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.     

Lower eyelid reconstruction with the upper eyelid rotation flap

A new technique of lower eyelid reconstruction was developed by using an ipsilateral upper eyelid rotation flap. After resection of a tumor in the lower eyelid, it is possible to replace the defect by a full-thickness upper eyelid rotation flap. Knowledge of exact eyelid anatomy is necessary to perform this kind of operation. In addition to the well-known techniques, the rotation flap constitutes a complete anatomic reconstruction of the lower eyelid with no functional loss of the upper eyelid.     

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.     

Lower eyelid reconstruction with a conchal cartilage graft

A conchal cartilage graft without skin or mucosa was used as a posterior lining for lower eyelid reconstruction in seven patients. The raw surface of the graft was smooth enough to cause no corneal irritation and was epithelialized from the surrounding mucosa about 3 to 4 weeks after the operation. The lower eyelid reconstructed in this method produced a stable lid margin.     

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.     

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.     

Radical excision of huge angioma of face, with reconstruction: case report.

We present a case of a massive angioma of the face treated by radical excision and subsequent reconstruction. At present the patient feeds normally, she speaks well, and she is taking a post-graduate course in mining engineering.     

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

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

A new Middle Miocene tarsier from Thailand and the reconstruction of its orbital morphology using a geometric-morphometric method

Tarsius is an extant genus of primates endemic to the islands of Southeast Asia that is characterized by enormously enlarged orbits reflecting its nocturnal activity pattern. Tarsiers play a pivotal role in reconstructing primate phylogeny, because they appear to comprise, along with Anthropoidea, one of only two extant haplorhine clades. Their fossils are extremely rare. Here, we describe a new species of Tarsius from the Middle Miocene of Thailand. We reconstructed aspects of its orbital morphology using a geometric-morphometric method. The result shows that the new species of Tarsius had a very large orbit (falling within the range of variation of modern Tarsius) with a high degree of frontation and a low degree of convergence. Its relatively divergent lower premolar roots suggest a longer mesial tooth row and therefore a longer muzzle than in extant species. The new species documents a previous unknown Miocene group of Tarsius, indicating greater taxonomic diversity and morphological complexity during tarsier evolution. The current restriction of tarsiers to offshore islands in Southeast Asia appears to be a relatively recent phenomenon.