Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience.

During the past 5 years, the authors have used a direct trans-lower lid blepharoplasty subperiosteal approach to the lower lid and midface for the purpose of correction of midfacial aging in 757 patients. In a smaller but significant group, this approach has proven valuable in difficult reconstructive situations. The purpose of this article is twofold: (1) to provide a comprehensive retrospective evaluation of the value and promise of the technique and (2) to provide a comprehensive discussion of the pitfalls and complications that have been associated with use of this technique. In addition, technical modifications that may lower the rate of morbidity associated with the use of the procedure are described.

Redraping the inferior orbicularis arc.

The surgical technique of redraping of the inferior arc of the orbicularis oculi muscle is used primarily to produce lower lid and midfacial smoothing in patients undergoing aesthetic surgery. The midfacial fat compartments, suborbicularis oculi fat and malar fat, are bound to the orbicularis muscle by the superficial muscular aponeurotic system so that redraping the orbicularis muscle also repositions the midface. Orbicularis arc redraping should be accompanied by lateral canthoplasty to ensure stability to the shape of the eyelid fissure postoperatively. Modifications in orbicularis redraping and canthoplasty technique are necessary in patients with prominent eyes and distensible lower lids. Supraplacement of canthal fixation is needed in patients with prominent eyes, and lid shortening is needed in patients who have distensible lower lids. This technique also can be used in patients undergoing reconstructive surgery for correction of lower lid retraction because of its ability to recruit periorbital skin upward into the lower lid. For more severe cases of lower lid retraction after aesthetic surgery, adjunctive procedures such as spacer implants in the lower lid and periosteal flap canthoplasty can be used together with the orbicularis arc redraping to rehabilitate patients.

The correction of lower lid malposition following lower lid blepharoplasty.

Lower eyelid malposition is the most common complication following lower eyelid blepharoplasty. This may take the form of a mild scleral show with the round eye syndrome or may progress to frank ectropion in some patients. When this problem occurs, it is imperative to soothe an already distressed patient by correcting the malposition by the most efficient method. A horizontal tightening of the lower lid at the lateral canthus can be helpful in many patients; however, in the more severe cases or in those in which the medial component is prominent, this procedure may not give the best correction. It is preferable to avoid using autogenous grafts in these patients because in most cases they will induce another incision line with potential deformity and, more important, are perceived by these sensitive patients as being more of an involved procedure. The preserved fasciae latae sling is an alternative procedure which is effective in the more severe cases of postblepharoplasty lower eyelid malposition, particularly in those cases in which the medial component of malposition is prominent.

The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure.

We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.

Browplasty and browpexy: an adjunct to blepharoplasty.

Surgical approaches to the eyelids and eyebrows have been refined by application of their anatomy and appreciation of their pathophysiology. Sexual variations in eyebrow appearance can be attributed in part to the eyebrow fat pad. In females, the eyebrow is generally arched and above the level of the supraorbital rim. The male eyebrow is flatter and at the level of the supraorbital rim. The eyebrow fat pad is more prominent in the male, producing a fuller appearance in the lateral brow area. Many women are concerned about the flatter, full lateral brow, which assumes a masculine quality. The authors describe a surgical technique that permits identification of the brow fat pad and then the ability to debulk the eyebrow (browplasty). In addition, the brow can be elevated by internal plication suture to physically elevate the eyebrow (browpexy). This procedure is designed to utilize an eyelid crease incision, and it reduces the indications for more involved procedures to eliminate brow ptosis, such as midforehead or coronal approaches.

Reconstruction of the anophthalmic socket: lower eyelid malposition and canthal tendon laxity.

There are a number of etiologies underlying the development of socket deformity with associated lower eyelid malposition, lateral canthal tendon laxity, and/or contraction of the inferior fornix. In addition to cosmetic considerations, each of these anatomic problems can interfere with comfortable wear and retention of a prosthesis. This chapter gives an overview of these problems and details our preferred surgical approaches to repair of these anatomic deformities. Specifically discussed are techniques for: mucous membrane and ear cartilage grafting to repair lower lid inner lamellar tissue shortage, reconstruction of the inferior fornix/cul-de-sac, direct lower eyelid lateral canthal resuspension, and resuspension using a periosteal flap or autogenous fascia lata from the iliotibial tract.

Mascara and eyelining tattoos: MRI artifacts.

Magnetic resonance imaging (MRI) is very useful in the evaluation of ocular and orbital disease. Heavy metal particles, used in the pigment base of mascara and eyelining tattoos, have a paramagnetic effect that causes alteration of the local magnetic field in adjacent tissues. These changes in normal signal result in distortion of the globes. In some cases, the distortion may mimic actual ocular disease such as a ciliary body melanoma or cyst.

Blepharochalasis.

Blepharochalasis is an uncommon disorder distinguished by recurrent episodes of eyelid oedema in young patients. A hypertrophic form, manifested as fat herniation, and an atrophic form, manifested as fat atrophy, have been described. Ptosis with excellent levator function, laxity of the lateral canthal structures with rounding of the lateral canthal angle, nasal fat pad atrophy, and redundant eyelid skin develop after many episodes of eyelid swelling. Fine wrinkling, atrophy, and telangiectasias characterise the excess eyelid skin. We describe four cases of this syndrome in which external levator aponeurosis tuck, blepharoplasty, lateral canthoplasty, and dermis fat grafts were used to correct atrophic blepharochalasis after the syndrome had run its course.

The evaluation and management of the patient with ptosis.

This article deals with fundamentals in evaluation and correction of ptosis, with some references to special situations. Ptosis defies a cookbook approach if one wishes predictable results. In a certain percentage of patients, the result will remain unpredictable and the surgeon must be prepared to perform revisional surgery.

Ganglioglioma of the optic nerve.

We examined a 15-year-old boy who had a ganglioglioma involving the left optic nerve, which caused proptosis, decreased vision, and optic atrophy. Computed tomography demonstrated an intraconal mass along the course of the orbital portion of the optic nerve. The only evidence of systemic neurofibromatosis was axillary freckling. The patient underwent a combined medial and lateral orbitotomy and excision of the tumor. Histologic examination demonstrated a mass composed of neurons and glial cells characteristic of ganglioglioma. After a one-year follow-up period, we have found no evidence of recurrence.

Aneurysmal bone cyst of the orbit.

Proptosis of the left eye had developed in a 42-year-old woman for 2 months' duration. Roentgenogram studies showed a mass in the roof of the left orbit and bone erosion. An excisional biopsy confirmed the presence of an aneurysmal bone cyst. To the authors' knowledge, the patient is the oldest reported patient who has this uncommon orbital lesion.

Chronic hematic cyst of the orbit.

Three middle-aged male patients had painless superior temporal orbital tumor causing globe displacement. Roentgenograms revealed superior temporal orbital tumor with lysis of bone. Surgical excision and curettage completely removed the lesions, which extended from the frontal bone to the periorbita and the dura. Histologically, these were cystic lesions containing a granulomatous reaction to blood breakdown products, including cholesterol clefts, hemosiderin, giant cells, and hematodin, consistent with chronic hematic cyst. A fibrous pseudocapsule formed the cyst wall.

Laser ablation of blepharopigmentation.

This article discusses laser ablation of blepharopigmentation in four stages: first, experimentally, where pigment vaporization is readily achieved with the argon blue-green laser; second, in the rabbit animal model, where eyelid blepharopigmentation markings are ablated with the laser; third, in human subjects, where the argon blue-green laser is effective in the ablation of implanted eyelid pigment; and fourth, in a case report, where, in a patient with improper pigment placement in the eyelid, the laser is used to safely and effectively ablate the undesired pigment markings. This article describes in detail the new technique of laser ablation of blepharopigmentation. Potential complications associated with the technique are discussed.

Dermis-fat graft for orbital reconstruction after subtotal exenteration.

A surgical technique for reconstruction after subtotal orbital exenteration uses an autogenous dermis-fat graft. A musculocutaneous flap is advanced over the graft to provide the anterior vascular supply for the free dermis-fat graft. The periorbita and remaining orbital tissue provide the vascular supply posteriorly. This technique eliminates extensive skin grafting and delayed spontaneous healing. Wound healing is rapid and surgical morbidity is minimized. We have used this procedure in three patients with sebaceous gland adenocarcinoma, two patients with severe posttraumatic contracted sockets, and as a palliative procedure in one patient with a fungating choroidal melanoma and widespread metastasis.

Management of complications following dermis-fat grafting for anophthalmic socket reconstruction.

Sixty consecutive cases of dermis-fat grafts for anophthalmic socket reconstruction were reviewed to examine the frequency, severity, and management of postoperative complications. In seven patients, the conjunctiva failed to resurface the graft and central ulceration developed. Ten cases resulted in enophthalmos. Two patients developed keratinized sockets with chronic discharge and desquamation. Three patients required excision of conjunctival granulomas. One patient developed a primary graft infection. A donor site hematoma occurred in one patient. Secondary surgical intervention was required in ten patients. Nine complications in eight patients were managed in the office; five complications in four patients were observed and subsequently resolved without surgical intervention. Most complications occurred in patients with severely traumatized sockets who had undergone extensive earlier ocular surgery, or who had a systemic disease contributing to defective wound healing.

Current trends in orbital decompression.

A questionnaire was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) and the Orbital Society in regard to indications, surgical techniques and results of orbital decompression for Graves' disease. It was found that more than 60% of orbital decompressions were performed for mild to severe exophthalmos to correct corneal exposure or disfigurement. A total of 3.9% of these procedures were performed to relieve visual loss in compressive neuropathy. The large majority of decompressions were performed using antral-ethmoidal decompression via a translid or fornix approach. The amount of retrodisplacement was greatest with Kennerdell-Maroon or four-wall decompression and the least with lateral wall decompression. The antral-ethmoidal and three-wall decompression techniques gave an average of 4 to 6 mm of retrodisplacement. It was determined from the survey that antral-ethmoidal decompressions performed through the transantral approach were more likely to relieve the pressure in compressive neuropathy and also more likely to induce a worsening of muscle balance. In contrast, antral-ethmoidal decompressions performed via the translid approach were not as effective in relieving compressive neuropathy but had a much lower incidence of worsened muscle balance, and in fact, resulted in a higher incidence of improved muscle balance. The same trends were confirmed in the author's surgical practice, and an anatomic explanation is offered. The importance of creating nasoantral windows following decompression is emphasized. The risks of cerebrospinal fluid leakage and changes in eyelid positioning following decompression are described.

Pressure-volume orbital measurement comparing decompression approaches.

Commonly used orbital decompressions are lateral wall, antral-ethmoidal, "three-wall," and "four-wall" decompressions. Bladders filled with saline were placed in intact bony orbits before and after decompression for comparison of compliance curves by these four methods. The lateral wall decompressions produced the least volume change, while the four-wall produced the most. The three-wall decompression provided next best pressure reduction.