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.     

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.     

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.     

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.     

Lower eyelid reconstruction with a cheek flap supported by fascia lata.

The use of a cheek rotation flap is a well-known method for reconstruction of a large defect of the lower eyelid. In this technique, a separate lining tissue supporting the cheek flap is required for full-thickness reconstruction. Previously, a chondromucosal graft or conchal cartilage has been used to support this flap. Recently, we have used a homologous or autologous fascia lata as support for the cheek flap instead of rigid tissues like cartilages. A fascia lata strip is fixed with tolerable tension to the medial canthal tendon and lateral orbital rim. The inner surface of the fascia and the cheek flap is lined with a buccal mucosa graft to decrease irritation of the conjunctiva and cornea. We present here seven patients in whom this procedure was used for lower eyelid reconstruction following resection of a malignant skin tumor. Based on follow-ups of 7 to 22 months, the functional and aesthetic results have been good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.     

Surgical correction of Tessier number 8 cleft

The number 8 Tessier cleft can be a discrete horizontal shadow at the level of the lateral canthus of the palpebral fissure or a true coloboma with absence of the commissure between the upper and lower eyelids. A surgical technique, which has been used in eight patients, is described to correct this congenital defect. Four flaps are created and transposed as two Z-plasties. The lateral canthal ligament is fixed to the lateral orbital rim, and the orbicularis muscle is interdigitated to restore its continuity. This procedure reconstructs the depth of the conjunctival fornix, provides proper form and length to the palpebral fissure, and restores continuity and an anatomic angle to the malformed canthus.     

Restoring palpebral fissure shape after previous lower blepharoplasty

The youthful palpebral fissure can be described as long and narrow. Both the aging process and transcutaneous lower blepharoplasty can cause descent of the lower lid margin and medial migration of the lateral canthus, resulting in a rounding of the palpebral fissure. This article presents a technique to correct significant postsurgical lower lid malposition and palpebral fissure distortion without the use of outer or inner lamellar grafts. In overview, subperiosteal dissection frees scarred lid structures and cheek soft tissues, creating a continuous composite flap. Elevation of the cheek soft tissues recruits deficient outer lamellae and allows the sub-orbicularis oculi fat to be positioned between the orbital rim and scarred lid structures, filling this space and helping to support the repositioned lid margin. Titanium screws placed in the lateral orbit provide a point for secure fixation of elevated cheek tissues. Transosseous wire fixation securely repositions the lateral canthus. This procedure not only restores lower lid position and the vertical height of the palpebral fissure, but it also restores the palpebral fissure's horizontal length and the lateral canthal angle. It has been effective in correcting palpebral fissure distortion after lower blepharoplasty in 15 patients during a 6-year period.     

Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment

The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.     

Correction of lower eyelid ptosis in the anophthalmic orbit: a long-term follow-up

We describe a 10-year review of 53 patients having had correction of lower eyelid ptosis using fascia lata sling suspension by the operation first described in 1973. The overall conclusion is that this continues to be a reliable procedure with a low complication rate. Four major changes relating to operative technique that create a better result are as follows: (1) the surgical correction must begin with a prosthesis that is ideal for the socket; (2) the fascial strip is narrower at 2 mm; (3) the lateral orbital rim burr hole is placed higher; and (4) the passage of the fascial strip is facilitated by the use of Wright's needle. The optimal sequence of operative procedures in the anophthalmic orbit syndrome is (1) correction of enophthalmos and superior sulcus depression, (2) correction of lower eyelid ptosis, and (3) correction of upper eyelid ptosis.     

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.     

Temporoparietal fascial flap for orbital and eyelid reconstruction.

The temporoparietal fascial flap is a recognized technique for the transfer of vascularized tissue in the craniofacial region. The flap has a predictable axial vessel, provides thin vascularized tissue, and can be harvested with minimal donor-site morbidity. The temporoparietal fascial flap is well suited for orbital or eyelid reconstruction because of its proximity to the orbit. The flap is useful for reconstruction of anatomic barriers between the orbit, intracranial cavity, and paranasal sinus spaces. We present four patients in whom the temporoparietal fascial flap was used for orbital reconstruction following extirpative surgery for orbital neoplasm and two patients in whom the flap was used for lower eyelid and malar reconstruction.     

Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction

Experience with a single lower eyelid incision with mobilization of the lateral canthus is described for exposure of the zygoma, lower and lateral orbit, and zygomaticofrontal suture. The incision may be either subciliary with a skin-muscle flap or transconjunctival. Both require mobilization of the canthus. Reattachment of the canthus is not required in acute zygomatic fracture treatment but is preferred for secondary orbital reconstruction or in patients in whom a simultaneous coronal incision is employed. The approaches described reduce cutaneous scarring and provide generous exposure of the lower and lateral orbit. Predictable and improved aesthetic results are routinely achieved.     

Reconstruction of the medial half of the lower eyelid using a "switch" split-lid procedure

Reconstruction of the medial half of the lower eyelid has one major disadvantage: It produces a scar at right angles to the eyelid rim. In contrast, use of a "switch" split-lid procedure avoids this inconvenience. The lateral half of the lower eyelid is split in two lamellae. The inner layer is transferred medially, and the resulting defect is closed with a buccal graft. The outer layer is drawn laterally to cover the raw surface of the mucosal pedicle and graft. The surplus of skin over the lateral canthal area is removed. This procedure, which so far has been used in three patients, promises to be a useful alternative for reconstruction of the medial half, but not more, of the lower eyelid.     

Transblepharoplasty endoscopic subperiosteal midface lift

The use of endoscopy in the transblepharoplasty midface lift is essential for preventing the complications of facial nerve injury and bleeding. Complete observation allows precise dissection and release of all structures in the composite flap. This technique fully preserves the zygo-orbicular nerve plexus and prevents denervation of the orbicularis oculi and zygomaticus muscles. Blind dissection has a significant probability of denervation of the entire zygo-orbital muscle complex, and avulsion of the zygomaticofacial vessels, with associated postoperative bleeding complications. The modification involving suturing of the "vest" of the combined lateral orbital periosteal and superficial layers of the deep temporal fascia over the elevated "pants" of the orbicularis periosteal flap provides very secure fixation for suspension of the lower eyelid and midface. The use of slowly absorbable polydioxanone sutures for this technique prevents the problems caused by permanent sutures beneath the very thin skin of the lateral canthal area. Careful trimming of the prominent roll of the orbicularis muscle that often develops with suspension eliminates the uneven contour and yields a smooth lower lid appearance. The details and modifications described should decrease the complications and morbidity that can occur with this procedure and provide for a more precise and reliable procedure for rejuvenation of the lower eyelid and midface.     

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.     

Medial canthal reconstruction using a medially based upper eyelid myocutaneous flap

Periorbital reconstruction following skin cancer ablation represents a challenging problem. A thorough understanding of the complex periorbital anatomy is necessary to preserve lid function and protect the ocular surface. The medial canthal region represents the most difficult periorbital zone to reconstruct. This area has a complex anatomy involving both the medial canthus itself and the lacrimal apparatus. The authors present their experience with a versatile technique for reconstruction of the medial canthal periorbital region, namely, a medially based upper eyelid myocutaneous flap. In the 10 patients in whom this procedure was used, there was one partial and no complete flap losses. The authors believe that the medially based upper lid myocutaneous flap offers an excellent solution to the difficult problem of medial canthal periorbital reconstruction.     

The tarsal tuck procedure: avoiding eyelid retraction after lower blepharoplasty

Eyelid retraction and ectropion are the most common complications of lower blepharoplasty. These complications often occur as a result of removing excessive skin and muscle in the face of a lax lower eyelid. The tarsal tuck technique tightens and stabilizes the lower eyelid, thereby minimizing these complications. The lateral canthus and lower eyelid are elevated with the tarsal tuck, which reduces the amount of skin removal required and avoids the "round eye" appearance.     

睑袋和面中部松垂联合矫正术

目的:探讨应用睑袋和面中部联合手术改善面中部老化的方法与效果。方法:采用睑袋常规切口,从眼轮匝肌及面中部SMAS下分离。使颧脂肪垫复位固定,并将眶肌筋膜韧带牵拉缝合于外眦部骨膜上。结果:本组共69例,其中58例术后1-18个月获得随访,睑袋、加深的鼻唇沟基本消失,面中部松垂明显改善,效果良好。结论:本术式操作简便,年轻化效果满意,创伤轻,并发症少,是一个临床可以选用的较好手术方法。     

The muscle-suspension lower blepharoplasty.

The muscle-suspension (or muscle sling) lower blepharoplasty is a technique that can be used to some extent for all lower lids in which tightening and smoothing is desired. It seems to provide an extra degree of support by counteracting the natural tendency of gravity to produce scleral show or ectropion when the lid skin is tightened. It consists of anchoring a sling of orbicularis muscle to the periosteum of the lateral orbital rim, with an upward and lateral pull--while the skin is pulled in a more medial or upward direction.