Malar mounds and festoons: review of current management.

Blepharoplasty, the most common aesthetic eyelid procedure, sometimes involves a challenging patient subgroup: those who present with malar edema, malar bags, and festoons. In this review article, the authors describe the relevant anatomy in festoon development, discuss the pathophysiological basis of this condition spectrum, outline clinical examination basics, summarize various surgical approaches for treatment and propose an algorithm for their application, and describe the most common postsurgical complications.

Dynamic diagnosis of "fishmouthing" syndrome, an overlooked complication of blepharoplasty.

BACKGROUND: Dysfunction and/or dehiscence of the lateral canthus is 1 source of symptomatic eyelid closure disorder after blepharoplasty. Because the resulting concentric blinking movement resembles mouth closure in a fish, the name "fishmouthing" syndrome (FS) was given to this condition. Fishmouthing syndrome appears to be an overlooked complication of blepharoplasty. OBJECTIVES: The authors performed dynamic assessments of patients who had eyelid discomfort after blepharoplasty to establish the clinical signs of FS. METHODS: Preoperative and postoperative videos of 36 patients who presented for secondary blepharoplasty were analyzed retrospectively. All 36 patients experienced symptoms of dry eyes and eye discomfort after their initial blepharoplasty and desired symptomatic and cosmetic improvement. The dynamic signs and diagnostic criteria for FS were established clinically and through video analysis of patients' blinking movements. RESULTS: The most common clinical characteristics of FS included lash deformity ("cow lash" sign), abnormal medial displacement of the lateral canthus during blinking, deformity (rounding/narrowing) of the lateral scleral triangle, and visible eyelid closure deficiency or gapping. Other characteristics were lower-lid retraction and compensatory hypercontraction of the orbicularis oculi adjacent to the inner canthus. CONCLUSIONS: Patients with FS present with a combination of clinical symptoms and signs and are best diagnosed through dynamic visualization of the animated tissue during blinking. Evaluation of preoperative videos is an essential tool for surgical planning and for analyzing the results, both before and after corrective surgery, in patients with potential FS. LEVEL OF EVIDENCE: 4.

Concepts in eyelid biomechanics with clinical implications.

The inner canthal orbicularis drives spontaneous blinking of the eyelids and is richly innervated by a branching network of twigs based largely on the buccal branch of the facial nerve. This segment of the orbicularis is relatively resistant to denervation from subciliary incisional approaches. Combined with proper eyelid tension, contraction of this segment of orbicularis results in the normal physiologic blink mechanism. The authors discuss how to achieve proper eyelid tension and position intraoperatively during the treatment of patients with a range of orbital morphologies.

Management of postblepharoplasty chemosis.

Clinically significant chemosis occasionally complicates lower eyelid blepharoplasty. In this report, the etiologic components of postblepharoplasty chemosis are discussed. The time course and duration of chemosis vary according to the underlying cause. Early, late, and prolonged chemosis are managed with different strategies. Diagnostic and therapeutic algorithms for chemosis assessment and management are presented.

Buccal mucous membrane graft-assisted lacrimal drainage surgery.

PURPOSE: Dacryocystorhinostomy (DCR) success may depend on mucous membrane alignment across the osteotomy and entire surgical lacrimal outflow conduit. Scar tissue, obliteration of the lacrimal sac, and obstruction at the level of the common canaliculus may result from prior surgery or may occur as an isolated problem. We describe and evaluate the efficacy of a technique of grafting autologous buccal mucous membrane during external DCR in cases complicated by scarring and/or common canalicular obstruction. METHODS: We retrospectively reviewed 11 nasolacrimal outflow system obstructions (in 9 patients) treated with a buccal mucous membrane graft-assisted DCR. The surgical technique is described in detail. RESULTS: All cases presented with insufficient nasolacrimal outflow. Ten tear ducts failed prior DCR procedures, while one case had isolated common canalicular obstruction, resistant to multiple probing and intubation and was previously recommended a Jones tube procedure. Three tear outflow systems (in 2 patients) exhibited common canalicular obstruction; the rest were obstructed at the level of the lacrimal sac. Two patients had bilateral obstruction. Ten eyes had symptomatic epiphora. One eye had dacryocystitis alone, and 2 eyes had dacryocystitis and epiphora. Six tear ducts had more than one previous DCR procedure. Four tear ducts had prior endonasal DCR procedures, while 6 had a previous external DCR. All eyes with epiphora preoperatively had complete relief of tearing. All cases of dacryocystitis resolved with no recurrences. Nine tear ducts were patent to irrigation testing postoperatively (2 were not tested). CONCLUSIONS: Buccal mucous membrane grafting may improve the success of DCR in cases complicated by scarring, mucosal shortage, and/or common canalicular obstruction.

Managing postseptal fat in periorbital rejuvenation: anatomic intraorbital replacement using passive septal tightening.

The authors provide their perspective on managing postseptal fat in lower lid and midface rejuvenation. Using the concept of "passive septal tightening," the technique corrects "apparent" lower lid fat excess by restoring the fat to a more youthful intraorbital position. The potential surgical trauma in the critical plane between the orbicularis oculi and septum is avoided, minimizing the risk of middle lamella scarring and postoperative lower lid malposition.

Lateral canthal anchoring.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the principles involved in canthal support for patients undergoing cosmetic and reconstructive surgery. 2. Understand the variations in surgical techniques required to perform canthal anchoring in differing patients. 3. Describe the significance and techniques of canthal anchoring (canthoplasty and canthopexy) as they relate to cosmetic and reconstructive lower lid surgery. 4. Describe the effect of canthal anchoring on the function of the upper and lower lids and eyelid fissure shape. Any surgeon performing cosmetic or reconstructive surgery procedures on the lower lid or midface through the lower lid should be comfortable with canthal anchoring procedures. Appropriate canthal anchoring is effective in preventing postoperative lower-lid malposition, in ensuring eyelid closure, and in improving or maintaining proper eye shape. In many patients, a canthopexy (nonlysis canthal anchoring) is effective. However, in patients with significant horizontal laxity, cantholysis with appropriate lid shortening is required. It should be remembered that canthal anchoring, no matter how well performed, will not prevent severe lower-lid complications in cases of over-resection of lower-lid skin and of poorly performed midface procedures that do not support the lower lid and cheek.

Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system.

The purpose of this study was to evaluate a standard method for the identification of eye prominence and to review operative modifications necessary in patients with prominent eyes. A Hertel exophthalmometer was used to define a classification system according to the degree of eye prominence. A total of 43 patients undergoing lower lid or midfacial rejuvenation were included in the study. Preoperative parameters, including vector analysis, laxity, scleral show, rotational deformity, lateral canthus-to-lateral orbital rim distance, lateral-to-medial canthal distance, and exophthalmometry measurement, were documented. Intraoperatively, techniques including horizontal shortening and lateral canthoplasty placement were documented. Postoperative evaluation included scleral show, rotational deformity, and lateral-to-medial canthal distance. The proposed morphologic classification system divided patients into four groups on the basis of their degree of prominence, as measured by exophthalmometry, defined as deep-set (<14 mm), normal (15 to 17 mm), moderately prominent (18 to 19 mm), and very prominent (>20 mm). Operative techniques were different between the groups, with correction of laxity in the deep-set eyes and accentuated overcorrection of scleral show in the prominent eyes. The use of an exophthalmometer to classify patients before blepharoplasty may help reduce the risk of complications by identifying high-risk patients.

The open brow lift.

The open brow lift procedure is discussed in terms of relevant surgical anatomy, preoperative evaluation, and detailed surgical technique for pretrichial coronal forehead lift with hair-bearing temporal lift, direct incisional brow lift, and coronal brow lift. Complications are discussed, and information is presented on patient evaluation and expectations, with a discussion of what patients can expect before and after brow lift surgery.

Upper and lower eyelid reconstruction.

Reconstruction of the eyelids can range from simple repair to the integration of multiple complex procedures. Knowledge of eyelid anatomy, adequate preoperative planning, and meticulous surgical technique will optimize the anatomical and functional result. The purpose of this article is to review the relevant anatomy for eyelid reconstruction, to simplify defect analysis and preoperative planning, and to provide options for reconstruction of this complex area.

Optimizing blepharoplasty outcomes in patients with previous laser vision correction.

BACKGROUND: Dry eye syndrome, often referred to as dysfunctional tear syndrome, can occur following laser vision correction surgery and routine blepharoplasty. Identifying patients prone to developing or worsening of dysfunctional tear syndrome following blepharoplasty can help optimize surgical outcomes. METHODS: The authors highlight the salient features of the dysfunctional tear syndrome including key steps in identifying at-risk patients. The authors discuss changes in the cornea that occur with keratorefractive surgery and their significance in patients seeking blepharoplasty. The authors suggest guidelines for blepharoplasty in these patients and discuss the timing of surgery. RESULTS: After blepharoplasty, lagophthalmos of the upper lid is a common temporary finding. This change in eyelid function may unmask underlying deficiencies in the tear film or corneal sensation. Coexisting lower lid malposition can displace the existing tear meniscus and increase exposure of the cornea. Whether in combination or alone, these findings can create a dry eye problem. Dysfunctional tear syndrome should be considered in all patients with a history of laser vision correction during the preoperative evaluation for blepharoplasty. Surgeons should rely on preoperative history and physical examination, including assessment of preoperative eyelid anatomy and the status of the ocular surface. Patients with prior laser vision correction should wait at least 6 months before undergoing blepharoplasty because of the effects on corneal sensation, tear production, and tear film alteration. CONCLUSIONS: Identification and appropriate treatment of dysfunctional tear syndrome together with intraoperative modifications will optimize postoperative outcomes and avoid a potentially disabling condition after blepharoplasty in patients with previous laser vision correction surgery.

Transblepharoplasty ptosis repair: three-step technique.

BACKGROUND: The ability to predict postoperative lid levels in ptosis surgery has been refined over the years, but there is no completely predictable formula with which to predict the final tension in the upper lid that determines the final upper lid level. A significant percentage of patients continue to require postoperative surgical revision. The authors studied the effectiveness of a technique for the quantitation of aponeurotic repair that is not a measured resection procedure, does not require voluntary patient cooperation, and can be performed under general anesthesia. METHODS: The surgical technique involves reapproximation of specific anatomical landmarks, adjustment of upper lid level by eyelid gapping, and adjustment of upper lid tension with a spring-back test. Consecutive patient charts were reviewed retrospectively for age, sex, clinical examination, levator function, and outcomes, including revision rate and patient satisfaction. A total of 144 procedures were performed for 80 patients (64 bilateral and 16 unilateral). The series was reported for a 3-year period (2002 through 2005). The mean age was 62 years (range, 40 to 85 years). The average follow-up was 18 months. All patients had acquired adult ptosis with levator dehiscence and good levator function. RESULTS: The criterion for surgical revision was a greater than 1-mm asymmetry between the eyelids or patient dissatisfaction. Twelve patients (15 percent) were considered to be slightly asymmetric postoperatively, but only two (2.5 percent) exceeded the criterion and required surgical revision in the early postoperative period (<1 year). CONCLUSION: Tarso levator surgery can be performed under general anesthesia using a three-step technique to correct ptosis with a superior predictability.

Evaluation of conventional subciliary incision used in blepharoplasty: preoperative and postoperative videography and electromyography findings.

BACKGROUND: The purpose of this study was to evaluate the innervation and function of the orbicularis oculi area clinically, with video imaging, and electrically, with electromyography, before and after lower-eyelid blepharoplasty using a conventional subciliary incision. METHODS: Nine patients (18 eyes) were studied before and 4 to 12 weeks after lower-eyelid blepharoplasty. Video imaging documented clinical changes in involuntary (blink) and voluntary (squeeze and squint) eyelid function as well as resting lid position and tone. Electromyography was performed using concentric needle electrodes (25 mm in length, 0.03 mm in diameter) placed in the lateral and medial subciliary orbicularis oculi. A total of 36 sites in nine patients (four sites per patient) were studied. Acute denervation was identified by the presence of fasciculation; fibrillation potentials; insertional activity; sharp waves; and grade based on standard electromyography techniques. All patients underwent lower-eyelid blepharoplasty with a subciliary incision, skin-muscle flap and canthal anchoring with canthopexy or cantholysis, and canthoplasty. RESULTS: Video imaging of the lower eyelid before and after blepharoplasty showed evidence of eyelid malposition or abnormal voluntary or involuntary orbicularis oculi muscle function. There was no evidence of acute denervation in 34 of 36 sites (94 percent). Two patients had abnormal fasciculation in the left lateral position on two of 36 sites (6 percent). Thirty-three weeks postoperatively, one patient was retested and a normal electromyography result was obtained. CONCLUSIONS: This study demonstrated that lower-lid malposition or abnormal function after lower-lid blepharoplasty cannot be explained by denervation of the zygomatic branch of the facial nerve. Any acute or residual denervation seen in the subciliary orbicularis is not clinically significant. The importance of lower-lid support and canthal anchoring cannot be emphasized enough in preventing lower-lid malposition. Blepharoplasty is a challenging procedure that requires careful preoperative planning, intraoperative reassessment, and meticulous surgical technique to optimize facial rejuvenation and patient safety.

Upper eyelid reconstruction.

There are several options available for upper eyelid reconstruction that depend on the extent of involvement of the anterior and posterior lamella. Knowledge of the anatomy will ensure that in addition to the creation of an aesthetically acceptable eyelid reconstruction, a functional upper lid will be restored. The purpose of this article is to outline the anatomy of the eyelid, to analyze the components of eyelid defects, and to provide options for lid reconstruction.