In the 1990s, we also entered the age of the lateral canthus and the appreciation of this anatomic region for stabilization of the lower eyelid during blepharo­plasty. As procedures such as the lateral tarsal strip were still the most popular, the previous history should have been a clue to potential future problems. Cantho-lytic canthoplasty was used primarily for the treatment and correction of lower eyelid malposition and ectro­pion, both involutional and iatrogenic.⁸⁴‘¹⁰⁹ Despite its usefulness for the treatment of these misadventures, problems related to its use in primary hlepharoplasty were soon to follow. Canthal asymmetry, misalign­ment, and most of all eventual shortening of the hori­zontal palpebral aperture, all made these procedures suboptimal (except in certain circumstances) for the average patient who presented for cosmetic lower hlepharoplasty. Flowers, Jelks, and McCord’s contri­butions in the advancement of routine canthopexy/ plasty have been enormous.¹¹⁰“¹¹⁵

May and colleagues”⁴ in 1990 described sculpting and resection of the retro-orbicularis oculi fat as a solution to the perceived heaviness and fullness of the infra-brow region in selected patients. In 1995, Aiche and Ramirez¹¹⁵ also described the excision of the suborbicularis oculi fat. Knize¹¹⁶ and Guyuron and colleagues¹¹⁷ described resection and/or interruption of the corrugator supercilii and procerus muscles through eyelid incisions; this process has only recently gained popularity. Owsley¹¹⁸ initially described a cheek lift by elevating the malar fat pad to reduce prominent naso­labial folds. This was performed through a preauricu­lar incision. May and associates¹¹⁹ described malar augmentation and a cheek lift through a subciliary incision. That same year, McCord and colleagues¹²⁰ described a subperiosteal malar cheek lift combined with lower eyelid hlepharoplasty that is still currently used. The aim was to discover a solution to midfacial descent, and improve the deflationary changes of the lower periorbita by elevating the stronger tissue of the midface into the atrophic lower periorbita. A contin­uum of techniques has been developed, combined with simpler and more effective suture suspension methods for the lateral canthus. These address the descent of the orbicularis oculi and associated retaining ligaments for lower periorbital rejuvenation, resulting in fewer complications.¹²¹ Midfacial suspension has also been well-described through distant incisions (i.e. away from the eyelid; posterior hairline via the endoscope) and the process continues to evolve.¹²²

A major focus has also been on fixation and suspen­sion devices that continue to emerge. Barbed suture technology is evolving, whereby soft tissue can be more reliably suspended by sutures that can better grasp the affected regions with a greater drag coefficient (com­pared with simple braided or monofilament sutures). Absorbable plastic devices such as the CoApt systems offer the potential for better bone attachment during the healing (scarring) period to give longer lasting results.¹²³‘¹²⁴

Botulinum toxin A

Purified botulinum toxin type A was initially devel­oped as an alternative to the surgical treatment of
strabismus. In the early 1970s, many ophthalmologists participated in the Food and Drug Administration (FDA) approved study of the efficacy of botulinum toxin A in the treatment of benign essential blepharo­spasm and hemifacial spasm. Noting the coordinated beneficial effects on periocular wrinkles and glabel­lar frown lines first reported by Carruthers and Carruthers,¹²⁵ surgeons began using botulinum toxin A for cosmetic purposes in the early 1990s. In 1994 others also reported on their experiences with the cosmetic use of botulinum. That same year, Keen and Blitzer¹²⁶ performed a double-blind study confirming the efficacy of botulinum toxin A for the treatment of hyperkinetic facial lines. Facial aesthetic enhancement by botulinum toxin type A injection is currently the most commonly performed cosmetic procedure. The perceived simplicity, unfortunately, has resulted in its use by non-physicians, as well as practitioners of every specialty outside those that traditionally perform cosmetic procedures (e.g. emergency room physicians, family practice physicians, anesthesiologists, obstetri­cians, dentists, nurses . . . and the list keeps growing). In our society today, a rapid demand has grown for procedures that are minimally invasive, safe, and effective. The popularity of botulinum continues to escalate, as results can be achieved with even novice injectors with no ‘down time’ in a non-clinical setting.

Tags: blepharoplasty, botulism, cosmetic surgery, cosmetics, eye lift, eyelid surgery, face lift, plastic surgery