Transconjunctival Capsulopalpebral Fascia Fixation for the Correction of Orbital Fat Bulging

PURPOSE: The orbital fat bulging may cause irregular contour of lower eyelid, which is not youthful appearance. The conventional method of fat excision may cause the eyeball to move backward and downward, making enopthalmia is inevitable. The transcutaneous approach to reach the orbital septum can increase the risks of scleral show resulting from scarification at the level of the septum orbicularis junction and damaging the vertical motor branches of the preseptal orbicularis oculi muscle of the lower eyelid. METHODS: From July 2007 to March 2008, total of 21 patients underwent transconjunctival capsulopapebral fascia fixation procedure. In 8 patients, the herniated fat pad of the lower eyelid was relocated back into the orbit without external skin excision using capsulopalpebral fascia fixation. But in 13 patients, excision of redundant skin of the lower eyelid was performed using pinching technique, not involving orbicularis oculi muscle. In 5 patients, lateral canthotomy was done bilaterally for good visual field. In 6 patients, lateral canthopexy was also combined to correct loosening of lower eyelid. RESULTS: Most of the patients were satisfied after at least 5 months of follow up. No patient showed scleral show. But 2 patients complained of undercorrection slightly, without secondary operation in 1 patient and re- capsulopalpebral fascia fixtation through transconjunctival approach in another patient. CONCLUSION: Orbital fat repositioning using transconjunctival capsulopalpebral fascia fixation is a good procedure to maintain youthful appearance without increasing the risk of scleral show and also showed fast recovery compared to the conventional transcutaneous approach.

Spacer Graft Combined with Canthal Sling in Paralytic Ectropion

Lower eyelid retraction and ectropion is a result of two factors; (1) weakened intrinsic forces associated with senile change or (2) from extrinsic forces by the augmented distraction activity as a result from scar contracture after surgery, laser therapy, or trauma. Facial nerve palsy, in patients with leprosy, causes paralysis of the orbicularis muscle. Its antagonizing muscles, namely, the levator of the upper lid and the capsulopalpebral fascia of the lower lid, function as normal. This counterbalance results in lagophthalmos and retraction of the eyelids. Conventional surgical methods used to correct the ectropion and retraction of the lower lid include lateral canthoplasty, lateral canthopexy, lateral tarsal strip procedure and medial tarsorrhaphy. Recently the use of spacer graft has been incorporated in treating lower eyelid retraction. The use of spacer grafts creates separation between the tarsal plate and the capsulopalpebral fascia, to introduce materials like palatal mucoperiosteum, conchal cartilage or AlloDerm into the space between the two structures. In this study, we designed as AlloDerm or deep temporal fascia graft to function not only as a spacer graft but also as canthal sling. The use of a long spacer graft-sling to supplement the canthal sling showed superior results in elevating the lower eyelid and reducing ectropion. The use of the spacer graft in this method is more effective than other conventional methods.

Spacer graft combined with canthal sling in paralytic ectropion(Part 2) / 나학회지

The lower eyelid descent and ectropion is resulted from either a decrease in intrinsic forces by senile change or an increase in extrinsic forces by the augmented distraction activity as a result of surgery, laser therapy, or trauma. Although facial nerve palsy in patients with leprosy causes paralysis of the orbicularis muscle, its antagonizing muscles, namely, the levator of the upper lid and the capsulopalpebral fascia of the lower lid, are functioning properly, resulting in lagophthalmos and retraction of the eyelids. There are various conventional surgical methods to correct the ectropion and retraction of the lower lid such as lateral canthoplasty, lateral canthopexy, lateral tarsal strip procedure as well as medial tarsorraphy. Spacer graft, recently introduced, is used to create separation between the tarsal plate and the capsulopalpebral fascia, and to insert maerials like palatal mucoperiosteum, conchal cartilage or Alloderm into the space between the two structures. In this study, we added to one more process to the routine procedure, canthal sling, in which two ends of lengthened Alloderm by 15mm were fixed to both canthal ligaments like a fascial sling. Spacer graft combined with concomitant cnathal sling was proven to be effective in elevating and reducing retraction of the lower lid, and to be superior to any other conventional methods.

The Lower Eyelid Movement by Inferior Oblique Muscle Action According to the Age

PURPOSE: There have been few studies on the dynamic analysis of lower eyelid movement. The inferior oblique muscle deep in the inferior orbit is well connected with the extraocular muscle by capsulopalpebral fascia and is involved in the lower eyelid movement. The purpose of this study was to determine the graphical equation of the lower eyelid contour and to quantify the dynamic movement of the lower eyelid at primary gaze and inferior oblique action gaze in normal eyes according to age, as such findings have never been reported before. METHODS: One hundred and forty subjects who had no previous eye or eyelid disease and surgery, aged from 5 to 68 years (35.75+/-30.59 years) were enrolled and divided into 7 age groups. We analyzed digital camera images to obtain the lower eyelid curvature and traveling distance of the lowest point of the lower eyelid accompanied by the action of the inferior oblique muscle. RESULTS: Graphical analysis presented the relationship of the cubic equation resembling the lower eyelid contour. The curvature of the lower eyelid at the gaze of inferior oblique muscles action became flatter than that of the primary position in all age groups. The lowest point of the lower eyelid moved significantly to the medial position and up from the primary gaze at the gaze of the inferior oblique muscles action in all age groups. There was no difference in traveling distance of the lower eyelid at each direction between sexes and age groups. CONCLUSIONS: The lower eyelid movements associated with the inferior oblique muscle are believed to be innate. We suggest that the digital image analysis of the lower eyelid contour will be useful to analyze the lower eyelid movements.

No title available / 나학회지

The lower eyelid is anatomically composed of three layers consisting of the anterior lamellar, the middle lamellar and the posterior lamellar. The anterior lamellar is composed of skin and the orbicularis muscle. The middle lamellar is composed of the orbital septum and orbital fat. The posterior lamellar is composed of the tarsus and the capsulopalpebral fascia and conjunctiva. The function of the lower eyelid is dependent upon a net result of balanced forces from the tarsal plate, canthal tendon and the orbicularis muscle sling acting on the lower eyelid. These forces provide the intrinsic support required to maintain contact between the lower eyelid and the globe. Forces acting against the intrinsic support of the lower eyelid (extrinsic forces) provide inferior and anterior net vector from the globe. The normal anatomic function and aesthetic appearance of the eyelid is achieved when the intrinsic forces are greater than or equal to extrinsic forces. The lower lid descent and ectropion characterized by unfavorable imbalance are a result of either a decrease in intrinsic forces by weaking the support as in senescence or an increase in extrinsic forces by strengthening the distraction forces as a result of surgery, laser treatment, or trauma. Either way, the extrinsic forces become greater than intrinsic forces. Facial nerve palsy of a leprosy patient causes paralysis of the orbicularis muscle but its antagonistic action muscles (the levator muscle of the upper lid and the capulapalpebral fascia of the lower lid) are functioning resulting in retraction and lapophthalmus of the upper and lower eyelid. Ectropion and retraction in the lower eyelid require various traditional surgical methods such as cantopexy, canthoplasty, lateral tarsal strip procedure as well as medial tarsorrhaphy. In addition to traditional methods, we used a spacer graft consisting of hard palate mucosa or Alloderm. Spacer grafts can be used in either a posterior or anterior method. In the posterior method, the spacer graft is used to create separation between the tarsal plate and the capsulopalpebral fascia / conjunctiva structure. A 5 to 25mm elliptical strip of hard palate mucosa is harvested from the patient and insterted between the two structures. The conjunctiva is dissected in this procedure. In the anterior method, we disinserted the lower edge of the tarsus and the capsulopalpebral fascia. A 5 to 25mm elliptical shaped strip of Alloderm was then inserted between the two structures. The conjunctiva remains intact in this procedure. In addition, a 5 to 35mm Alloderm strip was inserted to immitate the function of the fascia sling and increase the elevation of the lower lid as a spacer graft. The spacer graft with traditional surgical methods was more effective in elevating the lower lid and significantly reducing retraction than using traditional methods alone.

The Capsulopalpebral Fascia Repair for Senile Entropion

PURPOSE: We report that simple capsulopalpebral fascia (CPF) repairs were effective when patients diagnosed as senile entropion had the disinsertion lines of the CPF on everted lower conjunctivas (demarcation line). METHODS: Twenty patients (27 eyes) who had demarcation lines and showed no severe horizontal lid laxity were operated for senile entropion during the period March 1, 1996 to July 30, 2001. After subciliary skin incision, the disinserted CPF was identified and repaired by reattaching the superior edge of the CPF to the inferior edge of the lower tarsus. RESULTS: This procedure was performed on 27 eyes of 20 patients (women 11, men 9, average age 68.6 years). We followed up the patients from 3 to 30 months after surgeries (average 7.8 months). Two patients showed complications, one was conjunctival prolapse and the other was recurrence of entropion. CONCLUSIONS: Simple capsulopalpebral fascia (CPF) repairs gave good results in patients with senile entropion who had disinsertion lines of the CPF on everted lower conjunctiva (demarcation line) without severe horizontal lid laxity. Moreover this procedure had shorter operation and recovery times compared with other combined surgeries.