Experience with tarsal suspension as a factor in lower lid blepharoplasty

The bowed lower eyelid, with scleral show, is a common but untoward result following blepharoplasty with even minimal skin excision. A number of conditions, unrecognized preoperatively, can predispose a patient to scleral show. These include eyelid laxity with or without atrophic orbicularis muscle tone, lax canthal tendons, hypoplastic malar eminences, unrecognized Graves' ophthalmopathy, unilateral high myopia, or the secondary blepharoplasty. Suspension of the tarsus of the lower eyelid, concomitant with or following blepharoplasty, can straighten bowed lids and provide 2 to 3 mm of elevation, if desired. A classification of patients likely to develop scleral show is presented along with a revised technique of tarsal suspension.     

The evaluation and management of lower eyelid retraction following cosmetic surgery

Lower eyelid retraction is a common complication after cosmetic surgery of the lower eyelids, midface, and the adjacent face. Lower eyelid retraction is defined as the inferior malposition of the lower eyelid margin without eyelid eversion. Lower eyelid retraction presents clinically with scleral show; round, sad-looking eyes; lateral canthal tendon laxity; and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. These patients frequently require ocular lubricants, including artificial tears and ointments, which often provide only minimal alleviation of their symptoms. The author has observed that lower eyelid retraction is usually accompanied by midface descent. On the basis of surgical observations, the causes of lower eyelid retraction seem to be multifactorial and include scarring between the orbital septum and capsulopalpebral fascia (or lower eyelid retractors), lateral canthal tendon laxity, and midface descent. After describing the causes of lower eyelid retraction, the author presents a system for evaluating patients that can assist the surgeon in choosing the surgical procedure(s) required to correct the lower eyelid malposition. The surgeon must know how to tighten a lax lateral canthal tendon, be familiar with the anatomy of the lower eyelid from conjunctiva to skin side, and know how to surgically elevate the midface. The techniques for correcting lower eyelid retraction are also presented. Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malpositions with minimal complications.     

Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: a safe and advantageous technique

Carbon dioxide (CO2) laser blepharoplasty with orbicularis oculi muscle tightening and periorbital skin resurfacing is a safe procedure that produces excellent aesthetic results and diminishes the occurrence of complications associated with skin and muscle resection in the lower lid, particularly permanent scleral show and ectropion. The authors present a review of 196 cases of carbon dioxide laser blepharoplasty and periocular laser skin resurfacing performed at their center from April of 1994 to September of 1998. Of these cases, 113 patients underwent four-lid blepharoplasty, 59 underwent upper lid blepharoplasty only, and 24 underwent lower lid blepharoplasty only. Prophylactic lateral canthopexy was performed in 24 patients. Concomitant procedures (brow lift/rhytidectomy/rhinoplasty) were performed in 92 patients. The carbon dioxide laser blepharoplasty procedure resulted in no injuries to the globe, cornea, or eyelashes. Combined with laser tightening of the orbicularis oculi muscle and septum and periocular skin resurfacing, the transconjunctival approach to lower blepharoplasty preserves lower lid skin and muscle. Elimination of the traditional scalpel skin/muscle flap procedure results in a dramatically lower complication rate, particularly with regard to permanent ectropion and scleral show. Laser shrinkage of the orbicularis muscle and septum through the transconjunctival incision enables the correction of muscle aging changes such as orbicularis hypertrophy and malar festoons. The addition of periocular resurfacing enables the correction of skin aging changes of the eyelid that are not addressed by traditional scalpel blepharoplasty. In addition, lateral canthopexy constitutes an important adjunct to the laser blepharoplasty procedure for the correction of lower lid canthal laxity.     

The superficial lateral canthal tendon: anatomic study and clinical application to lateral canthopexy

Most patients who undergo facial cosmetic surgery procedures that could cause lower eyelid retraction or ectropion should have an additional surgical procedure to support the lower eyelid and lateral canthus. The lower eyelid should be supported when performing laser planing of the eyelid; midface elevation through a lower eyelid incision approach; or conventional blepharoplasty, in patients with lower eyelid laxity. Suspending the lateral canthus by surgically altering the lateral canthal tendon is a proven technique that can provide support for the lower eyelid. However, a technique of this complexity may be unnecessary for most cosmetic surgery patients. To increase understanding of the fascial support system of the lateral canthus, four fresh cadaver dissections were performed to investigate the attachments of the lateral canthus to the lateral orbital rim. The most commonly appreciated attachment between the eyelids and the lateral orbital rim is the lateral canthal tendon (the lateral canthal raphe). However, the lateral canthus also is attached to the orbital rim at a more superficial level through the septum orbitale. This superficial fascial plane may be modified and used as a structure to stabilize or suspend the lateral canthus. This structure is defined in this article as the "superficial lateral canthal tendon."     

Lateral canthal anchoring

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the principles involved in canthal support for patients undergoing cosmetic and reconstructive surgery. 2. Understand the variations in surgical techniques required to perform canthal anchoring in differing patients. 3. Describe the significance and techniques of canthal anchoring (canthoplasty and canthopexy) as they relate to cosmetic and reconstructive lower lid surgery. 4. Describe the effect of canthal anchoring on the function of the upper and lower lids and eyelid fissure shape. Any surgeon performing cosmetic or reconstructive surgery procedures on the lower lid or midface through the lower lid should be comfortable with canthal anchoring procedures. Appropriate canthal anchoring is effective in preventing postoperative lower-lid malposition, in ensuring eyelid closure, and in improving or maintaining proper eye shape. In many patients, a canthopexy (nonlysis canthal anchoring) is effective. However, in patients with significant horizontal laxity, cantholysis with appropriate lid shortening is required. It should be remembered that canthal anchoring, no matter how well performed, will not prevent severe lower-lid complications in cases of over-resection of lower-lid skin and of poorly performed midface procedures that do not support the lower lid and cheek.     

Achieving aesthetic balance in the brow,eyelids, and midface

An approach to the brow, eyelids, and midface emphasizing release and advancement of the orbicularis oculi muscle, conservative removal of orbital fat, preservation of the nerve supply to the orbicularis oculi muscle, and avoidance of canthal division was evaluated in 100 consecutive patients. The technique describes the selected release of three key retaining ligaments to the forehead, brow, and upper eyelid; mobilization of the lateral retinaculum and division of the lower lid retaining ligament; and division of the midface malar retaining ligament (zygomatic-cutaneous ligament). Preservation of motor branches to the lower lid orbicularis is stressed. Of significance to this series of patients is the inclusion of 50 patients with morphologically prone lower eyelids defined as atonic lower lids, exorbitism, and/or negative vector orbits. Three sites had failure of brow fixation, two patients had midface asymmetry requiring revision, and three patients failed to have complete correction of their preoperative lower lid retraction. There was zero incidence of scleral show or lower lid retraction that was not present preoperatively. No patients required division of the lateral commissure with canthoplasty, taping or suture suspension, massage, or steroid injections. Only two patients required division of the deep head of the lateral canthus, and these patients were noted to have had lateral canthal malposition preoperatively.     

Embryonic quail eye development in microgravity.

The US-Russian joint quail embryo project was designed to study the effects of microgravity on development of Japanese quail embryos incubated aboard Mir. For this part of the project, eyes from embryonic days 14 and 16 (E14 and E16) flight embryos were compared with eyes from several groups of ground-based control embryos. Measurements were recorded for eye weights; eye, corneal, and scleral ring diameters; and numbers of bones in scleral ossicle rings. Transparency of E16 corneas was documented, and immunohistochemical staining was performed to observe corneal innervation. In addition, corneal ultrastructure was observed at the electron microscopic level. Except for corneal diameter of E16 flight embryos, compared with that of one of the sets of controls, results reported here indicate that eye development occurred normally in microgravity. Fixation by cracking the shell and placing the egg in paraformaldehyde solution did not adequately preserve corneal nerves or cellular ultrastructure.     

Experimental surface strain mapping of porcine peripapillary sclera due to elevations of intraocular pressure

To experimentally characterize 2D surface mapping of the deformation pattern of porcine peripapillary sclera following acute elevations of intraocular pressure (IOP) from 5 mm Hg to 45 mm Hg. Four porcine eyes were obtained within 48 h postmortem and dissected to the sclera. After the anterior chamber was removed, each posterior scleral shell was individually mounted at the equator on a custom-built pressurization device, which internally pressurized the scleral samples with isotonic saline at 22 degrees C. Black polystyrene microspheres (10 microm in diameter) were randomly scattered and attached to the scleral surface. IOP was incrementally increased from 5 mm Hg to 45 mm Hg (+/-0.15 mm Hg), and the surface deformation of the peripapillary sclera immediately adjacent to the dural insertion was optically tracked at a resolution of 2 micrompixel one quadrant at a time, for each of four quadrants (superior, nasal, inferior, and temporal). The 2D displacement data of the microsphere markers were extracted using the optical flow equation, smoothed by weighting function interpolation, and converted to the corresponding Lagrangian finite surface strain. In all four quadrants of each eye, the principal strain was highest and primarily circumferential immediately adjacent to the scleral canal. Average maximum Lagrangian strain across all quadrants for all eyes was 0.013+/-0.005 from 5 mm Hg to 10 mm Hg, 0.014+/-0.004 from 10 mm Hg to 30 mm Hg and 0.004+/-0.001 from 30 mm Hg to 45 mm Hg, demonstrating the nonlinearity in the IOP-strain relationship. For each scleral shell, the observed surface strain mapping implied that the scleral stiffness was relatively low between 5 mm Hg and 10 mm Hg, but dramatically increased for each IOP elevation increment beyond 10 mm Hg. Peripapillary deformation following an acute IOP elevation may be governed by the underlying scleral collagen microstructure and is likely in the high-stiffness region of the scleral stress-strain curve when IOP is above 10 mm Hg.     

Quantitative assessment of osseous, ocular, and periocular changes after hypertelorism surgery

The purpose of this study was to develop a methodology to quantify osseous, ocular, and periocular fat changes caused by correction of orbital hypertelorism to test the hypothesis that there is a quantitatively predictable relationship between the movement of the osseous orbit and that of the ocular globe. A retrospective review was performed of 10 patients who were status post unilateral or bilateral transcranial medial orbital translocation, for whom there were archival digital data for preoperative and postoperative (mean interval = 30 months) three-dimensional computed tomographic (CT) scans. In addition to standard demographic and surgical data, the clinical preoperative and postoperative interpupillary and intermedial canthal distances were recorded. By using a computer graphics workstation, the CT digital data were registered to four surgically unaltered anatomic fiducial points to allow longitudinal quantitative comparisons. The following three-dimensional measurements were made for each patient preoperatively and postoperatively: interdacryon and interocular centroid distances, and on a standard series of three horizontal and two vertical planes, the position of the medial and lateral orbital walls, and the thickness of the medial and lateral periorbital fat (20 orbits). CT digital distances were compared with similar clinical distances when possible. The age at operation ranged from 4.0 to 12.5 years (mean, 6.6 years). The reduction in interdacryon distance exceeded the reduction in intercentroid distance (mean interdacryon change = -5.3 mm versus mean intercentroid change = -2.7 mm). Although there was a strong correlation between the amount of reduction of the lateral orbital wall and intercentroid distances, there was only a moderate correlation between the reduction in the intercentroid distance and that of the medial orbital wall. Similarly, there was a moderate correlation between the decrease in thickness of the lateral periorbital fat and the reduction of intercentroid distance but not of the medial orbital fat. In conclusion, medial translocation of the orbit does not produce equivalent movement of the ocular globe; neither the intermedial canthal nor the interdacryon distance is a useful predictor of ocular centroid position; and if the goal of hypertelorism operation is reduction of interocular distance, then CT measurement of globe intercentroid distance is essential for outcome assessment.     

Selective alteration of palpebral fissure form by lateral canthopexy

A method is described for altering the shape and position of the palpebral fissure at the lateral canthus. Three steps are essential to alter shape and position. They are (1) identification of a lateral canthal soft-tissue mass consisting of periosteum, lateral canthal ligament, and orbicularis muscle, (2) extensive subperiosteal soft-tissue mobilization of the lateral canthal soft-tissue mass (LCSTM) from a point just superior to the zygomaticofrontal suture and inferiorly along the infraorbital rim to a point corresponding with a vertical line drawn from the pupil downward, and (3) cutting of all soft tissue, including orbicularis muscle from dermis to bone and from bone to conjunctiva, from the lateral canthal soft-tissue mass medially to a point equal to a vertical line drawn from the pupil downward. After tension-free shifting laterally and superiorly has been accomplished, the lateral canthal soft-tissue mass is fixed into bone with minimal overcorrection. If there is still soft-tissue skin resistance, then overcorrection is desirable. The most difficult judgments in the procedure are the amount of superior and lateral tension to be placed on the palpebral fissure. As an aid in these judgments, the lateral-most extent of the palpebral fissure should be approximately 3 mm above the medial canthus horizontally and 3 to 4 mm medial to the medial-most portion of the lateral orbital rim. If overcorrection occurs, it can be released relatively simply.     

Horizontal Eye Position in Thyroid Eye Disease: A Retrospective Comparison with Normal Individuals and Changes after Orbital Decompression Surgery

Objective

To compare horizontal eye positions between proptotic thyroid eye disease patients and normal individuals, and to examine positional changes after orbital decompression surgery in thyroid eye disease patients.

Methods

The present case-controlled and retrospective comparative study included 78 proptotic thyroid eye disease patients who underwent bilateral orbital decompression surgery [lateral orbital wall decompression (Group L), 47 patients; medial orbital wall decompression (Group M), 9 patients; and balanced orbital decompression (Group B), 22 patients] and 143 age-matched healthy volunteers as controls. The interpupillary distance was measured to determine horizontal eye positions before and 3 months after surgery in thyroid eye disease patients and was also examined in control eyes. Horizontal eye shifts were calculated by subtracting postoperative from preoperative interpupillary distances.

Results

Preoperative interpupillary distances in thyroid eye disease patients were significantly larger than in controls. The interpupillary distances were significantly decreased postoperatively in Groups M and B, but were significantly increased in Group L. The order of the magnitude of the horizontal shifts was Groups M>B>L.

Conclusions

Proptotic thyroid eye disease patients preoperatively showed laterally displaced eyes in comparison with controls. However, the eyes shifted medially after the medial orbital wall decompression and the balanced orbital decompression, although the former showed more shift. Medial orbital wall or balanced orbital decompression can be used to correct both lateral and anterior displacement of the eyes.     

Peripapillary Arterial Circle of Zinn-Haller: Location and Spatial Relationships with Myopia

Purpose

To measure histomorphometrically the location of the peripapillary arterial circle of Zinn-Haller (ZHAC) and assess its associations with axial length.

Methods

Using a light microscope, we measured the distance from the ZHAC to the peripapillary ring (optic disc border), the merging point of the dura mater with the posterior sclera (“dura-sclera point”), and the inner scleral surface. In the parapapillary region, we differentiated between beta zone (presence of Bruch''s membrane, absence of retinal pigment epithelium) and gamma zone (absence of Bruch''s membrane). The peripapillary scleral flange as roof of the orbital cerebrospinal fluid space was the connection between the end of the lamina cribrosa and the posterior full-thickness sclera starting at the dura-sclera point.

Results

The study included 101 human globes (101 patients) with a mean axial length of 26.7±3.7 mm (range: 20.0–39.0 mm). The distance between the ZHAC and the peripapillary ring increased significantly with longer axial length (P<0.001; correlation coefficient r = 0.49), longer parapapillary gamma zone (P<0.001;r = 0.85), longer (P<0.001;r = 0.73) and thinner (P<0.001;r = −0.45) peripapillary scleral flange, and thinner sclera posterior to the equator (P<0.001). ZHAC distance to the peripapillary ring was not significantly associated with length of parapapillary beta zone (P = 0.33). Including only non-highly myopic eyes (axial length <26.5 mm), the ZHAC distance to the disc border was not related with axial length (P = 0.84). In non-highly myopic eyes, the ZHAC was located close to the dura-sclera point. With increasing axial length and decreasing thickness of the peripapillary scleral flange, the ZHAC was located closer to the inner scleral surface.

Conclusions

The distance between the ZHAC and the optic disc border is markedly enlarged in highly myopic eyes. Since the ZHAC is the main arterial source for the lamina cribrosa blood supply, the finding may be of interest for the pathogenesis of the increased glaucoma susceptibility in highly myopic eyes.     

Retinoscleral control of scleral remodelling in refractive development: a role for endogenous FGF-2?

AIMS: Studies in avian models of myopia have shown that refractive error development can be influenced by exogenously delivered fibroblast growth factor (FGF)-2. The present study sought to determine whether endogenous FGF-2 was associated with retinoscleral signalling or scleral remodelling during changes in refractive error in a mammalian model of myopia. METHODS: Myopia was induced in tree shrews over a 5-day period. One group of animals was then allowed 3 days of recovery from the induced myopia. Endogenous levels of FGF-2 were measured in scleral and retinal homogenates using ELISA. Real-time PCR was used to investigate scleral FGF-2 and FGF receptor (FGFR)-1 mRNA expression. RESULTS: No difference in FGF-2 content was found in posterior scleral or retinal extracts of myopic eyes (scleral -4+/-9%, retinal +23+/-17%) or recovering eyes (scleral -10+/-18%, retinal +1+/-13%), when compared with contralateral control eyes. In addition, no significant changes were found in scleral FGF-2 mRNA expression in myopic or recovering eyes (+106+/-56% and +14+/-12% respectively, P=0.21). However, FGF-2 concentration was significantly higher in anterior, relative to posterior, scleral regions in all animals (1602+/-105 vs 1030+/-50pg/mg respectively P<0.001). Expression of scleral FGFR-1 mRNA was upregulated in myopic eyes (+186+/-32%, P=0.01) but returned to control eye levels during recovery (+63+/-20%). CONCLUSIONS: The findings indicate that alterations in endogenous retinal or scleral FGF-2 levels are not associated with changes in scleral remodelling in this mammalian model of myopia. However, the reversible changes found in FGFR-1 expression in the sclera of myopic eyes mean that an indirect role for FGF-2 in the control of scleral remodelling is implicated. The anteroposterior difference found in scleral FGF-2 concentration indicates a role for this cytokine in the control of normal scleral growth and development and, presumably, eye size.     

Transblepharoplasty lower eyelid and midface rejuvenation: part I. Avoiding complications by utilizing lessons learned from the treatment of complications

Transblepharoplasty midface elevation has become a common aesthetic procedure in recent years. As new techniques have been utilized, complications have arisen. Management of these referred complications has resulted in the development of a technique that elevates the midface and restores the normal position and shape to the lower eyelid with minimal postoperative problems. Four principles must be followed to achieve satisfactory results. The orbicularis oculi/orbital septum bond must not be altered in midface surgery. The lateral canthus must be reattached to its normal anatomic location at the lateral orbital rim if there is lateral canthal tendon laxity. The orbital fat should be addressed via a transconjunctival approach, when necessary, to prevent middle lamella inflammation and orbital septum retraction. A suture at the inferior lateral orbital rim simulating the orbitomalar ligament, as well as orbicularis oculi muscle sutures, elevates the midface. Utilizing these steps, the midface and lower eyelid can be satisfactorily repositioned with minimal complications. This surgical approach can be utilized in all appropriate candidates but is especially useful in reoperative cosmetic surgery patients and the older patient population.     

Medial epicanthoplasty combined with plication of the medial canthal tendon in Asian eyelids

The authors present a new technique for the correction of the medial epicanthal fold using the Y-W-plasty or inverted Y-V-plasty combined with plication of the medial canthal tendon. From January of 1996 to April of 2001, 10 patients with epicanthal folds received a medial epicanthoplasty combined with plication of the medial canthal tendon. The patients ranged in age from 20 to 49 years (average, 27.3 years). Eight patients with epicanthal folds received the Y-W-plasty with plication of the medial canthal tendon. Two patients were operated by inverted Y-V-plasty. The follow-up period ranged from 5 months to 2 years. Neither injury of the lacrimal apparatus nor asymmetry of the eyes was noted. Fibrosis and redness of the operated scar was noted in the first 2 to 3 months. However, the scar maturated by 3 months in all patients, and the hypertrophic scar was unnoticeable in all patients. Two key modifications of this technique are plication of the outer leaflet of the medial canthal ligament and lateral advancement of the central triangular flap. These modifications remarkably reduce the tension along the skin suture line. This method is very effective for the correction of the moderate-to-severe epicanthal fold. In addition, these modifications can be applied in most other medial epicanthoplasty techniques.     

The course of the inferior alveolar nerve in the normal human mandibular ramus and in patients presenting for cosmetic reduction of the mandibular angles

This study was undertaken to quantify the path of the inferior alveolar nerve in the normal human mandible and in the mandibles of patients presenting for cosmetic reduction of the mandibular angles. The goals were: (1) to provide normative information that would assist the surgeon in avoiding injury to the nerve during surgery; (2) to characterize gender differences in the normal population; and (3) to compare the course of the nerve in the normal population to its course in a group of patients who presented with a complaint of "square face." The study was based upon the computerized tomographic scans of 10 normal patients (six men, four women) and 8 patients (all women) complaining of "square face." Using AnalyzePC 2.5 imaging software, the mandibles were segmented and the position of the nerve was recorded within its osseous canal in the mandibular ramus on each axial slice in which it was identifiable. Distances were calculated between the nerve and the anterior, posterior, lateral, and medial cortices. The positions of the lateral ramus prominence and the lowest point on the sigmoid notch were also recorded. The position of the mental foramen was recorded in relation to the nearest tooth, and the three-dimensional surface distances from the foramen to the alveolar bone, the inferior border of the mandible, and the mandibular symphysis were determined. The distances from the entrance of the nerve into the mandible to the lateral ramus prominence and the lowest point on the sigmoid notch were calculated. Summary statistics were obtained, comparing differences in gender. The nerve was identifiable in each ramus over a mean distance of 12.7 mm. On average, the lateral ramus prominence was 0.3 mm higher on the caudad-cephalad axis than the point at which the nerve entered the bone, whereas the location of the lowest point on the sigmoid notch was 16.6 mm above the nerve. The average distances from the nerve to the anterior, posterior, medial, and lateral cortices were 11.6, 12.1, 1.8, and 4.7 mm, respectively. Gender differences were significant for all of these except the medial cortex to nerve distance. On average, the mental foramen exited the body of the mandible immediately below the second premolar and the average surface distances from the foramen to the symphysis, the most cephalad alveolar bone, and the inferior border of the body were 30.9, 14.2, and 19.3 mm, respectively. With regard to the patients presenting for mandibular angle reduction, there were a few statistically significant but small scalar differences from normal controls.     

Lateral canthoplasty to change the eye slant

A technique is described to modify eyelid slanting and correct excessive scleral show. The anatomic relations of the canthal ligament with the fibrous supporting structures of the eyelid are discussed. The procedure is indicated in aesthetic surgery, in congenital anomalies, and in sequelae of trauma.     

The eye of the magellanic penguin (Spheniscus magellanicus): structure of the anterior segment

We undertook a light and scanning electron microscopic study of the eye in the Magellanic penguin (Spheniscus magellanicus). The anatomical peculiarities of the eyeball shape in Sphenisciformes have been previously described by others; here, we show that they are accompanied by several modifications in the organization of the anterior segment of the eye. The main change was found in the portion of opaque sclera extending from the cornea to the anterior border of the scleral ossicles, which was much broader than in other avian eyes. This scleral region was made of a very dense fibrous tissue and was as difficult to cut as the ossicles. The corneo-scleral boundary was also different from that of other birds, since the aqueous humor channel and the pectinate ligament were located 1.0-1.5 mm posterior to the cornea. The osseous ring was formed by 13 bones, including three pairs of over- and underplates. There was a single ciliary muscle, with meridionally oriented striated fibers. They were inserted on a circumference along the boundary between the fibrous sclera and the ossicles, far away from the wall of the aqueous humor channel. On their posterior end, the muscle fibers formed a tendinous structure attached to the inner surface of the sclera and to the outer surface of the ciliary body. Only short zonular fibrils were observed. These anatomical features are probably relevant for the adaptation of penguin eyes to vision on land and in the aquatic environment.     

Correcting the saddlebag deformity in the massive weight loss patient

Skin redundancy of the trunk and thigh is treated by a circumferential abdominoplasty and a lower body lift. Despite preservation and tight approximation of the subcutaneous facial system, the authors have failed to adequately correct severe saddlebag deformity and midthigh laxity in the massive weight loss patient. The technique used in the last nine of the senior author's 43 lower body lifts was modified by fully abducting each operated thigh on a side utility table, before closure in the prone position. This maneuver permits an increase in width of skin excision and causes the lateral thigh skin to be taut upon leg adduction. This is a retrospective review of the senior surgeon's experience over a 3-year period. Postoperative follow-up of the nine-patient cohort ranged from 8 to 12 months. A standardized set of six-view preoperative and postoperative photographs was available for each patient. A regional grading system was developed to assign points for deformity seen in preoperative and postoperative photographs. To compare the effect of the new technique on the correction of hip/lateral thigh deformities, the authors used this same grading system to analyze 10 other lower body lift patients treated by the same surgeon without full thigh abduction who had six sets of standardized photographs. A deformity severity score was determined for each anatomic region by four trained observers blinded to the surgical technique. The nonparametric Mann-Whitney U test using exact p values was used to compare preoperative and percentage change in deformity severity score from preoperative to postoperative scores relative to preoperative scores for each anatomical region among subjects in each treatment group. The nonparametric Wilcoxon signed rank test using exact p values was used to evaluate the change in deformity severity score from preoperative to postoperative values. The change in technique resulted in an observable symmetrical correction of the severe saddlebag deformity and better contour to the distal lateral thighs. All evaluated patients were satisfied with the lateral thigh skin contour. The grading system revealed that patients treated with or without intraoperative thigh abduction had similar preoperative deformity severity scores for each anatomic region (p > 0.05). Postoperatively, all subjects showed improvement in scores for all treated regions. However, patients closed during full thigh abduction had significantly lower deformity severity scores for the hip/thigh complex when compared with patients treated without full thigh abduction (p < 0.05). Complications in these 19 patients consisted of one 6-cm superficial skin layer dehiscence due to a broken polyester suture that healed spontaneously. There were three seromas that responded to a short series of aspirations or catheter drainage. There were no infections. Distal abdominal flap tip skin necrosis in four patients responded to outpatient débridement and healed secondarily. A new grading system for body contour deformities was successfully utilized to judge differences in the quality of trunk and thigh deformity and outcome in 19 patients with adequate photographic records. Tight suture closure in full thigh abduction in the prone position results in improved treatment of significant saddlebag deformity and midthigh skin laxity in the massive weight loss patient. The essential principles are meticulous planning, careful isolation, tight closure of the lateral trunk and thigh subcutaneous fascial system, and artistic contouring of remaining tissues. Dehiscence, undesirable scarring, and seromas were minor issues in the entire group of 43 patients.     

An aesthetic classification of the abdomen based on the myoaponeurotic layer.

An objective classification for abdominoplasty based on myoaponeurotic deformities is described. Types A, B, C, and D correspond to different myoaponeurotic deformities. Patients with type A display rectus diastasis secondary to pregnancy, and plication of the anterior rectus sheath is indicated. Patients with type B present with laxity of the lateral and inferior areas of the abdominal wall after approximation of the anterior rectus sheaths. An L-shaped plication of the external oblique aponeurosis is performed in addition to the correction of rectus diastasis. Patients with type C are those whose rectus muscles are laterally inserted on the costal margins. Release and undermining of the rectus muscles from their posterior sheath and advancement of these muscles, attached to the anterior sheath, is the procedure of choice in these cases. Patients with type D display a poor waistline definition; external oblique muscle rotation associated with plication of the anterior rectus sheath is the procedure used to correct this deformity. Eighty-eight patients who underwent abdominoplasty were reviewed, and the incidence of each deformity was determined on this population. This study presents a practical classification that permits the plastic surgeon to critically evaluate which is the best option to correct abdominal deformities considering specific areas of myoaponeurotic weakness.