- Email: [email protected]
Periorbital rejuvenation
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Periorbital Rejuvenation Tom Shokri MD , Jessyka G. Lighthall MD PII: DOI: Reference:
S1043-1810(18)30089-7 https://doi.org/10.1016/j.otot.2018.10.011 YOTOT 838
To appear in:
Operative Techniques in Otolaryngology - Head and Neck Surgery
Please cite this article as: Tom Shokri MD , Jessyka G. Lighthall MD , Periorbital Rejuvenation, Operative Techniques in Otolaryngology - Head and Neck Surgery (2018), doi: https://doi.org/10.1016/j.otot.2018.10.011
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Periorbital Rejuvenation Tom Shokri MD1, Jessyka G. Lighthall MD2 1
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Corresponding Author: Tom Shokri, MD Penn State College of Medicine The Milton S. Hershey Medical Center Division of Otolaryngology-Head and Neck Surgery 500 University Drive, MC H091 Hershey, PA 17033 Email: [email protected]
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Division of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania; 2 Director, Section of Facial Plastic and Reconstructive Surgery, Assistant Professor, Division of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
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Abstract. The periorbital region, consisting of the eyebrows, upper and lower eyelids, glabella, and pericanthal region, is particularly susceptible to early signs of aging. Overall, this process is influenced by both genetic and environmental factors. Periorbital rejuvenation continues to be an area of advancement with evolution in both noninvasive and invasive techniques. In this article, we will review minimally invasive and surgical procedures in the treatment of periorbital aging.
Introduction
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The periorbital region, consisting of the eyebrows, upper and lower eyelids, glabella, and pericanthal region, is particularly susceptible to early signs of aging. Overall, this process is influenced by both genetic and environmental factors. Periorbital aging is characterized by the appearance of rhytids, uneven and irregular texture, dryness, and pigmentation changes.1 Volume loss as well as animation lines along the glabella and lateral canthi further intensify the aging appearance. Factors that further accentuate this process include ultraviolet radiation exposure, repeated facial expressions, and tobacco use; all of which additively contribute to decreased skin elasticity with resultant tissue descent and volume loss.2,3 In this article, we will review minimally invasive and surgical procedures in the treatment of periorbital aging. Anatomy
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Successful treatment of periorbital aging requires an understanding of the relevant anatomy, in particular the relationship of the brow and the upper lid. Due to their intricate interrelationship, the upper eyelids are considered a continuous aesthetic unit with the brow. 4 The brow includes hairbearing skin and soft tissue overlying the superior orbital rim. The corrugator supercilii muscle lies deep to the hair-bearing skin. The corrugator, in addition to the procerus and orbicularis oculi, acts as a brow depressor. The frontalis muscle, which is absent laterally, acts as the sole brow elevator (Figure 1).
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The brow transitions to the upper eyelid at the arcus marginalis along the superior orbital rim. Deep to the orbital orbicularis and frontalis muscles, the retro-orbicularis oculi fat pad (ROOF) provides fullness to the brow and upper lid. Historically, resection of the ROOF was performed as an adjunct to upper lid blepharoplasty. However, modification of the ROOF may produce an atrophic appearance to the upper lid which then accentuates hollowing that increases with aging, creating an “A-frame” deformity. Modern techniques have therefore shifted to retaining or augmenting volume within this region. The upper eyelid is divided into anterior and posterior lamellae separated by the orbital septum, a thin adventitial layer of connective tissue. The anterior lamella consists of the skin and orbicularis muscle while the posterior lamella is composed of the levator palpebrae superioris muscle and levator aponeurosis, tarsus, Müller’s muscle, and conjunctiva. The orbital septum acts as a retaining layer for the orbital fat and is an important landmark during blepharoplasty. It originates from the arcus
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marginalis superiorly, fuses with the levator aponeurosis and tarsal plate inferiorly, and lies deep to the preseptal orbicularis oculi muscle. Orbital fat is located posterior to the orbital septum and anterior to the levator aponeurosis (Figure 2). The upper eyelid consists of two fat compartments: the nasal (medial) fat pad and central (middle) fat pad. A thin fibrous sheet and the trochlea of the superior oblique separate these compartments (Figure 3). Whitnall’s ligament originates on the superior surface of the trochlea and attaches to the lateral orbital rim deep to the lacrimal gland. The central fat pad, often whiter and denser than the nasal fat, can aid in distinguishing the origin of fat during blepharoplasty, orienting the surgeon to the location of the levator aponeurosis. The lateral third of the orbit is occupied by the lacrimal gland which lies within the lacrimal fossa. Lacrimal gland prolapse is common with aging and therefore one must be careful not to mistake the gland for fat during surgery. Moderate gland prolapse has been noted in up to 60% of patients and may be addressed with suture repositioning.5 The levator palpebrae superioris muscle and aponeurosis is the main retractor of the upper eyelid. The levator aponeurosis inserts onto the inferior two-thirds of the tarsus and has anterior fibers which attach it to the orbicularis oculi muscle and overlying skin, forming the supratarsal crease. Müller’s muscle consists of smooth muscle fibers innervated by the sympathetic system that act as an accessory lid elevator. It originates from the undersurface of the levator at the muscle-aponeurotic junction and inserts on the superior tarsus, providing 1.5 to 2.0 mm of elevation. The tarsal plate is a band of fibrous connective tissue that is an important structural support along both eyelids. Palpebral conjunctiva is adherent to the tarsus and Müller muscle and opposes the globe (Figure 2).
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The anatomy of the lower eyelid is somewhat analogous to that of the upper. The sub-orbicularis oculi fat pad (SOOF) lies deep to the orbicularis oculi muscle in the lower lid and is analogous to the ROOF in the upper lid. The retractors of the lower lid, in particular the capsulopalpebral fascia, are analogous to the levator aponeurosis in the upper eyelid. The head of the capsulopalpebral fascia separates to surround and ultimately fuse with the inferior oblique muscle. The two heads fuse to form the Lockwood suspensory ligament, analogous to Whitnall’s ligament in the upper lid, which suspends the globe between the medial and lateral check ligaments. The capsulopalpebral fascia fuses with the orbital septum approximately 5 mm below the tarsal border inserting into the anterior and inferior surfaces of the tarsus.6 The inferior tarsal muscle is analogous to Müller’s muscle in the upper lid and originates from the sheath of the inferior rectus muscle. It runs superficially to the inferior oblique muscle, attaches to the inferior oblique and fuses to the inferior tarsal border (Figure 2). The orbital septum, orbicularis oculi muscle, and lower lid skin act as the anterior barrier for orbital fat. The three inferior post-septal fat pads can be divided into lateral, central, and medial compartments. The lateral and central fat pads are separated by the arcuate expansion of Lockwood’s ligament and the central compartment is separated from the medial by the inferior oblique muscle (Figure 3). Due to relaxation of these connective tissues with aging, the orbital fat pseudoherniates forward forming a displeasing full lower eyelid. A relative loss of orbital volume occurs as there is commensurate hollowing with fat recession. These changes are targeted in the procedures discussed below. Brow and Eyelid Aesthetic Examination Attempts at rejuvenation of the periorbital area must be made after considering the relationships of adjacent facial subunits that contribute to changes associated with aging within this region. When
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addressing the periorbital complex, brow position, glabellar rhytids, dermatochalasis, fat pseudoherniation, lid ptosis, crow’s feet, ptotic lacrimal glands, and eyelid laxity must all be taken into account prior to performing surgery.
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The ideal brow anatomy differs depending on gender. The arch of the brow should extend superiorly above the orbital rim for females. The highest point should lie at the level of the lateral limbus or lateral canthus. In women, the medial brow origin is at the level of a vertical line drawn through the alar-facial junction. The lateral brow should fall within a line drawn from the lateral canthus to the nasal alar-facial junction. The masculine brow should have less of an arch with a more horizontal contour and location at the supraorbital rim. The distance between the mid-pupillary line and inferior brow should measure approximately 2.5 cm while the distance from the hairline to the superior brow border should be approximately 5 cm.1-3 Thorough evaluation of brow positioning is critical in preoperative planning as brow ptosis will significantly alter the appearance of the eyelids. Upper eyelid blepharoplasty alone will not correct brow ptosis and may in fact further accentuate brow ptosis by fixing the brow in an inferior position. Therefore, repositioning of the brow, via brow lift, prior to performing blepharoplasty is essential.
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In addition to a basic vision exam and evaluation for any symptoms or signs of dry eye syndrome, an aesthetic analysis of the eyelids is also a crucial aspect of preoperative planning. The lateral canthus should lie 2-4 mm superior to the medial canthus. The horizontal length of the palpebral fissure should measure approximately 25-30 mm while the vertical aspect should measure 10 mm. Symmetry of the palpebral fissures should be closely examined as any asymmetry, particularly vertically, may suggest blepharoptosis, prompting consideration of ptosis repair in addition to blepharoplasty. The upper lid margin should cover approximately 1-2 mm of the superior limbus, while the lower lid margin ideally lies at the inferior limbus or 1 mm below it. Ptosis may be quantified using the margin-reflex distance (MRD-1), the distance between the corneal light reflex and the upper lid margin, which ideally measures 3-4.5 mm. In addition to the MRD-1, the central interpalpebral distance should also be documented. This is the distance between the upper and lower lid margins at their highest respective points. The central interpalpebral distance should measure 8-10 mm. 1-3 Finally, an assessment of skin quality, texture and elasticity with a pinch and snap test should be standard. Decreased elasticity of the lower eyelid should be addressed at the time of lower eyelid blepharoplasty with a tightening procedure to avoid post-operative eyelid malposition.
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Minimally Invasive Techniques With advances in cosmetic medicine, minimally invasive techniques in aesthetic rejuvenation have become increasingly popular. Commonly employed treatments include topical therapies, mechanical and chemical skin resurfacing, fillers, neuromodulation with use of botulinum toxin (BoNT), as well as laser and radiofrequency devices.7 A review of these techniques is beyond the scope of this article, however many of these treatments may be used as adjuncts to surgery and therefore a brief overview follows.
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Adjunctive skin care in the form of topical therapies is important in prevention of facial aging as well as in treatment and maintenance following procedural intervention. Due to the multitude of available products, it is important that the surgeon review which products are most effective for the patient’s specific needs. It is important to note that eyelid skin is the thinnest of the body and therefore extremely susceptible to injury from topical products.8 Sunscreens play a critical role in the prevention of photodamage and mitigate the development of post-procedural hyperpigmentation. To maximize potential benefit, a sun protection factor (SPF) of 30 or higher, for ultraviolet B [UVB] protection, and “broad spectrum”, for ultraviolet A [UVA] protection, lotions are recommended. Topical antioxidant therapies include vitamin C and E, both of which have been shown to have additive effects, and Niacinamide.8 Topical retinoids have also shown to improve wrinkles by upregulating dermal collagen synthesis and downregulating collagen degradation. Topical growth factors and peptides have been shown to have similar effects on collagen. However, cosmeceuticals containing growth factors have a theoretical risk of increasing skin cancer although there are no documented reports in the literature. Patients suffering from hypotrichosis of the eyelashes or brow, should be counseled regarding use of topical bimatoprost 0.03%. This treatment is FDA-approved for enhancement of eyelashes, resulting in increased density and length.9 Application to the eyebrows has also been documented, although this is considered off-label use and is not well studied.10
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Skin resurfacing is also often used as an adjunct to surgical procedures due to its unique ability to address skin texture and dyschromia while also decreasing wrinkles and scarring. Skin resurfacing can be achieved through different techniques including dermabrasion, chemical peels, and laser therapy. For further details regarding the utility of each modality, readers are directed to the listed references.8,11-19
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Botulinum toxin (BoNT) has become the most commonly employed cosmetic procedure in the treatment of periorbital aging and facial enhancement. Although irreversible, BoNT effects deteriorate within three to six months as new axon terminals are generated.20 Use of neuromodulators is contraindicated in patients with myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis, and pregnancy. Common side effects include erythema, pain, and bruising. A particular side effect, when applied to the periorbital region, is ptosis secondary to paralysis of the levator palpebrae or inferior frontalis muscles.8, 20 Common dosages of BoNT vary depending on the location of use. In larger muscles, such as the frontalis, lower concentrations may be used to increase diffusion. Conversely, if higher concentrations are needed, lower volumes may decrease diffusion and pain with injection. Common dosages when used in the periorbital region are included in Table 1. Erickson et al.20 review the key steps in periorbital use of BoNT. It should be noted that use of neuromodulators one to two weeks prior to skin resurfacing has been documented to improve outcomes.21 Lastly, fillers are a unique option to augment volume loss as a result of the aging process and addressing static rhytids. Hyaluronic acid (HA) is considered the workhorse, particularly in the periorbital area, due to its efficacy and predictable outcomes, although autologous fat is also often used, particularly for areas with larger volume deficits.22 The non-invasive treatment options, detailed above, can be implemented as monotherapy or adjuncts to surgery based on the severity of periorbital aging and patient expectations.
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Upper Lid Blepharoplasty The aesthetic ideals and interrelationship between the eyelids, eyebrows, orbit, midface, and forehead should be reviewed prior to surgery in order to tailor the patient’s treatment plan to his or her anatomy. Standardized photo documentation as well as a candid discussion with the patient regarding desired outcomes and realistic expectations is essential for optimization of outcomes and patient satisfaction. Blepharoplasty is performed as an outpatient procedure under either local or general anesthesia.23, 24
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If upper lid blepharoplasty is to be performed in conjunction with a brow lift, the blepharoplasty incision marking should be created after completion of the brow lift as the brow lift will alter the amount of skin to be excised. Eyelid marking is the most important step in this procedure and therefore must be done with care to ensure precision. The initial lid marking is made at the level of the supratarsal crease in Caucasians, medially from the level of the lacrimal punctum, across the lid, and extending laterally to the lateral orbital rim. In some cases, extensive lateral skin hooding may require skin excision beyond the lateral orbital rim. Patients must be counseled prior to surgery that wound healing may be prolonged in this region due to greater skin thickness.23,24,25 In cases where the lid crease is indistinct or the patient displays blepharoptosis, the incision should be marked between 8-10 mm in women and 6-8 mm in men from the inferior margin of the eyelid. The lateral aspect of the incision curves upward along the natural crease between the orbital rim and eyelid. The incision should be gently curved so that the medial end descends approximately 1-2 mm from the central vertical height. In order to determine the extent of skin excision, the pinch test is performed to assess for redundancy. Iris or green fixation forceps are used to grasp the skin at the marked lid crease and a point superiorly until slight eversion of the lid is accomplished (Figure 4) to optimize skin excision while preventing excessive skin resection resulting in lagophthalmos. Traditionally, a minimum of 20 mm of eyelid skin should remain between the lid margin and the inferior portion of the brow to mitigate the risk of lagophthalmos. When markings are completed, the medial and lateral aspects of the fusiform excision should form 30-degree angles to facilitate closure.23,24,25
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After markings are complete, 1-2 ml of local anesthesia is injected within the subcutaneous tissue plane. The skin incisions are then made with scalpel blade or needle-tip monopolar electrocautery and the skin is then excised as either a single layer or an en bloc resection including skin and a strip of orbicularis oculi muscle (Figure 5A-B). If a single layer excision is performed, a separate step involving resection of the orbicularis oculi muscle may be performed. The extent of orbicularis resection is dependent on the degree of muscle hypertrophy. Pseudoherniation of fat can be addressed by one of two common techniques. The degree of pseudoherniation may be decreased by bovie cauterization of the orbital septum resulting in contraction of the septum. Alternatively, the orbital septum may be incised and fat from the medial and nasal compartments may be conservatively resected. Only fat that protrudes into the wound with gentle globe pressure and anterior traction should be excised in order to prevent excessive resection and a hollowed appearance (“A-frame deformity”). Laterally, the lacrimal gland should be identified in order to avoid injury. It often appears pink, firm, and more vascular than fat. If necessary, pexy of the lacrimal gland may be performed. If blepharoptosis repair is required, the levator aponeurosis advancement may be performed at this time. Wound closure may then be performed with a single layer closure of the skin with 6-0 fast absorbing gut suture or surgeon’s preferred suture
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technique (Figure 5C-D).23, 24, 25 This sequence of steps is then repeated for the contralateral eyelid with attention to providing symmetry. Lower Lid Blepharoplasty
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Several techniques for lower lid blepharoplasty have been described throughout the literature. However, three main surgical approaches predominate as follows: transcutaneous skin only flap, transcutaneous skin-muscle flap, and transconjunctival. We will focus this discussion on the two most common techniques, the transconjunctival and the transcutaneous skin-muscle flap approach. Transconjunctival blepharoplasty has gained popularity due to inconspicuous incision placement, maintenance of orbicularis support, and decreased incidence of postoperative ectropion.26 Appropriate candidates for this approach include patients that are concerned for scarring, have history of hypertrophic scars, and those with pseudoherniation of fat with little lower lid skin redundancy. Patients with large amounts of excess skin or orbicularis hypertrophy may benefit from a subciliary or transcutaneous approach.26,27 However, moderate skin excess in the lower eyelid does not preclude a transconjunctival approach, in that the addition of a pinch excision of skin or lid resurfacing techniques may allow for effective multimodal intervention. Fat repositioning to address infraorbital hollowing and the nasojugal groove may be performed with any approach. Care should be taken to provide lower eyelid tightening with preoperative evidence of decreased elasticity. Transconjunctival Approach
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Local anesthesia is injected and the lower eyelid conjunctiva is subsequently exposed. A Desmarres retractor used to evert the lower eyelid while a Jaeger lid plate may be used to protect the globe. If the surgeon elects to pursue a preseptal approach, a transconjunctival incision is made at the inferior aspect of the tarsal plate (Figure 6 & Figure 7A). Dissection is then continued in the avascular plane deep to the orbicularis oculi muscle and superficial to the orbital septum. This plane of dissection is continued to the orbital rim without exposing the orbital rim. A traction suture is then passed through the edge of the conjunctiva for both corneal protection and added exposure (Figure 7B). The orbital septum can then be clearly visualized and selectively entered with monopolar electrocautery (Figure 7C). In a postseptal approach, an incision is placed approximately 4 mm below the inferior tarsal margin, through the conjunctiva and lid retractors, and posterior to the orbital septum to expose the orbital fat compartments (Figure 6). The inferior oblique muscle should be identified in order to delineate the medial and middle fat pads in both approaches. Fat is either resected with electrocautery or repositioned into the infraorbital hollow based on an intraorbital pedicle and secured to treat the nasojugal groove. The temporal fat pad may be identified and conservatively resected. Incisions may be left to heal spontaneously or 6-0 fast absorbing gut suture may be used to loosely reapproximate the conjunctiva. If redundant lower eyelid skin is present, a subciliary pinch excision may be performed with subsequent closure of the incision using 6-0 fast absorbing gut suture. Lid laxity should be addressed to minimize the risk of lower eyelid malposition. Transcutaneous Myocutaneous Flap
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The transcutaneous approach to lower eyelid blepharoplasty using a skin-muscle flap is a useful method to address age-related changes to the lower lid while preserving the integrity of the orbicularis oculi sling and maintaining lower eyelid position.28 Many modifications of this technique exist and may include release of the orbitomalar ligament with either fat excision or fat transposition. This is also a useful technique when there exists extensive excess skin, orbicularis hypertrophy (festoons), or significant lower eyelid laxity requiring a lid tightening procedure.
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The skin of the lower eyelid is incised 1 mm below the lash margin in subciliary fashion, 2 mm lateral to the punctum and extending laterally approximately 10 mm from the lateral canthus (Figure 8A). A midline lower eyelid retraction suture is placed and pulled superiorly. The skin flap is then typically elevated 1.5 cm inferiorly using iris scissors thereby preserving a muscular sling, constituting the pretarsal orbicularis oculi muscle. The orbicularis is then incised inferior to the elevated skin flap and incision is extended for the length of the orbit (Figure 8B). A composite myocutaneous flap is then elevated off of the orbital septum inferiorly to the orbital rim (Figure 8C).
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Once the orbital rim is reached, the retaining ligaments of the orbit are released using monopolar or bipolar cautery. This part of the dissection is performed just superficial to the SOOF while being careful to preserve the infraorbital nerve. A Desmarres retractor is then used to retract the composite flap inferiorly and gentle manual retropulsion of the globe is applied to aid in identifying the fat compartments. The orbital septum of the medial and central fat compartments is then entered using sharp scissors. Cotton tip applicators are used to aid in blunt dissection and the inferior oblique muscle is identified, separating the medial and central compartments. The fat pads may then be either excised or repositioned. If they are to be transposed, the nasal and medial fat pads are left pedicled and mobilized inferiorly over the orbital rim and into the tear trough defect allowing for volumization and camouflage. The fat is then sutured to the supraperiosteal tissue with 5-0 chromic suture. Excessive fat from the lateral fat pad may be resected but is typically not transposed due to its fibrous nature resulting in irregular contouring. Overaggressive resection is avoided, particularly in patients with prominent globes or hypoplastic malar eminences (negative vector), as this may result in creation of a deep sulcus postoperatively.
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Attention is then turned to the lateral orbit, using scissors to dissect to the periosteum of the lateral orbital rim. The dissection is then turned superolaterally extending superior to the lateral canthal tendon. Two 6-0 nylon sutures are then passed through the periosteum of the internal lateral orbital rim. One of these sutures is then used to suspend the lateral tarsal plate. The second suture is then passed to the superior edge of the orbicularis oculi muscle flap facilitating elevation of the superior midface. This step is crucial due to earlier destabilization of the midface when releasing the orbital retaining ligaments. The skin flap is then redraped superolaterally into the skin incision and 1-2 mm of skin may be removed medially depending on the extent of skin excess. The skin is then closed with 6-0 nylon sutures in an interrupted fashion lateral to the lateral canthus and with a 7-0 running locking silk suture medially.
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Complications of Periorbital Rejuvenation
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A discussion of possible complications and realistic outcomes should be discussed with the patient prior to surgery. Postoperative asymmetry is common and may initially be exacerbated by bruising, edema, or sleep posture. However, it may also be a result of unidentified preoperative asymmetry, such as subtle ptosis, further exaggerated by post-operative edema. Only once the lids have stabilized with near resolution of the edema and bruising should revision procedures be considered, typically at least eight weeks after the initial surgery for persistent asymmetry. Although the reported need for revision is low, ptosis and exophthalmos may increase revision rates to 10%.29 Retrobulbar hemorrhage is a particularly rare but severe complication of eyelid surgery. Postoperatively, it is important to educate the patient regarding signs of orbital hemorrhage. Increased edema, ecchymosis, and severe orbital pain should prompt urgent examination. High flow oxygen and steroids may be used in conjunction with mannitol to decrease swelling, however if severe pain is accompanied by vision loss, emergent lateral canthotomy with cantholysis should be performed. The patient should be observed and if no improvement is noted orbital decompression is pursued. Failure to adequately identify and address this complication has been shown to result in permanent blindness within 90 minutes.30,31
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Lagophthalmos, or inability to close the eye, is commonly observed in the immediate postoperative period following upper eyelid blepharoplasty, particularly if brow lift and ptosis repair are performed in conjunction.31 This is often a result of levator spasm, edema, or orbicularis paresis. Lagophthalmos may persist for a few weeks following surgery. Patients should be managed with proper precautions in order to prevent injury from corneal exposure, including use of artificial tears throughout the day and ointment at night. Use of a humidification chamber or taping the eye closed may be considered if lagophthalmos is severe. If the patient is unable to close his or her eye six to eight weeks following surgery, an overaggressive excision of the lid skin may have been performed. A skin graft may then be used to replace the missing skin.30,31
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Eyelid malposition may also occur postoperatively ranging from mild scleral show to overt lower eyelid eversion or inversion. Ectropion and lower lid retraction may result from overaggressive skin excision with contraction of the lower lid anterior lamella. Alternatively, ectropion may be a result of failure to effectively address lower lid laxity. This can be prevented by performing a lid shortening or tightening procedure at the time of blepharoplasty. Ectropion may be corrected following surgery with either a tarsal strip or lysis of cicatricial adhesions, depending on which of the two above mentioned contributing factors are indentified.25,230,31 In contrast, entropion may result from shortening of the posterior lamella and subsequent scar contracture after transconjunctival approach. This may be similarly corrected with lysis of cicatricial adhesions with use of a hard palate mucosal graft to prevent recurrent cicatrix.32 Finally, asymmetry, inadequate skin excision, adverse scarring, or inadequate fat resection may also lead to an unhappy patient and may require revision. Conclusion
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Periorbital rejuvenation continues to be an area of advancement with evolution in both noninvasive and invasive techniques. A careful functional and aesthetic assessment of the brow-lid complex, care to address brow ptosis prior to blepharoplasty, and careful preoperative counseling to set realistic expectations is paramount. When appropriate, a multimodal approach incorporating both surgical and adjunctive nonsurgical techniques should be employed to enhance the appearance of the periorbital region. Detailed preoperative planning and meticulous surgical technique are crucial in diminishing complications and optimizing outcomes.
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Figures:
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Figure 1. Periorbital facial musculature.
Figure 2. Cross-sectional anatomy of the eyelids. Anterior lamella: skin and orbicularis muscle; Posterior Lamella: upper lid elevators including Müller’s muscle, levator muscle, tarsus, and conjunctiva. The ROOF is positioned superficial to the septum. Capsulopalpebral fascia and inferior tarsal muscle act as lower lid retractors. The orbitomalar ligament, extending from the arcus marginalis to the lower lid skin, forms the nasojugal fold.
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Figure 3. Fat compartments of the eyelids.
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Figure 4. Pinch test, in which forceps are used to grasp skin of the upper eyelid to asses for skin redundancy and the extent of skin excision possible without resultant lagophthalmos.
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Figure 5. (A) Upper eyelid blepharoplasty incision (B) Skin and central portion of orbicularis muscle excised exposing orbital septum. (C) Orbital septum incised, and orbital fat exposed. (D) Blepharoplasty incision closed with 7-0 polypropylene suture in running fashion.
Figure 6. Lower eyelid blepharoplasty. Transconjunctival (1) preseptal and (2) postseptal approaches.
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Figure 7. Transconjunctival preseptal lower lid blepharoplasty with fat excision A) transconjunctival preseptal incision B) Traction suture placed for corneal protection C) Orbital Septum is entered with resection or reposition of fat.
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Figure 8. Transcutaneous skin-muscle flap lower lid blepharoplasty; A) Subciliary skin incision along lower eyelid B) Placement of retraction suture pulled superiorly with skin flap elevation and incision of orbicularis with intact muscular sling C) Elevation of composite myocutaneous flap with entrance of the medial and central fat compartments.
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Periorbital Region
OnabotulinumtoxinA/ IncobotulinumtoxinA Units (e.g. Botox ®, Xeomin ®) 15-30 20-30
AbobotulinumtoxinA Units (Dysport ®)
Glabella 40-60 Bilateral Lateral Canthal +/40-70 Infrabrow for Chemical Brow Lift Bilateral Infraorbital 2-5 5-15 Forehead 10-20 20-50 Table 1. Common dosages of botulinum toxin neuromodulator in periorbital rejuvenation.
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References: 1) Glaser DA, Patel U. Enhancing the eyes: use of minimally invasive techniques for periorbital rejuvenation. J Drugs Dermatol 2010;9(8):s118–28 2) Bartlett SP, Grossman R, Whitaker LA. Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis. Plast Reconstr Surg 1992;90(4):592–600.
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3) Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007;120(5):1367–1377. 4) . Lam VB, Czyz CN, Wulc AE. The brow-lid continuum: an anatomic perspective. Clin Plast Surg 2013;40: 1–19.
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5) Massry GG. Prevalence of lacrimal gland prolapse in the functional blepharoplasty population. Ophthal Plast Reconstr Surg 2011;27: 410–413.
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6) Jones LT: The anatomy of the lower eyelid and its relation to the cause and cure of entropion. Am J Ophthalmol 1960;49: 29-36. 7) Glaser D.A., and Patel U.: Enhancing the eyes: use of minimally invasive techniques for periorbital rejuvenation. J Drugs Dermatol 2010; 9: s118-s128
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8) Bucay V.W., and Day D.: Adjunctive skin care of the brow and periorbital region. Clin Plast Surg 2013; 40: 225-23
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9) Smith S, Fagien S, Whitcup SM, et al: Eyelash growth in subjects treated with bimatoprost: a multicenter, randomized, double-masked, vehicle-controlled, parallel-group study. J Am Acad Dermatol 2012; 66: 801-806
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10) Schweiger ES, Pinchover L, and Bernstein RM: Topical bimatoprost for the treatment of eyebrow hypotrichosis. J Drugs Dermatol 2012; 11: pp. 106-108 11) Glaser DA, Kurta A. Periorbital Rejuvenation: Overview of Nonsurgical Treatment Options. Facial plastic surgery clinics of North America. 2016; 24(2):145-152. 12) Jackson A.: Chemical peels. Facial Plast Surg 2014; 30: 26-34 13) Hassan K.M., and Benedetto A.V.: Facial skin rejuvenation: ablative laser resurfacing, chemical peels, or photodynamic therapy? Facts and controversies. Clin Dermatol 2013; 31: pp. 737-740
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14) Brauer J.A., Patel U., and Hale E.K.: Laser skin resurfacing, chemical peels, and other cutaneous treatments of the brow and upper lid. Clin Plast Surg 2013; 40: pp. 91-99 15) Shook B.A., and Hruza G.J.: Periorbital ablative and nonablative resurfacing. Facial Plast Surg Clin North Am 2005; 13: pp. 571-582
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16) Alster T.S., and Bellew S.G.: Improvement of dermatochalasis and periorbital rhytides with a highenergy pulsed CO2 laser: a retrospective study. Dermatol Surg 2004; 30: pp. 483-487 17) Caniglia R.J.: Erbium:YAG laser skin resurfacing. Facial Plast Surg Clin North Am 2004; 12: pp. 373-377 18) Alexiades-Armenakas M.R., Dover J.S., and Arndt K.A.: The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. Dermatology 2008; 58: pp. 719-737
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19) Carniol P.J., Hamilton M.M., and Carniol E.T.: Current status of fractional laser resurfacing. JAMA Facial Plast Surg 2015; 17: pp. 360-366 20) Erickson B.P., Lee W.W., Cohen J., et al: The role of neurotoxins in the periorbital and midfacial areas. Facial Plast Surg Clin North Am 2015; 23: pp. 243-255 21) Zimbler M.S., Holds J.B., Kokoska M.S., et al: Effect of botulinum toxin pretreatment on laser resurfacing results: a prospective, randomized, blinded trial. Arch Facial Plast Surg 2001; 3: pp. 165-169
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22) Lee S., and Yen M.T.: Injectable hyaluronic acid fillers for periorbital rejuvenation. Int Ophthalmol Clin 2013; 53: pp. 1-9
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23) Moses JL, and Tanenbaum M: Blepharoplasty: cosmetic and functional. In McCord CD, Tanenbaum M, and Nunery WR (eds): Oculoplastic Surgery. New York: Raven Press, 1995. 285
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24) Hahn S, Holds JB, Couch SM. Upper Lid Blepharoplasty. Facial Plastic Surgery Clinics. 2016 May 1;24(2):119-27.
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25) Rankin BS, Arden RL, and Crumley RL: Lower eyelid blepharoplasty. In Papel I, Frodel J, and Holt G (eds): Facial Plastic and Reconstructive Surgery, ed 2. New York: Thieme, 2002. pp. 196
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27) Yousif N.J., Sonderman P., Dzwiersynski W.W., et al: Anatomic considerations in transconjunctival blepharoplasty. Plast Reconstr Surg 1995; 96: 1271-1276 28) Hashem AM, Couto RA, Waltzman JT, Drake RL, Zins JE. Evidence-based medicine: A graded approach to lower lid blepharoplasty. Plastic and reconstructive surgery. 2017 Jan 1;139(1):139e-50e. 29) Codner MA, Wolfi J, and Anzarut A: Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg 2008; 121: pp. 241-250 30) Castanares S: Complications in blepharoplasty. Clin Plast Surg 1978; 5: pp. 149 31) Adams BJS, and Feurstein SS: Complications of blepharoplasty. Ear Nose Throat J 1986; 65: pp. 11
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32) Kersten RC, Kulwin DR, Levartovsky S, Tiradellis H, David TT. Management of lower-lid retraction
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with hard-palate mucosa grafting. Archives of Ophthalmology. 1990; 108(9):1339-1343.
Periorbital Rejuvenation Tom Shokri MD , Jessyka G. Lighthall MD PII: DOI: Reference:
S1043-1810(18)30089-7 https://doi.org/10.1016/j.otot.2018.10.011 YOTOT 838
To appear in:
Operative Techniques in Otolaryngology - Head and Neck Surgery
Please cite this article as: Tom Shokri MD , Jessyka G. Lighthall MD , Periorbital Rejuvenation, Operative Techniques in Otolaryngology - Head and Neck Surgery (2018), doi: https://doi.org/10.1016/j.otot.2018.10.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Periorbital Rejuvenation Tom Shokri MD1, Jessyka G. Lighthall MD2 1
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Corresponding Author: Tom Shokri, MD Penn State College of Medicine The Milton S. Hershey Medical Center Division of Otolaryngology-Head and Neck Surgery 500 University Drive, MC H091 Hershey, PA 17033 Email: [email protected]
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Division of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania; 2 Director, Section of Facial Plastic and Reconstructive Surgery, Assistant Professor, Division of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
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Abstract. The periorbital region, consisting of the eyebrows, upper and lower eyelids, glabella, and pericanthal region, is particularly susceptible to early signs of aging. Overall, this process is influenced by both genetic and environmental factors. Periorbital rejuvenation continues to be an area of advancement with evolution in both noninvasive and invasive techniques. In this article, we will review minimally invasive and surgical procedures in the treatment of periorbital aging.
Introduction
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The periorbital region, consisting of the eyebrows, upper and lower eyelids, glabella, and pericanthal region, is particularly susceptible to early signs of aging. Overall, this process is influenced by both genetic and environmental factors. Periorbital aging is characterized by the appearance of rhytids, uneven and irregular texture, dryness, and pigmentation changes.1 Volume loss as well as animation lines along the glabella and lateral canthi further intensify the aging appearance. Factors that further accentuate this process include ultraviolet radiation exposure, repeated facial expressions, and tobacco use; all of which additively contribute to decreased skin elasticity with resultant tissue descent and volume loss.2,3 In this article, we will review minimally invasive and surgical procedures in the treatment of periorbital aging. Anatomy
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Successful treatment of periorbital aging requires an understanding of the relevant anatomy, in particular the relationship of the brow and the upper lid. Due to their intricate interrelationship, the upper eyelids are considered a continuous aesthetic unit with the brow. 4 The brow includes hairbearing skin and soft tissue overlying the superior orbital rim. The corrugator supercilii muscle lies deep to the hair-bearing skin. The corrugator, in addition to the procerus and orbicularis oculi, acts as a brow depressor. The frontalis muscle, which is absent laterally, acts as the sole brow elevator (Figure 1).
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The brow transitions to the upper eyelid at the arcus marginalis along the superior orbital rim. Deep to the orbital orbicularis and frontalis muscles, the retro-orbicularis oculi fat pad (ROOF) provides fullness to the brow and upper lid. Historically, resection of the ROOF was performed as an adjunct to upper lid blepharoplasty. However, modification of the ROOF may produce an atrophic appearance to the upper lid which then accentuates hollowing that increases with aging, creating an “A-frame” deformity. Modern techniques have therefore shifted to retaining or augmenting volume within this region. The upper eyelid is divided into anterior and posterior lamellae separated by the orbital septum, a thin adventitial layer of connective tissue. The anterior lamella consists of the skin and orbicularis muscle while the posterior lamella is composed of the levator palpebrae superioris muscle and levator aponeurosis, tarsus, Müller’s muscle, and conjunctiva. The orbital septum acts as a retaining layer for the orbital fat and is an important landmark during blepharoplasty. It originates from the arcus
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marginalis superiorly, fuses with the levator aponeurosis and tarsal plate inferiorly, and lies deep to the preseptal orbicularis oculi muscle. Orbital fat is located posterior to the orbital septum and anterior to the levator aponeurosis (Figure 2). The upper eyelid consists of two fat compartments: the nasal (medial) fat pad and central (middle) fat pad. A thin fibrous sheet and the trochlea of the superior oblique separate these compartments (Figure 3). Whitnall’s ligament originates on the superior surface of the trochlea and attaches to the lateral orbital rim deep to the lacrimal gland. The central fat pad, often whiter and denser than the nasal fat, can aid in distinguishing the origin of fat during blepharoplasty, orienting the surgeon to the location of the levator aponeurosis. The lateral third of the orbit is occupied by the lacrimal gland which lies within the lacrimal fossa. Lacrimal gland prolapse is common with aging and therefore one must be careful not to mistake the gland for fat during surgery. Moderate gland prolapse has been noted in up to 60% of patients and may be addressed with suture repositioning.5 The levator palpebrae superioris muscle and aponeurosis is the main retractor of the upper eyelid. The levator aponeurosis inserts onto the inferior two-thirds of the tarsus and has anterior fibers which attach it to the orbicularis oculi muscle and overlying skin, forming the supratarsal crease. Müller’s muscle consists of smooth muscle fibers innervated by the sympathetic system that act as an accessory lid elevator. It originates from the undersurface of the levator at the muscle-aponeurotic junction and inserts on the superior tarsus, providing 1.5 to 2.0 mm of elevation. The tarsal plate is a band of fibrous connective tissue that is an important structural support along both eyelids. Palpebral conjunctiva is adherent to the tarsus and Müller muscle and opposes the globe (Figure 2).
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The anatomy of the lower eyelid is somewhat analogous to that of the upper. The sub-orbicularis oculi fat pad (SOOF) lies deep to the orbicularis oculi muscle in the lower lid and is analogous to the ROOF in the upper lid. The retractors of the lower lid, in particular the capsulopalpebral fascia, are analogous to the levator aponeurosis in the upper eyelid. The head of the capsulopalpebral fascia separates to surround and ultimately fuse with the inferior oblique muscle. The two heads fuse to form the Lockwood suspensory ligament, analogous to Whitnall’s ligament in the upper lid, which suspends the globe between the medial and lateral check ligaments. The capsulopalpebral fascia fuses with the orbital septum approximately 5 mm below the tarsal border inserting into the anterior and inferior surfaces of the tarsus.6 The inferior tarsal muscle is analogous to Müller’s muscle in the upper lid and originates from the sheath of the inferior rectus muscle. It runs superficially to the inferior oblique muscle, attaches to the inferior oblique and fuses to the inferior tarsal border (Figure 2). The orbital septum, orbicularis oculi muscle, and lower lid skin act as the anterior barrier for orbital fat. The three inferior post-septal fat pads can be divided into lateral, central, and medial compartments. The lateral and central fat pads are separated by the arcuate expansion of Lockwood’s ligament and the central compartment is separated from the medial by the inferior oblique muscle (Figure 3). Due to relaxation of these connective tissues with aging, the orbital fat pseudoherniates forward forming a displeasing full lower eyelid. A relative loss of orbital volume occurs as there is commensurate hollowing with fat recession. These changes are targeted in the procedures discussed below. Brow and Eyelid Aesthetic Examination Attempts at rejuvenation of the periorbital area must be made after considering the relationships of adjacent facial subunits that contribute to changes associated with aging within this region. When
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addressing the periorbital complex, brow position, glabellar rhytids, dermatochalasis, fat pseudoherniation, lid ptosis, crow’s feet, ptotic lacrimal glands, and eyelid laxity must all be taken into account prior to performing surgery.
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The ideal brow anatomy differs depending on gender. The arch of the brow should extend superiorly above the orbital rim for females. The highest point should lie at the level of the lateral limbus or lateral canthus. In women, the medial brow origin is at the level of a vertical line drawn through the alar-facial junction. The lateral brow should fall within a line drawn from the lateral canthus to the nasal alar-facial junction. The masculine brow should have less of an arch with a more horizontal contour and location at the supraorbital rim. The distance between the mid-pupillary line and inferior brow should measure approximately 2.5 cm while the distance from the hairline to the superior brow border should be approximately 5 cm.1-3 Thorough evaluation of brow positioning is critical in preoperative planning as brow ptosis will significantly alter the appearance of the eyelids. Upper eyelid blepharoplasty alone will not correct brow ptosis and may in fact further accentuate brow ptosis by fixing the brow in an inferior position. Therefore, repositioning of the brow, via brow lift, prior to performing blepharoplasty is essential.
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In addition to a basic vision exam and evaluation for any symptoms or signs of dry eye syndrome, an aesthetic analysis of the eyelids is also a crucial aspect of preoperative planning. The lateral canthus should lie 2-4 mm superior to the medial canthus. The horizontal length of the palpebral fissure should measure approximately 25-30 mm while the vertical aspect should measure 10 mm. Symmetry of the palpebral fissures should be closely examined as any asymmetry, particularly vertically, may suggest blepharoptosis, prompting consideration of ptosis repair in addition to blepharoplasty. The upper lid margin should cover approximately 1-2 mm of the superior limbus, while the lower lid margin ideally lies at the inferior limbus or 1 mm below it. Ptosis may be quantified using the margin-reflex distance (MRD-1), the distance between the corneal light reflex and the upper lid margin, which ideally measures 3-4.5 mm. In addition to the MRD-1, the central interpalpebral distance should also be documented. This is the distance between the upper and lower lid margins at their highest respective points. The central interpalpebral distance should measure 8-10 mm. 1-3 Finally, an assessment of skin quality, texture and elasticity with a pinch and snap test should be standard. Decreased elasticity of the lower eyelid should be addressed at the time of lower eyelid blepharoplasty with a tightening procedure to avoid post-operative eyelid malposition.
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Minimally Invasive Techniques With advances in cosmetic medicine, minimally invasive techniques in aesthetic rejuvenation have become increasingly popular. Commonly employed treatments include topical therapies, mechanical and chemical skin resurfacing, fillers, neuromodulation with use of botulinum toxin (BoNT), as well as laser and radiofrequency devices.7 A review of these techniques is beyond the scope of this article, however many of these treatments may be used as adjuncts to surgery and therefore a brief overview follows.
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Adjunctive skin care in the form of topical therapies is important in prevention of facial aging as well as in treatment and maintenance following procedural intervention. Due to the multitude of available products, it is important that the surgeon review which products are most effective for the patient’s specific needs. It is important to note that eyelid skin is the thinnest of the body and therefore extremely susceptible to injury from topical products.8 Sunscreens play a critical role in the prevention of photodamage and mitigate the development of post-procedural hyperpigmentation. To maximize potential benefit, a sun protection factor (SPF) of 30 or higher, for ultraviolet B [UVB] protection, and “broad spectrum”, for ultraviolet A [UVA] protection, lotions are recommended. Topical antioxidant therapies include vitamin C and E, both of which have been shown to have additive effects, and Niacinamide.8 Topical retinoids have also shown to improve wrinkles by upregulating dermal collagen synthesis and downregulating collagen degradation. Topical growth factors and peptides have been shown to have similar effects on collagen. However, cosmeceuticals containing growth factors have a theoretical risk of increasing skin cancer although there are no documented reports in the literature. Patients suffering from hypotrichosis of the eyelashes or brow, should be counseled regarding use of topical bimatoprost 0.03%. This treatment is FDA-approved for enhancement of eyelashes, resulting in increased density and length.9 Application to the eyebrows has also been documented, although this is considered off-label use and is not well studied.10
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Skin resurfacing is also often used as an adjunct to surgical procedures due to its unique ability to address skin texture and dyschromia while also decreasing wrinkles and scarring. Skin resurfacing can be achieved through different techniques including dermabrasion, chemical peels, and laser therapy. For further details regarding the utility of each modality, readers are directed to the listed references.8,11-19
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Botulinum toxin (BoNT) has become the most commonly employed cosmetic procedure in the treatment of periorbital aging and facial enhancement. Although irreversible, BoNT effects deteriorate within three to six months as new axon terminals are generated.20 Use of neuromodulators is contraindicated in patients with myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis, and pregnancy. Common side effects include erythema, pain, and bruising. A particular side effect, when applied to the periorbital region, is ptosis secondary to paralysis of the levator palpebrae or inferior frontalis muscles.8, 20 Common dosages of BoNT vary depending on the location of use. In larger muscles, such as the frontalis, lower concentrations may be used to increase diffusion. Conversely, if higher concentrations are needed, lower volumes may decrease diffusion and pain with injection. Common dosages when used in the periorbital region are included in Table 1. Erickson et al.20 review the key steps in periorbital use of BoNT. It should be noted that use of neuromodulators one to two weeks prior to skin resurfacing has been documented to improve outcomes.21 Lastly, fillers are a unique option to augment volume loss as a result of the aging process and addressing static rhytids. Hyaluronic acid (HA) is considered the workhorse, particularly in the periorbital area, due to its efficacy and predictable outcomes, although autologous fat is also often used, particularly for areas with larger volume deficits.22 The non-invasive treatment options, detailed above, can be implemented as monotherapy or adjuncts to surgery based on the severity of periorbital aging and patient expectations.
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Upper Lid Blepharoplasty The aesthetic ideals and interrelationship between the eyelids, eyebrows, orbit, midface, and forehead should be reviewed prior to surgery in order to tailor the patient’s treatment plan to his or her anatomy. Standardized photo documentation as well as a candid discussion with the patient regarding desired outcomes and realistic expectations is essential for optimization of outcomes and patient satisfaction. Blepharoplasty is performed as an outpatient procedure under either local or general anesthesia.23, 24
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If upper lid blepharoplasty is to be performed in conjunction with a brow lift, the blepharoplasty incision marking should be created after completion of the brow lift as the brow lift will alter the amount of skin to be excised. Eyelid marking is the most important step in this procedure and therefore must be done with care to ensure precision. The initial lid marking is made at the level of the supratarsal crease in Caucasians, medially from the level of the lacrimal punctum, across the lid, and extending laterally to the lateral orbital rim. In some cases, extensive lateral skin hooding may require skin excision beyond the lateral orbital rim. Patients must be counseled prior to surgery that wound healing may be prolonged in this region due to greater skin thickness.23,24,25 In cases where the lid crease is indistinct or the patient displays blepharoptosis, the incision should be marked between 8-10 mm in women and 6-8 mm in men from the inferior margin of the eyelid. The lateral aspect of the incision curves upward along the natural crease between the orbital rim and eyelid. The incision should be gently curved so that the medial end descends approximately 1-2 mm from the central vertical height. In order to determine the extent of skin excision, the pinch test is performed to assess for redundancy. Iris or green fixation forceps are used to grasp the skin at the marked lid crease and a point superiorly until slight eversion of the lid is accomplished (Figure 4) to optimize skin excision while preventing excessive skin resection resulting in lagophthalmos. Traditionally, a minimum of 20 mm of eyelid skin should remain between the lid margin and the inferior portion of the brow to mitigate the risk of lagophthalmos. When markings are completed, the medial and lateral aspects of the fusiform excision should form 30-degree angles to facilitate closure.23,24,25
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After markings are complete, 1-2 ml of local anesthesia is injected within the subcutaneous tissue plane. The skin incisions are then made with scalpel blade or needle-tip monopolar electrocautery and the skin is then excised as either a single layer or an en bloc resection including skin and a strip of orbicularis oculi muscle (Figure 5A-B). If a single layer excision is performed, a separate step involving resection of the orbicularis oculi muscle may be performed. The extent of orbicularis resection is dependent on the degree of muscle hypertrophy. Pseudoherniation of fat can be addressed by one of two common techniques. The degree of pseudoherniation may be decreased by bovie cauterization of the orbital septum resulting in contraction of the septum. Alternatively, the orbital septum may be incised and fat from the medial and nasal compartments may be conservatively resected. Only fat that protrudes into the wound with gentle globe pressure and anterior traction should be excised in order to prevent excessive resection and a hollowed appearance (“A-frame deformity”). Laterally, the lacrimal gland should be identified in order to avoid injury. It often appears pink, firm, and more vascular than fat. If necessary, pexy of the lacrimal gland may be performed. If blepharoptosis repair is required, the levator aponeurosis advancement may be performed at this time. Wound closure may then be performed with a single layer closure of the skin with 6-0 fast absorbing gut suture or surgeon’s preferred suture
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technique (Figure 5C-D).23, 24, 25 This sequence of steps is then repeated for the contralateral eyelid with attention to providing symmetry. Lower Lid Blepharoplasty
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Several techniques for lower lid blepharoplasty have been described throughout the literature. However, three main surgical approaches predominate as follows: transcutaneous skin only flap, transcutaneous skin-muscle flap, and transconjunctival. We will focus this discussion on the two most common techniques, the transconjunctival and the transcutaneous skin-muscle flap approach. Transconjunctival blepharoplasty has gained popularity due to inconspicuous incision placement, maintenance of orbicularis support, and decreased incidence of postoperative ectropion.26 Appropriate candidates for this approach include patients that are concerned for scarring, have history of hypertrophic scars, and those with pseudoherniation of fat with little lower lid skin redundancy. Patients with large amounts of excess skin or orbicularis hypertrophy may benefit from a subciliary or transcutaneous approach.26,27 However, moderate skin excess in the lower eyelid does not preclude a transconjunctival approach, in that the addition of a pinch excision of skin or lid resurfacing techniques may allow for effective multimodal intervention. Fat repositioning to address infraorbital hollowing and the nasojugal groove may be performed with any approach. Care should be taken to provide lower eyelid tightening with preoperative evidence of decreased elasticity. Transconjunctival Approach
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Local anesthesia is injected and the lower eyelid conjunctiva is subsequently exposed. A Desmarres retractor used to evert the lower eyelid while a Jaeger lid plate may be used to protect the globe. If the surgeon elects to pursue a preseptal approach, a transconjunctival incision is made at the inferior aspect of the tarsal plate (Figure 6 & Figure 7A). Dissection is then continued in the avascular plane deep to the orbicularis oculi muscle and superficial to the orbital septum. This plane of dissection is continued to the orbital rim without exposing the orbital rim. A traction suture is then passed through the edge of the conjunctiva for both corneal protection and added exposure (Figure 7B). The orbital septum can then be clearly visualized and selectively entered with monopolar electrocautery (Figure 7C). In a postseptal approach, an incision is placed approximately 4 mm below the inferior tarsal margin, through the conjunctiva and lid retractors, and posterior to the orbital septum to expose the orbital fat compartments (Figure 6). The inferior oblique muscle should be identified in order to delineate the medial and middle fat pads in both approaches. Fat is either resected with electrocautery or repositioned into the infraorbital hollow based on an intraorbital pedicle and secured to treat the nasojugal groove. The temporal fat pad may be identified and conservatively resected. Incisions may be left to heal spontaneously or 6-0 fast absorbing gut suture may be used to loosely reapproximate the conjunctiva. If redundant lower eyelid skin is present, a subciliary pinch excision may be performed with subsequent closure of the incision using 6-0 fast absorbing gut suture. Lid laxity should be addressed to minimize the risk of lower eyelid malposition. Transcutaneous Myocutaneous Flap
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The transcutaneous approach to lower eyelid blepharoplasty using a skin-muscle flap is a useful method to address age-related changes to the lower lid while preserving the integrity of the orbicularis oculi sling and maintaining lower eyelid position.28 Many modifications of this technique exist and may include release of the orbitomalar ligament with either fat excision or fat transposition. This is also a useful technique when there exists extensive excess skin, orbicularis hypertrophy (festoons), or significant lower eyelid laxity requiring a lid tightening procedure.
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The skin of the lower eyelid is incised 1 mm below the lash margin in subciliary fashion, 2 mm lateral to the punctum and extending laterally approximately 10 mm from the lateral canthus (Figure 8A). A midline lower eyelid retraction suture is placed and pulled superiorly. The skin flap is then typically elevated 1.5 cm inferiorly using iris scissors thereby preserving a muscular sling, constituting the pretarsal orbicularis oculi muscle. The orbicularis is then incised inferior to the elevated skin flap and incision is extended for the length of the orbit (Figure 8B). A composite myocutaneous flap is then elevated off of the orbital septum inferiorly to the orbital rim (Figure 8C).
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Once the orbital rim is reached, the retaining ligaments of the orbit are released using monopolar or bipolar cautery. This part of the dissection is performed just superficial to the SOOF while being careful to preserve the infraorbital nerve. A Desmarres retractor is then used to retract the composite flap inferiorly and gentle manual retropulsion of the globe is applied to aid in identifying the fat compartments. The orbital septum of the medial and central fat compartments is then entered using sharp scissors. Cotton tip applicators are used to aid in blunt dissection and the inferior oblique muscle is identified, separating the medial and central compartments. The fat pads may then be either excised or repositioned. If they are to be transposed, the nasal and medial fat pads are left pedicled and mobilized inferiorly over the orbital rim and into the tear trough defect allowing for volumization and camouflage. The fat is then sutured to the supraperiosteal tissue with 5-0 chromic suture. Excessive fat from the lateral fat pad may be resected but is typically not transposed due to its fibrous nature resulting in irregular contouring. Overaggressive resection is avoided, particularly in patients with prominent globes or hypoplastic malar eminences (negative vector), as this may result in creation of a deep sulcus postoperatively.
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Attention is then turned to the lateral orbit, using scissors to dissect to the periosteum of the lateral orbital rim. The dissection is then turned superolaterally extending superior to the lateral canthal tendon. Two 6-0 nylon sutures are then passed through the periosteum of the internal lateral orbital rim. One of these sutures is then used to suspend the lateral tarsal plate. The second suture is then passed to the superior edge of the orbicularis oculi muscle flap facilitating elevation of the superior midface. This step is crucial due to earlier destabilization of the midface when releasing the orbital retaining ligaments. The skin flap is then redraped superolaterally into the skin incision and 1-2 mm of skin may be removed medially depending on the extent of skin excess. The skin is then closed with 6-0 nylon sutures in an interrupted fashion lateral to the lateral canthus and with a 7-0 running locking silk suture medially.
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Complications of Periorbital Rejuvenation
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A discussion of possible complications and realistic outcomes should be discussed with the patient prior to surgery. Postoperative asymmetry is common and may initially be exacerbated by bruising, edema, or sleep posture. However, it may also be a result of unidentified preoperative asymmetry, such as subtle ptosis, further exaggerated by post-operative edema. Only once the lids have stabilized with near resolution of the edema and bruising should revision procedures be considered, typically at least eight weeks after the initial surgery for persistent asymmetry. Although the reported need for revision is low, ptosis and exophthalmos may increase revision rates to 10%.29 Retrobulbar hemorrhage is a particularly rare but severe complication of eyelid surgery. Postoperatively, it is important to educate the patient regarding signs of orbital hemorrhage. Increased edema, ecchymosis, and severe orbital pain should prompt urgent examination. High flow oxygen and steroids may be used in conjunction with mannitol to decrease swelling, however if severe pain is accompanied by vision loss, emergent lateral canthotomy with cantholysis should be performed. The patient should be observed and if no improvement is noted orbital decompression is pursued. Failure to adequately identify and address this complication has been shown to result in permanent blindness within 90 minutes.30,31
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Lagophthalmos, or inability to close the eye, is commonly observed in the immediate postoperative period following upper eyelid blepharoplasty, particularly if brow lift and ptosis repair are performed in conjunction.31 This is often a result of levator spasm, edema, or orbicularis paresis. Lagophthalmos may persist for a few weeks following surgery. Patients should be managed with proper precautions in order to prevent injury from corneal exposure, including use of artificial tears throughout the day and ointment at night. Use of a humidification chamber or taping the eye closed may be considered if lagophthalmos is severe. If the patient is unable to close his or her eye six to eight weeks following surgery, an overaggressive excision of the lid skin may have been performed. A skin graft may then be used to replace the missing skin.30,31
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Eyelid malposition may also occur postoperatively ranging from mild scleral show to overt lower eyelid eversion or inversion. Ectropion and lower lid retraction may result from overaggressive skin excision with contraction of the lower lid anterior lamella. Alternatively, ectropion may be a result of failure to effectively address lower lid laxity. This can be prevented by performing a lid shortening or tightening procedure at the time of blepharoplasty. Ectropion may be corrected following surgery with either a tarsal strip or lysis of cicatricial adhesions, depending on which of the two above mentioned contributing factors are indentified.25,230,31 In contrast, entropion may result from shortening of the posterior lamella and subsequent scar contracture after transconjunctival approach. This may be similarly corrected with lysis of cicatricial adhesions with use of a hard palate mucosal graft to prevent recurrent cicatrix.32 Finally, asymmetry, inadequate skin excision, adverse scarring, or inadequate fat resection may also lead to an unhappy patient and may require revision. Conclusion
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Periorbital rejuvenation continues to be an area of advancement with evolution in both noninvasive and invasive techniques. A careful functional and aesthetic assessment of the brow-lid complex, care to address brow ptosis prior to blepharoplasty, and careful preoperative counseling to set realistic expectations is paramount. When appropriate, a multimodal approach incorporating both surgical and adjunctive nonsurgical techniques should be employed to enhance the appearance of the periorbital region. Detailed preoperative planning and meticulous surgical technique are crucial in diminishing complications and optimizing outcomes.
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Figures:
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Figure 1. Periorbital facial musculature.
Figure 2. Cross-sectional anatomy of the eyelids. Anterior lamella: skin and orbicularis muscle; Posterior Lamella: upper lid elevators including Müller’s muscle, levator muscle, tarsus, and conjunctiva. The ROOF is positioned superficial to the septum. Capsulopalpebral fascia and inferior tarsal muscle act as lower lid retractors. The orbitomalar ligament, extending from the arcus marginalis to the lower lid skin, forms the nasojugal fold.
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Figure 3. Fat compartments of the eyelids.
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Figure 4. Pinch test, in which forceps are used to grasp skin of the upper eyelid to asses for skin redundancy and the extent of skin excision possible without resultant lagophthalmos.
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Figure 5. (A) Upper eyelid blepharoplasty incision (B) Skin and central portion of orbicularis muscle excised exposing orbital septum. (C) Orbital septum incised, and orbital fat exposed. (D) Blepharoplasty incision closed with 7-0 polypropylene suture in running fashion.
Figure 6. Lower eyelid blepharoplasty. Transconjunctival (1) preseptal and (2) postseptal approaches.
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Figure 7. Transconjunctival preseptal lower lid blepharoplasty with fat excision A) transconjunctival preseptal incision B) Traction suture placed for corneal protection C) Orbital Septum is entered with resection or reposition of fat.
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Figure 8. Transcutaneous skin-muscle flap lower lid blepharoplasty; A) Subciliary skin incision along lower eyelid B) Placement of retraction suture pulled superiorly with skin flap elevation and incision of orbicularis with intact muscular sling C) Elevation of composite myocutaneous flap with entrance of the medial and central fat compartments.
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Periorbital Region
OnabotulinumtoxinA/ IncobotulinumtoxinA Units (e.g. Botox ®, Xeomin ®) 15-30 20-30
AbobotulinumtoxinA Units (Dysport ®)
Glabella 40-60 Bilateral Lateral Canthal +/40-70 Infrabrow for Chemical Brow Lift Bilateral Infraorbital 2-5 5-15 Forehead 10-20 20-50 Table 1. Common dosages of botulinum toxin neuromodulator in periorbital rejuvenation.
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References: 1) Glaser DA, Patel U. Enhancing the eyes: use of minimally invasive techniques for periorbital rejuvenation. J Drugs Dermatol 2010;9(8):s118–28 2) Bartlett SP, Grossman R, Whitaker LA. Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis. Plast Reconstr Surg 1992;90(4):592–600.
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5) Massry GG. Prevalence of lacrimal gland prolapse in the functional blepharoplasty population. Ophthal Plast Reconstr Surg 2011;27: 410–413.
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6) Jones LT: The anatomy of the lower eyelid and its relation to the cause and cure of entropion. Am J Ophthalmol 1960;49: 29-36. 7) Glaser D.A., and Patel U.: Enhancing the eyes: use of minimally invasive techniques for periorbital rejuvenation. J Drugs Dermatol 2010; 9: s118-s128
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8) Bucay V.W., and Day D.: Adjunctive skin care of the brow and periorbital region. Clin Plast Surg 2013; 40: 225-23
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10) Schweiger ES, Pinchover L, and Bernstein RM: Topical bimatoprost for the treatment of eyebrow hypotrichosis. J Drugs Dermatol 2012; 11: pp. 106-108 11) Glaser DA, Kurta A. Periorbital Rejuvenation: Overview of Nonsurgical Treatment Options. Facial plastic surgery clinics of North America. 2016; 24(2):145-152. 12) Jackson A.: Chemical peels. Facial Plast Surg 2014; 30: 26-34 13) Hassan K.M., and Benedetto A.V.: Facial skin rejuvenation: ablative laser resurfacing, chemical peels, or photodynamic therapy? Facts and controversies. Clin Dermatol 2013; 31: pp. 737-740
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14) Brauer J.A., Patel U., and Hale E.K.: Laser skin resurfacing, chemical peels, and other cutaneous treatments of the brow and upper lid. Clin Plast Surg 2013; 40: pp. 91-99 15) Shook B.A., and Hruza G.J.: Periorbital ablative and nonablative resurfacing. Facial Plast Surg Clin North Am 2005; 13: pp. 571-582
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16) Alster T.S., and Bellew S.G.: Improvement of dermatochalasis and periorbital rhytides with a highenergy pulsed CO2 laser: a retrospective study. Dermatol Surg 2004; 30: pp. 483-487 17) Caniglia R.J.: Erbium:YAG laser skin resurfacing. Facial Plast Surg Clin North Am 2004; 12: pp. 373-377 18) Alexiades-Armenakas M.R., Dover J.S., and Arndt K.A.: The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. Dermatology 2008; 58: pp. 719-737
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19) Carniol P.J., Hamilton M.M., and Carniol E.T.: Current status of fractional laser resurfacing. JAMA Facial Plast Surg 2015; 17: pp. 360-366 20) Erickson B.P., Lee W.W., Cohen J., et al: The role of neurotoxins in the periorbital and midfacial areas. Facial Plast Surg Clin North Am 2015; 23: pp. 243-255 21) Zimbler M.S., Holds J.B., Kokoska M.S., et al: Effect of botulinum toxin pretreatment on laser resurfacing results: a prospective, randomized, blinded trial. Arch Facial Plast Surg 2001; 3: pp. 165-169
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22) Lee S., and Yen M.T.: Injectable hyaluronic acid fillers for periorbital rejuvenation. Int Ophthalmol Clin 2013; 53: pp. 1-9
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23) Moses JL, and Tanenbaum M: Blepharoplasty: cosmetic and functional. In McCord CD, Tanenbaum M, and Nunery WR (eds): Oculoplastic Surgery. New York: Raven Press, 1995. 285
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24) Hahn S, Holds JB, Couch SM. Upper Lid Blepharoplasty. Facial Plastic Surgery Clinics. 2016 May 1;24(2):119-27.
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25) Rankin BS, Arden RL, and Crumley RL: Lower eyelid blepharoplasty. In Papel I, Frodel J, and Holt G (eds): Facial Plastic and Reconstructive Surgery, ed 2. New York: Thieme, 2002. pp. 196
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27) Yousif N.J., Sonderman P., Dzwiersynski W.W., et al: Anatomic considerations in transconjunctival blepharoplasty. Plast Reconstr Surg 1995; 96: 1271-1276 28) Hashem AM, Couto RA, Waltzman JT, Drake RL, Zins JE. Evidence-based medicine: A graded approach to lower lid blepharoplasty. Plastic and reconstructive surgery. 2017 Jan 1;139(1):139e-50e. 29) Codner MA, Wolfi J, and Anzarut A: Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg 2008; 121: pp. 241-250 30) Castanares S: Complications in blepharoplasty. Clin Plast Surg 1978; 5: pp. 149 31) Adams BJS, and Feurstein SS: Complications of blepharoplasty. Ear Nose Throat J 1986; 65: pp. 11
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32) Kersten RC, Kulwin DR, Levartovsky S, Tiradellis H, David TT. Management of lower-lid retraction
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with hard-palate mucosa grafting. Archives of Ophthalmology. 1990; 108(9):1339-1343.