TITLE: Ble= pharoplasty
SOURCE: Grand Rounds Presentation, University of Texas Medical Branch,
Dept. of Otolaryngolog= y
DATE: August 31, 2010
RESIDENT PHYSICIAN: Ryan Ridley, MD
FACULTY PHYSICIAN: Raghu A= thre, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Qui= nn, MSICS

&q= uot;This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program = of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purp= ose of stimulating group discussion in a conference setting. No warranties, eit= her express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes= of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion."

Introduction

The window to a person’s soul is oftentime= s said to be the eye. This belief ca= me about due to the multitude of expressions conveyed by the eyes. However, what many people fail to distinguish is the fact that the globe itself is void of expression yet the soft tissues and muscles around the eye are fully animated to display any emotion possible; anger, sadness, worry, joy, etc. As a person ages, these periorbital tissues and muscles undergo a process that renders them less elastic, le= ss robust, and at the mercy of gravitational forces pulling them downward. This may cause a person to appear = sad, tired, or mad when in fact they feel completely the opposite. For this reason and many others to= include a rejuvenated appearance, blepharoplasty is one= of the most commonly performed cosmetic procedures.

The Aging Process

Aging affects the skin and underlying tissues in= an intrinsic and extrinsic manner. The naturally occurring effects of time on the skin are referred to as intrinsi= c, while extrinsic factors are those such as gravity, smoking, and sun exposure that have negative effects on the skin.&nb= sp; Extrinsic factors are more controllable as opposed to intrinsic factors. Intrinsic skin chang= es include the loss of collagen and elastic fibers (elast= osis), loss of the dermal-epidermal junction, thinning of the dermis and epidermis, and weakening/thinning of the underlying muscle. These changes along with the extri= nsic alterations imposed by the sun (solar keratosis= ), smoking, and gravity result in rhytids, pigmentary changes and skin irregularities.

On a macroscopic level, aging causes brow ptosis, lateral hooding, crows feet, deep rhytids, skin laxity and loss of elasticity. Due to the fact that the eyes unve= il emotion, aging of the upper third of the face is usually of greater impact = and more noticeable and aging from the lower face. Likewise, rejuvenation of the uppe= r face will have greater impact than correction of the lower face and neck.

Eyelid Anatomy

The eyelids function as the protective covering = for the globe. The eyelid is divi= ded in to an anterior and posterior lamella. The anterior lamella consists of the eyelid skin and the orbicularis oculi muscle.= The posterior lamella is composed = of the tarsus and the conjunctiva. <= /p>

The horizontal palpebral fissure is normally 28-30mm and vertically 9-10mm. The intercant= hal distance should be 25-30mm or approximately the same distance from medial <= span class=3DSpellE>canthus to lateral canthus of the eye. The upper lid crease is = formed by the insertion of the levator aponeurosis and septum into the orbicularis oculi muscle and skin. The upper ey= elid crease should be 10-12mm from the lid margin in females and 7-8mm from the = lid margin in males. The upper ey= elid should rest at a point between the pupil and the superior corneal limbus. The inferior lid should be within 1-2mm of the corneal lim= bus or abutting the corneal limbus. Important to note, in the Asian ey= elid, the fusion of the levator = aponeurosis and the septum to the orbicularis oculi and the skin occurs more inferiorly. As a result, the fat can prolapsed anteriorly and obliterate the definition of the upper lid crease and give the eyelid a more full prominent appearance.

Now that a brief overview of the eyelid anatomy = has been given, the layers of the eyelid from superficial to deep will now be covered in slightly more detail:

Eyelid = skin - This along with the orbicularis oculi form the anterior lamella. Th= e skin of the eyelid is the thinnest in the body and richly v= ascularized. This allows for rapid healing of incisions during surgery. The= skin of the eyelid is innervated by the ophthalmic division of the trigeminal ne= rve via the lacrimal nerve and the frontal nerve. The frontal nerve branches to form= the supratrochlear and supraorbital<= /span> nerves.

Orbicularis oculi - Subcutaneous muscle that serves a sphincteric function for the eye as well as serves as= a pump mechanism for tears to go through the punctum, canaliculi and the lacrimal sac. The orbicularis oculi has 3 parts; all of which contribute to e= ye closure but they have specific roles. The orbital portion is under voluntary control (i.e. winking). The pretarsal= orbicularis is involved in the involuntary blinking a= ction and the preseptal fibers of the orbicularis contribute to both involuntary and voluntary actions of the orbicularis oculi muscle.&= nbsp;

Orbital= septum - This is a fibrous extension of the orbital periosteu= m that lies just beneath the orbicularis muscle a= nd forms the anterior border of the orbit confining the orbital fat. The septum also acts as a barrier = to the spread of infection and neoplasms. In Caucasian= lids, the septum fuses with the levator aponeurosis approximately 3mm above the superior tarsal border. In Asians, this fusion occurs more inferiorly (below the superior tarsal border) which permits orbital fat to reside anterior to the tarsus preventing the attachment of the levator to the skin and expunging the upper eyelid crease. In the lower lid, the septum fuses with the capsulopalpebral fascia (orbital retractor) 5mm below the inferior tarsal border.

Orbital= fat pads - These lie just beneath the orbital septum. In the upper lid, there are 2 fat = pads: the medial and central fat pads. The medial and central fat pads are separated by the superior oblique muscle. Lateral to the centra= l fat pad is the lacrimal gland which must be avoided during upper eyelid surgery to prevent postoperative x= erophthalmia. The lac= rimal gland is usually identified by its pink hue rather than the yellow color of fat. The lower lid has = 3 fat pads: medial, central and lateral. The medial and central are separated by the inferior oblique muscle. It is important to av= oid the extraocular muscles when performing upper or lower eyelid surgery to avoid postoperative diplopia.

Upper l= id retractors - Located deep to the fat.&= nbsp; The levator palpebr= ae superioris originates at the orbital apex; specifically the lesser wing of the sphenoid. It receives innervations from the = oculomotor nerve (cranial nerve III). The levator begins posteriorly as horizontally oriented muscle fibers that extend anteriorly (~36mm) until it reaches Whitnall’s ligament. At this point, the orientation of the fibers changes to become vertical and travels another 14-20mm until it reaches the tarsal plate.= In addition, it fuses with the septum several millimeters above the = tarsal border. As stated earlier, the upper lid crease is formed once the fused septum/levat= or complex attaches to the skin. Muller’s muscle (aka superior tarsal muscle) originates on the posterior surface of the levator just above Whitnall’s ligament and travels 10-12mm inferio= r to insert onto the tarsal plate. Muller’s muscle is innervated by sympathetic fibers and is responsible for 2-3mm of upper lid retraction.

Lower l= id retractors - Located deep to fat as in the upper lid. The capsulopa= lpebral fascia originates from the inferior rectus fascia to insert on the inferior border of the tarsal plate. Therefore, this lid retractor does not have independent movement but mimics the movements of the inferior rectus muscle. The inferior tarsus muscle is anot= her lower lid retractor and it originates from the undersurface of the capsulopalpebral fascia and is adherent to the lower = lid conjunctiva in addition to the capsulopalpebral fascia. This also has sympath= etic innervations.

Tarsus<= /b> - The tarsal plates can be thought o= f as the “skeleton of the eyelid”.&= nbsp; Each plate is roughly 25-30mm horizontally and 10-12 mm (upper lid) = or 3-5mm (lower lid) in vertical dimension.&n= bsp;

Conjunctiva:- This is the inner= most eyelid surface composed of 2 parts: the bulbar conjunctiva and the palpebral conjunctiva. The bulbar porti= on lines the globe and the palpebral portion lines= the eyelid. The two parts meet at= the conjunctival fornix at the bases of the eyelids. The conjunctiva is composed of nonkeratinized stratified squamous epithelium with go= blet cells that produce a mucinous layer of tear film. There are also numerous glands dispersed throughout the conjunctiva that produce an aqueous form of tear film.

Patient Assessment/Physical Exam: The Office Consultation

In addition to performing a general exam to incl= ude a complete head and neck exam, a focused evaluation of the brow and periorbital region should be performed. The following areas should be addressed: 1) the brow position, 2) eyelid shape, 3) lid position,   4) position of the upper lid crease, 5)assessment of the l= ids for fat herniation, skin excess/laxity, and orbiculari= s hypertrophy.

1.      Brow position: It is helpful to consider the upper eyelid and brow as one unit rather than two separate entities. Their positions relative to each o= ther play a crucial role cosmetically.

Female brow: medi= ally, it should be on the orbital rim and just off of the rim centrally. Laterally, it should arch so that = the highest point in the arch is located between the lateral limbus and the lateral canthus (~1 cm above the orbita= l rim)

Male brow: In mal= es, the eyebrow arch is flatter and may be located on orbital rim or slightly below.

In both males and females, attention should be given to any deg= ree of lateral hooding or brow ptosis as this can be addressed simultaneously with a blepharoplasty.=

2.      Eyelid shape: the eyelid should ideally have a positive canthal tilt. This means that the lateral canthus should be 2mm superior to the medial canthus.

3.      Lid position: the upper lid should cover 2-3mm o= f the superior limbus but not encroach on the pupil.<= span style=3D'mso-spacerun:yes'> The lower lid should rest on the inferior limbus or be 1mm below the inferior limbus. Note the presence of lid ptosis, lagophthalmos, or Bell’s phenomenon.

4.      Upper lid crease: In females, the upper lid crease s= hould be 9-10mm above the lash line. In males, it should be 8mm above the lash line.

5.      Assessing skin excess/laxity and lacrimal gland ptosis: Assessing the skin is important especially in an older individual with thin skin. This patient will require a more conservative resection of fat as well as orbicularis oculi muscle to avoid a “hollowed-out” appearance. In contrast, a yo= unger patient with thicker skin may require relatively more aggressive excision of skin, orbicularis muscle and fat. When assessing the lower eyelid, t= he snap test is useful to determine skin laxity. To perform this test, the lower ey= elid is pulled away from the eye and then quickly released. The lid should audibly and quickly= snap back in place. If the lid rem= ains pinched away or fails to return, this may alert the surgeon that a lid shortening/tightening procedure may be necessary.

Preoperative Medical Evaluation/History

Remember that blepharoplast= y, like other cosmetic procedures is elective surgery. Preexisting medical conditions mus= t be stable. Fortunately, the use = of local anesthetic may circumvent some of these issues. A complete medical history should = be obtained in addition to lifestyle history (smoking, alcohol use, drugs, etc). An ophthalmologic histo= ry should also be elicited from the patient with emphasis on vision, previous = ocular trauma, corrective lenses, glaucoma, excess tearing, dry eye, and Lasik procedure history. A Shirmer’s test should be performed if there is = any question regarding the presence of dry eye. If a patient has a history of Lasik procedures, no periorbital surgery should be performed for 6 months at the minimum.&nbs= p;

Upper lid Surgery

Incision planning-

The upper eyelid is marked with the patient in t= he upright position. The natural= upper lid crease is marked with the marking pen.= Both eyelid creases are marked symmetrically so that both upper eyel= id creases are 8-12mm above the lid margin.&n= bsp; In females, this marking can be carried out beyond the lateral orbit= al rim at which point the line takes a slightly superior direction. This extension is not advised for = male patients. The amount of exces= s skin present will determine where the superior aspect of the incision will be placed. As a rule of thumb, t= he superior border of the incisi= on should not be closer than 1cm from the inferior border of the brow hairs. Placing the superior portion of the incision closer than 1 cm to the eyebrow hair will yield a suboptimal cosme= tic result. This often occurs whe= n a patient undergoes upper lid blepharoplasty with= out having the ptotic brow addressed. Web formation can occur if the inc= ision is carried to far medial. Laterally, the incision is placed to help compensate for the degree = of lateral hooding (i.e. the greater degree of lateral hooding, the more later= al the incision may be carried out to compensate.) Of course, the lateral extent of t= he incision must be balanced by the appearance of the scar. After the superior and inferior lid crease lines are drawn, they are connected by approximate 30 degree lines medially and laterally to form a gentle arched shape. The reasoning for this is to conse= rve fat and skin excision which should avoid an over-operated look while still producing rejuvenation that is pleasing cosmetically.

Technique-
First, a protective corneal shield should be placed. Next, 1-2 mL of local anesthesia (1% lidoc= aine with 1:100,000 epinephrine) is injected into the tissues using a 3cc LuerLock syringe and a 30-gauge needle. It is important to perform these injections carefully as careless injection can lead to damage to eyelid vessels, obscure anatomy and lead to a more ecchymotic= postoperative appearance.

An assistant then provides counter traction usin= g a cotton tip applicator medial to the incision. A 15 blade is then used to incise = the eyelid skin. A Bishop forceps= with blepharoplasty scissors is used to excise skin from t= he orbicularis oculi muscle = which lies directly beneath the skin. The orbicularis muscle is then removed using the sa= me instruments with care not to violate the orbital septum. Once the muscle is removed, the ne= xt step is to address the fat pads. The septum is incised over the medial and central fat pads as needed. The medial fat pad has a light yellow/off white, creamy appearance while the central fat pad is dark yellow. Placing gentle pressu= re on the globe can assist the surgeon with the determination of how much fat to = resect as the excess fat will readily come forth in m= ost cases. The herniating fat is then removed using electrocautery and sh= arp dissection. Care is taken to achieve meticulous hemostasis at this point. Afterwards, the lid sulcus can be deepened using electrocautery if needed = to contract the septum. Once hemostasis is ensured, the incision can be closed. There are many methods employed to= close the skin but a popular method is the use of 6-0 polypr= olene in a running subcuticular fashion with knots ti= ed at the medial and lateral ends and taped to the skin to avoid displacement. This will allow suture removal by cutting the knot on one end a= nd pulling the suture out from the opposite end 5-7 days postoperatively. Once the procedure has been perfor= med bilaterally, a cool compress is placed over the eyes.

Complications-

·        -Retroorbital hemorrhage with visual loss

·        -In= fection (uncommon due to rich blood supply)

·        -Ex= cess skin removal

·        -lagophthalmos (may be transient or permanent)

·        -ectropion of upper lid

·        -web formation (incision placed too far medi= al)

·        -Blepharoptosis = (levator muscle injury)

·        -Diplopia (superior or inferior oblique musc= le damage)

·        -Hollowed out appearance (overaggressive fat removal)

·        -Milia

Lower Lid Surgery

There are 3 main methods to carry out lower lid = blepharoplasty: transcutaneous skin flap technique, transcutaneous skin-muscle flap technique, and the transconjunctival technique.

Transcutaneous skin flap technique-

In this technique, only the skin is addressed. The patient is marked preoperative= ly in the upright position. Corneal eye shields should be used during lid surgery. After infiltration w= ith local anesthesia, the incision is made 1-2mm below the lash line and may be= carried up to 1-1.5cm laterally into a crow’s foot rhyti= d. The dissection is performed carefu= lly between the skin and the orbicularis muscle. Strict attention is paid to hemostasis and preservation of the eyelash follicles.= Once the desired amount of skin is undermined, it is then retracted superiorly and conservatively resected. Closure is performed using 6-0 absorbable suture in a running subcuticular fashion.

Transcutaneous skin-muscle flap technique-

This consists of elevating the skin and orbicularis ocluli muscle= off of the orbital septum. As in the= transcutaneous technique, the patient’s eyelids= are marked in the upright position. The patient is then asked to perform upward gaze and the fat compartments to be addressed are marked. After insertion of corneal eye shields and infiltration with local anesthetic , an incision is made identical to that described above for the transcutaneous technique. At the lateral por= tion of the incision, the orbicularis fibers are inc= ised and blunt dissection is performed from lateral to medial separating the orbicularis oculi muscle = from the orbital septum beneath. Next,= a flap is elevated using the blepharoplasty sciss= ors to remove 5-7mm of skin from the pretarsal orbicularis oculi. The orbicular= is muscle is then incised with blepharoplasty scis= sors 5-7mm below the lid margin. T= he fat compartments are then addressed after blunt dissection has been carried out= and the orbital septum exposed. T= he orbital septum is then incised over the compartments to be addressed and the fat is expelled, cauterized at the base and then excised with scissors. After this has been accomplished, = excess subcilliary skin is conservatively trimmed. A small 2-3mm strip of orbicularis may need to be removed at the subcilliary wound edges to permit apposition of the s= kin edges. The subcilliary incision is then closed with 6-0 absorbable running suture. The lateral extension in the crow’s foot rhytid is closed with interru= pted 6-0 prolene suture.

Transconjunctival technique-

This procedure is mainly used to address pseudoherniated fat but it cannot address skin excess= or orbicularis muscle hypertrophy. However, it does avoid external incisions and avoids the complications of ectropion and scleral show. After injection of local anesthesia and placement of eye shields, a guarded Des= marres retractor is placed inside the lower lid with gentle inferior pressure. The globe is also depressed at the= same time to confirm the locations of the infraorbital fat. Mon= opolar cautery is used to make in incision just below = the tarsal plate. The length of t= he incision will be dictated by how many fat compartments will be addressed. The lower portion of the incision = is grasped with Bishop forceps and pulled superiorly to permit the placement o= f a 5-0 silk traction suture in the midline edge. Using blephar= oplasty scissors, dissection is carried out in the submuscular= plane. Cotton tip applicators= may be used to bluntly dissect with gentle sweeping motions down to the infraorbital rim.&nb= sp; This should allow good visualization of the fat compartments and they may then be addressed as needed after the septum over the compartments has = been incised. The herniating fat is grasped with small forceps and cauterized at the base using bipolar = cautery and trimmed using scissors. Afterwards, closure of the transconjunctival incision is not necessary.

Conclusion

Upper and lower eyelid procedures can be very gratifying for both the surgeon and most importantly, the patient. The surgeon can increase his/her c= hances for success by identifying the expectations of the patient preoperatively to determine if those expectations are achievable. In addition , determining preexist= ing conditions that may increase the occurrence of postoperative complications = is key. Recognition of these fac= ts preoperatively along with meticulous surgical technique intraoperatively, will allow the surgeon to be able to restore the patient’s “win= dows to the soul”.

References

Bailey= ’s 4th ed. Head & Neck Surgery - Otolaryngology

Flint: Cummings Otolaryngology: Head & Neck Surgery, 5th ed.=

Trussler and = Rohrich. MOC-PS CME Article: “Blepharoplasty”. Plastic and Reconstructive Surgery Jan 2008. Vo= l 121: 1

Naik, et al. “Blepharoplasty: An Overview”. J Cutan Aesthet Surg. 2009 = Jan-Jun; 2(1):6-11

Benjam= in A. Bassichis. “Lower Lid Blep= haroplasty”. Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 18, Issue 3, September 2007, P= ages 209-216

Benjam= in A. Bassichis. “Cosmetic Upper Lid Blepharoplasty= ”. Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 18, Issue 3, September 2007, P= ages 203-208

Samuel= M. Lam. “Asian Blepharoplasty”. Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 18, Issue 3, September 2007, P= ages 267-272

Kweon I. Stambaugh. “Lower Lid Blepharoplasty”.<= span style=3D'mso-spacerun:yes'> Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 10, Issue 3, September 1999, P= ages 177-183

Robert= DeFatta, Yadranko Ducic. = “Midface Lifts” Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 18, Issue 3, September 2007, P= ages 217-232

http://drmeronk.com/anatomy.html

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