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Blepharoplasty
Cosmetic Surgery, Plastic and Reconstructive Surgery: - lower lid blepharoplasty
Lower lid blepharoplasty
The lower eyelid is a common area for patients to notice changes of aging. This article describes the anatomy of the lower eyelid and the reasons for aging. It focuses on different operating principles and variations in practice, including complications and adjunctive procedures
Introduction
The disruptions caused by aging are first noticed around the eyes and then in the neck and lower face. Periorbital rejuvenation continues to evolve with more detailed understanding of the anatomy of the eyelid and its subsequent effect on the anatomy of aging. Procedures have been developed over time, with surgeons strive for a more youthful look.
Anatomy of the lower eyelid
The anterior lamella consists of skin and orbicularis muscle eyelids. The middle lamella consists of the orbital septum, which originates from the arcus marginalis and inserted into the lower margin of tarsus. The back sheet includes the conjunctiva and lower eyelid retractors.
The orbicularis muscle is immediately deep skin of the lower eyelid and extends from near the ciliary margin last infraorbital rim on the cheek. It has two components tarsal and preseptal. Pretarsally the orbicularis firmly adheres to the underlying tarsus. Part preorbital the orbicularis has cephalic attachment to the orbital rim along the orbicularis retaining ligament and along the caudal margin of the fascia that surrounds the origin of upper lip levator muscles (zygomaticus). The ligaments that support the contention orbicularis to the orbital rim and cheek serve to fix the underlying muscle hard against the frame underlying facial.
The orbital septum is below the eyelids. A plane of connective tissue lax, suborbicular fascia, lies between the orbicularis and orbital septum. Suborbicular oculi fat (SOOF) is on this plane and is the continuation of the fat pad14 malar. The triangular malar fat pad is based on the nasolabial fold and its apex at the malar eminence, and is located between the skin and muscle aponeurotic system superficial (SMAS). It is less connected to the SMAS and firmly adhered to the skin.
The orbital septum fuses with the talus superiorly and down to the periosteum of the infraorbital rim, This lower wall attachment is called the arcus marginalis. Marginal medial arch gives the anterior lacrimal crest and thins as it extends laterally enclosing approximately 2 mm below the rim on the facial aspect of the zygomatic bone. The orbital septum is used to retain orbital fat within the orbit. Fat mass, as it involves the muscles extraocular causes is divided into three pads, medial, central and lateral.
The aging lower eyelid, cheek complex
The pathogenesis the inferior herniation of orbital fat has been debated for decades. If the excess fat in old age appeared or if it is to change the orbital contents was not clear. The concepts of Manson and others and Camirand et al attributed less extrusion of fat to a weakening of the suspensory ligament of Lockwood in the presence of orbital septum of compartment fat limit the degree of protrusion. De la Plaza and Arroyo first proposed the theory that the protrusion of fat is associated with a weak support system in the world letting you down and cause pseudoherniation enopthalmos and bottom cover (bags).
The most poorly supported the orbicularis is the preseptal portion and this part of the orbicularis that shows the greatest tendency to decline. As the retaining ligaments relax with aging, herniated lower eyelid fat is not only forward but also downward below the orbital rim. This is most evident along the central fat pad, but can be seen medial as well. It is common to see a side platform of fat under the infraorbital rim. In youth there is a herniated orbital fat, the lateral orbicularis mixed with the malar. Malar bags are rarely evident and there is a smooth contour between the preseptal and preorbital orbicularis. In youth, there are relatively more in the eyelid SOOF and more than cheek fat subcutaneously. This helps lower eyelid appear soft and smooth, with no clear demarcation between the eyelid and cheek that become evident with aging.
Hamra youth noted that the eyelid-cheek complex is a line slightly convex in profile, ranging from inferior tarsus on the young cheek. Aging causes and subsequent decline of the globe pseudoherniation intraorbital fat. The drop bottom and sides of these structures produce an orbit that seems deeper with a larger diameter. This ptosis and progressive relaxation of the soft tissue coverage of the skeletonization result orbital area and reveal all the topographic contours of the inferior orbital rim bone. A youthful midface is characterized by a malar fat pad sitting on the zygomatic arch, its upper edge that covers the orbital orbicularis oculi and its bottom edge located along the nasolabial fold. With age, fat pad malar along with the slides inferonasal SOOF address and forwards over the SMAS. What stands out against the fixed nasolabial crease and exacerbates the appearance of nasolabial folds.
The combination of declining orbicularis oculi fat, malar SOOF with aging and becomes the only convexity youth aging double convex pattern.
Historical correction of the aging lower eyelid
Historically lower lid blepharoplasty was seen as an operation to remove skin and fat the lower lid. Blepharoplasty covers traditional open skin or skin-muscle flap between the infraorbital rim and subciliary incision. Orbital fat appeared excess was removed, but the "malar crescent" or lower edge of the orbicularis unchanged from its position on the malar eminence.
After operation, the appearance of lower lid became softer and more generally, especially in patients with a negative vector. The emergence of malar "half moon" or less orbicular edge if present before surgery remained unchanged. orbital fat removal caused the eventual collapse of the existing roof on the skin, creating more wrinkles than before. With the continuation of age, ptosis and the attenuation of the orbicularis oculi leading to a sunken appearance typical scleral show possible.
Repositioning of the orbicularis
Use of the orbicularis muscle as a flap in lower eyelid surgery was first described by Adamson et al, Courtiss, Furnas and was first used for the treatment of malar bags / scallops Furnas advocating for lateral tension placed on the orbicularis muscle.
Hamra said that by elevating the orbicularis muscle of the malar eminence, on a suborbicular oculi, and repositioning to the axis of the muscle from the medial orbital side of the union could be changed and the ring of muscle around the bony orbit may be tightened. Hamra argues that to deny the vector of aging in the orbicularis an inferolateral direction of the malar eminence, the vector of the repair be superomedial. This could well superomedial vector obtained by any of a compound rhytidectomy or by using a laterally based flap of orbicularis muscle. The base flap lateral orbicularis became higher in the raphe and sutured to extreme stress in the periosteum of the lateral orbital rim.
Hamra account limitations of this procedure, which included prolonged malar Odem and occasional inability to exert enough tension in this case the skin muscle flap to fear of lower eyelid retraction. Thus adapting the dissection plane to continue the dissection suborbicular in medial zygomaticus minor and major muscles, maintaining an adequate soft tissue coverage over the periosteum. With this level of dissection found no need to alter the origin of the zygomaticus muscle, but could still replace the orbicularis, with even more tension than before. This zygorbicular (Zygomatic, orbicularis) plane offered many advantages. Hamra think this dissection plane is preferable zygorbicular subperiosteal plane introduced by Tessier and recommended by Hester.
After dissection of the flap zygoorbicular used a 4-0 nylon suture through the longitudinal axis of the lateral canthal tendon and sutured to the inner wall of the lateral orbital periosteum. This suture stabilized the lower eyelid, however, in a position of ensuring the stability of the eyelids when the suture the septum with the proper tension on the orbital rim. He called this "transcanthal" canthopexy, which required neither canthal tendon release one side or canthotomy.
Preservation of the orbital fat / septal reset
Loeb was the first to describe the technique of fat mobilization through the medial orbital rim infraorbital. It is used to fill the groove and so nasojugal camouflage. Hamra extended this concept by advocating the complete liberation of the arc marginal subseptal allow the fat to be elevated to the orbital rim. Loeb extended the concept to include the promotion of all of lower eyelid fat pads in an effort to hide the infraorbital rim and recreate the youthful fullness of the lower eyelid. As previously described, the marginal arch was cut and the orbital fat only forward and sutured to the fat preperiosteal of the upper cheek. Later, he perfected his technique Hamra leave the orbital septum intact once removed and reset the bottom septum after the arcus marginalis release on the orbital rim. The orbital fat flap septal includes creating a smoother transition of the soft tissue covering bone edge and a convex smooth, firm surface for the overlying skin flap overlying the muscles thus reducing wrinkles. Hamra called a reset procedure septum. Hamra was a marked improvement with the repositioned orbicularis now rests on a lower surface of the signing of the septum, rather than in the concavity created by the fat removal, or the fullness of soft fat.
Surgical Technique
Perioperatievly subciliary the dermis of the incision line is injected local anesthesia, combined with percutaneous injections of local anesthetic drops with adrenaline in layers on the periosteum of the maxilla and malar.
Incision subciliary the skin is followed by a skin flap dissection to the junction of the preseptal portion with the periorbital orbicularis of the eyelids. The orbicularis preseptal opens, leaving calm tarsal muscle. After dissection to the orbital rim to the orbital septum, the dissection continues suborbicular in the zygomatic muscles. The origins of the zygomaticus major and minor muscles remain intact and an adequate layer of soft tissue overlying left periosteum. The dissection begins with the cutting cautery, continued with scissors, or sometimes a "Kitna." This blunt dissection avoids possible nerve damage, and pushes the limits of dissection in the middle portion of the zygomaticus major and minor zygomatic arch and lateral dissection zygoorbicular performed. The arcus marginalis is released by incising the orbital septum of the union and the inferior orbital rim periosteum with cauterization of the court after zygorbicular dissection has been achieved. Decisions on fat removal and repositioning of the orbital rim is determined before the operation
A some medial and central fat, as it can be resected lateral fat is in most cases used for recovery. Before the septal reset is completed, canthopexy transcanthal with a nylon 4.0, is done fixing the position of the lower eyelid to the partition restoration can be completed without tension. The lower edge of the septum is then reset over the orbital rim with multiple 5-0 Vicryl sutures. Usually, 5-0 from eight to 12 stitches needed to septal re-create a smooth transition, the voltage should be sufficient to create a firm surface for the lower orbicularis to rest.
After restoration is complete, the flap zygorbicular midface is advanced. Several 3-0 Vicryl sutures are placed between the flap preperiosteal zygorbicular and tissue to reduce dead space and serum collection. A lateral orbicularis pedicle base is created in the "dogleg" side of the incision blepharoplasty. This pedicle is passed under the skin and muscles of the raphe which is fixed with two stitches Monocryl 4-0 in the periosteum of the lateral orbital rim. The last maneuver is cutting the skin, in case that the adjustment should be made.
Fat removal
Before surgery, the surgeon must decide if the fat should be resected or not, and if so, how. This is a preoperative view dictated by the anatomy of each patient, which is difficult to assess when the patient is anesthetized. Eyelid positive and negative vectors refer to the axis of previous low point of the globe to the cheek. The positive vector eyelid is usually most easy to achieve a good result when a conventional blepharoplasty, eyelid negative vector and presents a challenge when using a conventional blepharoplasty. In the case of a positive vector eye, with no excess fat, restore partition takes a small amount of fat zero. In the case of a negative vector eye, most fat is needed to properly fill in the depression between subciliary line and the mound of the cheek create the outline of youth. Patients with a negative vector can also present with congenital excess fat. In these cases, conservative fat removal may be appropriate. In the lower eyelid hollow, if iatrogenic or natural, all the fat possible from space is recruited subseptal to effectively achieve a correction.
Transconjunctival versus transcutaneous.
The transcutaneous method of lower lid blepharoplasty has generally been met with some resistance. Transconjunctival approach advocates recommend it, since it addresses all of the prominent lower eyelid orbital fat attributable to a much lower risk of lid retraction without visible incisions and can be combined so secure rejuvenation techniques. Concerns relate to transconjunctival blepharoplasty half laminar shrinkage / reduction, rounding side scleral show and ectropion. The causal factors attributed the violation of the orbicularis resulting in denervation of the orbicularis oculi. Hamra admits with the compound that combines lift and repositioning of the orbicularis that partial denervation of the orbicularis muscle can occur. Although this is likely to be partial denervation in a long-term effects have been postulated. However, clinical studies have shown a mixed innervation of the muscle inside the Oral and lateral branches of the facial nerve temporal branch of the nerves. Functional reinnervation of surgery after normality has been demonstrated. Even studies of myomectomy orbicular for the treatment of blepharospasm have not produced a long-term denervation or loss of tone.
Honest review of 4395 cases showed that patients eligible for transconjunctival blepharoplasty are younger patients with smooth skin, and moderate fat pseudoherniation booty muscles.
It is generally accepted that the transcutaneous approach is required for orbicularis hypertrophy, excess skin, sagging lower eyelids or canthopexy necessary transconjunctival although methods have been adapted to address these issues. A transconjunctival excision of excess fat may be followed by a transcutaneous method leave the orbicularis / septum complex and the removal of excess skin. Canthoplasty also be combined as an adjuvant may resurfacing procedures when necessary. Septum transconjunctival orbicularis tightening CO2 laser resurfacing in combination with periocular skin has also been postulated. It is proposed to leave complex orbicular / partition avoids the problems of laminar adjustment means. Hester et al have questioned whether the top of many procedures to support the need to conduct through the transconjunctival approach if the morbidity can be less than a transcutaneous procedure.
Hamra suggests however that the transconjunctival approach results in an optimal result sub.
Reproducibility
Hamra advocates addressing the complex of the lid / cheek as part of a compound of cosmetic surgery. The isolated technical Hamra the lower lid blepharoplasty has been widely adopted, though its concepts have proven to be reliable and reproducible by others. Barton et al describe their use in the group of patients they call the "triad through tears."
These patients' hernia of fat, prominent orbital rim depression malar retrusion and negative edge vector. "technique is performed in 71 patients without a half sheet shortening or contracture. They added that the dissection infraorbital larger drainage channels interrupted for more than node on the cheek that is sometimes a prolonged edema. To avoid this, use an irrigation solution triamcinolone suborbicular in space before closing the lid of the defender and manual stretching exercises.
Orbicularis repositioning / transcanthal canthopexy / dissection plane zygoorbicular
The plane of dissection is discussed, Hester recommend a subperiosteal plane based on the work of Tessier. For patients with the fat pseudoherniation orbital, with minimal skin / muscle excess and patients with minimal decline in union lid / cheek and malar prominence Hester recommended that dissection preperiosteal the cheek is enough. This is based on their extensive review of complications in 757 cases transblepharoplasty approach therefore advised to avoid swelling and shrinkage the low in the lower eyelid. It also recommends a minimum of lower eyelid skin excision.
Although Hester makes a subperiosteal dissection flap release was used arc marginal transcanthal canthopexy and orbicularis laterally based pedicle flap passed under the union side. We found an improvement in their original state and canthotomy canthoplasty technique. Hamra see this change in practice as the turning point in the author's search for a natural look.
Despite the incorporation of orbicularis repositioning techniques offer a vertical solution that generally result in lateral dog ear training, especially in patients with excess skin. Removing the skin to cope with the maximum lateral dog-ear as recommended by Hester is necessary, which is well tolerated, with a minimum of complaints.
Repositioning the fat mobilization
While conservation of fat is a growing trend discussion is still focused on mobilizing fat replacement against fat. Repositioning the fat in a subperiosteal pocket subseptal is advocated by Goldberg. Repositioning is also defended by Moelleken instead of a restore partition, because of the risk of contracture laminar medium. Rohrich concluded that Hamra This technique is useful in the central and outer lid lower but falls short in the medial, requiring autologous fat transfer or from the central and lateral compartment or autologous fat injection in the suborbicular plan to soften the medial sulcus nasojugal.
Adjuvant rejuvenation procedures
Adjuvant therapies such as laser resurfacing have been used for transcutaneous blepharoplasty injections including TCA / rejuvenation laser peels or injections of fat. Hester uses TCA or rejuvenation laser over 60 percent of uncomplicated cases and also proposed the restoration of the volume of fat injection into the slot nasojugal. Hamra postulates that best results are the same 2.1 years later, with or without adjuvant therapy.
Complications
Complications following techniques lower blepharoplasty include lateral orbital fullness, thongs song, scleral show minor, ectropion, poor positioning and lower lid prolonged edema, dog ears and the sides of the slot nasojugal recurrence.
For significant scleral show / ectropion canthoplasty Hester recommended. To bad position recalcitrant lower eyelid usually with symptoms of dry eye is not corrected by repeated canthoplasty and elevation of the bottom cover Hester et al recommended the use of spacers eyelid lower and ear cartilage and mucosa of the hard palate. Hamra Alloderm recommended as an alternative.
Consultation
For anyone considering blephaoplasty is important to consult a surgeon who has experience in all previous techniques. For more information www.garylross.com
(C) Copyright 2009 garyross
About the Author
Mr. Gary Ross is a consultant plastic surgeon NHS in the GMC register of specialists for plastic surgery, a member of BAAPS and Bapro. He has trained in Australia, UK and Canada and has become a leading figure in the highly competitive field of Plastic Surgery. Your privacy practice Cheshire reflects his interest in the aesthetics of the head and neck and chest. He has been named senior honorary professor at the University of Manchester and has published more than 50 reviewed a series of articles and book chapters (including face lifts, brow lifts, blepharoplasty). He has performed around the world 200 times a teacher key note presenter. He has organized a series of international conferences and training courses and does not offer surgical options including laser, botox, fillers and peels. It offers the full range of cosmetic surgery procedures specializing in facial aesthetics, breast surgery and body contouring. More information www.garylross.com
Upper Blepharoplasty Procedure
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