In managing periorbital ageing, one must evaluate the brow, the upper lid, the lower lid (position, amount of skin, muscle and herniated fat pads), the anti-Mongoloid fissure, the wrinkles (frontal, corrugator, pro-cerus, static and dynamic crow's-feet), the width of the forehead (level of the hairline), the tear trough deformity and the very important position of the globe in the orbit (enophthalmia).
As we age, the hairline recedes and the brow comes down. The width of the forehead increases, an obvious sign of ageing. The brow coming down below the orbital rim will come closer to the eyelashes (the normal distance being 2.5 cm in women and 2 cm in men) creating a pseudodermachalasis of the upper lid. This will camouflage in many cases the ageing of the shallow upper lid. The lowered brow will be partly responsible for the static crow's-feet and the chalasis in the glabellar area. We develop frontal wrinkles because we soon learn that when we look in the mirror, we improve our appearance (brow and upper lid) and eventually we develop a reflex of raising one's brow when we recognise someone on the street, thus giving a better impression of our physical appearance. We also raise our lowered brows to see better, all of this accentuating the frontal wrinkles. An upper blepha-roplasty with an unaddressed lower brow will further activate the frontal muscles and make the frontal wrinkles more obvious. Besides, it will further reduce the distance between the brow and the eyelashes.
An open brow lift will raise the brow, reduce the pseudodermachalasis of the upper lids, and improve the glabellar wrinkles and static crow's-feet. One can simultaneously do an upper blepharoplasty but I prefer to wait 3 months longer to do it. I cut and coagulate the procerus, the corrugator and occasionally the vertical fibres of the lateral orbicularis oculi muscle. This will prevent or delay a recurrence. Sectioning the vertical fibres will reduce the dynamic crow's-feet.
A subcutaneous, a subgaleal or a subperiosteal approach can be utilised; I prefer the subperiosteal approach and go below the orbital rim and I section the periosteum with small scissors from one side to the other. This can give me a more permanent result and reduce the tension on skin closure.
Only the open hairline incision can reduce the width of forehead, the most obvious signs of the ageing face (man or woman) and, in practice, this has been the greatest source of satisfaction. The hairline incision can be inconspicuous if it is bevelled in order to cut the hair follicles of the proximal flap as the hair will grow through the distal flap provided it is bevelled with the same angle as the incision (approximately 45°) (Figs. 34.1, 34.2). Besides bevelling the incision, we "W" plasty it [9, 10].
The endoscopic lift is very efficient in raising the median forehead and brow but remember the frontal muscle does not raise the tail of the brow and therefore it would not help much to improve crow's-feet. In most patients, the lateral part must be raised more than the medial counterpart. The same applies for the transpalpebral corrugator and procerus resection . We can say the same for the use of Botox. So, the lateral brow being lower than its medial counterpart will become more obvious by weakening the central depressor as it gives an unnatural and older look.
The majority of my patients need more of a lateral raise than a medial raise and mostly the incomparable benefit of advancing and lowering the hairline makes the open brow lift my procedure of choice and this can be done with a resulting inconspicuous scar.
As the brow comes down, we get a pseudodermacha-lasis of the upper lid, which is best managed by a brow lift.
Also, one can have a chalasis with a high brow, then an upper blepharoplasty is indicated. Often, the descended brow will bring abundant skin, muscle and orbital fat in the supratarsal space, giving the illusion of fullness even in the presence of a sunken upper lid. So, before doing a blepharoplasty, always raise the brow approximately 2.5 cm from the upper eyelashes, as you will likely observe a sunken upper lid. You will then often decide to perform a conservative skin resection, without an orbicularis oculi and herniated fat resection. As we age, the levator may stretch or detach from the tarsus, but remains attached to the proximal skin, thereby raising the supratorsal fold, and occasionally you get an associated ptotic lid. The sunken upper lid gets worse as the orbital fat moves out of the orbit and is herniated in the lower lid (Table 34.1) -the Rouleau phenomenon. This is aggravated by the fat atrophy of ageing. All of these factors aggravate the sunken upper lid and enophthalmia.
While performing upper blepharoplasty, I only remove skin and rarely some fat from the medial compartment. Exceptionally, I create a deeper supratarsal fold (by removing orbicularis oculi and fat) when a patient insists.
Table 34.1. Lowering of the Lockwood suspensory ligament
A J space between globe and B J, space between globe and ^ Sunken upper lid made floor of the orbit roof of the orbit worse by:
4. Sunken upper lid
The volume of the nonstretchable bony orbit is constant and the volume of the noncompressible orbital fat is constant until ageing and this then atrophies, making things worse
Now, I make my excisions much lower, approximately 5 mm  above the ciliae to recreate a lower supratarsal fold and lid fullness of youth. Remember with age, the levator stretches and detaches itself from the superior tarsus, but its skin attachment raises the supratarsal fold, an obvious sign of ageing. It is wise to reverse this sign of ageing.
One might have to shorten the levator in cases of ptosis.
As the lateral canthus stretches the lateral commissure comes down, and with ageing we reduce our Mongoloid appearance. Also, it gives less support to the lower lid and it results in a pseudodermachalasis, a rounded lower lid and scleral show. Anatomically, we know that the Lockwood suspensory ligament, which is a hammock-like structure anchored to the
Fig. 34.3. Parasagittal section to show anterior orbital structures. 1 Superior rectus muscle, 2 levator muscle, 3 conjoining of superior rectus muscle with levator muscle sheath, 4 Tenon's capsule, 5 suspensory ligament of superior fornix, 6 Whitnall's ligament, 7 frontalis muscle, 8 brow fat pad, 9 orbital orbicularis, 10 arcus marginalis, 11 orbital septum, 12 preaponeu-rotic fat pad, 13 preseptal orbicularis, 14 postorbicularis fascia, 15 levator aponeurosis, 16 superior conjunctival fornix, 17 Muller's muscle, 18 conjunctiva, 19 superior tarsus, 20 pretar-sal orbicularis, 21 inferior tarsus, 22 musculocutaneous rectra-tor insertion, 23 conjunctiva, 24 inferior conjunctival fornix, 25 Tenon's capsule, 26 inferior orbital septum, 27 Lockwood's ligament, 28 inferior tarsal muscle, 29 suspensory ligament of inferior fornix, 30 inferior oblique, 31 capsulopalpebral fascia, 32 inferior rectus muscle medial and lateral canthi, maintains the level of the globe in the bony orbit (Figs. 34.3, 34.4). As the lateral canthus comes down, so does the Lockwood suspensory ligament and this will reduce the space between the globe and the floor of the orbit [1-8]. Inevitably the noncompressible infraorbital fat will be projected anteriorly (the path of least resistance) and this fat will herniate anteriorly and above the orbitomalar ligament, which is not stretchable: we get herniated fat pads and a tear trough deformity (Table 34.1). By the same mechanism, we get an enophthalmia and sunken upper lid (Fig 34.5).
In young patients, for congenital reasons, the Lockwood suspensory ligament, or even the lateral can-thus, can stretch prematurely and it ends up with her-niated fat pads and enophthalmia. If we relocate the fat pad, we do not create exophthalmia, which proves the volume of fat was always normal.
The enophthalmia is inevitable because the volume of the rigid bony orbit is constant, so is the volume of the noncompressible or extensible volume of the orbital fat. If fat comes out of the orbit, the eyeball has to move back and down. It is inevitable.
The sunken upper lids result mostly because of the lowering of the globe but also because the orbital fat herniates into the lower lid and because of the reduction of the volume of the orbital content. In older age, senile atrophy also plays a role. The sunken upper lid might be masked by the ptosis of the brow. As the distance between the brow and upper lid is reduced, the volume of the redundant skin orbicularis oculi is larger than the volume of the herniated extraconical fat, which is approximately 1 ml. By raising the brow, the deep upper lid becomes obvious.
If you have a herniated fat pad it will move anteriorly and above the nonstretchable (with time it will stretch) orbitomalar ligament and we get the tear trough deformity (Fig. 34.5). It will be managed by relocating the herniated fat pad into the orbit where it belongs.
A tear trough deformity cannot exist without a herni-ated fat pad. We feel our approach is more physiological and anatomical than sectioning the orbitomalar ligament and then splaying the fat into the cheek. By freeing the orbitomalar ligament and relocating fat onto the cheek, you add bulk that never was there when younger. Besides, you might reduce the fat pad volume or its projection, but never by as much as if you relocated it completely into the orbit where it was located before ageing; in other words, you only get a partial correction of the herniated fat pad, some of which is left in place. Beside the orbitomalar ligament is an osseocutaneous ligament giving support to the cheek and indirectly to the premalar fat pad. Will they lose support with time? Should it not be left intact?
In 1993, while performing a transconjunctival lower blepharoplasty, we sutured the lower flap (conjunctiva, inferior tarsal muscle, and capsulopalpebral fascia) to the arcus marginalis, which is the fusion of the orbital septum with the periosteum of the orbital rim (Fig. 34.3). We removed the double-pronged hook and replaced the eyelid on the eyeball. Pressing on the globe, we noticed two hernias, one on each side of the stitch.
Encouraged by this observation, we placed two more stitches to suture the lower flap to the orbital rim. Then, pressing on the eyeball, we could not recreate the herniated fat pad nor the enophthalmia. On the opposite side, we used a continuous suture, and this has been our only management of the herniated fat pad since [1-8]. The level of satisfaction of our patients has been very high (Fig. 34.6). As you perform your next tranconjunctival blepharoplasty, try one, two, or three stitches, as I did the first time. Then if you do not like it, remove your stitches and remove the fat as usual. One can use the conventional trans-conjunctival incision. You must keep away from the inferior tarsus because you can damage anteriorly the orbital septum and adjacent orbicularis oculi. They converge with the capsulopalpebral fascia as they enter into the inferior tarsus (Fig. 34.3). You must avoid scarification at this level, and you must avoid the numerous vertical motor nerves innervating the pretar-sal orbicularis oculi muscle from behind (the nerves run deep to the orbicularis oculi muscle; although there is a multiplicity of nerves and it is difficult to denervate the orbicularis oculi, one must be cautious).
Before prepping and draping, I use 1% Xylocaine 1% with epinephrine to anaesthetise the lower lid and
By a rouleau phenomenon
Sunken upper lid can be obliterated by a ptotic brow
Herniated fat pad
Tear trough deformity
Lowered and retrodjsplaced globe
Sunken upper lid can be improved in some cases
Globe mobilised upward and anteriorly
Herniated fat pad improved
Tear trough improved
Lower (Ocular) flap made up of Conjunctiva interior tarsal muscle Capsuiopalbebral fascia: it behaves as a hinge, allowing full motion of the globe.
Fig. 34.5. As the globe comes down, the extraconical orbital fat must herniate anteriorly, which reduces the orbital content and makes enophthalmia inevitable. Because the fat herniates above the orbital malar ligament, tear trough deformity occurs, as well as a sunken upper lid that can be masked by a ptotic brow
into the orbital floor. Once draped, I use two drops of 0.5% Alcaine and two drops of Proviodine in each conjunctival cul de sac it is always very contaminated according to my ophtalmologist colleagues. Then, I insert a corneal lens and raise the upper lid by suturing it to the forehead with a nylon 3x0 suture. Using a double-pronged hook, I evert the lower lid and with curved pointed scissors, I palpate and incise just below the orbital rim and expose the fat as in any trans-conjunctival blepharoplasty. With Adson-Brown forceps and curved scissors, I free from the anterior surface the herniated fat pad and expose the orbital rim, which is easily palpable with the finger, the forceps or the scissors. An assistant, using a Desmarais retractor, or a double-pronged hook in one hand to evert the lower lid and using a freer in the other hand to push the herniated pad back over the orbital floor, exposes the orbital rim. If any difficulty is encountered, then we do not hesitate to perform a lateral can-
ing a mirror: it is minimal! If any fat ever herniates between stitches, we push it back with forceps or use the bipolar instrument to cauterise it; the resulting scar would prevent a recurrence.
Once the suturing is complete, we always make sure we have full movement of both the lower eyelid and the eyeball. Using Adson-Brown forceps, we pull the lower lid above the superior limbus and mobilise the eyeball with the forceps to eliminate any possibility of tethering. Because the lower flap is sutured anteriorly to the orbital rim, the flap becomes almost horizontal (in the upright position) or perpendicular to the globe, behaving as a hinge (Fig. 34.5) and not interfering with the motion of the globe. Besides, the capsulopalpebral fascia is a very stretchable membrane. Even so, the amount of tension required to stretch the capsulopalpebral fascia is much greater than the amount of tension required to maintain the relocated fat pad within the orbit. With our technique, the resulting conjunctival defect is no greater than that resulting from transconjunctival blepharoplasty. The conjunctiva has a great propensity to regenerate, and this could be the reason why no one has ever needed to graft a posttraumatic conjunctival defect. We never suture our conjunctival defect. With our incision, we button-hole the inferior tarsal muscle, which maintains its medial and lateral attachment to the tarsus, so it remains functional. One must remember this is an autonomous involuntary muscle for emotional expression, as in a state of surprise or fear it lowers the lower lid. Under normal circumstances, the lower lid comes down because of gravity as we relax the pretarsal orbicularis oculi, the push of the more convex cornea and the downward voluntary pull of the inferior rectus muscle and sheath, none of which are manipulated with our technique.
Postoperatively, we recommend 0.3% Ciloxan (cip-rofloxacine chlorhydrate) drops four times a day for
1 week and Ciloxan ointment H.S. for 4 days, FML (fluorometholone, a steroid by Allergan) four times a day for 1 week then three times daily for 2 days, twice daily for 2 days and daily for 2 days. For pain, we give 1-2 caplets of 500 mg acetaminophen every 4 h as required.
When the commissure is short or too tight, or when facing a technical difficulty, we should not hesitate to do a lateral tarsorhaphy or tenolysis; it is most simple and useful, with minimal mobidity. I use straight scissors at the level of the lateral commissure and in one motion cut horizontally the whole thickness from skin to conjunctiva.
Then, we cut vertically the lower lateral canthal ligament. This will expose the fat and orbital rim very well and give us plenty of space to visualise and facilitate the suturing of the lower flap (containing the cap-sulopalpebral flap) to the lower orbital rim.
If the lower lid has insufficient support, I remove a few millimetres of the inferior lateral tarsal ligament or inferior tarsus. Then, I put one stitch (Bondex) to reapproximate perfectly the ligament and suture the skin with a continuous 6x0 plain catgut. This manoeuvre will tighten the lower lid and improve the chalasis and ageing of the lower lid.
Even if I do not resect some ligament, I put one stitch, but some ophthalmologists tell me there is no need for it. This manoeuvre creates very little swelling and is unlikely to cause more morbidity, but it certainly facilitates the procedure.
In cases of a marked anti-Mongoloid slant (because of marked downward movement of the weak lateral can-thus), a well-performed canthoplasty alone can overcome most of the signs of ageing provided the brow is not too low, in which case one would almost suture the lateral ocular commissure to the brow. In such a case, therefore, a concomitant brow lift would be imperative. However, if the Lockwood suspensory ligament stretches more than the lateral canthus, which is usual in younger patients, our technique is indicated. Our technique of relocating the herniated fat pad can be performed concomitantly with a canthoplasty if necessary, but a good canthoplasty should be sufficient when indicated, usually in older patients.
Rarely, we have seen allergies to topical medication and using a protective lens, we never saw a corneal abrasion.
At first, we did have some recurrences, but very rarely has this happened over the past 9 years. Rarely, we had to use the transcutaneous approach to remove a vestigious lateral fat pad. The transconjunctival approach would have been an alternative. On a few occasions we had conjunctival granulomas. These are easily removed with a few drops of ophthalmic local anaesthesia with or without local infiltration. We grab the granuloma with forceps and cut the stalk with small pointed scissors. We never had a granuloma recur. The incidence was reduced considerably by the use of resorbable sutures, and the application of a few drops of Betadine before incising; the cul de sac is always contaminated.
On a few occasions, we had downward retraction and scleral show from scarification (not from pretar-sal paresis or paralysis because we do not touch or damage the orbicularis oculi and its innervation). Massage could improve this with time. If not using local anaesthesia to the lower lid or around the infraorbital rim and waiting 25-30 min, we use a double-pronged hook on the conjunctival side of the lower lid to pull and evert the lower lid.
Holding the hook between the thumb and the index finger of the left hand, we apply our third finger (of the left hand) to the skin of the lower lid and feel bands of scar if weeks or months have passed since surgery.
If this procedure is performed early after surgery, we can palpate a tightness through the skin or with the tip of the scissors. Using small curved and pointed scissors and penetrating the conjunctiva above the original suture of the flap to the rim, we cut this scar until the third finger cannot feel transcutaneously any tethering throughout the whole lower lid. The lower lid must be free to move above the upper lim-bus. This manoeuvre must be performed thoroughly whether it is done early or late postoperatively.
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