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.     

Lateral subcutaneous brow lift and interbrow muscle resection: clinical experience and anatomic studies

The authors report consistent improvement in 65 patients with lateral brow ptosis by using a lateral subcutaneous brow lift at the temporal hairline. In 48 of these patients, vertical glabellar wrinkles were improved by the direct excision of procerus, corrugator, and orbicularis muscles through 3-mm medial brow incisions. Anatomic dissections in 10 cadavers and examinations of 50 skulls were used to study the location of the supraorbital and supratrochlear nerves. Dissections revealed that the supratrochlear nerve was never closer than 1.6 cm to the midline at the level of the supraorbital ridge. In no dissection was a supratrochlear foramen noted. Lateral subcutaneous brow lift was consistently successful in elevating the lateral brow. In no patient was nerve damage to the supraorbital nerve noted. In most patients, the temporal hairline was improved by excising a triangle of balding scalp. Through 3-mm medial brow incisions, the interbrow musculature can be excised by using a small rongeur in an area 3.2 cm wide without risk of nerve damage, improving vertical glabellar wrinkles.     

Correction of lateral brow ptosis: a nonendoscopic subgaleal approach

The authors present their experience with a relatively uncomplicated, rapid technique for elevation of the lateral eyebrow and a simultaneous correction of eyelid hooding that is secondary to the descent of the eyebrow. The procedure is designed for all patients requiring lateral brow elevation, either separately or in combination with other procedures. The authors describe and illustrate their technique.     

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.     

Subperiosteal brow lifts without fixation

Most surgeons today advocate an endoscopic subperiosteal brow lift for surgical correction of the upper third of the face. At the author's clinic, this operation has been performed since 1994 and the subgaleal bicoronal brow lift is no longer used. In earlier investigations, the author showed that the subperiosteal approach (n = 60) gives a better result than the subgaleal method (n = 60) when compared 1 year after surgery. In the literature, however, there are no published data regarding the long-term results of subperiosteal brow lifts. The author took material from his earlier investigations and looked at the same patients 5 years postoperatively. He compared the subperiosteal approach (n = 30) with the subgaleal brow lift (n = 15) and found that after 5 years the brows of the subgaleal patients were on the same level as they were before surgery, but in the group of subperiosteal brow lifts, almost all of the brows were higher 5 years after surgery than they were 1 year after surgery, with a mean increase in height of 2.5 mm. These findings led the author to the question whether scalp fixation was necessary at all when performing a subperiosteal brow lift. He performed 20 subperiosteal endoscopic brow lifts where scalp fixation was not used at all, relying only on changing the balance of muscle vectors around the eyebrows. Using a computerized instrument, measurements were made of the distance between the medial canthus and the top of the eyebrow, the midpupil and the top of the eyebrow, and the lateral canthus and the top of the eyebrow. All patients were measured before and 1 year after surgery. The author found an increase of the vertical height from the midpupil to the top of the brow, with an average increase of 3.9 mm. There were no differences between patients who had only a brow lift and those who had a brow lift and an upper blepharoplasty at the same time. The author concludes that for most cases where an increased vertical height of the brows of more than 4 mm is not needed, it is not necessary to use scalp fixation to achieve a natural result.     

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.     

Transcoronal blepharoplasty.

Some of the patients requesting blepharoplasty have a combination of excessive eyelid fat and brow ptosis but little or no dermatochalasis. Coronal brow lift, combined with transcoronal fat removal, serves these patients well. The prelevator fat pocket is easily entered from above by incising the periosteum of the anterior orbital roof just inside the orbital rim. Since the orbital septum and anterior lamella of the eyelid rim remain undisturbed, the result appears natural. Contraindications to the procedure include significant medical pocket fat and hair patterns that would exclude a coronal or hairline incision. Two complications, unilateral ptosis and unilateral chemosis, were temporary and totally reversible. Minor changes in the procedure have prevented the recurrence of these problems.     

Anatomical structure of the buccal fat pad and its clinical adaptations

Before performing plastic and aesthetic surgery around the buccal area, the authors reviewed the anatomical structures of the buccal fat pad in 11 head specimens (i.e., 22 sides of the face). The enveloping, fixed tissues and the source of the nutritional vessels to the buccal fat pad and its relationship with surrounding structures were observed in detail, with the dissection procedure described step by step. The dissection showed that the buccal fat pad can be divided into three lobes-anterior, intermediate, and posterior-according to the structure of the lobar envelopes, the formation of the ligaments, and the source of the nutritional vessels. The buccal, pterygoid, pterygopalatine, and temporal extensions (superficial and profound) are derived from the posterior lobe. The buccal fat pad is fixed by six ligaments to the maxilla, posterior zygoma, and inner and outer rim of the infraorbital fissure, temporalis tendon, or buccinator membrane. Several nutritional vessels exist in each lobe and in the subcapsular vascular plexus forms. The buccal fat pads function to fill the deep tissue spaces, to act as gliding pads when masticatory and mimetic muscles contract, and to cushion important structures from the extrusion of muscle contraction or outer force impulsion. The volume of the buccal fat pad may change throughout a person's life. Based on the findings of the dissections, the authors provide several clinical applications for the buccal fat pad, such as the mechanism of deepening the nasolabial fold and possible rhytidectomy to suspend the anterior lobe upward and backward. They suggest that relaxation, poor development of the ligaments, or rupture of the buccal fat pad capsules can make the buccal extension drop or prolapse to the mouth or subcutaneous layer. As such, the authors refined their methods and heightened their focus when using the buccal fat pad to perform a random or pedicled buccal fat pad fat flap or to correct a buccal skin protrusion or hollow.     

Bending but not breaking the supraorbital bar

Surgical bending or contouring of the supraorbital bar may cause inadvertent fractures during craniofacial surgery. Wires may be placed in the bony segments themselves to facilitate reshaping with the Tessier rib bender. The wires are especially helpful in stabilizing the more acute curve at the lateral orbital rim.     

The brow slide: a technique for the aesthetic treatment of eyebrow tumors.

Skin neoplasms involving the eyebrow are not an uncommon problem. Standard surgical resections that depend on elliptical excision and closure tend to either remove an excessive amount of brow or place scars in an unfavorable position. We present a simple technique that allows for maximal brow preservation, alignment of remaining brow, and a minimal amount of exposed scars.     

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.     

Morphology and relationships of the orangutan fatty cheek pads

The present paper examines the anatomical relationships as well as possible developmental and functional relationships of the fatty cheek pad characteristic of the adult male orangutan. The research involves the dissection of 11 orangutans of both sexes in a variety of age categories. All specimens possess either a fat pad or a subcutaneous connective tissue fascial compartment in the lateral face extending superiorly from slightly above the inferior border of the mandible to the temporal region. In immature specimens as well as adult females, fat deposits within the connective tissue compartment are scarce or nonexistent, whereas pubescent male specimens or older possess accumulations of fibro-fatty tissues in this region. The extensive fat accumulations of the adult male cheek flange are related to age and sex and to modifications in related facial musculature, especially mm. platysma, zygomaticus, orbicularis oculi, and orbitotemporalis and frontalis. These muscles are clearly related to the cheek pad structures in both sexes but appear to assume a supportive role in the males. The cheek pad has no direct bony attachments, but its mass may have a significant effect on facial morphology. The development of the cheek pad is temporally variable and its function remains speculative although the presence of a fully developed flange may be related to behavioral modifications.     

The anatomy and clinical applications of the buccal fat pad

The buccal fat pad is an anatomically complex structure that has great importance in facial contour. In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in facial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh cadaver dissection, the anatomy of the buccal fat pad is delineated and its relationship to the masticatory space, facial nerve, and parotid duct is defined. An intraoral approach for buccal fat harvesting is described based on these anatomic findings. Clinical experience manipulating the buccal fat pad for aesthetic modification of facial contour is illustrated.     

5 alpha-reductase activity in rat adipose tissue

We measured the 5 alpha-reductase activity in isolated cell preparations of rat adipose tissue using the formation of [3H]dihydrotestosterone from [3H]testosterone as an endpoint. Stromal cells were prepared from the epididymal fat pad, perinephric fat, and subcutaneous fat of male rats and from perinephric fat of female rats. Adipocytes were prepared from the epididymal fat pad and perinephric fat of male rats. Stromal cells from the epididymal fat pad and perinephric fat contained greater 5 alpha-reductase activity than did the adipocytes from these depots. Stromal cells from the epididymal fat pad contained greater activity than those from perinephric and subcutaneous depots. Perinephric stromal cells from female rats were slightly more active than those from male rats. Estradiol (10(-8) M), when added to the medium, caused a 90% decrease in 5 alpha-reductase activity. Aromatase activity was minimal, several orders of magnitude less than 5 alpha-reductase activity in each tissue studied.     

Subperiosteal and full-thickness skin rhytidectomy

Subperiosteal lateral brow and midface elevation, upper lid blepharoplasty, transconjunctival retroseptal fat removal, lower lid skin excision, and full-thickness skin rhytidectomy are combined in one operation to rejuvenate the entire face. This combination of procedures is designed to restore both anthropometric and subjective attributes of youth. The attributes of a youthful face may be summarized as brows with an apex lateral slant, eyes that are narrow, lower lids that are short, cheeks that are full, and necks that are well defined. In addition to restoring a youthful appearance, the techniques described avoid some common iatrogenic sequelae of facial rejuvenative surgery. In a clinical experience with 28 patients over 3 years, this combination of procedures has proved to be safe and predictable.     

Patterns on the Face: The Eyebrow Flash in Crosscultural Comparison

255 instances of “brow raise” filmed in three cultures in unstaged social interactions were analyzed on different levels using the “Facial Action Coding System” (FACS, Ekman & Friesen 1978). Contraction and slackening of the M. frontalis, pars medialis et lateralis are involved, and show temporal constancy in all three cultures, creating a pattern with a typical movement configuration. This configuration is discussed as a universal prerequisite for stimulus generation perception. The total time of contraction varies with contextual features, and brow raise in openings is longer than during interactions. An analysis of co-occurrence of other facial movements showed universal patterns occurring in all three cultures. Brow raise is most often accompanied by a smile. The antithesis of this “eyebrow flash”, both in neuromuscular and semantic aspect, is brought about by the action of the M. corrugator supercilii, lowering the brows and pulling them together. In addition, a set of functional patterns could be identified in all three cultures, ranging from a factual “yes” to a “yes to social contact”. Thus, the eyebrow flash can be interpreted as a “social marking-tool” which emphasizes the meaning of other facial cues, head movements and even verbal statements.     

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.     

Influence of dietary macronutrient composition on adiposity and cellularity of different fat depots in Wistar rats

The aim of this study was to investigate the role of dietary macronutrient content on adiposity parameters and adipocyte hypertrophy/hyperplasia in subcutaneous and visceral fat depots from Wistar rats using combined histological and computational approaches. For this purpose, male Wistar rats were distributed into 4 groups and were assigned to different nutritional interventions: Control group (chow diet); high-fat group, HF (60% E from fat); high-fat-sucrose group, HFS (45% E from fat and 17% from sucrose); and high-sucrose group, HS (42% E from sucrose). At day 35, rats were sacrificed, blood was collected, tissues were weighed and fragments of different fat depots were kept for histological analyses with the new softwareAdiposoft. Rats fed with HF, HFS and HS diets increased significantly body weight and total body fat against Control rats, being metabolic impairments more pronounced on HS rats than in the other groups. Cellularity analyses usingAdiposoft revealed that retroperitoneal adipose tissue is histologically different than mesenteric and subcutaneous ones, in relation to bigger adipocytes. The subcutaneous fat pad was the most sensitive to the diet, presenting adipocyte hypertrophy induced by HF diet and adipocyte hyperplasia induced by HS diet. The mesenteric fat pad had a similar but attenuated response in comparison to the subcutaneous adipose tissue, while retroperitoneal fat pad only presented adipocyte hyperplasia induced by the HS diet intake after 35 days of intervention. These findings provide new insights into the role of macronutrients in the development of hyperplastic obesity, which is characterized by the severity of the clinical features. Finally, a new tool for analyzing histological adipose samples is presented.     

The development of the vermiculate pattern in the brow region of crania from Indian Knoll, Kentucky

A convoluted brow surface consisting of fine ridges, grooves, and depressions, first identified in ancient fossil hominids and termed the vermiculate pattern (VP), is often low in frequency and of moderate rugosity in crania of anatomically modern human populations. Burials at Indian Knoll, Kentucky, constitute an excellent series for study of the development of the VP, since cranial surfaces are usually well preserved, there are hundreds of immature and mature individuals previously assessed for age, and the VP is high in frequency and rugosity. While a surface pattern resembling a miniature VP is found on the supraorbital surface of all newborns, it is not found on any children age 2 or older. This newborn pattern is probably different in structure and origin from the adult VP. The smooth surface characteristic of children shows evidence of changing to the VP in some adolescents, but the fullest development of the VP occurs in adults. The VP continues to develop in rugosity into the fourth decade, especially in males. These observations indicate that the human VP is different in etiology from somewhat similar brow surfaces found sporadically in immature individuals of some species of nonhuman primates. Statements lumping all vermiculate bone surfaces as "fine cancellous bone" are premature. The human VP development shows no apparent relationship to phases of tooth eruption, as postulated for the appearance of areolar surfaces on brow ridges of immature non-human primates.