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Transconjunctival Approach to Resection of Lower Eyelid Herniated Orbital Fat

The transconjunctival approach to removal of herniated orbital fat is the preferred method of treatment in patients who have only herniated orbital fat with minimal or no evidence of dermatochalasis (excess skin) and no hypertrophic orbicularis oculi muscle. This technique is also especially advantageous for:

• Younger patients with large amounts of herniated orbital fat.
  • Patients who have had previous blepharoplasties in whom an external approach might lead .to eyelid retraction or ectropion.
  • Patients with lower eyelid retraction secondary to thyroid disease in whom hard-palate grafts are required (Chapter 18).
  • Patients with wrinkled or minimally excessive lower eyelid skin in whom plication of the lateral canthi or laser resurfacing of lower eyelid skin is useful (see Chapter 15).

If there is horizontal lower eyelid laxity, this procedure can be easily combined with a horizontal eyelid tightening through a tarsal strip procedure (see Chapter 1).

Many patients want this approach done because it eliminates external scarring and produces less ecchymosis; however, it has been my experience that many patients develop conjunctival chemosis and slight redundancy and wrinkling of skin compared with those who were treated with the external approach. Therefore, I find that more frequently I am combining this approach with a lower eyelid skin flap dissection and excision with orbicularis tightening.

A contraindication to this procedure is with patients with minimal lower eyelid fat, inferior orbital rim or nasojugal hollowing and depression. In these patients, fat repositioning or cheek-midface lifting are indicated

Endoscopic brow techniques were developed to provide the ability to lift the brow while minimizing the complications characteristic to open techniques such as long scars, hair loss, and scalp parasthesias. Endoscopic surgery can be technically demanding and requires both access to and familiarity with the equipment. The most significant difference between endoscopic techniques and open techniques is that endoscopic techniques provide for repositioning of redundant/ptotic skin whereas open techniques allow excision of redundant skin. Although no studies have demonstrated a clear-cut superiority of one technique versus another,  the  authors feel  that  repositioning

tissues does not provide as long lasting a result as excisional techniques.

Essential components of the endoscopic brow lift include the creation of an optical cavity within the soft tissue planes of the forehead; release of the lateral peri­osteal attachments of the lateral brow; and transection of the medially located brow depressors to allow superior repositioning of the brow by the frontalis musculature. Failure to accomplish these goals will compromise the end result.

Advantages:

1.  Small incisions.

2.  Potential for preservation of scalp sensation.

3.  Direct visualization of muscle resection.

Disadvantages:

1. Technical learning curve.

2.  Need for fixation of scalp.

Equipment

Detailed discussion of available endoscopic equipment is beyond the scope of this text. There are a multitude of different camera and instrument systems available and in general are selected based upon surgeon prefer­ence. For endoscopic facial plastic surgery 4 mm endo­scopes are optimal as they are able to provide the lighting and imaging necessary while being small enough for the limited spacial relationships encoun­tered in the facial region. For brow techniques the authors find that use of a 30 degree camera equipped with a retractor hood provides the best opportunity to visualize the areas of interest and to account for the convex curvature of the forehead. Silicone skin protec­tors are also available to help prevent traction or thermal injury to the port-site skin which may lead to alopecia.

Technique

Incisions are located in the hair-bearing scalp and usually consist of a central, lateral and temporal inci­sion. Incisions are vertically oriented, 2 cm in length, and at least 1—2 cm into the hairline. The central inci­sion is located in the midline; the lateral incision should be located above the medial one-third of the brow; the temporal incision should be just medial to a line passing through the lateral ala and lateral brow. Incision loca­tions are injected with 1% lidocaine with 1:100,000 epinephrine. The periorbital soft tissues along the superior and lateral orbital rims are infiltrated simi­larly. The incisions are performed with a #10 blade. The central and lateral incisions are carried through periosteum.   A  large periosteal  elevator  is  used  to elevate the forehead tissues in the subperiosteal plane stopping 2 cm superior to the superior orbital rim to prevent avulsing the supraorbital neurovascular struc­tures. The endoscope may be utilized to perform this release under direct visualization. Blunt dissection is performed through the temporal incision to the level of the deep temporal fascia. Keeping the periosteal elevator against the deep temporal fascia, blunt dissection proceeds inferomedially to release the zone of fixation. At this point the temporal dissection transi­tions from a subgaleal plane to a subperiosteal plane. Maintenance of the subperiosteal plane of dissection medial to the zone of fixation is important to protect the deep division of the supraorbital nerve. Blunt dis­section under direct vision proceeds to release the peri­osteal attachments along the superior orbital rim and to release the soft tissues surrounding the supraorbital nerve. The supraorbital nerve may be represented by a single bundle or may consist of 2—3 branches exiting the orbit separately. All branches are preserved. Dis­section proceeds laterally to release the arcus margina-lis along the lateral rim to allow for superior repositioning of the lateral brow. The medial dissec­tion divides the corrugator and procerus if indicated. The corrugator muscle will be visualized adjacent to the supraorbital nerve with fibers oriented inferomedi­ally. Transection of the corrugator is accomplished by grasping the muscle fibers near their insertion on the overlying skin and avulsing them with care to avoid

Scarring

Reproduced with permission from Elkwood A, Matarasso A, Rankin M, et al: National plastic surgery survey: Brow lifting techniques and complications. Plast Reconstr Surg 2001; 108(7):2143-2150.

the neurovascular bundles. Complete release of the corrugator is confirmed with identification of the brow fat pad that lies superficial to the corrugator. The procerus is divided similarly centrally in the glabellar region. The cavity is then irrigated and meticulous hemostasis is accomplished.

The brow is then elevated to its desired position. Typically the lateral brow requires preferential eleva­tion. This may be accomplished by rcdraping the lateral brow tissues in a superiomedial vector. Brow fixation may be accomplished in a wide variety of ways,¹⁰ but is typically accomplished with either a fixation screw or creation of a cortical tunnel for suture fixation. Animal studies have demonstrated that periosteal readherence requires at least 6 weeks, with complete adherence by 12 weeks.¹¹ Therefore suture selection should be directed towards the use of a material that provides secure brow position for 6-12 weeks. The authors’ preferred method is to perform a cortical tunnel in the frontal bone over the midportion of the brow along the desired vector using a 4 mm long 2.0 mm drill. Two separate, opposing drill holes are made through the superficial cortex that communicates in the diploic can­cellous space. A 2-0 PDS suture is then passed through the tunnel and used to secure a strong bite of galea in the inferior edge of the incision. The brow is then redraped and manually held in position while the suture is tied. The procedure is repeated on the contralateral side. The incisions are closed with staples.

Other methods of acceptable fixation include Lacto-sorb (Walter Lorenz) resorbable endobrow screws, and titanium screws. The Lactosorb polymer has been shown to resorb over the course of 12 months and therefore will maintain brow position long enough for adhesion to develop. The screw may be palpable ini­tially, but the patient can be reassured it is temporary. Titanium screws offer permanent fixation, but may require removal if palpability is objectionable to the patient. Endotine Forehead 3.5 (Coapt Systems, Paola Alta, CA) is a resorbable device for rapid fixation of the brow tissues. The device consists of five 3.5-mm prongs that are set into the skull with a single drill hole. The device has been reported to be palpable up to 24 weeks. Due to issues with palpability, the device is recom­mended for patients with scalps 5-6 mm thick.¹²

The limited incision forehead lift was designed to provide an effective means of addressing advanced brow ptosis while minimizing the risk for permanent injury to the supraorbital nerve branches (Fig. 6-9).

STF    Zygomatic arch

Figure 6-9 Eyebrow elevation through small incision into scalp. A subperiosteal forehead flap is raised and the orbital ligament is transected for maximum upward movement of the superficial temporal fascia. Modified with permission from Knize DM: Limited-excision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 1996; 97:1334.

Advantages:

1. Limited temporal incision avoids transection of the deep division of the supraorbital nerve.

2.  Preferentially elevates the lateral brow tissues.

3.  Allows for easy placement of durable sutures for suspension of elevated lateral brow segment.

4.  May be combined with transpalpebral resection of corrugators when performing concomitant blepharoplasty.

Disadvantages:

1.  Limited exposure for addressing deep forehead rhytids.

2.  Limited exposure to corrugators and procerus.

Technique

The vector for lateral brow elevation is determined by manually elevating the lateral brow segment. The temporal incisions are designed perpendicular to this vector and placed 2-3 cm behind the temporal hairline. The incisions are 4—5 cm in length and do not extend medially past the superior temporal line to avoid injury to the deep division of the supraorbital nerve (which travels below the deep galeal plane 0.5—1.5 cm medial to the superior temporal line).

Blunt dissection should proceed to the level of the underlying deep temporal fascia. The operator can easily confirm this plane as one should be unable to grasp loose tissue above the glistening temporalis fascia in this location. Dissection proceeds anterioinferiorly with blunt-tipped scissors, keeping tips against the deep temporal fascia to protect the temporal branch of the facial nerve that travels within the overlying temporal-parietal fascia. The zone of fixation will be encountered as a tenacious region that resists medial dissection. At this point the dissection should proceed in the subperiosteal plane to release the zone of fixation while protecting the supraorbital nerve. The perios­teum should be released medially 2—3 cm and down to the level of the supraorbital rim. Careful scissor spread­ing perpendicular to the orbital rim releases the peri­osteal attachments of the brow including the orbital ligament near the zygomaticofrontal suture, in order to allow for brow repositioning.

The inferior flap may now be advanced along the desired vector to elevate the brow. Forceps are used to grasp both the superior and inferior flaps to produce overlap of the flaps until the desired brow elevation is obtained. The level of overlap is marked on the inferior flap. A small window of deep temporal fascia is removed exposing the underlying muscle allowing sub­sequent cicatrix formation between the muscle and superficial fascia to assist in stabilizing the repositioned brow. The superficial fascia of the inferior flap is re-approximated to the superficial fascia of the superior flap with several 2-0 Vicryl sutures. A 3-point suture may be performed to include the deep temporal fascia. Redundant scalp is not excised and skin edges are re-approximated with surgical staples or running 4-0 monofilament suture

Direct brow techniques involve placement of access incisions within the forehead skin, potentially produc­ing visible scarring. For this reason patient selection is critical. This technique is usually reserved for males with deep forehead rhytids or with male-pattern hair-loss which makes it difficult to camouflage coronal incisions or endoscopic access incisions. Placement of the incision within transverse rhytids or along the eyebrow provides the most aesthetic alternative inci­sion placement.

Several variations of direct brow techniques exist. The incisions may be placed within deep transverse rhytids of the forehead that may be isolated above each brow or even as a single incision across the forehead. When separate incisions are made above each brow, they may be placed in rhytids at different levels to assist in camouflaging the incisions. Alternatively the incisions may be placed along the superior margin of the eyebrow.

Advantages:

1. Ease of access to brow structures.

2.  Correction of asymmetric brow ptosis.

Disadvantages:

1.  Visible scarring.

2.  Hypesthesia of forehead/scalp.

Technique

The ideal patient is male with deep transverse forehead rhytids and a receding anterior hairline. In patients without deep rhytids, consideration can be given to placing the incision along the superior margin of the eyebrow. In the authors’ experience, however, inci­sions camouflaged within deep rhytids are aesthetically superior to those along the brow margin. Incision loca­tion is marked with a surgical marker prior to admin­istration of a local anesthetic solution with epinephrine to prevent distortion of landmarks. After onset of hemostasis, the incision is performed with a #15 blade. The incision is carried to the subcutaneous plane. Sharp dissection is usually required to carry the dissec­tion to the level of the superior brow. A transverse incision is made through the galea approximately 3 cm above glabella and the subgaleal plane is entered to allow access to the corrugators and procerus. To protect sensation to the scalp the incision should not extend past the supraorbital nerves. Transection of the corrugator and procerus is performed under direct visualization. Hemostasis is provided with monopolar or bipolar cautery. The forehead flap is redraped in the appropriate vector to obtain the desired brow effect. Redundant skin is excised from the inferior flap, the amount of which is tailored to differentially elevate the medial or lateral brow. The superior flap is undermined slightly with sharp dissection to allow a precise closure. The brow is secured to the periosteum cephalad with permanent suture. The flaps are approximated in the deep dermal plane with 3-0 Vicryl suture. Epidermal edges may be reapproximated with a running subcuticular or simple suture.