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.     

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."     

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.     

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.     

Periosteal pennant lateral canthoplasty.

A periosteal pennant method of primary lateral canthoplasty is described, and it effectively maintains surgical correction of the axis of the palpebral fissure and the position of the lateral canthus. In using it more than 50 times, we have not had to do a secondary correction.     

Soft-tissue refinements in the treatment of unicoronal craniosynostosis: the rotational forehead flap

Unicoronal craniosynostosis is characterized by ipsilateral superior and posterior displacement of the supraorbital rim and frontal bone, ipsilateral widening of the palpebral fissure, ipsilateral superior displacement of the brow, and contralateral brow depression. In the literature, surgical treatment has focused on bony anatomy, with little written about soft-tissue correction. Over the last 25 years, the senior author (L.A.W.) has incorporated soft-tissue refinements, including a rotational flap of the forehead, elevating the contralateral brow, depressing the ipsilateral brow, and equilibrating the supratarsal sulci in unicoronal craniosynostosis. This rotational forehead repositioning is a simple innovation that has provided for improved orbital and brow symmetry on long-term follow-up.     

Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: do we have to make an additional scar to correct the Asian epicanthal fold?

The epicanthal fold along with a lack of a superior palpebral fold, excessive fat, and laxity of pretarsal skin represent the ethnic characteristics and a traditional sense of beauty in the Asian upper eyelid. But, too prominent an epicanthal fold may ruin an otherwise beautiful eye; furthermore, it becomes a restriction that makes the out-fold type double eyelidplasty, one of the two main types of double eyelidplasty, impossible. If a double eyelid as an out-fold type is desired, a concomitant epicanthoplasty should be performed with the possibility of hypertrophic scarring of the medial canthal area in Asians. To address the Asian epicanthal fold without danger of hypertrophic scarring, the authors developed an anchor epicanthoplasty technique that leaves no additional scar when combined with a double eyelidplasty. This technique is based on the concept of trimming of muscle and soft tissue under the Asian epicanthal fold and downward medial advancement and anchoring of the medial canthal skin to the deep tissue. The technique consists of five procedures based on the assumed causes of the Asian epicanthal fold: (1) augmentation rhinoplasty, (2) downward medial advancement of the medial upper lid skin, (3) removal of the superficial insertion of the medial canthal ligament and selective removal of the orbicularis oculi muscle, (4) subcutaneous contouring of the thick nasal skin, and (5) anchoring of the medial end of the incision to the deep tissue. During the past 12 years (1988 to 1999), 67 anchor epicanthoplasty procedures have been performed. Twenty-eight cases were followed up for more than 3 months, and all of the patients were satisfied with the results. There were only a few minor complications, which could be corrected with minimal revision. As an ancillary procedure to a double eyelidplasty, this anchor epicanthoplasty can reduce the Asian epicanthal fold and make a double fold as an out-fold type without an additional scar. In terms of hypertrophic scarring and compatibility with out-fold type double eyelidplasty, this anchor epicanthoplasty is the best method for correcting Asian epicanthal fold compared with other preexisting procedures. Other advantages of this technique are a wide range of applications and no compromise of medial, canthal skin to interfere with other epicanthoplasty techniques. Some disadvantages of this technique are technical difficulty and the possibility of active bleeding.     

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.     

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.     

Transcutaneous stitch for transperiosteal identification of the medial canthal ligament

This paper presents a technique whereby the canthal ligament can be identified through the periosteum without creating an external incision. Prior to releasing the tendon from the bones, the assistant will stretch the lateral canthal ligament while the surgeon places a stitch through the medial canthal ligament and tattoos the ligament and the underlying bone. After the forehead flap is mobilized and the ligament is detached from the bone by elevation of the periosteum, the previous stitch on the medial canthal ligament is pulled, which will provide a firmer consistency to the ligament, thereby facilitating the differentiation of the ligament from the surrounding soft tissue. Using this and the tract tattooed previously, the ligament can be identified easily without creating any external scars.     

MACROSCOPIC OBSERVATIONS OF THE FACIAL MUSCLES IN THE BAIKAL SEAL (PHOCA SIBIRICA)

This study was performed to determine if, as expected, the enlarged eye of the Baikal seal ( Phoca sibirica ) has an influence on the form and function of the skull and facial muscles. Macroscopic observation of these muscles demonstrated that the M. orbicularis oculi expands around the palpebral fissure and that some facial muscles attach and insert in the M. orbicularis oculi , possibly supporting M. orbicularis oculi function. We suggest that these muscles move the eye and palpebral area and constitute a morphological and synergistic facial muscle complex system. Further, the development of the M. rectus lateralis around the sclera of the eye indicates that this muscle is also involved in eye movement.     

Rare craniofacial clefts: Tessier no. 4 clefts

A major difficulty in understanding rare craniofacial clefts arises from the fact that previous reports have focused on a single case or have grouped together different types of rare clefts. Less than 50 Tessier no. 4 clefts have been reported. This paper examines our experience with eight patients treated primarily or secondarily for Tessier no. 4 clefts. A treatment plan is recommended. The primary early concern is protection of the eye. Early correction of soft-tissue deformities should include skin, muscle, and lining of the orbit, cheek, and oral cavity. Contrary to the dictum that all soft tissue must be preserved, the medial portion of the upper lip from the cleft to the philtral ridge must be resected to prevent poorly camouflaged scars, muscle deficiency, and macrostomia. Bone grafting should be undertaken at an early age using calvarial bone. Late operations will be necessary for correction of medial and lateral canthal position, epiphora, lower eyelid skin deficiency, and further bony augmentation.     

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.     

Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system

The purpose of this study was to evaluate a standard method for the identification of eye prominence and to review operative modifications necessary in patients with prominent eyes. A Hertel exophthalmometer was used to define a classification system according to the degree of eye prominence. A total of 43 patients undergoing lower lid or midfacial rejuvenation were included in the study. Preoperative parameters, including vector analysis, laxity, scleral show, rotational deformity, lateral canthus-to-lateral orbital rim distance, lateral-to-medial canthal distance, and exophthalmometry measurement, were documented. Intraoperatively, techniques including horizontal shortening and lateral canthoplasty placement were documented. Postoperative evaluation included scleral show, rotational deformity, and lateral-to-medial canthal distance. The proposed morphologic classification system divided patients into four groups on the basis of their degree of prominence, as measured by exophthalmometry, defined as deep-set (<14 mm), normal (15 to 17 mm), moderately prominent (18 to 19 mm), and very prominent (>20 mm). Operative techniques were different between the groups, with correction of laxity in the deep-set eyes and accentuated overcorrection of scleral show in the prominent eyes. The use of an exophthalmometer to classify patients before blepharoplasty may help reduce the risk of complications by identifying high-risk patients.     

Lower blepharoplasty using bony anatomical landmarks to identify and avoid injury to the inferior oblique muscle

In the resection of redundant orbital fat during lower blepharoplasty, selective excision is performed from the medial, central, and lateral compartments. During transcutaneous blepharoplasty, the inferior oblique muscle is susceptible to injury because of its intimate association between the medial and central compartments. When performing a transconjunctival approach, the inferior oblique muscle is even more susceptible to injury because it lies in the direct path of dissection for fat pad exposure. Injury to the inferior oblique muscle can result in symptoms ranging from transient diplopia to a more debilitating permanent strabismus. Fresh cadaver heads were used to identify bony anatomical landmarks that would help to more accurately define the origin and body of the inferior oblique muscle. The orbital rim, infraorbital foramen, and supraorbital notch were chosen as guideline landmarks. The origin of the inferior oblique muscle was designated with respect to the above structures, and the muscle course was delineated. The inferior oblique muscle originates on the orbital floor, 5.14 +/- 1.21 mm posterior to the inferior orbital rim, on a line extending from the infraorbital foramen to 10 +/- 0.9 mm inferior to the supraorbital notch along the supramedial orbital rim. The muscle belly extends from this origin to its insertion into the posterolateral globe in an oblique direction toward the lateral canthal area. Identification of the orbital rim, infraorbital foramen, and supraorbital notch more accurately localizes the origin and course of the inferior oblique muscle, which may facilitate fat resection during lower blepharoplasty by preventing morbidity associated with inferior oblique muscle injury.     

Temporal brow lift using botulinum toxin A

The objective of this study was to determine whether brow elevation occurs as a result of paralysis of brow depressors after botulinum toxin A injection. The study's design was a prospective case series with pretreatment and posttreatment outcome evaluation with statistical analysis at a university-based division of facial plastic surgery private clinic. Twenty-two patients of a consecutive sample desiring a cosmetic enhancement underwent injection of botulinum toxin A directed to brow depressors. Injections consisted of 7 to 10 units of botulinum toxin A (Botox, Allergan, Irvine, Calif.) into selected brow depressor muscle (lateral orbicularis oculi) bilaterally. No patients withdrew for adverse effects. All patients were evaluated 2 weeks after treatment. The outcomes were measured by change in brow elevation along vertical axis extending from both midpupil and lateral canthus to the caudal row of brow hairs with eyes at neutral gaze and the head at Frankfort plane. Preintervention and postintervention brow height was measured by the primary clinical investigator. The average brow elevation from the midpupil observed after selected injection of brow depressors with botulinum toxin A was 1.02 mm (p = 0.038). The average brow elevation from the lateral canthus observed after selected injection of brow depressors with botulinum toxin A was 4.83 mm (p<0.0001). Significant temporal brow elevation occurs as the result of paralysis of brow depressors by using botulinum toxin A injection. This procedure may be considered an alternative to surgical brow elevation.     

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.     

Improving periorbital appearance in the "morphologically prone"

Patients with prominent eyes are predisposed to lower lid descent and rounding of the palpebral fissure. This deformity may be exaggerated and symptomatic after conventional lower blepharoplasty. Normalization of the periorbital appearance in "morphologically prone" patients involves three basic maneuvers. Augmenting the projection of the infraorbital rim with an alloplastic implant effectively changes the skeletal morphology, thereby providing support for the lower lid and midface soft tissues. Subperiosteal freeing and elevation of the lower lid and midface recruits soft tissues and allows lower lid repositioning. Lateral canthopexy restores palpebral fissure shape and provides additional lid support. The technique can be adapted for morphologically prone patients who are first seeking improvement in their periorbital appearance or for those whose lid malposition and round eye appearance have been exaggerated by previous lower blepharoplasty. This surgery has been effective treatment for 13 morphologically prone patients operated on over a 4-year period.