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.     

Temporary tarsorrhaphy suture to prevent or treat scleral show and ectropion secondary to laser resurfacing or laser blepharoplasty

The temporary tarsorrhaphy suture is introduced as a simple effective technique to prevent scleral show or ectropion secondary to laser skin resurfacing or laser blepharoplasty. In all but severe cases of prior existing scleral show or ectropion, the temporary tarsorrhaphy suture has been completely effective. It is also successfully used to prevent scleral show and ectropion for patients with poor lid snap and loss of elasticity of the lower eyelid at the time of laser skin resurfacing and blepharoplasty. A 5-0 Prolene suture is placed through the gray line to approximate the upper and lower eyelids and is left in place for 5 days. This supports the lower eyelid during the critical period of dermal and epidermal regeneration and during the formation of new collagen and elastin.     

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.     

Use of a muscle flap in lower blepharoplasty.

An adjunctive technique for lower lid blepharoplasty is presented. This operative procedure uses the principle of anchoring the upper margin of the lower lid by suturing a triangular muscle flap from it to the lateral-superior part of the orbital rim. This more effective support for the lower lid margin permits one to excise more redundant tissue without getting an ectropion.     

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."     

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.     

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.     

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.     

Acquired strabismus following cosmetic blepharoplasty

The purpose of this study was to report on 12 patients with acquired strabismus following cosmetic blepharoplasty and to identify patterns of strabismus related to the surgical procedure. Clinical ophthalmologic examinations were performed to specifically clarify the type of strabismus. Operative reports of the blepharoplasty procedures were reviewed. Patients were followed for a minimum of 3 months after the blepharoplasty procedure before surgical intervention was considered. Operative findings at corrective strabismus surgery were noted and an attempt was made to correlate these findings with the clinical ophthalmologic examination and the blepharoplasty surgical procedure. Twelve cases of persistent vertical strabismus occurred following blepharoplasty procedures. Five patients had clinical findings consistent with the diagnosis of acquired superior oblique palsy; one of these five patients also showed signs of an acquired Brown syndrome. Seven patients developed an incomitant vertical deviation consistent with an inferior rectus paresis. Strabismus occurred after conventional lower lid, upper lid, and four-lid blepharoplasty with or without laser blepharoplasty. Acquired strabismus accompanied by persistent diplopia may occur as a complication of cosmetic blepharoplasty. Extraocular muscle damage resulting in either superior oblique muscle palsy or inferior rectus paresis was noted in these patients. In some cases, patients with inferior rectus paresis also showed mechanical restriction to upward rotation of the globe.     

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.     

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.     

Expanded applications for transconjunctival lower lid blepharoplasty.

There has been a recent upsurge in interest in the transconjunctival approach for lower lid blepharoplasty. Initial reports have focused on the young patient with isolated fat prominence. We describe our experience with transconjunctival lower lid blepharoplasty in 104 patients over the past 2 years. There have been no instances of prolonged lower lid retraction problems, presumably related to leaving the skin, orbicularis, and orbital septum intact. Our experience with expanding the indications for the transconjunctival approach to include patients with fine skin wrinkling as well as frank skin excess has been extremely favorable. We conclude that the skin excess is often more apparent than real, with the skin being necessary to recontour the lower eyelid after fat excision. Although skin excision may be required during the initial procedure or at a later stage, patients with apparent skin excess need not be excluded from consideration for transconjunctival lower lid blepharoplasty.     

Transpalpebral browpexy

Transpalpebral browpexy could be performed as an adjuvant procedure to the upper blepharoplasty or as a separate procedure. It is done by separating interdigitalizing connections between the orbicularis and frontalis muscles, moving the orbicular part of the orbicularis muscle with overlying brow to the more cephalad position and again uniting both of these muscles with nonresorbable sutures in a new higher position. During the years 1990 to 1999, 55 patients (47 women and eight men) were operated on with this technique, which was partially developed by the author. Additional time required to achieve transpalpebral brow stabilization during standard blepharoplasty was approximately 30 minutes. Forty-three patients were followed, 38 of them for longer than 4 years. The elevation effect gradually decreased but persisted, with wide variations, between 1.5 and 7 more years. At the last follow-up examination, 36 of 43 patients had maintained lateral brows in the same position as before operation and sometimes even higher, which was appreciated by the patients. Complications were very few and they were correctable. Transpalpebral browpexy proved to be a useful addition to blepharoplasty and can be used for the minor adjustments after an open coronal or endoscopic brow lift. Particular indications included patients with lateral brow ptosis and discrete forehead wrinkles and balding men.     

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.     

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.     

Secondary correction of unsatisfactory blepharoplasty: removing multilaminated septal structures and grafting of preaponeurotic fat

Oriental blepharoplasty, commonly known as a "double eyelid operation," is the most frequently practiced cosmetic procedure in Orientals, who have probably become more fold conscious because of social westernization and an influx of Caucasians into their society. Anatomically, the upper eyelids of an Oriental are considerably different from those of a white person, and nearly half of Orientals have single eyelids. When performing blepharoplasty, an appropriate design and operative technique must be carefully selected, taking into consideration the anatomical characteristics of Koreans to obtain an aesthetically pleasing result. However, the incidence of complications is high. Patients who are faced with unsatisfactory results are often perplexed by the fact that such a commonly performed procedure could have a very high rate of dissatisfaction and that an improvement is not easy. An unfavorable result need not imply a postoperative complication, but only that the result is not acceptable to the patient, whose goal may not be based on good aesthetic principles. The most common sources of dissatisfaction are postoperative asymmetry and high placement of the lid fold. From 1991 to 1998, secondary blepharoplasty was performed on 72 patients by slitting transversely, removing the multilaminated septal structures exposed to the previous operative scar, spreading the preaponeurotic fat that extruded, and removing the septal structures into a space where the scar was eliminated to prevent secondary adhesion. The average age of the patients was 26.5 years, and the average follow-up period was 2 years. No remarkable complication was encountered after operation with this method, and the desired aesthetic improvements were achieved in the majority of the patients.     

The role of the Schirmer's test and orbital morphology in predicting dry-eye syndrome after blepharoplasty

The Schirmer's test for tear production has been recommended to identify patients with diminished tear production prior to blepharoplasty. The decision to operate may rest with this simple clinical test. This paper reports a prospective clinical evaluation of 100 consecutive blepharoplasty patients to determine the role of preoperative assessment of the orbital and periorbital morphology and the Schirmer's test in predicting the likelihood of the development of the dry-eye syndrome (DES) postoperatively. Our findings indicate that the morphology of the orbital region is a more important and reliable method of evaluating a predisposition to developing dry eyes postoperatively than is the Schirmer's test. The value of the Schirmer's test is to flag patients prior to blepharoplasty, but it should not be relied on as the sole method of screening patients and it is definitely of less importance than the history and physical examination.     

Reduction of lower palpebral bulge by plicating attenuated orbital septa: a technical modification in cosmetic blepharoplasty

Bulging of the lower eyelid is regarded as a sign of aging. "Herniation" of the periorbital fat pads is traditionally regarded as the factor responsible for the change. Excision of fat pads, therefore, has been the mainstay of treatment in reducing the palpebral bulge in cosmetic blepharoplasty. The surgical excision of"excess" and "herniated" fat pads, however, causes problems such as lid ecchymosis, chemosis, lid contour irregularity, ectropion, and retrobulbar hematoma formation. The author proposes that the loss of fat pad support caused by the attenuation of the orbital septa, not herniation of the excess fat pads, is the major factor responsible for the bulge. The author further proposes that the functional integrity of the orbital septum can be restored by plicating the attenuated orbital septa with 5-0 absorbable sutures. This technique of invaginating the protruded fat pad was performed in 138 individuals (276 lower eyelids). The operation was technically simple, and the approach was "tissue friendly." The results obtained, with the exception of a mild degree of puffiness encountered soon after the surgery, were satisfactory. Morbidity was minimal.     

Treatment guidelines for botulinum toxin type A for the periocular region and a report on partial upper lip ptosis following injections to the lateral canthal rhytids.

Inactivation of the orbicularis oculi muscle by chemodenervation with botulinum toxin type A (Botox, Allergan, Inc., Irvine, Calif.) as a sole procedure or in conjunction with blepharoplasty has proved to be a reliable method to improve the appearance of the periocular area. Botox has the unique and ideal characteristic in that, with repeated use, there is potential for a prolonged clinical effect with smaller dosages. In addition, if a complication does arise--while not aesthetically acceptable and potentially untoward--it is time-limited, and the anatomical area will eventually return to its pretreatment baseline status. In this study, in three cases [in more than 1000 crow's feet treatment sessions (2000 sides)] over the course of 1 year, partial lip ptosis resulting from weakening of the zygomaticus major muscle after the injection of Botox into the periocular region are reported. This article reviews suggested treatment guidelines and anatomic considerations for the periocular region to maintain injection standardization and improve the safety profile of Botox as the aesthetic indications for its use expand and the number of individuals who inject it increases.     

A 5-year study of the transmalar subperiosteal midface lift with minimal skin and superficial musculoaponeurotic system dissection: a durable, natural-appearing lift with less surgery and recovery time

The transmalar subperiosteal midface lift is a simple, direct-approach procedure to be performed with a meloplasty. The entry into the midface is at the site of maximum suture tension, which allows for more elevation. The skin is elevated enough to expose the entry site, which is on the zygoma just cephalad to the origins of the zygomaticus muscles. Through a small hole at that site, a periosteal elevator is used for the midface dissection. This is a blind dissection, and the technique is described. The advantages of the technique are that there is (1) no lower-lid incision or risk of an ectropion, (2) a resultant tightening and elevation of the lower lid, (3) more elevation and durability because the zygomaticus muscle origins are elevated with the periosteum and are sutured to the very substantial deep temporal fascia, (4) a simple and fast procedure, and (5) no telltale sign of a face lift. Both the superficial musculoaponeurotic system (SMAS) and the skin are substantially elevated with the transmalar subperiosteal midface lift to the extent that they should be only minimally dissected. In the author's opinion, the extended dissection of the skin and/or the SMAS does not increase the amount of tissue lift and probably reduces it in most cases, considering that the goal is a natural look and not one that appears pulled or stretched. The skin is elevated only for exposure, and the SMAS is elevated only enough to create a preauricular SMAS-platysma flap to tighten the neck. With two fewer layers of dissection, there is significantly less postoperative swelling and recovery time. The article presents the technique, the results on 272 patients over a period of 5 years, and a discussion. No patients described have had secondary procedures such as lasers, so the transmalar subperiosteal midface lift can be evaluated on its own merit.