Wayne, PA) will paralyze the pretarsal orbicularis and the eyes will remain open. Dr. McKinney: Dr. Camirand, do you use the tear film test before surgery? Dr. Camirand: No, I rely on the patient s history. I want to make sure these patients do not have chronic irritation. If they wear contact lenses and do not get chronic irritation, tearing, and redness, they are suitable. If I have any doubt, I refer the patient to an ophthalmologist. Dr. McKinney: Do any of you believe that a preoperative tear film test has any role in blepharoplasty? 4 Dr. Carraway: I perform Schirmer s test on every patient, and I find it very helpful. I perform it with 2 applications of topical anesthetic, 5 minutes apart. I always use 2 anesthetics to eliminate the possibility of one type of reflex stimulation. Dr. McKinney: So you do a Schirmer II? Dr. Carraway: I do a Schirmer with double application of the topical anesthetic to reduce or eliminate reflex tearing. Dr. McKinney: Does that test allow you to assess basal secretion without any irritation of the patient s eye? Dr. Carraway: That is correct. It is very helpful to me in assessing the patient. This particular patient had a history of previous upper lid blepharoplasty. The scar tissue in an upper lid is not flexible and will transmit the pull from the brow area to the lid margin more so than in an eyelid that has not been operated on. If the patient has lagophthalmos resulting from surgery elsewhere, I make an incision and release the scar tissue, leaving that wound open 2 or 3 mm. It will heal very nicely. Dr. McKinney: How do you use the Schirmer test information? Are there certain test levels that will stop you from operating or influence you to work more conservatively? Dr. Carraway: When I perform an upper lid blepharoplasty in a patient A ESTHETIC S URGERY J OURNAL ~ january/february

8 with reduced tear secretion, I want to be sure that I do not interfere with eyelid flexibility or elasticity; that is the cardinal rule. If a patient has dry eyes, for example, measures 2 and 5, left and right, I may perform a blepharoplasty, but I will be more conservative by leaving more skin. In the lower lid I use a transconjunctival approach that releases the lid retractors and helps the lower lid come up to a better position. You can actually improve a dry eye with a tarsoconjunctival incision because you are cutting the lid retractors. Dry or slightly dry eyes make me approach the surgery in a more conservative manner and sometimes cause me to consider not performing surgery on the lids at all. Dr. McKinney: Does anyone else have comments on the tear film test? Dr. Fagien: I have found that Schirmer s and other basic secretion tests are not as helpful as we would like, mostly because they are so variable. 5 The results of these tests can also be very misleading. As Dr. Camirand mentioned, a patient s history, including dryness before surgery and dependence on artificial tears or lubricants, is very telling, even though their measurements of basic secretion and Schirmer s test may be normal. When patients report that they use topical emollients frequently, that they cannot play golf because their eyes tear too much in the golf environment, that they cannot sleep with the paddle fan going, or that they have become contact lens intolerant, that history is far more significant than the number derived from Schirmer s test. Dr. McKinney: The next patient is a 52-year-old woman who underwent an open coronal brow lift and an upper lid blepharoplasty 3 years ago (Figure 6). She is complaining of fullness of the brow area and upper eyelids, which she noticed after the coronal lift. Her eyebrows are tattooed. Dr. Fagien, why does she have this fullness, and what would you have done to prevent it? Dr. Fagien: This is the perfect example of What is one man s pleasure is another man s poison. Many patients presenting with volume depletion of the lateral brow are injected with fat to get a result like this one. Some find the fullness aesthetically desirable, and others, such as this patient, are horrified by it. It is difficult to see where her actual brow is. Despite the location of her brow, we are also seeing a bony orbital problem, and brow lift or blepharoplasty will not correct this. If she were absolutely demanding surgery and had some fold asymmetry and a little more redundancy on the right side, I might consider a minimal skin-ellipse excision on the right upper lid. But that would be the extent of my surgical intervention. She has already had a secondary procedure. I would tell her (but not recommend) that the fullness that she sees might be addressed by bony surgery, which some have proposed, to reduce the lateral orbital rim. However, I do not think that it is a good idea because it causes volume depletion, which I believe would make her look older. Dr. McKinney: Dr. Camirand, does the lacrimal gland have any role in this complaint? Dr. Camirand: I cannot know with- out examining the patient. I do notice ptosis, and she is in an age group in which I cannot rule out myasthenia gravis. She also complains of brow heaviness. I would find out whether this heaviness gets worse at different times of day. Dr. McKinney: Dr. Carraway, do you perform brow sculpting that is, removing the lateral retroorbicularis oculi fat (ROOF) laterally? Dr. Carraway: I think this is the time to listen to the patient; her suprabrow area does have lateral fullness. I used to take down the orbital rim to reduce this, but now I simply excise the ROOF through a standard blepharoplasty incision. That approach does lead to numbness of the suprabrow area, which is sometimes more disconcerting than the numbness experienced after face lift. I have also used lipoplasty in a patient who had fat grafts in the suprabrow area. This can be performed with a 1.2- mm triple-hole cannula, and it is possible to reduce the fullness of the area to an excellent contour. Dr. McKinney: Dr. Carraway, can you comment on the role of the lacrimal gland and lateral fullness? Dr. Carraway: The bulging lacrimal gland lateral fullness is seen near the lateral eyelid crease area. By lifting the skin away from the crease, you can actually see the lacrimal gland bulge after opening the orbital septum to expose the gland. I place a suture in the lateral horn to the orbital rim and tuck the gland in behind that. I never put a suture in the gland. I put either 1 or 2 permanent tacking sutures in from the lateral horn of the aponeurosis to the 58 A ESTHETIC S URGERY J OURNAL ~ january/february 2004 Volume 24, Number 1

9 orbital rim. It works very nicely. Dr. Camirand: Can improper injection of Botox result in a similar ptosis? cern with sculpting and removing the subbrow and ROOF fat is the effect this will have as the patient ages; I worry what debulking will look like in 5 years. Courtiss, G, ed. Male Aesthetic Surgery. St. Louis, MO: Mosby; 1981: Blepharoplasty. In: McKinney P, Cunningham, BL. Aesthetic Facial Surgery. New York: Churchill Livingstone; McKinney P, Byun M. The value of tear film breakup and Schirmer s tests in preoperative blepharoplasty evaluation. Plast Reconstr Surg 1999;104: Fagien S. The follow-up on The value of tear film breakup and Schirmer s tests in preoperative blepharoplasty by McKinney P, Byun M [discussion]. Plast Reconstr Surg 1999;104;1. Dr. Carraway: You can certainly have brow ptosis as a result of Botox injection. I have seen some patients who have had blepharoplasty and Botox injections to the forehead and have experienced brow ptosis as a result. These are people who wanted to get rid of forehead lines with Botox but really needed a brow lift instead. Dr. Fagien: Most involutional acquired ptosis is seen in patients with a high upper lid crease, and this patient does not have this. My con- Dr. Carraway: We still have to listen to the patient. In the last 10 years, I have probably had 50 upper lid blepharoplasty patients tell me, Can you take just a little more off? I have never had a single patient I perform more than 300 blepharoplasties a year tell me to put more skin or fat back in. References 1. Fagien S. Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper periorbita. Plast Reconstr Surg 2002;110: Connell BF. Eyebrow and forehead lifts. In: Reprint requests: Peter McKinney, MD, 1242 Lakeshore, Chicago, IL X/$30.00 Copyright 2004 by The American Society for Aesthetic Plastic Surgery, Inc. doi: /j.asj A ESTHETIC S URGERY J OURNAL ~ january/february