Avoiding Pretarsal Denervation in Lower Blepharoplasty Incisions: Refined Pretarsal Motor Nerve Anatomy.

BACKGROUND: Pretarsal atrophy is not uncommonly found in patients who have undergone a transcutaneous or transconjunctival lower blepharoplasty due to intraoperative denervation of the pretarsal orbicularis oculi. The motor supplying concept to the lower eyelid was recently updated, however, there have not yet been any guidelines to preserve motor nerves in lower blepharoplasty incisions based on the refined knowledge. METHODS: 46 fresh cadaveric hemifaces were examined to find a safe zone for a lower blepharoplasty muscle incision and a danger zone for an infraorbital incision in the transblepharoplasty midface approach. Additionally, practical anatomy about the pretarsal motor supply was also investigated in detail. RESULTS: The medial, lateral, superior, and inferior borders of the safe zone for a lower blepharoplasty muscle incision were 9.4 mm from the medial canthus line, 3 mm from the lateral canthal crease, and 6.0 and 6.5 mm from the eyelid margin, respectively. The danger zone for an infraorbital incision ranged from 9.4 mm medial to the midpupillary line to 9.7 mm lateral to the midpupillary line. The motor nerve in the danger zone abutted the distal roof of the preseptal pocket making it vulnerable to electrocautery heat. Motor nerve distribution of the lower pretarsal orbicularis oculi was fully identified. CONCLUSION: There is a safe zone for the lower blepharoplasty muscle incision which if adhered to will preserve the pretarsal motor supply and prevent muscle atrophy. There is an infraorbital danger zone, where surgeons should pay special attention to avoid electrocautery heat injury.

How the Lifting Amount of Endoscopic Brow Lifts Is Influenced by Supraorbital Nerve Tension and Brow Gliding-Layer Mobility.

BACKGROUND: Sensory nerve tension and gliding-layer mobility in the brow may be significant factors affecting postoperative brow level in an endoscopic brow lift, yet they have rarely been studied. METHODS: To investigate the effects of sensory nerve tension and gliding-layer mobility, the following measurements were performed alongside the endoscopic brow lift in 50 fresh cadaveric hemifaces: amount of brow elevation, critical lifting amount (as sensory nerves became tense), laxity of sensory nerve courses, and mobility of brow-gliding layers. The sensory nerve situations in the subperiosteal and subgaleal dissections were also observed. RESULTS: Supraorbital nerve tension limited the cephalic advancement of the forehead flap. The mean elevation of the brow was 5.8 ± 1 mm (range, 3.5 to 8.6 mm). The mean critical lifting amount was 5.3 ± 1.1 mm (range, 4.0 to 7.3 mm). The mean amount of laxity in the supraorbital nerve (the permissible amount of lift) was 4.1 ± 0.9 mm (range, 2.5 to 5.5 mm). The galeal fat pad was responsible for 60% of brow mobility. The sensory nerve was more protected by a subgaleal dissection in the brow and inferior forehead and by a subperiosteal dissection in the middle and upper forehead. CONCLUSIONS: Cephalic movement of the forehead flap is limited by supraorbital nerve tension. The permitted lifting amount varies from 2.5 to 5.5 mm. Gliding-layer mobility in the brow offsets the postoperative amount of cephalic advancement of the forehead flap. Consideration of supraorbital nerve tension and gliding-layer mobility is recommended to obtain an optimal brow level in endoscopic brow lifts.

Refined Concept of Motor Supply to the Medial Periorbital Area Relevant to Periorbital Surgery.

BACKGROUND: Mimetic muscles in the medial periorbital area have been thought to be innervated solely by the angular nerve. Recently, however, the upper medial palpebral branch and lower palpebral branch were reported as additional motor suppliers in this area. This study aimed to define all the motor nerve systems passing through the medial canthal area. METHODS: Motor nerve branches that passed through the medial canthal region were identified and traced thoroughly from the parotid gland to their destinations under a surgical microscopic field in 74 hemifaces. The courses, anatomical positions of, and anatomical relationships between the angular nerve and the upper medial palpebral branch were observed. RESULTS: The upper medial palpebral branch and the angular nerve were found in all samples within a 3-mm to 6-mm area lateral to the intersecting point of the medial orbital rim and medial canthal ligament. The upper medial palpebral branch supplied the upper eyelid, whereas the angular nerve supplied the extraorbicularis muscles in the medial periorbital area. The medial pretarsal area of the upper eyelid was supplied solely by the pretarsal branches of the upper medial palpebral branch, which was formed by uniting three or four minor branches that traveled throughout the anterior cheek. CONCLUSIONS: Two separate motor nerve systems, the upper medial palpebral branch and the angular nerve, exist in the medial canthal area. The upper medial palpebral branch course along the medial orbital rim is considered as a facial nerve danger zone.

Distribution of the Laterally Supplying Facial Nerve to the Orbicularis Oculi Muscle.

BACKGROUND: The facial nerve that traverses the lateral border of the orbicularis oculi muscle is considered the primary motor for the muscle. Nevertheless, the lateral motor supply to the orbicularis oculi muscle has not yet been fully described. OBJECTIVES: The aim of this study was to report detailed anatomic information about the lateral motor supply route to the orbicularis oculi. METHODS: Facial nerve branches that cross the lateral orbicularis oculi border were fully traced from the parotid border to the nerve destinations in 43 fresh hemifaces by microscopic surgical dissection and time-lapse photography. RESULTS: Through the lateral route, the anterior temporal and upper zygomatic branches supply the superior orbital and superior preseptal orbicularis oculi of the upper eyelid, as well as the lateral pretarsal and malar orbicularis oculi, excluding the upper medial pretarsal portion of the upper eyelid and most of the lower eyelid. The nerve supplying the lateral pretarsal orbicularis oculi muscle crosses the anterior area of the zygomatic arch. It then traverses an area 6 mm above and 4 mm below the lateral canthal crease. CONCLUSIONS: The anterior area of the zygomatic arch and an area 6 mm above and 4 mm below the lateral canthal crease are the facial nerve danger zones. The present anatomic findings provide surgeons with further insights for performing blepharoplasty, midface lift, facelift, and facial nerve reconstructive surgery.

Facial Nerve Supply to the Orbicularis Oculi around the Lower Eyelid: Anatomy and Its Clinical Implications.

BACKGROUND: The motor innervation of the lower orbicularis oculi has not been clearly established. There is a discrepancy between anatomical descriptions and clinical outcomes of the motor innervation of the pretarsal orbicularis oculi muscle. Therefore, the purposes of this study were to identify every motor and sensory nerve of the lower eyelid, and to reveal the detailed motor nerve pathways toward the medial canthal area. METHODS: Fresh cadaver dissections were performed on 50 hemifaces under a surgical microscope. Submuscular and intramuscular nerves of the lower eyelid were identified, and the pathways of facial nerves that ran toward the medial canthus were traced. RESULTS: Vertical submuscular nerves at the lower eyelid originated from the infraorbital foramen, indicating that all were sensory nerves. The zygomatic branch of the facial nerve traveled obliquely through the anterior cheek and supplied the orbicularis oculi of the lower eyelid and the medial portion of the upper eyelid. Its route was defined as a clinically useful line, the medial orbicularis motor line. In addition, the nerve innervating the pretarsal orbicularis oculi arose at the superomedial preseptal area and extended horizontally and laterally. Interestingly, the angular nerve appeared not to innervate the palpebral orbicularis oculi. CONCLUSIONS: In the lower eyelid, the vertical sensory and the oblique motor nerve supplies are independent and clearly distinguished in aspect of their own routes. The medial orbicularis motor line represents the motor route to the medial portion of the orbicularis oculi. These results might provide valuable knowledge about surgical anatomy for safe lower blepharoplasty with or without midface lift.

Three Skin Zones in the Asian Upper Eyelid Pertaining to the Asian Blepharoplasty.

BACKGROUND: Natural looking double fold is an essential and aesthetically pleasing masterpiece in Asian blepharoplasty. This study aims to emphasize the 3 skin zone concept in the Asian upper blepharoplasty. METHODS: The authors examined the anterior lamella of each skin zone microscopically by performing 31 double-eyelid surgeries and 11 infrabrow lifts. Characteristics of dermal components, subcutaneous tissue, and outer fascia of OOM (OFOOM) at each skin zone were documented. The authors evaluated the vertical scales of each skin zone in young and aged Asian patients who visited the first author's clinic for the primary or secondary upper blepharoplasty with ×3.5 magnifying surgical loupe. RESULTS: The thickness of OOM had no difference among zones 1, 2, and 3. The skin and subdermal tissue had varying characteristics according to its skin zone. At zone 1, it seemed that only thin skin was on the OOM. The anterior lamella of zone 2 seemed to consist of skin, white fascia (OFOOM) including a venous network, and OOM in a gross field. At zone 3, thick skin, thick subcutaneous fatty layer, and OOM were magnified. The OFOOM of zone 3 was not significantly identified due to a sticky adherence with OOM. At the point of vertical scales of skin zone, good eyelids have lower zone 3 ratio and higher zones 1 and 2 ratio with qualified topographic condition. CONCLUSION: The authors classified the Asian upper eyelid as with 3 skin zones. Based on its anatomical investigation, the authors can afford anthropometric data and supplemental theory for the creation of aesthetic folds.

Outer Fascia of Orbicularis Oculi Muscle as an Anchoring Target Tissue in Double Eyelid Surgery.

BACKGROUND: Natural adhesion between the levator aponeurosis and the subcutaneous layer in the upper lid is essential for an aesthetically pleasing double eyelid. The study aims to emphasize the outer fascia of orbicularis oculi muscle (OFOOM) as a fixation point on the double eyelid surgery. METHODS: The authors examined the detailed anatomy of the anterior lamella microscopically during 28 cases of primary double eyelid surgery. Three cadaveric dissections were performed adjunctively to compare the dynamic status in the upper lids. Subdermal tissue components and tissue changes in the upper lids were observed in 64 eyelids from secondary revisional cases who had performed an incisional technique previously. The authors also compared the locations of threads in the anterior lamella in 36 eyelids on which a nonincisional surgery technique had previously been used. RESULTS: At the preferred crease zone in the upper lid, a definite anatomic structure, OFOOM was found between the skin and the orbicularis oculi muscle (OOM). The supratarsal creases created by the incisional technique showed that all of the anterior lamella components were fused tightly together by scar tissue. Examination of the 36 supratarsal creases created by the nonincisional technique showed that threads did not exist in the dermal layer, but were mainly within the OFOOM in 20 eyelids and mainly within the OOM layer in 16 eyelids. CONCLUSIONS: To produce satisfactory results during double eyelid surgery, the authors recommend direct suture fixation of the levator aponeurosis to the OFOOM, and not to the dermis or OOM.

Two-dimensional analysis of palpebral opening in blepharoptosis: visual iris-pupil complex percentage by digital photography.

The vertical dimension of the palpebral fissure and the marginal reflex distance are conventionally used to assess the amount or degree of blepharoptosis, and levator function is assessed by measuring total upper lid excursion between the extremes of down-gaze and up-gaze. However, these are 1-dimensional measures obtained with a ruler, and the results obtained are dependent on examiner skill. Digital photographs were obtained of 692 patients before and after upper blepharoplasty. Visual iris-pupil complex percentage (VIP) was measured in the 1,305 eyes by digital calculation using Adobe Photoshop CS3 (Adobe Systems, Inc). Perioperative eye images in primary gaze were evaluated independently by 2 surgeons, 2 nurses, and a graphic designer, and after excluding 50 eyes which were nonconcordant and 29 eyes which revealed retracted upper lids, the remaining 1,305 eyes were classified into 4 major groups, that is, into excellent (n = 415), good (n = 435), subclinical (n = 270), and prominent ptosis (n = 185) groups. In addition, eyes were subdivided into 5 types according to the iris-pupil complex position within the palpebral fissure. Visual iris-pupil complex percentages were from 85% to 94% in the excellent, from 78% to 84% in the good, from 70% to 77% in the subclinical ptosis, and below 70% in the prominent ptosis group. Patients in the subclinical or prominent ptosis eye group required surgery for blepharoptosis. Iris-pupil complex relation to the palpebral opening was classified into 5 eye types, namely, standard (n = 961), scleral (n = 266), sinking (n = 151), retracted (n = 3), and fish (n = 3). The authors devised a new prospective measurement method for assessing blepharoptosis in a clinical setting. Graphical comparisons between the devised method of measuring VIP and mathematical estimations showed that the devised method is easier, more practical, and more precise for measuring degree of blepharoptosis from general population trends, and that VIP also provides a useful objective index for evaluating the postoperative results of blepharoptosis.

A new crease fixation technique for double eyelidplasty using mini-flaps derived from pretarsal levator tissues.

BACKGROUND: Most double eyelid operations focus on using a levator insertion into the upper eyelid skin that induces adhesion. Although incision method provides a significant supratarsal fold, it has the disadvantage of causing a visible depression or scarring when eyes are closed in downward gaze. METHODS: The authors elevated multiple comblike mini-flaps from upper eyelid pretarsal levator tissues under loupe magnification. Flap bases were anchored on the tarsus using 7-0 nylon sutures, and distal flap portions were pulled out to the skin through a separate incision line and then interposed between edges of orbicularis muscle using absorbable microsutures to achieve a complete myocutaneous layer-by-layer repair. RESULTS: Five hundred twenty-two double eyelidplasties were performed by the senior surgeon (Y.C.) using the described miniflap method. Patients were followed for 6 to 38 months (mean, 26 months). Seven palpebral fold failures were encountered, especially on the medial side, and 12 cases of fold asymmetry occurred because of inappropriate anchoring of miniflaps; all 12 were revised secondarily. No granuloma formation or scar hypertrophy occurred on upper lids. Although mild erythematous skin changes inevitably occurred during the early postoperative period, patients were satisfied with the palpebral folds, which showed no scars during downward gaze at 2 years postoperatively. CONCLUSIONS: The authors introduce a modified double eyelidplasty involving the interposition of multiple comblike mini-flaps derived from the pretarsal levator tissue of the upper eyelid. The procedure not only allows clean repair of the upper eyelid without disrupting tissue layer continuity but also enables double eyelidplasty with minimal scar formation.

Tissue thread grafting: nonincisional double-eyelid operation.

Most double-eyelid operations emphasize the levator insertion into the upper eyelid skin using suture material. For supratarsal fixation, we used autogenous tissue threads from the patients' own temporal fascia, periumbilical tissues, capsulopalpebral fascia, and allogeneic human dermis. We engaged tissue threads using a newly designed Yeop's needle (AILEE Inc., BuSan, South Korea) or modified 5-0 Vicryl suture (Ethicon Inc., Somerville, NJ) material. The suture passed through the whole upper lid in the same pattern used with the conventional nonincisional technique. A total of 78 double-eyelid operations were performed. There were 53 primary cases, 22 secondary cases, and 3 tertiary cases. Tissue threads were maintained for 9.3 days on average. There were no complications regarding tissue threads, including infection or granuloma formation in the upper eyelid or at the donor site. Tissue thread grafts not only offer safe fixation of the palpebral crease, but they also incorporate safely into the eyelid tissues for scarless, natural-looking double-eyelids.