Volume 11 Issue C2 BLEPHAROPLASTY. Ricardo A. Meade, MD. Cosmetic

Transcription

1 Volume 11 Issue C2 BLEPHAROPLASTY Ricardo A. Meade, MD Cosmetic

2 OUR EDUCATIONAL PARTNERS Selected Readings in Plastic Surgery appreciates the generous support provided by our educational partners. PLATINUM PARTNERS facial aesthetics SILVER PARTNER

3 Editor-in-Chief Jeffrey M. Kenkel, MD Reconstruction Topics Editor Emeritus Contributing Editors Senior Manuscript Editor Business Managers Corporate Sponsorship F. E. Barton, Jr, MD W. P. Adams, Jr, MD S. M. Bidic, MD G. Broughton II, MD, PhD S. Brown, PhD J. L. Burns, MD J. J. Cheng, MD A. A. Gosman, MD J. R. Griffin, MD K. A. Gutowski, MD R. Y. Ha, MD R. E. Hoxworth, MD K. Itani, MD J. E. Janis, MD R. K. Khosla, MD J. E. Leedy, MD J. A. Lemmon, MD A. H. Lipschitz, MD J. H. Liu, MD R. A. Meade, MD J. K. Potter, MD, DDS S. M. Rozen, MD M. Saint-Cyr, MD M. Schaverien, MRCS J. F. Thornton, MD A. P. Trussler, MD R. I. S. Zbar, MD Dori Kelly Lynsi Chester Becky Sheldon Barbara Williams Breast Reconstruction Cleft Lip and Palate Craniofacial Eyelid Reconstruction Facial Fractures Hand: Congenital Hand: Extensor Tendons Hand: Flexor Tendons Hand: Peripheral Nerves Hand: Soft Tissue Hand: Wrist, Joints, Rheumatoid Arthritis Head and Neck Reconstruction Lip, Cheek, Scalp, and Hair Restoration Lower Extremity Reconstruction Nasal Reconstruction Surgery of the Ear Trunk Reconstruction Vascular Anomalies Wounds and Wound Healing Cosmetic Topics Blepharoplasty Body Contouring: Excisional Surgery Body Contouring: Noninvasive, Liposuction, Fat Grafts Breast Augmentation Breast Reduction and Mastopexy Brow Lift Facelift Injectable Agents and Dermal Fillers Lasers and Light Therapy Rhinoplasty Skin Care Selected Readings in Plastic Surgery (ISSN ) is published approximately 5 times per year by Selected Readings in Plastic Surgery, Inc. A volume consists of 30 issues distributed over 6 years. Please visit us at for more information. Published as electronic monographs.

4 BLEPHAROPLASTY Ricardo A. Meade, MD Dallas Plastic Surgery Institute, Private Practice University of Texas Southwestern Medical Center at Dallas Dallas, Texas INTRODUCTION Eyelid rejuvenation is a complex subject within aesthetic facial surgery. With this in mind, we must maintain a global perspective of the aging face. Successful rejuvenation requires an individualized approach with a clear understanding of the underlying conceptual framework that delineates the anatomic problems identified by preoperative assessment. The main areas of potential focus include the following: 1) resuspension of descended periorbital structures; 2) restoration of volume loss; 3) support of the lateral canthus; 4) establishing a smooth lower eyelid-cheek junction; and 5) resurfacing or removing lower and upper eyelid skin excess. HISTORY An excellent discussion of the history of eyelid surgery can be found in articles by Dupuis and Rees 1 and Stephenson 2 and in a textbook by Wolfort and Kanter. 3 A description of eyelid surgery can be found in the 2000-year-old Indian document, the Susruta. During the 10th and 11th centuries, Arabian surgeons treated dermatochalasis with a crescent-shaped cautery to burn the eyelid and correct drooping. 4 Johnson, 5 in 1678, described the works of Ambroise Paré who excised excess upper eyelid skin and emphasized the importance of avoiding over-resection. The first illustrations of excess eyelid folds in the medical literature were published in a textbook by the Viennese surgeon Georg Joseph Beer in von Graefe 7 was the first to use the term blepharoplasty to describe eyelid surgery. Mackenzie, 8 Alibert, 9 Graf, 10 and Dupuytren 11 described resecting only the excess skin of the eyelid. Sichel, 12 in his 1844 review, distinguished between paralytic ptosis, atonic ptosis, and fatty ptosis. He was the first to describe herniated intraorbital fat. Fuchs, 13 in 1896, described a patient with recurrent swelling of the upper eyelid that led to wrinkles, a condition he termed blepharochalasis. Cosmetic repair of baggy eyelids was popularized by Miller 14 in 1908 in the first textbook devoted to cosmetic surgery. In it were photographs illustrating lower eyelid incisions for the removal of wrinkled skin. Bourguet, 15 in 1928, was the first to note the separate fat compartments in the eyelids and described a transconjunctival approach to correction of lower lid fat bulging. Around the same time, Madame Noel s 16 technique involving a subciliary incision became the standard approach to the lower eyelid. Castañares, 17 in 1951, described modern blepharoplasty and detailed the pathological anatomy of the orbital fat compartments. The technique used by the author separated the skin of the lower eyelid from the orbicularis muscle. In 1952, Fox 18 first applied the term dermatochalasis to the eyelid with redundant skin. The skin-muscle flap was popularized by Rees and Dupuis 19 and others in the 1970s. The transconjunctival approach to correction of orbital fat was popularized by Zarem and Resnick 20 in

5 1992. In 1996, laser resurfacing and chemical peeling were proposed for the treatment of lower eyelid dermatochalasis. 21 Researchers attention turned to the rejuvenation of the lower eyelid-cheek junction, specifically tear trough deformity. Loeb initially reported reposition of lower eyelid medial and central compartment fat for the correction of deep nasojugal grooves. The technique was modified by Hamra 25,26 who then popularized it as the septal reset. The benefits of septal reset for tear trough deformity were further elucidated by Barton et al. 27 ANATOMY For more in-depth descriptions of the anatomy associated with blepharoplasty, the reader is referred to descriptive articles, textbooks, and atlases by Zide and Jelks, McCord et al., 31 and Baker et al. 32 The palpebral fissure, which is the aperture between the upper and lower eyelid margins, measures 12 to 14 mm vertically and 28 to 30 mm horizontally. The upper eyelid normally rests up to 2 mm below the limbus, with the lower eyelid margin at the level of the lower limbus. 33 The arterial distribution of the eyelids is illustrated in a 2007 article from Turkey. 34 Nineteen cadaver heads were injected, and schematization showed the marginal and peripheral arterial arcades and their feeding vessels. Skin The skin of the eyelid is the thinnest in the body. Subcutaneous fat is sparse. Edema fluid can rapidly engorge the loose subcutaneous space and defines the juncture with the surrounding subcutaneous fibroadipose tissue, which is denser. 32 Age-related changes in the sun-exposed area of the periorbita include decreased type I collagen synthesis and increased dermal collagenase activity. With time, these metabolic alterations lead to thinning, folding, and wrinkling of the eyelid skin. 35 Hwang et al. 36 discussed the loss of skin sensation or numbness after lower blepharoplasty. They dissected 14 fresh cadaver heads and found that the infraorbital nerve and the zygomaticofrontal nerve coursed through the infraorbital foramen and the zygomaticofacial foramen, respectively. The nerves coursed superficial to the periosteum, beneath and then within the epimysium of the orbicularis muscle, and then distributed to the skin; 99.4% of infraorbital nerve branches were medial to the lateral canthus. The zygomaticofacialis nerve terminal branches were found lateral to the lateral canthus. The authors concluded that the skin-muscle flap infringes less than the skin flap on these terminal branches during lower blepharoplasty. Orbicularis Oculi The orbicularis oculi is the sphincter of the eyelid. This broad, thin, oval muscle is adherent to the overlying skin and consists of three parts: a peripheral orbital portion spreading over the forehead and cheek, a palpebral portion that constitutes the voluntary muscle of the eyelids, and a small lacrimal portion associated with the medial palpebral ligament. The orbital portion attaches to the medial canthal tendon, the nasal part of the frontal bone, and along the inferomedial orbital margin. Laterally, the orbital portion of the orbicularis oculi continues around the orbit without interruption at the lateral canthus. 32 The palpebral portion of orbicularis oculi spreads concentrically in the subcutaneous tissue of the upper and lower eyelids. The palpebral orbicularis oculi has pretarsal and preseptal segments. Mild eyelid closure is primarily through contraction of the pretarsal and preseptal portions of the orbicularis oculi. Tight closure is the result of contraction of the orbital portion of the muscle. 37,38 Medially, the preseptal orbicularis oculi has two heads. The anterior head becomes the anterior crus of the medial canthal tendon and inserts into the frontal process of the maxilla. The posterior head inserts into the posterior lacrimal crest (Horner muscle). 32 Laterally, fibers of the preseptal palpebral portion of orbicularis oculi interdigitate superficial to the lateral palpebral ligament to form the lateral palpebral raphe. 31,38 The orbicularis oculi is anchored by welldefined ligamentous attachments. Muzaffar 2

6 et al. 39 provided a detailed description of the attachments. Medially, the orbicularis oculi has a direct attachment to the inferior orbital rim from the region of the anterior lacrimal crest to approximately the level of the medial limbus. Laterally, the attachment is indirect and is provided by the orbital retaining ligament (ORL) (Fig. 1). 39 This structure is the same as the orbitomalar ligament described by Kikkawa et al. 40 The ORL extends from the periosteum just outside the orbital rim to the fascia on the undersurface of the orbicularis oculi. At its lateral extent (and in the region of the lateral canthus), the ORL merges with the lateral orbital thickening (LOT). The LOT represents a triangular condensation of the superficial and deep orbicularis oculi that extends across the frontal process of the zygoma onto the deep temporalis fascia. In the study presented by Muzaffar et al., 39 the dimensions of the LOT varied greatly with age (Fig. 2). The ORL is predictably continuous with the LOT below the lateral canthal tendon; specifically, the ORL, LOT, and lateral palpebral raphe form a single anatomic unit in that region (Fig. 3). 39 Release of the ORL and LOT, therefore, allows untethered redraping of all the structures. Age-associated changes in the orbicularis oculi are caused by muscle relaxation and increasing laxity and attenuation of the orbicularis oculi ligamentous attachments. The changes ultimately result in progressive eyelid ptosis. Combined with ptosis of the malar soft tissues, with which they are frequently associated, the changes result in a characteristic deformity at the point where the inferior muscle border becomes visible, forming a malar crescent or festoon over the malar eminence and creating a clinical appearance of periorbital soft-tissue widening. 41 Septum The orbital septum consists of dense fibroelastic tissue and forms the anterior border of the orbital contents. The septum represents a continuation of the orbital periosteum. The junction is termed the arcus marginalis. Putterman and Urist 42 noted that the orbital septum inserts 10 to 15 mm above the superior tarsal border of the upper eyelid to join the levator aponeurosis. On the lower eyelid, the orbital septum joins the capsulopalpebral fascia 5 mm below the tarsal border. 42 The measurements, however, are subject to debate, as discussed by Zide. 28 Figure 1. Cadaveric dissection within the prezygomatic space. The upper border is indicated by the blue line. Medially, the orbicularis oculi (OO) originates directly from the orbital rim above the origin of the levator labii superioris (LLS). More centrally, the orbicularis has an indirect attachment to the orbital rim by means of the orbicularis retaining ligament (ORL), which courses directly on the orbital side of the zygomatico-facial nerve (ZFN). At the lateral orbital rim, the ligament merges into the lateral orbital thickening. Sub-orbicularis oculi fat (SOOF) lines the undersurface of the prezygomatic orbicularis (pars orbitalis). Zmaj., zygomaticus major muscle; Zmin., zygomaticus minor muscle. (Reprinted with permission from Muzaffar et al. 39 ) 3

7 not occur. Camirand 44 proposed that the cause of herniated fat and enophthalmia of aging is likely to be a combination of the descended Lockwood suspensory ligament, the relaxed muscle tone of the orbicularis oculi and extrinsic muscles, and the weight of the globe pushing on the orbital fat as the patient lies on the operating table. Figure 2. Dimensions of the orbicularis retaining ligament. The larger light blue outline is the ligament of the youngest specimen. The dark blue triangle defines the diminished attachment in the older specimens. (Reprinted with permission from Muzaffar et al. 39 ) Figure 3. Superficial fascia, or superficial musculoaponeurotic system, is a continuous unit composed of the temporoparietal fascia (TPF) and the orbicularis muscle fascia. It attaches to the skeleton along the orbital rim, by the lateral orbital thickening (LOT) in continuity with the orbicularis retaining ligament (ORL); to the lateral orbital tubercle by means of fibrous connections of the orbicularis fascia with the tarsal plates (TP); and from there to the deep head of the lateral canthal tendon (LCT). (Reprinted with permission from Muzaffar et al. 39 ) Camirand and colleagues 43,44 reported that the orbital septum does not offer much support and cannot maintain the fat within the orbit even at a very young age. After an orbital floor exploration or traumatic laceration, suturing of the orbital septum is seldom performed, yet herniated fat pads do Fat Postseptal (Intraorbital) Fat The postseptal, or intraorbital, fat lies on the eyelid proper. Bourguet 15 recognized two distinct adipose compartments in the upper eyelid, divided by the superior oblique. The medial fat pad is lighter in color and firmer in consistency than the central fat pad. The medial fat pad is associated with the infratrochlear nerve and the terminal branch of the ophthalmic artery. Bourguet, 15 and later Castañares, 17 also identified three distinct fat compartments in the lower eyelid, but the observation was subsequently challenged by Berry 45 and Beard, 46 who noted only two discrete compartments. Hugo and Stone 47 injected dye into individual fat pockets in the lower eyelids of cadavers and found that the dye diffused throughout the entire eyelid, indicating a lack of true compartmentalization. On the other hand, in vivo dye injection studies conducted by Barker 48 showed that the dye remained within the compartments. Preseptal (Extraorbital) Fat The preseptal, or extraorbital, fat accumulates outside the orbital rim on the inferior lateral brow and upper malar areas. Owsley 49 described a thick cushion of fatty tissue beneath the orbicularis muscle that overlies the lateral orbital rim extending outward toward the end of the brow. The lateral fat pad is superficial to the orbital septum, where it may overlie the lateral extension of the central fat pad. May et al. 50 reviewed the value of resecting the fat, which they termed the retroorbicularis oculi fat, in decreasing heaviness of the lateral brow and upper eyelid. Aiache and Ramirez 51 described a counterpart in the lower eyelid and called it the suborbicularis oculi fat. In their words, The suborbicularis oculi 4

8 fat represents the position of the fat pad in relation to the orbicularis oculi muscle and is analogous to the retro-orbicularis oculi fat designated to the fat pad located in the brow area. The authors suggested that malar bags are the result of ptosis of the suborbicularis oculi fat. Hwang et al. 52 delineated the retro-orbicularis oculi fat and suborbicularis oculi fat pads histologically and by precise anatomic location relative to the midpupillary line. Eyelid Retractors Upper Eyelid The levator palpebrae muscle originates from the lesser wing of the sphenoid and extends anteriorly along the superior orbit. 33 Approximately 14 to 20 mm above the superior border of the tarsus, the levator forms a condensation of fascia known as Whitnall ligament. 53 It functions as a fulcrum to translate a posterior vector into a superior vector. Anterior to that structure, the levator forms a bilamellar aponeurosis that joins with the septum to insert into the tarsus. A lateral horn divides the lacrimal gland into the palpebral and orbital lobes and contributes to the lateral retinaculum. A medial horn inserts into the lacrimal crest. 54 The posterior lamella contains Mueller muscle. 55 Lower Eyelid The equivalent retractor in the lower eyelid is formed by the capsulopalpebral fascia. It originates as a fibroelastic tissue from the inferior oblique muscle as two sheets. Anteriorly, the sheets fuse to form Lockwood ligament. Anterior to Lockwood ligament is the capsulopalpebral fascia. Approximately 5 mm below the inferior tarsus, the septum and the capsulopalpebral fascia fuse to insert into the tarsus. Some smooth-muscle fibers are present in the condensation (the inferior tarsus muscle). Other capsulopalpebral fibers extend through the orbicularis oculi toward the skin and contribute to the lower eyelid crease (Fig. 1). 32,39,56 Lateral Canthus Jelks and Jelks 30 stated that the lateral canthus defines the geometric pattern of the lateral aspect of the eyelids and is more appropriately termed a lateral retinaculum. The complex structure anchors the lateral soft tissues to the bony orbit. The retinaculum consists of the following: 1) lateral horn of the levator palpebrae superioris, 2) preseptal and pretarsal orbicularis oculi, 3) Lockwood ligament, and 4) check ligament of lateral rectus muscle. 30,57 The dimensions were described by Gioia et al. 58 Muzaffar et al. 39 and Flowers et al. 59 described the relationship between the lateral canthal tendon with the LOT and ORL, also known as orbitomalar ligament as labeled by Kikkawa et al. 40 Medial Canthus The medial canthal tendon inserts into the bony orbit in a tripartite manner: anterior and posterior horizontal elements and a vertical element. McCord et al. 31 defined the medial canthal retinaculum as the deep head of the pretarsal orbicularis, the orbital septum, the medial end of Lockwood ligament, the medial horn of the levator aponeurosis, the check ligaments of the medial rectus muscle, and Whitnall ligament. PERIORBITAL AESTHETIC GOALS Clearly defined goals of brow and orbital aesthetics are the basis of successful results in surgical rejuvenation of the upper portion of the face. The goals vary significantly with sex, age, fashion, race, culture, and personal preference. The globe by itself is entirely expressionless and depends on the surrounding soft-tissue complex to convey the myriad human emotions. Farkas and Kolar, 60 Flowers, 61 and Wolfort et al. 62 reviewed the aesthetic goals of blepharoplasty. Certain numerical guidelines are helpful in planning the surgery. At the midpupillary line, the anterior hairline to brow distance should measure 5 to 6 cm. The distances from brow to orbital rim, brow to supratarsal crease, and brow to midpupil should be 1, 1.6, and 2.5 cm, respectively. 63 Canthal tilt averages 4.1 mm (+4 degrees) in women and 2.1 mm (+3 degrees) in men. 64 Visible pretarsal skin should measure 3 to 6 mm, 65 whereas lash line to eyelid fold ranges from 8 to 10 mm. 66 The upper eyelid should cover 2 to 3 mm of the iris, and the lower eyelid forms a lazy-s and should just meet 5

9 its inferior aspect. 30 The intercanthal distance is ideally one-fifth of the facial width at eye level and represents one eye-width. 67 The cornerstone of successful eyelid surgery is comprehensive but judicious resection of redundant skin, fat, and muscle while preserving or restoring symmetry and function. Goals for the upper eyelid include the restoration of sharp, crisp tarsal folds and pretarsal show with deepening of the orbitopalpebral sulcus. The lower eyelids must appear smooth and soft. Distortion of eyelid shape and position must be avoided. The lateral canthal angles should be maintained as sharp and distinct. PREOPERATIVE EVALUATION Astute preoperative evaluation requires thorough general medical and ophthalmic histories, physical examination, and photographic documentation of the appearance and function of the globe, eyelids, and adnexal structures. With proper evaluation, many of the unfavorable postoperative outcomes can be anticipated and avoided. For preoperative evaluation considerations, please review the maintenance of certification continuing medical education article on blepharoplasty by Trussler and Rohrich. 68 Jelks and Jelks 69 detailed the steps of preoperative evaluation of a patient before blepharoplasty. In decreasing order of importance, they are as follows: detailed ocular history assessment of the ocular and periocular anatomy Schirmer test tear film breakup time assessment of Bell phenomenon The history should include subjective assessment of vision, use of corrective lenses and/ or contact lenses, symptoms of dry eye, facial nerve disorders, hypertension, bleeding disorders, endocrine disorders, cataracts, glaucoma, diabetes, corneal or previous eyelid surgery, psychiatric disorders, trauma, and medications. The physical examination should document any existing skin lesions and dermatological conditions. 69 The status of the extraocular muscles should be documented. The bony topography and asymmetries should be noted. Malar hypoplasia should be recognized preoperatively. Jelks and Jelks 69 described the relationship, as seen on lateral view, among the anteriormost projection of the globe, the lower eyelid margin, and the malar eminence. A negative vector is one that angles posteriorly and indicates an absence of support for the lower eyelid. Because patients with negative vectors frequently exhibit scleral show, appropriate modifications of lower eyelid surgery are indicated in such cases. 30 The upper eyelid examination should document asymmetries, ptosis, levator function, skin and fat excesses, and eyelid retraction. Examination of the upper eyelid is performed with the brow in its normal resting position and in an elevated position simulating browpexy. The lower eyelid is assessed for scleral show, eyelid position, eyelid tone and support, entropion and ectropion, malar bags, nasojugal folds, and skin, muscle, and fat excess. 70 The snap back test consists of pulling the eyelid down as far as it will go and watching its return to normal position when released. Hinderer 71 summarized the standard tests for lower eyelid laxity. Unfortunately, the eyelid snap back and distraction tests are unreliable predictors of postoperative eyelid malposition. Codner et al. 72 suggested pulling the incised lower eyelid laterally to determine intraoperatively the degree of laxity. The distance the lower eyelid stretches from the lateral commissure to the orbital rim represents the amount of redundancy and dictates treatment: <3 mm overlap of the lateral orbital rim generally is managed with a suture canthopexy, but more severe redundancy usually requires canthoplasty. A prominent globe is also a high-risk indicator for postoperative eyelid malposition. 72 Other preoperative evaluations should include the visual acuity in each eye, with and without correction, and a basic funduscopic examination. A Schirmer test can aid in screening patients prone to dry eye conditions postoperatively. The presence of Bell phenomenon should be noted. PITFALLS Jelks and Jelks 69 presented a review of the problems 6

10 that can occur in association with palpebral and periorbital surgery. Ptosis, Pseudoptosis, and Eyelid Retraction Depression of the eyelid margin to a position lower than normal (with relation to the limbus in central gaze) is a sign of possible ptosis. An elevated position of the supratarsal crease suggests levator dehiscence. Jones et al. 73 presented a discussion of the anatomy and pathology of eyelid ptosis. Possible causes of ptosis include trauma, chronic progressive external ophthalmoplegia, Horner syndrome, myasthenia gravis, and upper eyelid tumors. 31 Pseudoptosis occurs when excess skin is present and hooding depresses the upper eyelid. Pseudoptosis can be differentiated from true ptosis by elevating the excess skin. Eyelid retraction is indicated by elevation of the eyelid margin above the limbus. The most common cause of eyelid retraction is thyroid infiltrative ophthalmopathy. 74 Ptosis, pseudoptosis, and eyelid retraction must be accurately diagnosed preoperatively so that the appropriate levator surgery can be performed. Malar Hypoplasia and Prominent Globe Jelks and Jelks 30,69 analyzed the influence of the anatomic relationships of the orbital region on the outcome of lower blepharoplasty and suggested adding a lateral canthoplasty in the patient with a negative vector. With age, the orbital rim moves posteriorly, relative to the anterior cornea, and the negative vector becomes more pronounced. 75 To ensure stability of the surgical result, McCord et al. 76 recommended redraping of the inferior arc of the orbicularis oculi and lateral canthoplasty as adjuncts to blepharoplasty in the aging face. Patients who have scores of 19 mm on Hertel exophthalmometry are at increased risk of clotheslining when the lower eyelid is tightened, in which case both orbicularis oculi arc redraping and lateral canthoplasty require supra-placement of fixation. Dry Eyes Rees and Jelks 77 and Jelks and McCord 78 reviewed dry eye syndrome. Symptoms of itching, foreign body sensation, burning, mucoid secretions, frequent blinking, and conjunctival infection suggest dry eyes. The diagnosis is made clinically when mucous filaments are seen on a dull, gray-appearing cornea, by corneal staining with fluorescein testing, and by a positive result to a Schirmer test. The Schirmer I test measures both basic and reflex secretions, whereas the Schirmer II test measures basic secretion by using a topical anesthetic to block reflex tearing. Per Rees and Jelks, 77 a strip of #41 filter paper, 5 35 mm, is folded 5 mm at one end. The folded end is placed on the lateral one-third of the lower eyelid conjunctiva, and the patient is requested to fix the gaze on an object above the direct line of vision for 5 minutes. Less than 10 mm of wetting (of the paper) is considered hyposecretion. The normal range is between 10 and 30 mm. McKinney and Zubowski 79 found the Schirmer test to be an unreliable predictor of possible dry eye complications after blepharoplasty. The authors reported that the best predictor of dry eye was an abnormal preoperative ocular history or abnormal orbital and periorbital anatomy. In a 10-year update of their 1989 study, McKinney and Byun 80 confirmed their original impression and noted that they did even less preoperative tear film testing at the time of the second writing in They preferred to rely on the history and the anatomy as predictors of postoperative dryness, particularly the presence of scleral show, lagophthalmos, or a loose lower eyelid that is not adherent to the globe in its outer third. Rees and LaTrenta 81 noted that 65% of patients with postoperative dry eye syndrome had normal preoperative Schirmer test findings, and proposed five clinical variables that indicate morphologically prone eyes, as follows: relative or real proptosis exophthalmos hypotonia of the lower eyelids maxillary hypoplasia inferior scleral show These anatomic characteristics were found to be statistically significant predictors of dry eye syndrome, more meaningful than measured low tear film. Patients who exhibit one or more of these criteria should be treated with caution. The patients 7

11 can still undergo blepharoplasty as long as adequate ocular protection is provided and the procedure is altered to include a variety of reconstructive measures. Lee et al. 82 discussed changes in the cornea after keratorefractive surgery and the effect of the changes in patients seeking blepharoplasty surgery. The authors recommended a 6-month wait after laser vision correction before performing blepharoplasty surgery. The patient might develop dysfunctional tear syndrome after laser vision correction. Lower Eyelid Laxity and Ectropion The most common complication of lower blepharoplasty is distortion of the eyelid. Preoperative eyelid laxity and ectropion must be identified, shown to the patient, and accounted for in the surgical treatment plan. Failure to do so can lead to a typical deformity with marked scleral show worsening laterally, rounding of the lateral canthus, and a narrowed intercanthal distance. 83 Carraway and Mellow 70 suggested other conditions that cause lower eyelid malposition: large globe hypoplastic malar eminences paralysis of the orbicularis oculi adhesion of the orbital septum hematoma lax eyelid margin proptosis excessive skin, fat, or muscle removal scar contracture Postoperative malposition of the lower eyelid can be prevented by preoperatively checking for horizontal tension of the eyelid with a snap back or distraction test and identifying any scleral show. The tests were summarized by Hinderer. 71 UPPER BLEPHAROPLASTY Incisions By the 1930s, the basic blepharoplasty incisions had been described and standardized. The incision is placed 9 to 12 mm above the ciliary margin at the level of the upper edge of the tarsus. Baker et al., 66 Ellenbogen and Swara, 84 Gradinger, 85 and Flowers 65 emphasized the need for precise planning of the lower aspect of the incision. The superior aspect of the incision is determined by marking the level of overhanging skin after grasping the upper eyelid skin with Adson forceps. An alternative way to estimate the upper skin excess was proposed by Silver, 86 who marks only the eyelid crease and then redrapes the upper eyelid skin downward and removes the excess. Stambaugh 87 compared both techniques and found no significant difference between them regarding the amount of skin that is excised. Flowers 65 noted that the minimum distance from brow to fold is 12 mm, which is the minimum amount of skin that must be preserved. Modifications of the medial and lateral aspects of the incision for dealing with skin redundancy at either end include medial Z-plasty, 88 lateral Z-plasty, 89 lateral W-plasty, 90 and lateral Y-V-plasty. 91 Most authors use a scalpel to create the initial skin incision. Tebbetts 92 used a needlepoint Bovie on blended cutting current for skin and muscle resection. He reported that cautery helps to obtain hemostasis and minimize tissue morbidity. Mittelman and Apfelberg 93 compared the CO 2 laser with conventional techniques of blepharoplasty in 10 patients and found no difference in postoperative pain, swelling, ecchymosis, quality of scars, or long-term results. Intraoperative findings did suggest improved hemostasis, however. David and Sanders, 94 in a similar study of 13 patients, found no difference in final cosmetic appearance but did observe less ecchymosis and edema with laser surgery. Trelles et al. 95 questioned the methodology of the study by David and Sanders and cited his own favorable experience in 560 cases of blepharoplasty with the CO 2 laser. Januszkiewicz and Nahai 96 removed the medial fat pad in the upper eyelid through a transconjunctival incision followed by CO 2 laser resurfacing to address the skin excess in selected patients. Guerra et al. 97 reported use of the transconjunctival approach in 42 patients for the treatment of pseudoherniated upper medial fat with little or no excess skin. Halvorson et al. 98 reported their 10-year experience in marking for 8

12 upper blepharoplasty using a simple method to achieve expectations after surgery. Muscle Excision Opinions vary regarding the amount of muscle to resect during upper blepharoplasty, if any. Baker 99 excised a strip of orbicularis oculi 5 to 8 mm long from immediately above the supratarsal fold in all cases. Tebbetts 92 reported that a generous muscle resection, excising only 2 to 3 mm less than the skin resection, is necessary to avoid the excess orbicularis oculi from obscuring the supratarsal fold and to allow a natural fixation. Flowers 65,88 removed a maximum of 2 to 3 mm of muscle and cautioned that tenting up the muscle during the excision can lead to inadvertent transection of the septum and levator aponeurosis. Fat Excision The septum should be opened cautiously, placing pressure on the globe to identify the fat and septum. The incision is made somewhat high to avoid the insertion of the septum and aponeurosis inferiorly. Flowers 65 angled the incision upward, considering that the union between the septum and aponeurosis is higher in the central portion of the eyelid than laterally. Tebbetts 92 indicated several landmarks to look for during fat resection and recommends resecting only the fat that bulges anterior to the plane of the orbital rim without retraction or globe pressure. The dissection should be anterior to the septal plane to avoid injuring the neurovascular structures or extraocular muscles. Over-resection of fat will lead to an undesirable hollowed out look. Kranendonk and Obagi 100 reported the details of their fat transfer techniques as an enhancement of volume restoration using autologous fat transplantation. An argument against surgery of the eyelids was suggested because of the cosmetically unacceptable results that the authors often observed after those operations. Hamra 101 provided a strong argument opposing relying on fillers for facial rejuvenation, considering that surgery is the gold standard against which to compare results. He reported the long-term follow-up of patients who had undergone surgical anatomic correction and presented follow-up photographs that span many years. Supratarsal Fold and Fixation When the levator contracts and pulls the eyelid up, the dermal attachments of the levator aponeurosis produce a fold in the skin of the upper eyelid at the level of the superior tarsus (Fig. 2). 39 Traditional methods for reconstituting the crease after blepharoplasty involve precise surgical planning of the lower incision and strip orbicularis oculi excision. Fernandez, 102 Sheen, 103 and Flowers 104 proposed fixation of the pretarsal orbicularis oculi or dermis an anchoring technique to create a more precise upper eyelid crease. Several blepharoplasty surgeons, including McCord et al., 31 Hinderer, 71 and Siegel, 105 also have reported incorporating some type of anchoring sutures into their blepharoplasties (Fig. 3). 39 The aims are to excise less skin, recreate a more youthful upper eyelid, and achieve longer lasting results than if no fixation were used. Flowers 104 stated that a major problem with traditional blepharoplasty is that the supratarsal fold with its connections to the levator mechanism usually is excised, leaving a less-distinct fold than preoperatively. He cited photographs presented in an article by Baker 99 to support the need for tarsal fixation. Baker, however, reviewed his blepharoplasty cases and did not find long-term improvement in the crease with the anchor technique. Spira 106 analyzed his own cases and likewise could not confirm any benefit of supratarsal fixation. Asian Eyelid The Asian upper eyelid is characterized by an absent palpebral crease, a medial epicanthal fold hooding the caruncle, upward tilt of the lateral canthus, and a narrow palpebral aperture. 107,108 The levator muscle inserts into the superior tarsal edge, but no fibrous extensions continue through the orbital septum to the pretarsal orbicularis oculi. The lack of attachment frequently allows the pre-levator fat to prolapse inferiorly, making the eyelid 9

13 appear puffy. 102 In 1954, Sayoc 109 described an operative procedure designed to produce a more Western appearance to the Asian upper eyelid. Twenty years later, Sayoc 108 reviewed his and other authors experience with the procedure. 102, Several surgeons 102, have reported their individual modifications of the blepharoplasty operation for use in Asian eyelids. Most of the procedures involve at least some of the original elements proposed by Sayoc, 109 including the following: supratarsal incision excision of a 2-mm strip of orbicularis oculi over the entire length of the eyelid removal of excessive pre-levator fat anchoring the lower muscle and/or skin flap to the insertion of the levator aponeurosis at the upper tarsal edge to construct the absent fibrous attachment Combined with levator excursion, these maneuvers help create an upper palpebral fold. Baek et al. 116 proposed a single-stitch, nonincision technique to create an aesthetically pleasing supratarsal fold in Asian eyelids, with minimal morbidity. Their 762 patients were followed for up to 5 years, by which time the fold had disappeared in 2.9%. The authors concluded that the procedure is indicated in young patients whose upper eyelids have thin, non-redundant skin and no excessive fat. Bang 117 described the double-eyelid operation without supratarsal fixation for creating a supratarsal fold in Asian patients. Watanabe 118 noted that the Asian upper eyelid grooves differ in position and shape from those of Europeans. He devised a method for determining the amount of excess skin to remove from the upper eyelid. Yoon and Park 119 reported their experience with 241 young Asian patients who underwent blepharoplasty to create supratarsal folds. The authors described their systematic approach and selective tissue removal based on increasing degrees of skin thickness and eyelid puffiness, from resection of peri-incisional tissue only to pretarsal tissue, orbital fat, and upper retromuscular fatty tissue in the more severe cases. Zubiri 120 illustrated differences between European and Asian eyelids and noted three variants of the supratarsal fold as it relates to the epicanthus. Correction of the epicanthal fold by some form of Z-plasty frequently is necessary 108 to complete the conversion of Asian eyelids to a European look. Zubiri 120 and Hin 121 discussed potential complications of blepharoplasty in Asian patients and detailed methods for secondary revision. The epicanthal fold does not need to be modified in most cases and probably should not be unless it constitutes a severe deformity. del Campo 107 used a Z-plasty technique, whereas Flowers 65 preferred a V-W-plasty for correction (Fig. 4). 103 Wu 122 reported a simple and useful technique in epicanthoplasty with minimal scar as a modification of the technique presented by Fukuta. Figure 4. Illustration shows basic anatomy of eyelid in cross-section. The levator expansion perforates the orbital septum and the orbicularis to insert into the skin at the level of the superior edge of the tarsus. The attachments determine the level of the palpebral fold. (Reprinted with permission from Sheen. 103 ) 10

14 Kim et al. 123 reported their variation of improving Asian upper lateral eyelid hooding by an infrabrow excision in a select group of patients. Li and Ma 124 shared their V-Y epicanthoplasty technique in conjunction with double blepharoplasty. The Asian lower eyelid is also different. The subcutaneous tissue has only sparse fibers of capsulopalpebral fascia, making the lower eyelid crease minimal and poorly defined. Compared with European lower eyelids, in Asian eyelids, the orbital septum fuses with the capsulopalpebral fascia at a higher level, and the lower eyelid retractor does not attach to skin). 125 The concept of a glide zone and its biomechanics on the blinking Asian upper eyelid was reviewed by Chen. 126 The anatomy and the role of the upper eyelid crease and preaponeurotic space and fat in Asian and Caucasian eyelid anatomy were reviewed as applies to aesthetic blepharoplasty. Chen described the necessary third layer that should be entirely preserved to allow for frictionfree sliding of the upper eyelid blink. Lateral Fullness Excessive fullness in the lateral aspect of the upper eyelid can occur secondary to brow ptosis, prominent supraorbital rims, prominent lacrimal gland, or subcutaneous fat. Lassus 127 described ostectomy of the superior orbital rim in cosmetic blepharoplasty to decrease lateral fullness secondary to prominent and downward-slanting bony rims. Ortiz Monasterio 128 described remodeling of the orbital rim with a burr through a coronal approach. An enlarged or herniated lacrimal gland can also produce fullness of the lateral portion of the eyelid. The lacrimal gland accounts for lateral eyelid fullness in 10% to 15% of patients. 129,130 Horton et al. 131 resuspended the gland to the lateral rim. Beer and Kompatscher 132 used the lateral third of Whitnall ligament to resuspend the gland to the orbital rim with sutures. Excision of one lobe of the gland is discouraged because it can lead to keratoconjunctivitis sicca. Subcutaneous fat deposits superficial to the orbital septum (retro-orbicularis oculi fat) can produce excessive bulk laterally that can extend beyond the canthal region. Owsley 49 suggested removal through the upper blepharoplasty incision when indicated. May et al. 50 reported their experience with 63 cases. All patients had transient lateral brow numbness but no paralysis of the orbicularis oculi. The superior orbital nerve courses near the medial border of the fat and must be protected. To obtain a natural, sculpted eyelid, the fibrofatty layer must be carefully resected with meticulous hemostasis and painstaking feathering of the edges. 50 Gulyás 133 reported a technique using imbrication of the orbicularis oculi and grafting of 1 ml of fat in the crease to accent fullness and thus add to the convex appearance for a more youthful appearance. LOWER BLEPHAROPLASTY Skin Flaps In 1951, Castañares 17 reported that the skin flap method was most popular among American surgeons. The intraorbital space is approached through a subciliary incision, and the skin is elevated off the orbicularis oculi to the level of the infraorbital rim. Hinderer 71 trimmed hypertrophic orbicularis oculi fibers and removed fat after separating the orbicularis oculi fibers and opening the septum. Casson and Siebert 134 described their technique for skin-flap blepharoplasty with muscle split for easier identification of the fat pads. In patients with malar mounds or cheek pads, a subcutaneous dissection can be continued onto the cheek. Doing so, however, severs the attachments of the cheek skin to the orbital rim, with the subsequent possibility of the heavier cheek skin placing traction on the eyelid skin, risking ectropion. Furnas 135 addressed this concern by limiting the subcutaneous flap to the lateral aspect to the dissection and suspending the orbicularis oculi and dermis. The skin-flap-only approach is recommended for the removal of wrinkling and redundant skin when good orbicularis oculi tone is present. Drawbacks of the approach are the potential for devascularization of the flap and possible 11

15 impairment of the lymphatic drainage. Skin-Muscle Flaps The skin-muscle flap technique of lower blepharoplasty was reported by Beare 136 in 1967 as the McIndoe-Beare technique. In its technical details, the procedure is similar to other blepharoplasties described by contemporary authors. A 2-mm incision is made below the ciliary margin, and the dissection proceeds through the orbicularis oculi, exposing the orbital septum down to the level of the orbital rim. The periorbital fat is removed through perforating incisions in the orbital septum. After the skin-muscle resection is redraped, a 2-mm-wide strip of orbicularis oculi along the free upper edge of the skin flap usually is resected so that the muscle will not overlap in the pretarsal area). Aston 137 recommended a submuscular dissection from lateral to medial because it is quicker and easier to accomplish than is the classic dissection. The skin-muscle flap is considered to be less effective in patients with marked skin redundancy. Rees and Tabbal, 138 however, stated that the skinmuscle flap approach is indicated in more than 90% of patients, even young adults with baggy eyelids. Spira 139 compared patients who had skin flap only on one side and skin-muscle flap on the other and found little if any difference in postoperative appearance between the two groups. Putterman 140 reported that the cause of baggy eyes is the separation of the capsulopalpebral fascia from the orbital septum that allows fat to bulge into the lower eyelid. See also the discussion of Putterman s article by Codner. 141 Goldberg et al. 142 presented a study of 114 patients who were interested in lower blepharoplasty for fat pads. The histories and photographs were evaluated for the cause of the condition. The authors found that cheek descent and hollow tear trough were the most prevalent anatomic bases for lower eyelid bags. Other anatomic bases were prolapse of the orbital fat, skin laxity, eyelid fluid, orbicularis oculi prominence, and triangular malar mound. The authors concluded that surgery is designed according to skin elasticity, extent of prolapse, and midface descent, but no single anatomic basis was identified. The discussion presented by Codner 141 raised two points of clarification: first, the tear trough is a specific anatomic structure that manifests as a concavity overlying the narrow triangle formed by the origins of the orbicularis oculi, levator labii superioris, and levator labii alaeque nasi muscles. Second, the malar bag is made up of fat and fluid that accumulates between the orbitomalar and zygomatic cutaneous ligaments at the inferior border of the orbicularis oculi. The skin-muscle flap approach maintains the normal skin vascularity and skin-orbicularis oculi interface. It successfully corrects sagging from either cutaneous or muscular causes. Because the dissection proceeds along a relatively avascular plane, it results in less postoperative ecchymosis, subcutaneous scarring, and irregularity of the skin surface. 143 Associated complications include the possibility of denervation of the orbicularis oculi and paralytic ectropion. DiFrancesco et al. 144 presented a report of 18 eyes in nine patients. Electromyography and video of blink and squint were evaluated before, 4 weeks after, and 12 weeks after subciliary blepharoplasty. The results of that study showed that lower eyelid malposition or disfunction of the lower eyelid orbicularis oculi after blepharoplasty could not be explained by denervation of the zygomatic branch of the facial nerve. The most critical recommendation for this surgery presented by the authors is to properly perform a lower eyelid canthal anchoring maneuver. Despite the findings, some controversy exists. Lowe et al. 145 reported their findings on dissection of 16 cadaver heads. The authors located multiple motor nerves to the lower eyelid without a single dominant branch identified. Byrd 146 suggested that the terminal branches of the lateral innervation of the orbicularis oculi are probably divided with a subciliary transmuscular incision, which contributes to a loss of tone in the pretarsal strip and thus scleral show, necessitating canthoplasty. McCord et al. 147 stated that the inner canthal muscle is innervated by the buccal branch of the facial nerve and that the extra-canthal orbicularis oculi is innervated by the zygomatic branch of the facial nerve. The statement suggested that a subciliary 12

16 incision is not the cause of clinical lower eyelid denervation. The authors noted a parasitization of sensory nerves, both infratrochlear and infraorbital, by the buccal branch to augment its innervation and field of effect. Codner et al. 148 reported a 10-year experience with use of a transcutaneous incision and routine canthal support anchor in 264 patients. The authors achieved a very acceptable complication rate requiring reoperation for eyelid position in 3.5%, hematoma in 0.4%, blepharitis in 3.8%, and minor surgical revisions in 11.7%. Separate Skin and Muscle Flaps Klatsky and Manson, 149 Massiha, 150 and Hinderer 71 advocated separate skin and muscle flaps for lower blepharoplasty. After the skin flap is elevated off the orbicularis oculi, the pretarsal orbicularis oculi is left intact. Massiha 150 noted that the advantages of this protocol are that it leaves the orbicularis oculi-tarsus relationship intact and the pretarsal orbicularis oculi innervated. Skin and muscle can also be removed independently. Transconjunctival In 1928, Bourguet 15 described the transconjunctival approach to lower blepharoplasty. Almost 50 years later, Tomlinson and Hovey 151 reviewed the procedure and Schwartz and Randall 152 compared the preseptal and retroseptal approaches. Schwartz and Randall 152 stated that the preseptal approach affords better identification and control of the separated fat loculation. Baylis et al. 153 and Zarem and Resnick, 20,154 on the other hand, supported a retroseptal approach. The retroseptal approach has the theoretic advantage of leaving the septum intact, which could decrease the incidence of eyelid retraction. Although the transconjunctival blepharoplasty is limited in its ability to resect skin in the pure sense, Zarem and Resnick 154 proposed that the skin excess is often more apparent than real and that the skin is necessary to recontour the lower eyelid after the fat is excised. In approximately 50% of patients, the authors used additional subciliary incision and skin flap with skin resection in conjunction with a transconjunctival lower blepharoplasty. 155 Zarem and Resnick 155 presented an update of his experience and concluded that transconjunctival lower blepharoplasty is superior to other techniques in that it is possible to completely resect the fat, avoid retracted lower eyelids and dry eye postoperatively, and achieve long-lasting correction. Jelks 156 combined a transconjunctival blepharoplasty with a trichloroacetic acid peel for further skin tightening. The author introduced the concept of no-tack in lower blepharoplasty, which consists of transconjunctival fat removal, conservative pinch skin excision, and lateral canthopexy. The orbicularis oculi (or middle lamella) remains undisturbed. Good results have been achieved with the technique, as reviewed by Rohrich et al. 157 Stark et al. 158 reported realigning the intraorbital fat via a buccal mucosa incision in addition to an endoscopic midface-lift. McKinney et al. 159 combined transconjunctival resection of fat with full-strength Baker phenol chemical peeling to tighten the skin. Dinner et al. 160 removed skin after a transconjunctival blepharoplasty while leaving the middle lamellar structures intact. The CO 2 laser has also been used to tighten the skin in conjunction with transconjunctival blepharoplasty. 161 The main disadvantages of transconjunctival blepharoplasty are limited exposure and potentially inadequate fat removal, particularly from the lateral compartment. 154 Baker et al. 32 reported removing slightly more fat during a transconjunctival blepharoplasty than they would during transcutaneous blepharoplasty to obtain the same result in fat contouring. Possible complications with that approach include damage to the inferior oblique muscle and persistent chemosis. A review from the Manhattan Eye, Ear, and Throat Hospital 162 documented six patients who were referred with diplopia status posttransconjunctival lower blepharoplasty. The cause of diplopia was injury to the inferior rectus, inferior oblique, or lateral rectus muscle from intramuscular hemorrhage and edema, cicatricial changes within the muscle, or accidental incorporation of the extraocular muscle in the closure of the orbital septum. Two patients required muscle surgery for correction, and the other four 13

17 improved spontaneously after 6 to 8 months of observation. The authors recommended making the transconjunctival incision on the palpebral conjunctival surface, not deep in the interior fornix or on the bulbar conjunctiva. An article by Sadove 163 on transconjunctival septal suture repair for lower blepharoplasty argued in favor of muscle-preserving procedures. Comments indicated that tightening of the septum alone is not a panacea for rejuvenation of the lower eyelid; more is required for a comprehensive youthful result. Orbicularis Oculi Hypertrophy Sheen 164 suggested that pretarsal orbicularis oculi hypertrophy is characteristic of a youthful eyelid, and suspended the upper 8 mm of the skin-muscle flap to the tarsal plate to produce a lower eyelid fold. Rees and Tabbal, 138 however, warned of the dangers of extrusion of permanent sutures and ectropion with that type of technique. Fodor 165 recreated the youthful bulge by leaving the pretarsal orbicularis oculi intact and overlapping the cut edge of the skin on the skin-muscle flap. Castañares, 166 Loeb, 167 and Bernardi et al. 168 advocated resection of variable portions of the hypertrophied orbicularis oculi to reduce muscle bulge, which they considered unsightly. Connell and Marten 169 split the muscle vertically at the lateral canthus to lessen postoperative crow s feet from a hyperactive orbicularis oculi. Care must be taken during the dissection to avoid injury to the frontotemporal branch of the facial nerve. de Assis Montenegro Cido Carvalho et al. 170 described their technique of resection of the lateral third of the orbicularis oculi in 105 patients during face-lift dissection. A superficial musculoaponeurotic system graft was placed to avoid depression. The authors reported achieving excellent results without increasing complications. Orbicularis Oculi Suspension Furnas 171 offered an excellent review of the anatomy, physiology, and surgical alteration of the orbicularis oculi. Pretarsal hypertrophy, muscle laxity, festoons, and crow s feet are problems related to the orbicularis oculi and dictate modification of the blepharoplasty technique. Festoons of hypotonic muscle are diagnosed by the squinch test, in which the patient tightly contracts the orbicularis oculi and the fold disappears. Muscle suspension is indicated for correction in such cases. To improve the appearance of the lateral canthal area and reduce crow s feet, Aston 172 splayed the muscle and sutured it to the temporal fascia under tension. In cases of large skin folds and a thick muscle and in cases with perceived hyperactivity of the orbicularis oculi, the muscle ring can be divided and the ends suspended separately. Complementing these techniques, as an alternative to laser resurfacing, Gruber et al. 173 reported their dermabrasion technique as an effective, economic alternative for periocular rhytides confined to the lateral canthal region in 25 patients with no pigmentary changes. Mladick 174 preferred routine lateral suspension of the orbicularis oculi to the orbital periosteum. He suggested that the method reduces the risk of scleral show and rounding of the eyelid and produces better contact of the eyelid with the globe. Surgeons often suspend the orbicularis oculi after dissection in the suborbicularis plane or in the periosteal plane in an attempt to lift the malar fat pad, decrease the periorbital aperture, or both. Hamra, 41 Hester et al., 175 and Moelleken 176 described their respective techniques for suspension of the orbicularis oculi to the lateral orbit or temporal area. Orbital Septum The orbital septum is the fascial barrier that keeps the intraorbital fat from protruding anteriorly. Castañares 17 and Beare 136 concluded that it is not necessary to suture and reconstruct the septum during blepharoplasty to prevent subsequent reherniation of fat. Tipton 177 empirically confirmed that philosophy in a series of 33 consecutive blepharoplasties. The author sutured the septum on one side but not the other. At a follow-up visit 2½ years later, it was impossible to detect any significant differences between the two sides. 14

18 To lessen the risk of reherniation of the lower eyelid fat, Huang 178 and Sensöz et al. 179 plicated the orbital septum whereas de la Plaza and Arroyo, 180 Mendelson, 181 and Camirand 182 sutured the capsulopalpebral fascia to the periosteum of the lower eyelid. Stark et al. 183 suggested a pullout suture technique to facilitate fixation. A comparative study of 26 patients who had undergone capsulopalpebral fascia hernia repair in one lower eyelid and standard blepharoplasty in the other showed no discernible differences in aesthetic outcomes at 6 weeks and 6 months postoperatively. However, the capsulopalpebral fascia technique is associated with less discomfort and pain during the operation, less postoperative bleeding and hematoma, and a reduced incidence of hollowing and sunken eye appearance. 184 At 11.3 years of follow-up, the fat-preserving capsulopalpebral fascia repair presented by de la Plaza and Arroyo 180 for palpebral bags was associated with a lower recurrence rate than was blepharoplasty by lipectomy in the same 26-patient cohort. The average time for recurrence was 6.5 years in the second group. 185 van der Lei et al. 186 reported 296 bipolar coagulation assisted-orbital septoblepharoplasties of the upper eyelid. The authors considered the procedure to be an effective method to coagulate the septum for shrinkage to reposition the prolapsed fat pads. They reported no short-term (9 weeks 2 years) fat necrosis and no complications occurring in association with their controlled burn of the septum. A similar study 187 compared the use of CO 2 laser and Colorado needle tip cautery of the septum for non-resective shrinkage; no difference between the two was identified. Persing et al. 188 presented a report of the shade procedure. It is a variant of previously described fascial barriers to fat herniation with which augmentation of the infraorbital rim is achieved by septum and capsular palpebral fascia release from the lower eyelid, securing the fascia and released septum to an intramuscular pocket at the inferior orbital rim. With this procedure, canthopexy is necessary. The procedure is indicated for patients with lower eyelid fat herniation, particularly in cases in which the infraorbital rim is significantly depressed. McCord et al. 189 reported their use of Enduragen grafts for 129 eyelids. The complication rate associated with the material was very low. Reid et al. 190 reported a septal extension, confirming that the septum orbitale does continue onto the tarsal plate. Nasojugal Groove and Orbital Aperture Loeb 24 discussed the origin and management of palpebral depressions. He described using free fat grafts and sliding the fat from the retroseptal area over the arcus marginalis. Hamra 25 further championed the fat-sliding technique to soften the lower eyelid depressions and make the palpebral aperture smaller. He later modified his technique to include anterior reset of the septum. 41 Barton et al. 27 confirmed the benefits of anterior fat repositioning and septal reset and reported a low incidence of complications with appropriate patient selection. Goldberg and colleagues 191,192 attested to the usefulness of fat repositioning with lower blepharoplasty. Patipa 193 listed the following causes of lower eyelid retraction after blepharoplasty: 1. inadequate skin (anterior lamellar insufficiency) 2. middle lamellar inflammation and subsequent scarring between the orbital septum and capsulopalpebral fascia 3. lateral canthal tendon laxity or disinsertion 4. midfacial descent Fat pad manipulation or resection causes inflammation that can act as a scaffold for fibrosis between the overlying orbital septum and capsulopalpebral fascia, resulting in lower eyelid retraction. 193 As mentioned above, several authors use malar cheek lift and orbicularis oculi suspension to reduce the orbital aperture. 41,175,176,194 By elevating the malar fat pad and interrupting the arcus marginalis, the surgeon narrows the palpebral angle and creates a more youthful appearance. Malar cheek lifts performed through the lower eyelid have been associated with a higher risk of lower eyelid ectropion and malposition. 175,

19 Goldberg 197 wrote an editorial about three targeted periorbital hollow areas in which to inject filler and thus restore volume in lieu of any surgical options. He noted an alternative concept in aging (deflation) and concluded that gravitational changes might play less of a role in aging changes than traditionally thought. Hamra 101 disagreed and reminded the reader of the value of real plastic surgery for a long-lasting, comprehensive, harmonious rejuvenating result. Odunze et al. 198 reported that the lateral canthal complex descends relatively more quickly than in Caucasian women because of more dramatic attenuation. Laxity of the Lower Eyelid Preexisting laxity of the tarsal margin combined with slight over-resection of skin can lead to scleral show postoperatively and, if severe enough, to frank ectropion. Neuhaus 199 studied the anatomic etiology of horizontal lower eyelid laxity leading to senile (involutional) ectropion in 20 patients and noted significant attenuation of the lateral canthal tendon. That view was shared by several other authors. 83,200,201 Neuhaus 199 recommended surgery to correct the horizontally lax canthal tendon rather than full-thickness or tarsal resection of normal eyelid structures in the palpebral fissure. The following intraoperative measures help prevent post-blepharoplasty scleral show and ectropion: temporary external support of the eyelid margin wedge resection to shorten the eyelid suspension or tightening of the lower eyelid using skin or muscle components to create a suspensory sling 207,208 tarsal suspension to the periosteum or soft tissue of the lateral orbital rim lateral canthoplasty 215,216 Lisman et al. 217 reviewed the evolution of tarsal suspension techniques for lower blepharoplasty and described a modification that approximates the edge of the tarsal plate to the lateral orbital rim periosteum. Jordan and Anderson 218 reported their experience with a tarsal suspension operation during which the lateral border of the tarsus is sutured to the periosteum just superior to the insertion of the lateral canthal tendon inside the orbital rim. Techniques that rely on cantholysis and resuspension of the tarsus have been said to be appropriate for patients with horizontal eyelid lengthening, but Flowers 83 observed that many of the tarsal flap techniques and wedge resections shorten the aperture and give patients the appearance of having small, beady eyes. Weber et al. 219 illustrated several refinements of the tarsal strip operation. Fagien 220 noted that tarsal strip procedures have been misapplied to a number of eyelid types and conditions regardless of horizontal eyelid length, canthal position, orbital rim, and malar complex relationship, globe size, or degree of exophthalmos. McCord et al. 221 reviewed the principles involved in canthal support and illustrated the application of different techniques for canthal anchoring depending on the preoperative examination. Modifications are made based on presence of lower eyelid laxity and eye position (Figs. 5 9). According to Fagien, 220 many suture canthoplasty and retinacular suspension procedures have been described and have been very useful in patients for whom there is less need to actually shorten the eyelid, especially in aesthetic surgery. Fagien advocated lateral retinacular suspension according to the method presented by Jelks et al., 222 with which a double-armed suture is used to hitch the lateral canthal tendon to the periosteum of the upper lateral orbital rim (Fig. 10). 220 The trans-canthal canthopexy used by Hamra 41 is technically straightforward and only slightly more lateral than that used by Jelks et al. 222 Flowers 83 recommended routine suspension of the lateral canthal tendon at the time of lower blepharoplasty and opted for a drill-hole canthopexy to achieve lower eyelid support. The author reported his finding of the tarsal strap as a new anatomic finding. The strap anchors the tarsus to the periosteum of the inferolateral orbit. 59 Stampos 223 reported the use of Lockwood ligament to suspend the orbicularis oculi laterally. 16

20 Figure 5. Upper illustrations, standard canthal anchoring with lysis (canthoplasty) and without lysis (canthopexy) in a patient with standard eye position as measured by the Hertel exophthalmometer. The canthal anchoring is placed at the inferior edge of the pupil. Lower illustrations, drawing illustrates proper placement of the canthal anchoring suture through the lower and upper lateral canthal tendon. The canthal anchoring is placed at the inferior edge of the pupil. (Reprinted with permission from McCord et al. 221 ) Figure 6. Illustrations show upward clotheslining in patients with deep-set eyes (Hertel measurement, <15 mm). The position of fixation of canthal anchoring needs to move inferiorly to prevent upward clotheslining and narrowing of the lateral scleral triangle. It should also be placed internally, inside the lateral orbital rim, to maintain lid position against the globe. (Reprinted with permission from McCord et al. 221 ) COMPLICATIONS Chemosis Chemosis is the most common nonsurgical complication occurring in association with blepharoplasty. It is edema of the conjunctiva and very often occurs after eyelid or facial surgery. Clinically, it presents as visible swelling of the conjunctiva and has several levels of severity. Weinfeld et al. 224 reported an incidence of chemosis of 11.5% among 312 primary blepharoplasties. The authors presented a classification system: type 1, acute mild chemosis with complete eyelid Figure 7. Illustration shows downward clotheslining of the lower lid in patients with prominent eyes (Hertel measurement, >18 mm). In such cases, fixation for canthal anchoring needs to be supraplaced above the inferior pupillary edge to prevent downward clotheslining of the eyelid. (Reprinted with permission from McCord et al. 221 ) 17

21 Figure 10. Illustration shows lateral retinacular suspension canthoplasty. (Reprinted with permission from Fagien. 220 ) Figure 8. In patients with lax lower eyelids, the lid needs to be shortened by lysis canthoplasty before performing canthal fixation. This helps keep the eyelid tight against the glove, preventing ectropion. (Reprinted with permission from McCord et al. 221 ) Figure 9. Upper left, illustration shows position of drill hole on orbital rim. In many cases, the ideal position is higher or lower. The proper position of the drill hole can be determined by positioning the canthus against the lateral rim until the desired eye fissure shape is obtained. Upper right, passage of suture and fixation to deep temporal fascia. Lower illustration, axial view shows proper vector of inward slant of drill hole. (Reprinted with permission from McCord et al. 221 ) closure; type 2, chemosis-induced lagophthalmos; type 3, subchronic lasting longer than 3 weeks; and type 4, associated with eyelid malposition. They also presented a comprehensive review of pharmacological, mechanical, and surgical therapies for the management of chemosis. The authors emphasized the importance of prevention by minimizing triggering factors intraoperatively and immediately postoperatively. Hamawy et al. 225 reviewed the prevention and management of dry eyes after surgery by addressing risk factors before surgery (Fig. 11). 224 Cheng and Lu 226 reported an effective treatment procedure for chemosis using a 27-gauge needle for perilimbal manipulation of chemosis using local anesthesia. The authors observed improvement in all cases at 2 months. Visual Loss Approximately 78 cases of visual loss after blepharoplasty have been reported in the English language medical literature DeMere et al. 231 estimated the incidence of blindness after blepharoplasty to be 0.04%. The common event in most reported cases is intraorbital hemorrhage, although the source remains controversial. The widely accepted theory suggests that orbital bleeding increases intraorbital and intraocular pressure, compromising ocular circulation. 232 Ischemic optic neuropathy and 18

22 Figure 11. Chemosis classification system. Type 1, mild acute edema and inflammation with complete lid closure; Type 2, severe acute edema with inflammation that prohibits complete lid closure (chemosis-induced lagophthalmos); Type 3, subchronic edema and inflammation that persists longer than 3 weeks; and Type 4, chemosis associated with lower lid malposition. (Reprinted with permission from Weinfeld. 224 ) central retinal artery occlusion are thought to be the most common final events in most cases of blindness after blepharoplasty Suttcliff et al. 235 examined the sources of hemorrhage in an anatomic study. The transconjunctival CO 2 laser approach to lower blepharoplasty revealed left eye blindness in a case report from France. 236 Acute orbital hemorrhage is a medical and surgical emergency that demands prompt recognition and management. Severe, permanent visual impairment is likely to occur if the circulation to the globe is compromised for >90 minutes. 234 The clinical signs of retrobulbar hemorrhage include rapid onset of pain and proptosis, usually accompanied by eyelid ecchymosis. 233 Visual acuity usually is reduced but can range from normal to no light perception. An emergency ophthalmological consultation should be obtained, and treatment must not be delayed. Retrobulbar hemorrhage without visual impairment is managed by opening of the incisions with decompression and exploration to identify the source of bleeding. Usually, a source is not found. 237 Retrobulbar hemorrhage with visual impairment requires the following: surgical decompression of the orbit by opening the skin incisions and releasing the septum orbitale and the lateral canthus238 reduction of intraocular pressure with an intravenous osmotic agent such as 20% mannitol, 1 2 mg/kg body weight, 12.5 g administered during 3 minutes and the remainder during 30 minutes further control of intraocular pressure with 500 mg of acetazolamide (Diamox; Lederle Laboratories, Pearl River, NY) by intravenous injection and then 250 mg by mouth every 6 hours239 administration of 95% oxygen/5% CO2 mixture to dilate intraocular and intracerebral vessels Anterior chamber paracentesis remains controversial. 231,240 Bone decompression is recommended by several authors if the above 19

23 measures fail and has been successful in four cases reported by Sacks et al. 241 Hepler et al., 242 Castillo, 243 and Goldberg et al. 244 reviewed the management of acute intraorbital hemorrhage accompanied by visual loss. Corneal Injury Corneal injury can be prevented by careful attention to technique and the use of corneal shields. Hepler et al. 242 suggested that if corneal injury is suspected, fluorescein staining should be performed under high magnification to obtain a diagnosis. Large or deep corneal wounds should be referred to an ophthalmologist. Superficial injuries are managed with topical antibiotics and patching of the eye. Patients should be examined every 24 hours or whenever they complain of pain. Bleeding Meticulous hemostasis and avoidance of pharmacological impediments to clotting are imperative in preventing bleeding after blepharoplasty. Lisman et al. 245 outlined preventive measures. Likely causes of hemorrhage include traction on the posterior vessels during aggressive fat resection, poorly controlled fat pad vessels that retract into the orbit, and bleeding deep into the orbit from the cut edges of the orbicularis oculi. 233,235,245,246 Careful examination is required to differentiate a localized hematoma from a sightthreatening hemorrhage. Eyelid hematomas are anterior to the septum, without ocular symptoms. In the event of persistent bleeding or inability to rule out postseptal hemorrhage, the wound should be reexplored. Superficial hematomas might require observation only. Evacuation, if necessary, is performed in 7 to 9 days to allow time for liquefaction of the hematoma. 228,247 Diplopia Temporary diplopia has been attributed to wound reaction, edema, and hematoma. 248 Permanent strabismus results from structural damage to the extraocular muscles or nerves. Lowry and Bartley 227 stated that the inferior oblique muscle is most frequently injured and the superior oblique muscle the second most frequently injured. The mechanism of injury has been postulated to be excessive use of cautery or direct trauma during injection of the local anesthetic. 249,250 Secondary blepharoplasty seems to be a risk factor for the development of diplopia after surgery. Conservative management and close observation are recommended until no further improvement occurs. Refractory cases can be referred for appropriate strabismus surgery. 227 Ptosis The most frequent cause of perioperative upper eyelid ptosis is the failure to recognize the condition preoperatively. 251,252 Nevertheless, upper eyelid ptosis can result from direct injury to the levator aponeurosis during blepharoplasty. Baylis et al. 253 suggested that such injury occurs at the inferior one-half of the skin-muscle excision, where the levator merges with the septum. Any injury that is recognized intraoperatively or immediately postoperatively should be repaired immediately. Lagophthalmos Lagophthalmos often occurs to some degree during the first week after blepharoplasty. Lagophthalmos is well tolerated by patients who have normal tear production and resolves with conservative treatment such as lubrication, massage, eyelid taping, and patching. 227 Persistent lagophthalmos can occur secondary to excessive skin resection or incorporation of the orbital septum in the incisional scar. If conservative treatment fails to control ocular exposure, definitive surgical therapy is required, releasing the retraction by recreating the defect and applying a full-thickness skin graft. 254 Ectropion Malposition of the lower eyelids is the most common and possibly the most visible complication of blepharoplasty. Carraway and Mellow 70 stated that the ultimate position of the lower eyelid is determined by a balance of forces: the tarsus and canthal ligament pulling up against gravity; the pretarsal orbicularis oculi muscle fibers acting to support the eyelid; and cicatricial forces of skin, orbital septum, and capsulopalpebral fascia 20

24 pulling inferiorly. According to the authors, the possible causes of ectropion are as follows: excessive skin, fat, or muscle removal scar contracture paralysis of the orbicularis oculi adhesion of the orbital septum hematoma lax eyelid margin proptosis unilateral high myopia Techniques for the prevention of simple senile ectropion are described in the section, Lower Eyelid Laxity and Ectropion. McCord and Ellis 255,256 and Jelks and Jelks 257 proposed that mild cases of lower eyelid retraction after blepharoplasty are the result of previously unrecognized eyelid laxity and can be corrected with lateral canthoplasty. Progressive degrees of eyelid retraction must be addressed by additional means, including vertical skin recruitment and spacer grafts in the most severe deformities. 256,257 McCord et al. 258 described a special situation requiring cantholysis to perform a criss-cross anchoring technique of fixation of the upper and lower canthus separately. It is indicated in the case of primary blepharoplasty in which the patient has significantly prominent eyes and supra-placement of the lateral drill hole will not suffice, nor will release of the capsular palpebral fascia for sufficient superior displacement (>2 mm). Insertion of a posterior lamellar spacer might be required. Over-resection/Under-resection of Fat Excessive intraorbital fat resection can result in a hollowed out socket. 25 Inadequate fat resection most likely occurs in the upper and lower medial 259 and lower lateral 260 fat compartments. Maniglia et al. 261 reported a technique for surgical correction of a sunken upper eyelid. Asymmetry By far the most common complication associated with blepharoplasty is asymmetry of the results. 262 Fortunately, this is generally addressed satisfactorily with subsequent operations. REFERENCES 1. Dupuis C, Rees T. Historical notes on blepharoplasty. Plast Reconstr Surg 1971;47: Stephenson K. The history of blepharoplasty to correct blepharochalasis. Aesthetic Plast Surg 1977;1: Wolfort FG, Kanter WR. History of blepharoplasty. In, Wolfort FG, Kanter WR (ed): Aesthetic Blepharoplasty. Boston: Little, Brown; LeClerc L. The Surgery of Abulcasis [in French]. Paris: J.B. Baillière; Johnson T. The Works of That Famous Surgeon Ambroise Paré. London: Mary Clark; Beer GJ. Textbook of Diseases of the Eye [in German]. Vienna: CF Wappler; von Graefe CF. Rhinoplasty [In Dutch]. Berlin: Reime; Mackenzie W. A Practical Treatise on the Diseases of the Eye. London: Longman; Alibert JL. Skin Monograph: Precise Theory and Practice of Skin Diseases [in French]. Paris: Daynac; Graf D. Local hereditary conditions of eyelid skin [in German]. In, Romberg MH, Stosch AW, Thaer D, Casper JL (ed): Wochenschrift für die gesammte Heilkunde. Berlin: gedruckt und verlegt bei G. Reimer; 1836: Dupuytren G. Oral Lessons of the Surgery Clinic [in French]. 2nd ed, vol 3. Paris: Germer-Baillière; Sichel A. Aphorisms on various points of ophthalmology practices [in French]. Ann Ocul 1844;12: Fuchs E. About blepharochalasis [in German]. Wien Klin Wchnschr 1896;9: Miller CC. Cosmetic Surgery: The Correction of Featural Imperfections. Chicago: Oak Printing Co; Bourguet J. Our surgical treatment of pockets under the eyes without scar [in French]. Arch Fr Belg Chir 1928;31: Noel A. Aesthetic Surgery [in French]. Clermont de l Oise: Theron et Cie; Castañares S. Blepharoplasty for herniated intra-orbital fat: Anatomical basis for a new approach. Plast Reconstr Surg 1951;8: Fox SA. Ophthalmic Plastic Surgery. New York: Grune & Stratton; Rees TD, Dupuis C. Baggy eyelids in young adults. Plast Reconstr Surg 1969;43: Zarem HA, Resnick JI. Operative technique for transconjunctival lower blepharoplasty. Clin Plast Surg 1992;19:

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29 A novel approach to lower-lid blepharoplasty. Aesthetic Plast Surg 1991;15: Dinner MI, Glassman H, Artz JS. The no flap technique in lower lid blepharoplasty. Aesthetic Plast Surg 1992;16: Apfelberg DB. The ultrapulse carbon dioxide laser with computer pattern generated automatic scanner for facial cosmetic surgery and resurfacing. Ann Plast Surg 1996;36: Ghabrial R, Lisman RD, Kane MA, Milite J, Richards R. Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg 1998;102: Sadove RC. Transconjunctival septal suture repair for lower lid blepharoplasty. Plast Reconstr Surg 2007;120: Sheen JH. Tarsal fixation in lower blepharoplasty. Plast Reconstr Surg 1978;62: Fodor PB. Lower lid tarsal fixation blepharoplasty: A personal technique. Aesthetic Plast Surg 1989;13: Castañares S. Classification of baggy eyelids deformity. Plast Reconstr Surg 1977;59: Loeb R. Necessity of a partial resection of the orbicularis oculi in blepharoplasty in some young. Plast Reconstr Surg 1977;60: Bernardi C, Dura S, Amata PL. Treatment of orbicularis oculi muscle hypertrophy in lower lid blepharoplasty. Aesthetic Plast Surg 1998;22: Connell BF, Marten TJ. Surgical correction of the crow s feet deformity. Clin Plast Surg 1993;20: de Assis Montenegro Cido Carvalho F, Vieira da Silva V Jr, Moreira AA, Viana FO. Definitive treatment for crow s feet wrinkles by total myectomy of the lateral orbicularis oculi. Aesth Plast Surg 2008;32: Furnas DW. The orbicularis oculi muscle: Management in blepharoplasty. Clin Plast Surg 1981;8: Aston SJ. Orbicularis oculi muscle flaps: A follow-up of the technique to reduce crow s feet and lateral canthal skin folds. Clin Plast Surg 1981;8: Gruber R, Miranda E, Antony A. Dermabrasion for rhytids in the lateral canthal region. Aesthetic Plast Surg 2007;31: Mladick RA. Updated muscle suspension and lower blepharoplasty. Clin Plast Surg 1993;20: Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos A. 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: Moelleken B. The superficial subciliary cheek lift, a technique for rejuvenating the infraorbital region and nasojugal groove: A clinical series of 71 patients. Plast Reconstr Surg 1999;104: Tipton JB. Should incisions in the orbital septum be sutured in blepharoplasty? Plast Reconstr Surg 1972;49: Huang T. Reduction of lower palpebral bulge by plicating attenuated orbital septa: A technical modification in cosmetic blepharoplasty. Plast Reconstr Surg 2000;105: Sensöz O, Unlü RE, Perçin A, Baran CN, Celebioglu S, Ortak T. Septo-orbitoperiosteoplasty for the treatment of palpebral bags: A 10-year experience. Plast Reconstr Surg 1998;101: de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg 1988;81: Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clin Plast Surg 1993;20: Camirand A. Preserving the orbital fat in lower eyelidplasty [letter]. Plast Reconstr Surg 1999;103: Stark GB, Iblher N, Penna V. Arcus marginalis release in blepharoplasty I: Technical facilitation. Aesthetic Plast Surg 2008;32: Parsa FD, Miyashiro MJ, Elahi E, Mirzai TM. Lower eyelid hernia repair for palpebral bags: A comparative study. Plast Reconstr Surg 1998;102: Sensöz O, Yilmaz AD, Arpaci E. Lower blepharoplasty with capsulopalpebral fascia hernia repair for palpebral bags: A long-term prospective study [letter]. Plast Reconstr Surg 2008;122: van der Lei B, Timmerman IS, Cromheecke M, Hofer SO. Bipolar coagulation-assisted orbital (BICO) septoblepharoplasty: A retrospective analysis of a new fatsaving upper-eyelid blepharoplasty technique. Ann Plast Surg 2007;59: Prado A, Andrades P, Danilla S, Castillo P, Benitez S. Nonresective shrinkage of the septum and fat compartments of the upper and lower eyelids: A comparative study with carbon dioxide laser and Colorado needle. Plast Reconstr Surg 2006;117: Persing JA, Knoll B, Shin J. The shade procedure: For lower lid deformities. Plast Reconstr Surg 2008;121: McCord C, Nahai FR, Codner MA, Nahai F, Hester TR. 26

30 Use of porcine acellular dermal matrix (Enduragen) grafts in eyelids: A review of 69 patients and 129 eyelids. Plast Reconstr Surg 2008;122: Reid RR, Said HK, Yu M, Haines GK III, Few JW. Revisiting upper eyelid anatomy: Introduction of the septal extension. Plast Reconstr Surg 2006;117: Goldberg RA. Transconjunctival orbital fat repositioning: Transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 2000;105: Goldberg RA, Edelstein C, Balch K, Shorr N. Fat repositioning in lower eyelid blepharoplasty. Semin Ophthalmol 1998;13: Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg 2000;106: Hester TR, Codner MA, McCord CD. Subperiosteal malar cheek lift with lower lid blepharoplasty. In, McCord, CD, Codner MA, Hester, TR (ed): Eyelid Surgery: Principles and Techniques. New York: Lippincott-Raven; 1995: Hester TR Jr. Evolution of lower lid support following lower lid/midface rejuvenation: The pretarsal orbicularis lateral canthopexy. Clin Plast Surg 2001;28: Patipa M. Transblepharoplasty lower eyelid and midface rejuvenation: Part I. Avoiding complications by utilizing lessons learned from the treatment of complications. Plast Reconstr Surg 2004;113: Goldberg RA. The three periorbital hollows: A paradigm for periorbital rejuvenation. Plast Reconstr Surg 2005;116: Odunze M, Rosenberg DS, Few JW. Periorbital aging and ethnic considerations: A focus on the lateral canthal complex. Plast Reconstr Surg 2008;121: Neuhaus RW. Anatomical basis of senile ectropion. Ophthalmic Plast Reconstr Surg 19851: Hill JC. An analysis of senile changes in the palpebral fissure. Can J Ophthalmol 1975;10: Ousterhout DK, Weil RB. The role of the lateral canthal tendon in lower eyelid laxity. Plast Reconstr Surg 1982;69: Bick MW. Surgical management of orbital-tarsal disparity. Arch Ophthalmol 1966,75: McKinney P. Use of tarsal plate resection in blepharoplasty on atonic lower lids. Plast Reconstr Surg 1977;59: Rees TD. Prevention of ectropion by horizontal shortening of the lower lid during blepharoplasty. Ann Plast Surg 1983;11: Hurwitz JJ, Mishkin SK, Rodgers KJ. Modification of Bick s procedure for treatment of eyelid laxity. Can J Ophthalmol 1987;22: Callahan A. Reconstructive Surgery of the Eyelids and Ocular Adnexa. Birmingham: Aesculapius Publishing Co.; 1966: Edgerton MT, Wolfort FG. The dermal-flap canthal lift for lower eyelid support: A technique of value in the surgical treatment of facial palsy. Plast Reconstr Surg 1969;43: Edgerton MT. Follow-up clinic: The dermal-flap canthal lift for lower eyelid support. Plast Reconstr Surg 1976;58: Tenzel RR. Treatment of lagophthalmos of the lower lid. Arch Ophthalmol 1969;81: Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol 1979;97: Tenzel RR, Buffam FV, Miller GR. The use of the lateral canthal sling in ectropion repair. Can J Ophthalmol 1977;12: Custer PL, Tenzel RR. Lateral canthal sling update. Ophthalmic Plast Reconstr Surg 1985;1: Whitaker LA. Selective alteration of palpebral form by lateral canthopexy. Plast Reconstr Surg 1984;74: Ortiz-Monasterio F, Rodriguez A. Lateral canthoplasty to change the eye slant. Plast Reconstr Surg 1985;75: Hinderer UT. Blepharocanthoplasty with eyebrow lift. Plast Reconstr Surg 1975;56: Patipa M. Lateral canthal tendon resection with conjunctiva preservation for the treatment of lower eyelid laxity during lower eyelid blepharoplasty. Plast Reconstr Surg 1993;91: Lisman RD, Rees T, Baker D, Smith B. Experience with tarsal suspension as a factor in lower lid blepharoplasty. Plast Reconstr Surg 1987;79: Jordan DR, Anderson RL. The tarsal tuck procedure: Avoiding eyelid retraction after lower blepharoplasty. Plast Reconstr Surg 1990;85: Weber PJ, Popp JC, Wulc AE. Refinements of the tarsal strip procedure. Ophthalmic Surg 1991;22: Fagien S. Algorithm for canthoplasty: The lateral retinacular suspension: A simplified suture canthopexy. Plast Reconstr Surg 1999;103: McCord CD, Boswell CB, Hester RT. Lateral canthal anchoring. Plast Reconstr Surg 2003;112: Jelks GW, Glat PM, Jelks EB, Longaker MT. The inferior retinacular lateral canthoplasty: A new technique. Plast Reconstr Surg 1997;100:

31 223. Stampos M. Lower lid blepharoplasty: The use of Lockwood s ligament for orbicularis oculi suspension and orbital fat preservation: A new technique. Aesthetic Plast Surg 2007;31: Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg 2008;122: Hamawy AH, Farkas JP, Fagien S, Rohrich RJ. Preventing and managing dry eyes after periorbital surgery: A retrospective review. Plast Reconstr Surg 2009;123: Cheng JH, Lu DW. Perilimbal needle manipulation of conjunctival chemosis after cosmetic lower eyelid blepharoplasty. Opthal Plast Reconstr Surg 2007;23: Lowry JC, Bartley GB. Complications of blepharoplasty. Surv Ophthalmol 1994;38: Teng CC, Reddy S, Wong JJ, Lisman RD. Retrobulbar hemorrhage nine days after cosmetic blepharoplasty resulting in permanent visual loss. Ophthal Plast Reconstr Surg 2006;22: Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Ophthal Plast Reconstr Surg 2004;20: Wride NK, Sanders R. Blindness from acute angleclosure glaucoma after blepharoplasty. Ophthal Plast Reconstr Surg 2004;20: DeMere M, Wood T, Austin W. Eye complications with blepharoplasty or other eyelid surgery: A national survey. Plast Reconstr Surg 1974;53: Mahaffey PJ, Wallace AF. Blindness following cosmetic blepharoplasty: A review. Br J Plast Surg 1986;39: Callahan MA. Prevention of blindness after blepharoplasty. Ophthalmology 1983;90: Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology 1980;87: Sutcliffe T, Baylis HI, Fett D. Bleeding in cosmetic blepharoplasty: An anatomical approach. Ophthal Plast Reconstr Surg 1985;1: Yachouh J, Arnaud D, Psomas C, Arnaud S, Goudot P. Amaurosis after lower eyelid laser blepharoplasty. Ophthal Plast Reconstr Surg 2006;22: Jelks GW, Jelks EB. Blepharoplasty. In, Peck GC (ed): Complications and Problems in Aesthetic Plastic Surgery. New York: Gower Medical Pub; 1992: Tenzel RR. Complications of blepharoplasty: Orbital hematoma, ectropion, and scleral show. Clin Plast Surg 1981;8: Hueston JT, Heinze JB. Successful early relief of blindness occurring after blepharoplasty: Case report. Plast Reconstr Surg 1974;53: Hartley JH Jr, Lester JC, Schatten WE. Acute retrobulbar hemorrhage during elective blepharoplasty: Its pathophysiology and management. Plast Reconstr Surg 1973;52: Sacks SH, Lawson W, Edelstein D, Green RP. Surgical treatment of blindness secondary to intraorbital hemorrhage. Arch Otolaryngol Head Neck Surg 1988;114: Hepler RS, Sugimura GI, Straatsma BR. On the occurrence of blindness in association with blepharoplasty. Plast Reconstr Surg 1976;57: Castillo GD. Management of blindness in the practice of cosmetic surgery. Otolaryngol Head Neck Surg 1989;100: Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Blindness following blepharoplasty: Two case reports, and a discussion of management. Ophthalmic Surg 1990;21: Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 1988;15: Koornneef L. The architecture of the musculo-fibrous apparatus in the human orbit. Acta Morphol Neerl Scand 1977;15: Adams BJ, Feurstein SS. Complications of blepharoplasty. Ear Nose Throat J 1986;65: Smith B, Lisman RD, Simonton J, Della Rocca R. Volkmann s contracture of the extraocular muscles following blowout fracture. Plast Reconstr Surg 1984;74: Harley RD, Nelson LB, Flanagan JC, Calhoun JH. Ocular motility disturbances following cosmetic blepharoplasty. Arch Ophthalmol 1986;104: Neely KA, Ernest JT, Mottier M. Combined superior oblique paresis and Brown s syndrome after blepharoplasty. Am J Ophthalmol 1990;109: McLeish WM, Anderson RL. Cosmetic eyelid surgery and the problem eyelid. Clin Plast Surg 1992;19: Patipa M, Wilkins RB. Acquired ptosis in patients undergoing upper eyelid blepharoplasty. Ann Ophthalmol 1984;16:266, Baylis HI, Sutcliffe T, Fett DR. Levator injury during blepharoplasty. Arch Ophthalmol 1984;102: Baylis HI, Cies WA, Kamin DF. Correction of upper eyelid retraction. Am J Ophthalmol 1976;82: McCord CD Jr, Ellis DS. The correction of lower lid malposition following lower lid blepharoplasty. Plast Reconstr Surg 1993;92:

32 256. McCord CD Jr. The correction of lower lid malposition following lower lid blepharoplasty. Plast Reconstr Surg 1999;103: Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 1993;20: McCord CD, Ford DT, Hanna K, Hester TR, Codner MA, Nahai F. Lateral canthal anchoring: Special situations. Plast Reconstr Surg 2005;116: Seiff SR. Complications of upper and lower blepharoplasty. Int Ophthalmol Clin 1992;32: Putterman AM. The mysterious temporal fat pad. Ophthalmic Plast Reconstr Surg 1985;1: Maniglia JJ, Maniglia RF, Jorge dos Santos MC, Robert F, Maniglia FF, Maniglia SF. Surgical treatment of the sunken eyelid. Arch Facial Plast Surg 2006;8: Weng CJ, Noordhoff MS. Complications of Oriental blepharoplasty. Plast Reconstr Surg 1989;83:

33 RECOMMENDED READING Codner MA. Discussion of What causes eyelid bags?: Analysis of 114 consecutive patients. Plast Reconstr Surg 2005;115: Connell BF, Marten TJ. Surgical correction of the crow s feet deformity. Clin Plast Surg 1993;20: DiFrancesco LM, Anjema CM, Codner MA, McCord CD, English J. Evaluation of conventional subciliary incision used in blepharoplasty: Preoperative and postoperative videography and electromyography findings. Plast Reconst Surg 2005;116: Fagien S. Algorithm for canthoplasty: The lateral retinacular suspension: A simplified suture canthopexy. Plast Reconstr Surg 1999;103: Flowers RS. The art of eyelid and orbital aesthetics: Multiracial surgical considerations. Clin Plast Surg 1987;14: Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995;96: Hamra ST. The zygorbicular dissection in composite rhytidectomy: An ideal midface plane. Plast Reconstr Surg 1998;102: Hamra ST. $25,000 and still counting [letter]. Plast Reconstr Surg 2006;118: Hester TR Jr, Codner MA, McCord CD, Nahai F, Giannopoulos A. 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: Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: Bypassing the pitfalls. Clin Plast Surg 1993;20: Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 1996;12: Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 1981;8: McCord CD, Boswell CB, Hester RT. Lateral canthal anchoring. Plast Reconstr Surg 2003;112: McCord CD, Codner MA, Hester TR. Eyelid Surgery: Principles and Techniques. Philadelphia: Lippincott-Raven; McCord S, Codner M, Nahai F, Hester R. Analysis of the nerve branches to the orbicularis oculi muscle of the lower eyelid in fresh cadavers [letter]. Plast Reconstr Surg 2006;118: Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clin Plast Surg 1993;20: Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002;110: Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg 2008;122: Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven Press;

34 We thank the Aesthetic Surgery Journal and Plastic and Reconstructive Surgery for their support. Aesthetic Surgery Journal Official Journal of the American Society for Aesthetic Plastic Surgery Two Easy Ways to Order: Phone: (US & Canada) (Other Countries) Web: Aesthetic Surgery Journal is a peer-reviewed international journal focusing on scientific developments and clinical techniques in aesthetic surgery that recently became indexed in Medline/Pubmed. An official publication of the member American Society for Aesthetic Plastic Surgery (ASAPS), ASJ is also the official English-language journal of eleven major international societies of plastic, aesthetic and reconstructive surgery representing South America, Central America, Europe, Asia, and the Middle East, as well as the official journal of The Rhinoplasty Society. Visit for more information or to submit a manuscript.

35 This is your life. Whether you re performing a routine cosmetic procedure or a difficult burn repair, having the right tool for unexpected complications is critical. This is your website. The new Plastic and Reconstructive Surgery Online The intuitive, all-new, next-generation electronic journals platform from Lippincott Williams & Wilkins comes loaded with personalized options for its journal subscribers, including customizable state-of-the-art capabilities, self-service options tailored to your information preferences, rich media content, improved search options, better article readability in HTML and better tools to help you manage content that s vital to your practice and patient care. Register online at prsjournal.com Not a subscriber? Visit prsjournal.com to subscribe and find out more