Transcaruncular approach to the medial orbit and orbital apex.

OBJECTIVE: To present a versatile approach to the medial orbit and orbital apex through the caruncle. DESIGN: Retrospective, noncomparative, case series with description of surgical technique. PARTICIPANTS: Twenty-five consecutive patients underwent orbital surgery by use of a transcaruncular approach. INTERVENTION: Inferior and medial wall fracture repair or orbital decompression by means of a transcaruncular or combined transfornix-transcaruncular approach. MAIN OUTCOME MEASURES: The surgical indications and complications were recorded for each patient. RESULTS: Ten patients (10 orbits) underwent combined inferior and medial orbital wall fracture repair through a combined transfornix-transcaruncular approach. In 8 of 10 (80%) orbits, the inferior oblique muscle was disinserted during surgery. Fifteen patients (24 orbits) underwent orbital decompression surgery for dysthyroid orbitopathy. An isolated transcaruncular approach was used in 5 of 24 orbits, and a combined transfornix-transcaruncular approach was used in 19 of 24 orbits. There were no complications related to either approach. CONCLUSIONS: Orbital bone removal and fracture reduction may be safely completed through a combined transfornix-transcaruncular approach. The transcaruncular approach provides excellent and safe exposure of the medial orbital wall, and it avoids scarring associated with the Lynch approach.

Frontalis muscle flap advancement for correction of blepharoptosis.

PURPOSE: To describe a technique of frontalis muscle flap advancement to repair myogenic ptosis in lieu of a graft or suture material. METHODS: Ten ptotic eyelids in eight patients were repaired using the frontalis flap technique. Patients were selected at random by two separate surgeons; all patients had eyelid excursion measured as poor (or less than 6 mm). RESULTS: Nine of 10 ptotic eyelids were adequately corrected by the frontalis flap technique, with follow-up intervals ranging from 18 to 42 months. Adequate correction was defined as ptosis corrected within 1 mm of the fellow eyelid. Complications of frontalis advancement were few and primarily transient. CONCLUSIONS: Frontalis flap advancement is a technically simple, safe, and effective technique for the repair of myogenic ptosis. The primary advantage of frontalis muscle flap advancement over a graft or suture material that it elevates the eyelid directly by moving the insertion of the frontalis muscle into the eyelid, rather than by graft or suture material.

The deep plane facelift: a 20-year evolution of technique.

PURPOSE: This report reviews the unique technical and conceptual oculoplastic innovations in the discipline of facelift surgery by analyzing the evolution of facelift technique at a university-based oculoplastic program. DESIGNED: Retrospective, noncomparative case series. PARTICIPANTS: We analyzed 313 patients undergoing a facelift from 1980 through 1997. Most procedures were performed by the senior author. METHODS: Three primary eras of surgical technique were identified: limited skin flap with superficial musculo-aponeurotic system plication (25 patients), extended skin flap with neck dissection and superficial musculo-aponeurotic system plication (210 patients), and deep plane facelift with robust superficial musculo-aponeurotic system flap (78 patients). RESULTS: The steps in the evolution were designed to improve the results of the surgery regarding rejuvenation of the neck, jowls, and nasolabial fold, and to reduce the "tattletale signs" of facelift surgery including postauricular scarring, change in the position of the sideburn and temporal hairline, and unnatural results caused by pulling the tissues posteriorly, rather than repositioning them vertically. There were no complications in the skin flap only group. In the extended skin flap and superficial musculo-aponeurotic system plication group, there was one mandibular paresis which partially resolved. In the deep plane facelift (n = 78), there was one laceration of the parotid duct, successfully stented during surgery. CONCLUSIONS: The deep plane facelift, with vertical elevation of the midface, jowls, and neck, is a logical extension of the mid-facelifting techniques that have been used by oculoplastic surgeons. Compared with cutaneous undermining with superficial musculo-aponeurotic system plication, we found patient and physician acceptance higher using the deep plane technique.

Management of relative proptosis with a porous polyethylene orbital rim onlay implant.

PURPOSE: The position of the globe relative to the orbital rim plays a significant role in the relationship between the eyelids and the cornea. A prominent globe (relative proptosis) may cause eyelid retraction and exposure keratopathy. Simple horizontal lower eyelid tightening exacerbates eyelid retraction. Optimal correction with an orbital decompression or advancement of the orbital rim entails considerable risk. A technically simpler alternative, placement of an orbital rim onlay implant, was evaluated. METHODS: Fourteen patients with symptomatic relative proptosis underwent placement of a porous polyethylene orbital rim onlay implant. RESULTS: Lower eyelid position, exposure keratopathy, and ocular discomfort were improved in all patients. Two patients required minor surgical revisions. CONCLUSIONS: Porous polyethylene orbital rim onlay implants are a satisfactory option to treat the sequelae of relative proptosis.

The endoscopic forehead lift.

Endoscopic techniques are being successfully applied to address eyebrow and forehead ptosis. The methods rely on extensive subperiosteal and subgaleal release of the forehead and scalp flap, allowing the elevation of soft tissues. Ablation of the depressor supercilli and procerus can be performed to address skin folding in the glabellar region. The mobilized frontotemporal flap is then elevated to the desired level and fixated with microscrews to the outer table of the skull. Laterally, the flap is fixed to the deep temporalis fascia. The technique relies upon a solid knowledge of the regional anatomy and the use of specialized instruments now available for dissecting under the flap. The endoscopic forehead lift can achieve results comparable to those obtained by the open coronal forehead lift while minimizing the incidence and extent of postoperative cutaneous anesthesia and telogenic hair loss, which frequently follows open coronal forehead surgery. In addition, the endoscopic technique is able to address eyebrow ptosis in the balding male without causing disfiguring scarring.

Blepharoplasty and periorbital surgery.

Blepharoplasty is one of the most successful aesthetic surgical procedures. Careful preoperative planning and conservative tissue resections can help to minimize complications and optimize results. Although some young patients request blepharoplasty specifically because of age-related changes in the eyelid skin, the surgery is that of sculpture and contouring of the entire aesthetic unit. The aging process in the eyelid complex is characterized by skin texture changes with loss of elasticity and formation of wrinkles, fat redistribution, enophthalmos, and anterior displacement of fat with a lower eyelid orbital fat prolapse. Once the etiology of the deformity and the associated periorbital anatomy are recognized, a local assessment and surgical treatment plan can produce optimal results.

Transconjunctival lower eyelid blepharoplasty.

Although transconjunctival lower eyelid blepharoplasty was described as far back as 1924 and it offers certain advantages over the skin-muscle flap, many surgeons continue to use the transcutaneous approach. This is likely due to unfamiliarity with the transconjunctival approach and general overestimation of the ability of skin excision to improve lower eyelid wrinkles. Transconjunctival lower eyelid blepharoplasty, however, continues to gain favor over the transcutaneous approach as more surgeons appreciate the absence of a visible scar and significantly lower incidence of postoperative lower eyelid retraction or change in lower eyelid margin contour, allowing a nonsurgical look.

Lower eyelid retraction following blepharoplasty.

Thirty consecutive patients with lower eyelid retraction after blepharoplasty were treated surgically with varying degrees of success. Successful outcome depended on various anatomic and pathologic factors, including the time elapsed since blepharoplasty, the prominence of the globe and its effect on eyelid contour, and the degree of septal or skin involvement. Satisfactory results were also dependent on surgical techniques used. We discuss several surgical techniques and offer advice concerning the selection of a surgical procedure in light of various pathologic parameters.

The transconjunctival approach to the orbital floor and orbital fat. A prospective study.

The transconjunctival approach to the inferior orbit and orbital fat offers the potential advantage of avoidance of scar creation in the lower eyelid skin and anterior lamellae. Complications of this approach, including conjunctival fornix shortening and eyelid margin malposition, have been occasionally reported. We prospectively observed 25 patients undergoing transconjunctival blepharoplasty and orbital floor surgery. Fornix depth, eyelid margin position, and the presence or absence of eyelid retraction were measured preoperatively and at each postoperative visit. No significant permanent change in these parameters was observed. Temporary entropion was observed in two patients; this resolved with conservative treatment. On self-limited suture granuloma was observed. In a subgroup of six patients, the conjunctival incision was closed on one side and left unclosed on the other. No adverse healing was noted on the unclosed side. We conclude that the transconjunctival approach is associated with a low incidence of complications, and that it does not significantly alter the fornix depth or eyelid margin position. A skin incision is avoided. The inferior orbital septum is not violated, greatly reducing the risk of development of lower eyelid retraction.

Hypoglobus following orbital decompression for dysthyroid ophthalmopathy.

Hypoglobus following orbital decompression is not a rare complication. Hypoglobus requiring surgery to elevate the globe following orbital decompression is considered clinically significant hypoglobus. A retrospective analysis of 157 consecutive patients who had their orbits expanded by removing the medial wall and floor of the orbit found seven patients (4.5%) who required further surgery to elevate the globe. The seven patients who developed clinically significant hypoglobus following orbital decompression all developed a set of distinct clinical signs. These included a "setting sun" appearance of the globe, eyelid malposition, orbital volume loss, and strabismus. These clinical signs can be explained by the inferior movement of the globe and the orbital contents following the loss of support structures on the orbital floor. A two-wall orbital decompression performed on a cadaver reproduced the physical signs of hypoglobus. The dissection suggested that the periorbita is the most important structure supporting the globe in the orbit.

Transconjunctival lower eyelid blepharoplasty. Technique and complications.

The transconjunctival lower eyelid blepharoplasty is extremely effective at reducing lower lid fullness due to prominent orbital fat. The authors performed 122 consecutive transconjunctival blepharoplasties over a 24-month period. Four patients had skin excision via the pinch technique in conjunction with the transconjunctival fat excision. The main complication was under excision of fat which occurred in nine patients (7.4%). Moderate postoperative wound hemorrhage without hematoma formation occurred in one patient (0.8%). There were no cases of lid retraction, ectropion, entropion, inferior oblique palsy, or over excision of fat. The main advantage of this technique is that it avoids the most common complication of transcutaneous lower eyelid blepharoplasty, namely lower eyelid retraction.

Revascularization studies of an opposing eyelid pedicle flap.

Opposing eyelid pedicle flaps are used extensively in ophthalmic plastic surgery. Controversy exists over the timing of pedicle severance. Additionally, the functional and morphologic status of eyelid pedicle flaps at the time of severance has not been fully assessed. We attempt to investigate these questions by measuring the functional and morphologic changes that occur in an animal model of an opposing eyelid pedicle flap. These results were correlated with clinical case studies. Experimental results revealed vascularization of the animal model flap at 5 days. Clinical case studies revealed successful flap division by 3 weeks or less. We discuss factors that may delay flap revascularization.

Evisceration, enucleation, and exenteration.

The removal of the intraocular contents, the globe itself, or the entire orbital contents are three procedures that each present distinct pre- and postoperative problems. These procedures and the management challenges they present are discussed in this article.

Management of traumatic ptosis.

The management of traumatic ptosis is dependent on its etiology, interval between occurrence and examination, degree of ptosis, and levator function. The surgical approach and timing of intervention varies with each case and provides a challenge to the oculoplastic surgeon. We discuss our approach to the management of traumatic ptosis. Secondary surgery may be necessary to repair over- or undercorrection.

A structurally oriented approach to the repair of cicatricial entropion.

A modified technique for the repair of moderate to severe cicatricial entropion has been developed. This method is unique, as it involves the creation of a bipedicled tarsoconjunctival advancement flap. The technique avoids the causes of surgical failure seen with standard tarsal fracturing procedures.

Autogenous fat grafting by injection.

We describe our technique of fat grafting by injection for the repair of facial contour deformities. The technique involves removal of fat by liposuction, treatment with insulin, and then injection into the area of contour deformity. The efficacy of insulin treatment remains unproven. Pre and post injected fat is examined histologically.

The use of botulinum toxin in the medical management of benign essential blepharospasm.

Twenty-eight patients with mild or moderate cases of benign essential blepharospasm were treated with botulinum toxin Type A. Average follow-up was six months. The injection technique used on these patients is illustrated. The treatment was effective in virtually all patients treated, although transient; the mean interval of relief of spasm was approximately two and one-half months. Potential side effects include ptosis and epiphora. Botulinum toxin as an initial treatment or as an adjunct in postsurgical residual blepharospasm shows promise in this preliminary study.

Autogenous auricular cartilage grafting for lower eyelid retraction.

The authors discuss the surgical correction of lower eyelid retraction in dysthyroid, socket, and blepharoplasty patients. Sixty-three patients underwent a lateral canthal tightening combined with a vertical lengthening of the posterior lamella using autogenous posterior auricular cartilage. The average follow-up was for 2 years. We propose this combined procedure as the surgery of choice in the treatment of lower eyelid retraction seen in these three groups of patients.