Transconjunctival upper blepharoplasty

Transconjunctival lower lid blepharoplasty now has an established role as an option in rejuvenation of the lower eyelid. Transconjunctival upper lid blepharoplasty, or transconjunctival removal of medial upper eyelid fat, also has a role in rejuvenation of the upper eyelid. However, this is a rather limited role. We have found this approach safe and efficacious as a primary as well as a secondary procedure for removal of excess medial upper eyelid fat. We report on 20 patients who have undergone this operation: 5 as a primary procedure and 15 as secondary. There were no complications, no revisions, and the patients have been uniformly happy with their results.     

Complications of Oriental blepharoplasty

The complications of Oriental blepharoplasty are described according to their clinical appearance and anatomic findings at the time of surgery. The surgical correction of these complications is presented. A total of 42 patients with complications following blepharoplasty were treated. The types of deformities were categorized from their external appearance as asymmetry, retraction and ectropion, blepharoptosis, supratarsal depression, fading of the lid fold, and hemorrhage. The causes of each type of complication are identified according to the intraoperative findings, and the correlation between preoperative and intraoperative findings is explained. Correction of these complications follows identified guidelines, and the results were good to satisfactory.     

Upper eyelid skin grafting: an effective treatment for lagophthalmos following blepharoplasty

Patients who have undergone upper blepharoplasty occasionally develop anterior lamellar insufficiency, which can result in lagophthalmos, corneal decompensation, and even blindness. Historically, skin grafts in the upper eyelid have been considered a last-resort procedure because of poor cosmetic outcomes. Poor cosmetic outcomes result from the traditional practice of placing the skin graft above the eyelid crease. This article describes a surgical technique for upper eyelid skin grafting in which the graft is placed in a supraciliary position. Presented are results of a retrospective study of 20 patients (31 eyelids) who underwent supraciliary upper eyelid skin grafting. The postoperative results were evaluated by examining the improvement in lagophthalmos, the improvement of keratopathy and comfort of the patient, and the cosmetic appearance of the graft. Upper eyelid skin grafting using this surgical technique is an effective and cosmetically acceptable method to improve corneal integrity and comfort in patients who have corneal exposure from insufficient anterior lamella after upper eyelid or eyebrow surgery.     

Adipose compartments of the upper eyelid: anatomy applied to blepharoplasty

Many authors have indicated the presence of ectopic or accessory upper eyelid fat pads, but the effective rate of eyelid fat variations and the corresponding clinical features are still unclear. The purpose of this study was to evaluate the variability of upper lid fat and to define the anatomical landmarks of the adipose pockets of the upper lid. From January of 1998 to January of 2002, the authors investigated the upper eyelid fat compartments of 47 patients who underwent upper blepharoplasty. To support surgical findings, 11 fresh cadavers were also investigated; the anatomy of the intraorbital fat and of the upper eyelid fat compartments was reviewed. Ten patients (21.3 percent) showed an accessory fat pad in the upper lid, which was found on both sides in nine cases. In all patients, the third fat pad was situated lateral to the two classic compartments described by Castanares, behind the orbital septum. Surgical dissections demonstrated that this fat pad derived from the preaponeurotic fat. Anatomical dissections in three cadavers demonstrated an accessory fat compartment protruding under the inferior border of the lacrimal gland. This protruding fat derived from the preaponeurotic fat in all cases and might justify the clinical appearance of a bulge or fullness in the lateral third of the upper eyelid. In the authors' experience, the presence of an accessory upper eyelid fat pad was a frequent finding during blepharoplasty; it could be found and actually resected in about 21 percent of all cases. Surgical and experimental findings put this element as a lateral physiological extension of the preaponeurotic fat that can anteriorly protrude under the inferior border of the lacrimal gland toward the orbital septum. The clinical appearance may be a bulge or fullness in the upper eyelid, and its resection can better define the lateral one third of the supratarsal fold.     

Laser blepharoplasty for making double eyelids in Asians

The double-eyelid operation is a cosmetic procedure performed primarily on Asians who have no supratarsal folds. The goal in Oriental blepharoplasty is to ensure a stable double-eyelid fold with predictable and long-lasting results. Candidates for this procedure desire attractive eyelids with a natural-looking fold. Today, the CO2 laser is used as a surgical tool by plastic surgeons, and its use in cosmetic surgery has recently been expanded to blepharoplasties.We used the high-power CO2 laser (UltraPulse; Coherent, Santa Clara, Calif.) in the double-eyelid operation. Between September of 1995 and September of 1999, a total of 241 patients underwent laser double-eyelid operations at Korea University Medical Center and Dr. Choi's Aesthetic Clinic, with an average follow-up of 18 months.By using the CO2 laser, we could create a stable double-eyelid fold with long-lasting results. The rate of fold release was 2 percent, which was less than the rate using the conventional scalpel incision method. The CO2 laser contributed to a reduction in pain or discomfort after the operation; therefore, patient comfort and early recovery could be enhanced after double-eyelid surgery. In the healing of the incision line, it showed mild redness for 3 weeks, but long-term follow-up showed the scar produced by the laser appeared to be equal in quality compared with the conventional method. Laser blepharoplasty is a useful and effective method to create a stable and attractive double eyelid for Asian patients.     

Lower eyelid blepharoplasty: analysis of indications and the treatment of 100 patients

Traditionally, lower lid blepharoplasty has been confined to a choice of skin or skin-muscle flap transcutaneous blepharoplasty. In the past decade, in particular, various new techniques and technologies have emerged, altering our ability to treat the lower eyelids. These techniques include transconjunctival blepharoplasty, a variety of canthopexy procedures, fat-conserving or fat-replacing methods, wedge excision, and laser resurfacing techniques, and they allow a more individualized approach based on variations in anatomical features and patient goals. A retrospective review of data for 100 consecutive patients (ranging in age from 30 to 80 years) who underwent lower eyelid procedures during a 12-month period is presented. Procedures were categorized as follows: lower lid blepharoplasty, 35 cases; lower lid transconjunctival blepharoplasty, 27 cases; lower lid transconjunctival blepharoplasty with laser resurfacing, 17 cases; lower lid laser resurfacing, 16 cases; tarsorrhaphy with lower lid operation, three cases; tarsorrhaphy with laser resurfacing, two cases. Two complications of retained fat pads (one medial and one lateral) were encountered and were addressed with a secondary operation using a transconjunctival blepharoplasty approach. The results indicate that laser treatment has become the predominant form of lower eyelid resurfacing and that transconjunctival blepharoplasty is now the most common surgical procedure for the lower eyelid. All of our tarsorrhaphy procedures were performed for patients who had previously undergone surgical treatment of the lower eyelids. An algorithm based on physical findings and these techniques has been developed, for appropriate tailoring of the procedure to each patient's specific concerns. With the availability of a variety of techniques, an individualized approach based on variations in anatomical features is feasible.     

Severe ectropion: repair with a modified Tripier flap

Classical techniques, such as wedge resection, are well suited for mild cases of lower lid ectropion, but they often fail to cure severe cases. The reason these techniques often fail is because they address only the laxity and elongation of the ectropic lid, not the root cause. In nearly every case of severe ectropion, the root cause is importance of the pretarsal orbicularis muscle; i.e., there is inadequate muscle support for the pretarsal lower eyelid. A bipedicled musculocutaneous flap, transferred from the upper lid, was used to treat nine cases of severe lower eyelid ectropion. Eight patients had a good/excellent result. Four patients had electromyographic studies in the late postoperative period, without a single instance of even mild denervation. In cases of severe ectropion, this flap is an effective replacement for the missing skin and impotent muscle. It uses the often discarded blepharoplasty tissue, which has a perfect color and texture match. A single anatomic unit is rebuilt, transferring a strong new muscle strap with ideal supporting vectors and leaving scars in natural creases. This "blepharoplasty flap" may prove useful in other types of eyelid reconstruction.     

Frontalis muscle advancement: a dynamic structure for the treatment of severe congenital eyelid ptosis

Forty-two consecutive patients have had severe eyelid ptosis corrected by intraorbital frontalis flap advancement as a motor unit to substitute for the function of the levator muscle. This technique has avoided the need for the linking structure necessary in the standard frontalis sling approach and has improved the direction of pull to more closely mimic that of a normal levator. This simple technique includes elevation of the innervated frontalis muscle flap and the creation of a pulley near the insertion of the orbital septum at the superior orbital rim, which redirects the lid movement along the surface of the globe rather than lifting it from the globe's surface toward the brow. This type of displacement is produced because the muscle is directed posteriorly by the pulley, so that it conforms to the plane of the levator aponeurosis all the way down to the tarsal plate. In addition, to improve the remaining function of the levator muscle (if any) and to facilitate voluntary positioning of the eyelid, the levator aponeurosis is shortened by plication. Symmetry is created by intervention on the contralateral eyelid to provide symmetrical supratarsal creases.     

Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits

In 1985, Burget and Menick's landmark article on the nasal subunit principle popularized the technique of reconstructing the specific topographic subunits that they identified as the dorsum, tip, and columella and the paired alae, sidewalls, and soft triangles. In patients with more than 50 percent of subunit loss, Burget and Menick proposed removing the remaining portion of the subunit and reconstructing the entire subunit with a skin graft or flap. They further supported the placement of incisions for local flaps along borders of aesthetic subunits to maximize scar camouflage. Although the concept of nasal subunits is important in planning the reconstruction, other aesthetic considerations, such as skin texture, color, contour, and actinic damage, are also crucial in achieving an optimal result. Often, focusing on these aspects with the goal of nasal symmetry in mind leads to the violation of the subunit principle but provides a pleasing result of both the defect and the donor site. The purpose of this study was to demonstrate when and how the modification of the nasal subunit principle is used to achieve coverage of nasal skin defects. A retrospective analysis of patients who underwent nasal reconstruction after skin cancer ablation surgery by one surgeon at the Hospital of the University of Pennsylvania from 1987 to 2000 was performed. During this 13-year period, 219 patients underwent 245 nasal reconstructions. Seventy-four patients with 76 reconstructions (31 percent) had procedures that violated the classic nasal subunit principle. Eight of these 74 patients (11 percent) had complications, and eight (11 percent) had 10 revisions performed. The aesthetic and functional results were graded as excellent, good, and fair. The results for the 74 patients who underwent modification of the subunit were excellent in 85 percent, good in 13 percent, and fair in 2 percent. Case reports were selected to illustrate situations in which the nasal subunit was altered.     

Retro-orbicularis oculus fat (ROOF) resection in aesthetic blepharoplasty: a 6-year study in 63 patients

Sixty-three nonconsecutive patients have undergone resection of the retro-orbicularis oculus fat (ROOF) in conjunction with aesthetic blepharoplasty. In these patients, a consistent and useful ability to soften and flatten heaviness and bulkiness in the lateral upper orbital region was seen. Two patients developed postoperative hematoma, and two different patients had transient dry-eye symptoms following blepharoplasty. Twenty percent of patients had a transient degree of numbness in the lateral supraorbital nerve region, and all patients noted some transient numbness over the lateral upper brow region. No patient demonstrated significant paralysis of the orbicularis oculus or corrugator muscle. From this experience, retro-orbicularis oculus fat resection would appear to be a useful adjunct to standard blepharoplasty techniques in selected patients.     

Extended upper blepharoplasty for lateral hooding of the upper eyelid using a scalpel-shaped excision: a 13-year experience

Excess skin of the upper lids is often accompanied by lateral overlap of skin with crow's feet because of the absence of fixation to the tarsal plate, giving the eye a sad, heavy look that often disturbs the lateral visual field. The accepted crescent-shaped blepharoplasty is somewhat convex, which is widest at the center of the lid with or without a lateral extension. However, in patients who have normal brow position or minimal eyebrow ptosis and whose main concern is the excess upper eyelid skin and lateral hooding, such a crescent excision may not suffice. A scalpel-shaped excision that is widest laterally and that tapers to a point medially will extirpate the maximal skin where it is most needed and overcome the skin excess in the lateral aspect of the upper lid. Between 1990 and 2002, 301 white patients (275 women and 26 men) between the ages of 33 and 79 years were operated on using the extended scalpel-shaped upper blepharoplasty technique. The follow-up period was more than 1 year. The lower margin of the incision is along the supratarsal crease, about 10 mm above the ciliary line. It begins medially about 1 cm above and lateral to the medial canthus. Above the lateral canthus, the skin marking is gently curved upward and outward, often within a natural skin crease or crow's feet to reach a little below and slightly beyond the lateral extremity of the eyebrow. The upper border of the incision joins the two extremities of the skin outline in a gentle convex curve. The general outline of the incision takes on the shape of a number 20 scalpel blade in which the maximal width is located laterally. Following excision of the excess skin and removal of protuberant fat pads if needed, suturing is executed from lateral to medial. The final suture line is in the form of an oblique flattened lazy S. Following the removal of the stitches on the fifth postoperative day, no wound dehiscence was noticed at the lateral scar zone. In the older individuals, due to the lax skin, the scar becomes scarcely noticeable with time and often falls within a pre-existent crow's feet crease. Elimination of some of the crow's feet was also demonstrated. In patients with visual field impairment, significant functional and visual improvement was achieved. Most patients mentioned a pleasing postoperative open "Oriental" look of the eyes. The extended scalpel-shaped upper blepharoplasty adequately deals with the hooding of the skin laterally. This technique overcomes the excess of skin in both vertical and horizontal directions, since in suturing the lateral part of the skin defect in an oblique plane, slack skin is taken up transversely, and the technique provides some indirect upward support to the lateral eyebrow. In the absence of crow's feet in the younger person, this technique is not recommended because the lateral part of this suture line is visible, especially if the scar widens.     

Current concepts in aesthetic upper blepharoplasty

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss nomenclature and anatomy associated with upper blepharoplasty. 2. Perform preoperative assessment, decision-making, and counseling of patients. 3. Describe current surgical planning, eyelid marking, and various techniques used in upper blepharoplasty, including lasers. 4. Recognize and treat postoperative complications from blepharoplasty.Traditional blepharoplasty has often involved the excision of both lax skin and muscle and excessive removal of fat, leaving patients long term with a hollow orbit and a harsh, operated appearance that accelerates the aging process. Current methods of periorbital rejuvenation are more conservative, are based on concise preoperative evaluation, and involve the limited resection of the coveted soft tissue from the eye to restore a youthful appearance. The authors describe anatomy, preoperative assessment, decision-making and counseling of patients, surgical planning, eyelid marking, and various techniques, including lasers, along with postoperative complications associated with current concepts in aesthetic upper blepharoplasty.     

The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.     

Primary and secondary orbit surgery: the transconjunctival approach

The transconjunctival approach to the orbit is underutilized because of concern regarding inadequate exposure and higher postoperative rates of lower eyelid shortening and ectropion. All patients who had a transconjunctival incision performed for orbital surgery over the last 6 years (1990 to 1996) were studied. Patients who had a transconjunctival blepharoplasty were excluded. A total of 35 patients, average age 32 years, had 45 transconjunctival incisions performed. Lateral canthotomy or cantholysis was not done. Operations fell into three categories: fracture plating alone, 10 (22 percent); split-calvarial bone graft placement with or without plating, 26 (58 percent); and orbital decompression, 9 (20 percent). The overall incidence of ectropion was 6.7 percent (3 of 45). One patient (2 percent) had transient ectropion, and two patients (4 percent) had persistent ectropion, which required surgical correction. Ectropion occurred only in those lower eyelids that had a previous transcutaneous incision (3 of 18 = 17 percent). None occurred in those eyelids that had no prior incision or only a previous transconjunctival incision. The transconjunctival approach without a lateral canthotomy provides safe access to the orbit in eyelids that have not had a previous transconjunctival incision.     

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.     

Aesthetic eyelid ptosis correction: a review of technique and cases

Upper eyelid ptosis can present both functional and aesthetic problems. Because proper correction of ptosis can be difficult to achieve, numerous surgical procedures have been developed. Plication of levator aponeurosis can be combined with aesthetic blepharoplasty and facial rejuvenation procedures to successfully address ptosis. The authors assessed the effectiveness of levator aponeurosis plication for correction of acquired upper eyelid ptosis in patients presenting for concomitant cosmetic facial procedures. The medical records of 74 consecutive patients (68 women and six men) who had upper eyelid ptosis correction in conjunction with cosmetic facial procedures from January of 1994 to January of 2000 were reviewed. During this period, 400 endoscopic forehead lifts and 479 face lifts were performed. The correction was performed through an external upper blepharoplasty approach removing an ellipse of skin and orbicularis muscle. Once the orbital septum was opened, a plication of the levator aponeurosis was accomplished by one or more horizontal mattress sutures of 6-0 clear nylon (with the first bite placed at or just medial to the vertical level of the pupil). The average follow-up period was 14 months. Long-term correction of the ptosis was excellent. The complications were minor, with the most common occurrence being asymmetry. Revisions were performed on only four patients. Correction of ptosis can be performed safely and effectively in conjunction with periorbital and facial rejuvenation. The technique described is simple, reliable, and reproducible.     

A rational approach to nasal reconstruction in leprosy

Destruction of the nasal septum and nasal bones by Mycobacterium leprae and subsequent infection is still seen regularly in leprosy endemic areas. The social stigma associated with this deformity is significant. Many different procedures have been developed to reconstruct the nose. Patients operated on at Anandaban Hospital and the Green Pastures Hospital and Rehabilitation Center between 1986 and 2001 were reviewed. There were 48 patients with an average age of 47 years. Five deformities were mild, 22 were moderate, 13 were severe, and eight were not graded. Bone grafting with nasolabial skin flaps was performed in 14 cases, bone grafting alone was performed in 10 cases, flaps alone were performed in seven cases, and cartilage grafting was performed in 10 cases. In three patients, a prosthesis was inserted, and in three patients a gull-wing forehead flap was performed. Overall, excellent or good cosmetic results were obtained in 83 percent of cases. Grafting with conchal cartilage was associated with the best cosmetic results and had minimal complications. Bone grafting with or without nasolabial flaps was associated with a 50 percent complication rate of infection or graft resorption. In mild to moderate deformities, cartilage grafting is recommended; for more severe deformities, bone grafting with bony fixation and skin flaps is recommended. Perioperative antibiotics must be used, and these procedures should be performed by an experienced surgeon. In very severe cases with skin deficiency, reconstruction with a forehead flap gives good results.     

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.     

Indications and use of composite grafts in 100 consecutive secondary and tertiary rhinoplasty patients: introduction of the axial orientation

The fragile alar rims are complex structures whose specialized and supportive skin ensures the competence of the external valves and the patency of the inlets to the nasal airways. A chart review was performed of 100 consecutive secondary or tertiary rhinoplasty patients in whom the author had placed composite grafts before February 1999. Follow-up continued for at least 12 months. In 94 percent of the patients, composite grafts were harvested from the cymba conchae by removing the cartilage with its adherent anterior skin. In 6 percent of the patients, independently indicated alar wedges supplied the grafts. Six patients required secondary procedures to thin the alar rims, but such revisions have not been necessary since primary contouring of the cartilaginous graft component was instituted. Three auricular donor-site complications (one keloid, two thickened graft contours) were successfully revised through office procedures. Prior cosmetic rhinoplasty in a patient with normal alar cartilage anatomy exceeded all other etiologies as the cause of the deformity for which composite grafts were indicated (50 percent). The second most common etiology was deformity from prior rhinoplasty in a patient with alar cartilage malposition (33 percent of patients). Congenital deformities (7 percent of patients), trauma (6 percent), and prior tumor ablation (4 percent) comprised the remaining etiologies. Composite grafts were used most frequently to correct alar notching or asymmetry in rim height (43 percent of patients) or to provide an increase in apparent or real nasal length (28 percent). External valvular incompetence (14 percent of patients), nostril or vestibular stenosis (11 percent), or combined vestibular stenosis and lateral alar wall collapse (4 percent) were less common indications. Most composite grafts were oriented in the coronal plane (parallel to the alar rims). However, nostril or vestibular stenosis was corrected by sagittally placed composite grafts, and a third orientation (axial plane), to the author's knowledge not described previously, was used in patients with combined nostril stenoses and flattening of the alar walls. In this secondary rhinoplasty series, iatrogenic alar rim deformities or stenoses following cosmetic rhinoplasty dominated other causes requiring composite graft reconstruction (83 percent of patients). Of these 83 patients, 39.7 percent had preexisting alar cartilage malpositions, further supporting the importance of making accurate anatomical diagnosis part of every preoperative rhinoplasty plan.