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Posts Tagged cosmetic surgery

Upper Blepharoplasty: Volume Enhancement via Skin Approach: Lowering the Upper

Jan 2

Posted by for healthy life in Cosmetic | No Comments

Lid Crease
Steven Faeien
Over the years, success of a particular surgical procedure, even aesthetic, has been measured mostly by perceived outcome and to some degree by the frequency of complications. Since the overwhelming majority of aesthetic periorbital ‘complications’ have occurred with lower blepharoplasty, most of the attention on newer and improved techniques has focused on the lower periorbita’”6 (see Chapters 14-19, Lower blepharoplasty).
As functional misadventures are a much less encountered occurrence after upper blepharoplasty, complacency with existing methods and perpetuation of ill-perceived solutions to rejuvenation of the upper periorbita prevail.7,8
With rare exception, the approach to upper blepharoplasty has not been particularly physiologic or individualized and the universal application of traditional remedies for upper periorbital rejuvenation has translated to mediocrity.7″”9 The prevailing perception has been that the appearance of the aged upper eyelid is primarily due to excessive skin, muscle, and fat often in conjunction with brow descent. Additionally, there is the confounding erroneous memory in many individuals of what their upper periorbita looked like in youth. Finally, there is the influence of the ‘famous and beautiful’ people on what patients may request for their eventual appearance despite their configuration in earlier years (Fig. 8-1) that may explain some of the historical aesthetic desires as well as changes in ideas and what is currently expected after surgery.
Steven Fagien
The consultation
As with all surgical approaches to rejuvenation, we must take into account what are the actual changes that occur in the upper periorbita and whether the existing methods consider these occurrences for a wide variety of indi¬vidual presentations (Fig. 8-2). Do these techniques result in a rejuvenative appearance or simply achieve a ’cause and effect’ outcome whereby an altered appearance replaces youth? (Fig. 8-3). And, ultimately, what surgical procedures are some patients willing to undergo and what do they expect from surgery?

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Midcheek

Nov 25

Posted by for healthy life in Cosmetic | No Comments

Historically, periocular and midfacial rejuvenation surgery have been treated as separate entities with the orbital rim being considered the anatomical and conceptual barrier to a unified approach. More recently it has become recognized that these areas are interdependent anatomical and surgical regions, particularly at the lid-cheek junction of the lower eyelid. A thorough understanding of midfacial anatomy is therefore essential for any surgeon contemplating oculoplastic surgery. However, the anatomy of the midcheek is complex and has not been well described. It is easier to understand the midcheek when working from basic principles. For this reason a preliminary review of facial anatomy precedes the more detailed discussion.

The bony architecture is the predominant determinant of midfacial contour and is fundamental to facial aes¬thetics, although the relative thickness of the overlying soft tissue has a significant impact, particularly as it changes with advancing age. This bony platform (Fig. 5-13) provides the base for the attachment of the over¬lying muscles and ligaments that support the midfacial soft tissue. The surface anatomy should therefore be considered in terms of its relationship to the underlying bony anatomy. The midcheek has an upper and outer prczygomatic part that overlies the bony platform provided by the body of the zygoma. The medial and lower infrazygomatic part of the midcheek covers the vestibule of the oral cavity and overlies the maxilla.

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Lateral canthus

Nov 21

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Despite varied anatomical descriptions and nomencla­ture, the lateral canthus should be considered in terms of a deep skeletal attachment via the lateral canthal tendon and a superficial fibrous attachment via the lateral canthal raphe and lateral orbital thickening. The deep attachment serves to stabilize the tarsal plates whereas the superficial attachment functions to stabilize the orbicularis over the orbital rim.6

The lateral canthal tendon is less well defined than the medial side and has less orbicularis muscle connec­tion. It takes the form of a Y-shaped fibrous condensa­tion measuring 6 mm in transverse length and up to 10 mm in vertical height. It extends from the upper and lower tarsal plates and is reinforced by significant attachments from the lateral horn of the levator apo­neurosis and the check ligament of the lateral rectus muscle as well as from Lockwood’s ligament. This confluence of structures (the lateral retinaculum) attaches to the lateral orbital wall at Whitnall’s tuber­cle, which is located just inside the orbital rim and approximately 10 mm below the zygomaticofrontal suture.9 Whitnall’s (superior transverse) ligament is part of the levator aponeurosis and is not part of the lateral canthus.

Superficially, the preseptal orbicularis fibers of the upper and lower lid interdigitate to form the lateral canthal raphe. The raphe, although often referred to in eyelid texts, has not been clearly described and is diffi­cult to identify as a discrete anatomical structure. It is connected on its deep surface to the underlying septum orbitale and merges laterally with a significant conflu­ence of fibrous tissue known as the lateral orbital thick­ening1 (Fig. 5-7). This thickening is a condensation of fascia passing over the orbital rim, lateral and superficial to the lateral canthal tendon. It has also been termed the ’superficial leaf of the lateral canthal tendon’10 and the ‘precanthal web’.” It is a triangular fibrous adhesion connecting the orbicularis fascia on the undcr-surface of the muscle to the underlying deep fascia, which in this region is made up of thickened lateral orbital rim peri­osteum and adjacent deep temporal fascia. The lateral orbital thickening is continuous with the orbicularis retaining ligament inferomedially and must be released surgically if a canthoplasty is to be effective.

The lateral canthus is positioned approximately 2 mm higher than the medial canthus. Despite previous assumptions, this is the same for both sexes and does not change with increasing age.12 Inherent variations of the intercanthal angle do, however, have a signifi­cant impact on facial aesthetics in normal people and descent of the lateral commissure secondarily to lateral canthal tendon laxity produces an apparent change in the lateral canthus position, which predisposes to a premature aging appearance.

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A Comprehensive Evaluation of the Cosmetic Oculoplastic Surgery Patient: Beyond Formal Measurements

Nov 18

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At times when patients are undergoing cosmetic bleph­aroplasty combined with true blepharoptosis repair (see Chapters 10 and 11), visual field tests can be obtained either by the treating surgeon or the patient’s ophthalmologist to determine if the lid malposition causes any significant visual deficit. This can be docu­mented and submitted either by or for the patient (in a rare situation) for the consideration of insurance ben­efits. Either automated (Humphrey, Octopus etc.) or manual (Goldmann) field test can be obtained and similar information can be derived. Typically the tests are performed with the patient in their natural position (with upper lid malposition) and then the test is repeated with the lid taped into its normal position to determine a certain degree of visual field improvement. This continues to be a bit of a ‘gray area’ and is highly-dependent upon the skill of the technician performing these tests and influenced by the will of the patient. An insightful and experienced evaluation of the results of these tests relative to the eyelid measurements can often determine the integrity of these findings.

Assessment by photography

Accurate and comprehensive photography is essential for a variety or reasons, including preoperative coun­seling, preoperative study by the physician, documen­tation of the present situation including pre-existing pathology (i.e. asymmetry), as well as being a reward­ing gift to the patient following surgery so that they can fully appreciate their improvement. The patient’s periorbital  appearance  should  be  photographed  in

primary position (Fig. 4-9) as well as oblique peri­orbital views (Fig. 4-10) to reveal to both the treating surgeon and patient the balance prior to and achieved after surgery. It is helpful to illustrate the patients relaxed and animated (especially when their complaints include dynamic facial lines that are less effected/ improved by surgery) (Figs 4-18 and 4-20). For valid comparison, it is optimal (although not always possible) to have the patient photographed without cosmetic (make-up) application in both the pre- and postoperative photos. In situations where cosmetics have been applied (and the patient prefers not to remove them) during the preoperative photographic assessment, the ‘after’ photos are more easily com­pared with the cosmetic application; however the validity of the details of improvement that relate to the surgical efforts may be diminished.

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Assessment of asymmetry and how to best manage this

Nov 17

Posted by for healthy life in Cosmetic | No Comments

It is well known that most faces are not entirely sym­metric (Fig. 4-1). The notion that the establishment of symmetry is necessary to achieve optimal results is also an historical and philosophical fallacy. Some of the most attractive people demonstrate marked facial asymmetry. Interestingly, asymmetries are well toler­ated and often unnoticed in youth and much less toler­ated and more obvious with age. More often, patients are unaware of their facial asymmetry but might be more keenly observant of this after surgery due, in part, to their obsession with the mirror. During the evaluation of the patient, I will usually determine this and discuss this with the patient during the treatment planning. Although not perceived by the patient, the asymmetry is sometimes a large component of their displeasure with facial aging. The assessment of asym­metry must extend far beyond the simple evaluation for blepharoptosis to achieve maximum benefit through the surgical encounter. For instance, relative or asym­metric brow ptosis may be discussed (Fig. 4-1). At times, the brow position is influenced by the upper eyelid (especially in those who reflexively elevate their ipsilateral eyebrow in response to blepharoptosis) and the upper lid ptosis is only apparent when that brow is digitally depressed by me examiner to determine me true upper eyelid position (Fig. 4-2). A patient with brow asymmetry for any reason, may also sense a greater relative amount of ‘excessive’ skin on the brow protic side and if this relates to brow ptosis, this should be discussed to explain the rationale for the treatment and how it relates to the chosen procedures. The side with brow ptosis is also usually the small side of the face. This must be considered, especially if the parient is having lower eyelid, mid-, or lower facial surgery. Canthal dystopia and lower eyelid position asymmetry (even in the surgically naive patient) is also common and also more often unnoticed by the patient (see Fig. 4-1). The ‘big eye-small eye’ phenomenon (see Fig. 4-3) is also far more common than previously appreciated6 and aesthetic remedies may or may not be selected to address this. The ‘big eye’ is also usually on the large side of the face. When I detect this I ask patients what they see when they look at pictures of themselves (often this is exactly what brought them into your consulting room, but they simply have not realized this or simply can not verbalize their exacr reasons for unhappiness with their appearance). Surgical and non-surgical maneuvers may be performed to lessen the asymmetry in the patient who is desirous of this approach. Caution must be used however with any attempt to alter the natural asymmetry in selected patients. Although an

independent observer (and surgeon) might consider the subjective improvemenr in doing so, at times the patient feels as if they appear ‘out of balance’ much like looking at a photograph of oneself (in the days when we actu­ally used film!) where rhe negative had been reversed for the prinring. There is no question that this is the patient (in the photo) but the relative asymmetries that they have been accustomed to their whole life have now been altered. In general, I find the evaluation of periorbital asymmetry most useful to determine how I might titrate procedures to optimize results by either maintaining the asymmetry, or improving symmetry so rhat the asymmetric appearance does not become more obvious after surgery (Fig. 4-25).

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Examination of the upper eyelid

Nov 15

Posted by for healthy life in Cosmetic | No Comments

Typically several notations of the upper eyelid are important in giving a clear picture of the situation regarding the upper periorbita. Often patients com­plain of ‘hooding’ at the lateral aspect of the upper eyelid when this can be related to ptosis of the lateral eyebrow, simple volumetric diminishment, skin elasto-sis, and the appearance or illusion (see Chapter 2) of brow descent and excessive skin, or (more commonly) a combination of these factors. I then determine/ approximate the relative amount of apparent skin

‘excess’, especially when evaluating prior to surgery which may also define placement of the upper eyelid crease. The upper eyelid should be evaluated for lid position (as it relates to the pupil) by measuring the margin reflex distance (MRD) to detect even mild upper lid ptosis or eyelid retraction, position and irreg­ularities of the eyelid crease, and herniation of central and medial orbital fat (Fig. 4-12).

Lateral upper eyelid soft tissue ‘herniation’ may indicate a ptosis, malposition, and (even more rarely) pathology of the lacrimal gland. The native eyelid crease can be determined by raising the eyebrow digi­tally and observing the patient’s natural crease in down gaze. I usually pay less attention, however, to the native eyelid crease, since I more often try to surgically rede­fine the upper eyelid crease and fold according to where I (and the patient) believe aesthetically the crease should be placed or repositioned in any particular indi­vidual for the optimal rejuvenative result (Figs 4-13 and 4-14). I have found that the eyelid margin to fold measurement (MFD) and the patient’s predicted brow animation (do they continuously animate/raise brows during the interview etc.) also to be a more important determination of where to place the upper eyelid inci­sion to reduce visibility of the incision (Fig. 4-15) and how much skin excision will be performed in any par­ticular region of the upper eyelid. The MFD is the dis­tance between the eyelid—lash/margin to the first skin fold (see Chapter 3). This is almost always a smaller measurement laterally consistent with lateral brow ptosis and volumetric changes, and a greater measure­ment medially, often just beneath the supraorbital notch (Fig. 4-15). I find the MFD helpful to assist in deciding on the best placement for the eyelid crease, as well as determination of how much skin will be removed in any particular area along the upper eyelid to produce the desired aesthetic effect in re-creating the upper eyelid fold (Fig. 4-16).

While evaluating for  blepharoptosis, one  should consider the margin reflex distance (Fig. 4-17) as well

as the palpebral fissure measurement in downgazc (see Chapter 3). Even mild degrees of acquired blepha­roptosis will show diminishment of the palpebral fissure in downgaze on the affected side whereas congenital ptosis shows a wider (vertical) palpebral fissure in downgaze is seen in the more ptotie upper eyelid. An assessment of the levator function should also be made which may in part determine the longevity of ptosis, including congenital ptosis situations which were previously unnoticed. Determi­nation of eyelash fullness and position (especially lash ptosis) should be made as patients will often observe this after surgery when it had not been previously noted, even though present prior to the surgical proce­dure. Laxity of the pretarsal skin that manifests as horizontal striae should also be noted, as again once the eyelid fold is elevated this may become more appar­ent after surgery. Notations of prior surgery (even if not offered in the history) should be made. This is important not only in determining prior surgical pro­cedures but in assessing where the new eyelid incision would be placed, whether preferred or mandated in an attempt to remove the old scar and avoid the possibil­ity of leaving two!

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