Secondary blepharoplasty

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Introduction

The eyelids are one of the first areas on the face to show signs of aging. They undergo a predictable pattern of anatomical changes, typically producing a tired appearance, and may also develop functional issues such as eyelid malposition. Optimal periocular rejuvenation with blepharoplasty necessitates not only addressing aesthetic and functional concerns of the eyelids, but also those of the eyebrow and midface. In 2020 there were 325,112 blepharoplasties performed in the US, making blepharoplasty one of the most commonly performed aesthetic procedures in the United States. Eighty five percent (85%) of these procedures were performed in women and were mostly performed in patients 40 years and older (91%).

Given the commonality of this procedure and the global tendency for younger and younger patients to be undergoing plastic surgery, secondary blepharoplasties are being performed with increasing frequency and present a unique challenge for the plastic surgeon with the most common indication for secondary blepharoplasty being lid malposition of the upper eyelid. Most lid malpositioning resolves within 4–6 weeks; when malposition does not affect the cornea, correction should not occur until this window of time has passed as spontaneous resolution is common. During the interim period before operative repair or spontaneous resolution it is critical to instruct patients on corneal protection. This should include lubricating eyedrops, protective eyeglasses, and eyelid taping at night. Lid malposition that does compromise the cornea, however, should be treated as soon as possible. Overall, better results with secondary blepharoplasty are achieved when surgery is performed at 6 months to 1 year following the initial surgery. This fact alone can create consternation for the unhappy patient and the eager-to-please plastic surgeon. In most cases the senior author underscores the value in the adage “never put off to tomorrow what may be done day after tomorrow just as well”. This chapter discusses considerations specific to secondary blepharoplasty.

Anatomy

Skin

The skin of the eyelid is the thinnest in the body and has minimal subcutaneous fat. Tissue outside the eyelids but in and outside the periocular region (zones III, IV, V) is histologically, structurally, and mechanically thicker and less pliable and must be considered as contributory to eyelid functional and aesthetic disorders ( Fig. 14.1 ) . As patients age, the periorbital skin has decreased type I collagen synthesis and increased dermal collagenase activity. With time, these metabolic shifts lead to thinning, folding, and wrinkling of the eyelid skin.

Figure 14.1, Anatomical zones of the eyelids and periocular structures. Zone I, upper eyelid; zone II, lower eyelid; zone III, medial canthal structures including the lacrimal drainage system; zone IV, lateral canthal area; zone V, periocular contiguous area – glabella, eyebrow, forehead, temple, malar, nasojugal and nasal areas. Tissue in the periocular region outside of the eyelids (zones III–V) is thicker and less pliable. Examination of position and pliability of this tissue must be performed to understand its contribution to eyelid deformities.

Orbicularis oculi

The orbicularis oculi is the sphincter of the eyelid ( Fig. 14.2 ). This muscle is adherent to the overlying skin and comprises three parts: orbital, palpebral, and lacrimal. The outer orbital portion attaches medially to the medial canthal tendon, the nasal part of the frontal bone, and along the inferomedial orbital margin. Laterally, the orbital portion continues around the orbit and attaches to the lateral canthus. The palpebral portion of the orbicularis oculi, the middle segment, has pretarsal and preseptal segments. Medially, the preseptal segment of the palpebral portion of the orbicularis oculi has the anterior head, which becomes the anterior crus of the medial canthal tendon and inserts into the frontal process of the maxilla, and the posterior head, which inserts into the posterior lacrimal crest (Horner’s muscle). Laterally, the preseptal fibers of the palpebral portion of the orbicularis oculi coalesce with the lateral palpebral ligament to form the lateral palpebral raphe. The small, inner portion of the orbicularis oculi, the lacrimal segment, interdigitates with the medial palpebral ligament. This portion of the orbicularis oculi arises from the orbital surface of the lacrimal bone, passes behind the lacrimal sac, and divides into upper and lower slips. These slips insert into the superior and inferior tarsi, medial to the puncta lacrimalia.

The three segments of the orbicularis oculi have distinct functions. The orbital portion of the orbicularis oculi tightly closes the eye. Contraction of the pretarsal and preseptal portions of the palpebral orbicularis oculi primarily closes the eyelid. The lacrimal portion transposes the lacrimal canals medially to receive tears and compresses the lacrimal sac ( Fig. 14.3 ) .

Figure 14.3, Activation of the preseptal, pretarsal, and orbital portions of the orbicularis oculi muscle close the eyelid. Contraction of the lacrimal portion of the orbicularis moves the lacrimal canals into position to drain the tear film.

The orbicularis oculi is anchored by well-defined ligamentous attachments. Medially, the orbicularis occuli attaches directly to the inferior orbital rim. Laterally, the orbital retaining ligament bridges the fascia of the orbicularis oculi to the periosteum of the orbital rim. At the lateral canthus, the orbital retaining ligament merges with the lateral orbital thickening, a triangular condensation of the superficial and deep orbicularis oculi that extends across the frontal process of the zygoma onto the deep temporalis fascia. Release of the orbital retaining ligament and lateral orbital thickening allows untethered re-draping of the eyelid ( Fig. 14.4 ).

Figure 14.4, Pretarsal portion of orbicularis muscle joins with the lateral canthal tendon behind the orbital septum and ultimately inserts on Whitnall’s tubercle. Note the orbital septum dividing the orbicularis muscle into an anterior and posterior leaflet.

With age, the orbicularis oculi muscles relax, and the ligamentous attachments attenuate. This transformation results in progressive upper and lower eyelid ptosis. Malar ptosis compounds this eyelid ptosis, forming a malar crescent or festoon over the malar eminence with an aged appearance. In addition, the pigment of the orbicularis oculi becomes more apparent over the thinning skin. In effect, progressive senescent attenuation combined with Newtonian gravitational forces contributes to intercanthal narrowing, lateral canthal declination, lateral fat pad herniation due to septal laxity, eyelid malposition, and other pathology ( Fig. 14.5 ).

Figure 14.5, Attenuation and gravitational forces can lead to lateral canthal declination and, as this figure demonstrates, expected sequalae include septal laxity and eyelid malposition. (A–C) The lateral canthus is normally inclined cephalad by 10–15° compared with the medial canthus. Attenuation with aging produces a descent of the lateral canthus which rotates (clockwise on the left and counterclockwise on the right) around the medial canthus. The end result is a lateral canthus that is coplanar or declined compared with the medial canthus. As the lateral canthus sags inferiorly, the intercommisure distance shortens (distance between medial and lateral canthus) and the lower lid and inferior lateral septum become lax. This produces scleral show, ectropion or entropion, orbital fat prominence especially laterally, and tear film distribution and drainage problems.

The critical point to evaluate in the patient preoperative period is the pressure or absence of lid face ptosis. In corrective secondary procedures, zone II (lower eyelid) should not be used to support zone V (cheek) in order to achieve an optimal functional and cosmetic result ( Fig. 14.6 ).

Figure 14.6, A critical examination distinction is the degree of cheek support a patient has. The patient depicted in (A) has lower lid laxity and scleral show with only modest descent of malar soft tissues, which is confirmed by noting the relatively short distance between the lower lid margin and the cheek. This patient’s lower lid ptosis could be treated with a canthopexy alone. In contrast, the patient depicted in (B) has significant scleral show with a large difference between the lower eyelid and cheek soft tissues even with the lower eyelid having descended. Using a canthal procedure alone will not be sufficient and should not be attempted to support the malar soft tissue alone. Instead, this patient would require midface suspension as well as a canthal procedure.

Tarsal plates

The tarsal plates, composed of dense fibrous tissue, are located directly above the lid margins and contribute to the integrity and support of each eyelid. Each tarsus measures approximately 29 mm long and 1 mm thick. The semilunar, superior tarsus measures 10 mm centrally and narrows medially and laterally. Conversely, the rectangular, inferior tarsus measures 3.5–5 mm centrally. The medial and lateral ends of the tarsus are attached to the orbital rims by the medial and lateral palpebral ligaments. Each tarsus contains approximately two sebaceous meibomian glands. These glands secrete meibum which is an oily substance that prevents evaporation of the tear film.

Septum

The orbital septum has dense fibroelastic tissue and forms the anterior boundary of the orbital contents. On the upper eyelid, the orbital septum inserts 10–15 mm above the superior tarsal border and joins the levator aponeurosis. On the lower eyelid, the orbital septum joins the capsulopalpebral fascia 5 mm below the tarsal border. In addition, inferiorly, the orbital septum fixates to the rim of the orbital periosteum and forms the arcus marginalis.

Postseptal (intraorbital) fat

The upper eyelid has two distinct intraorbital fat compartments, medial and central, divided by the superior oblique. The medial fat pad is lighter and firmer than the central fat pad. In addition, the medial fat pad encompasses the infratrochlear nerve and the terminal branch of the ophthalmic artery. Of note, the lacrimal gland occupies the lateral compartment.

The lower eyelid has three distinct fat compartments: the medial, central, and lateral fat pads. The inferior oblique separates the medial and central fat pads. The central and lateral fat pads are separated by the arcuate expansion, a fascial band extending from the capsulopalpebral fascia to the inferolateral orbital rim.

The interconnecting septae of the intraorbital fat link the extraconal (outside the muscle cone) and intraconal (within the muscle cone) spaces. Traction on fat just posterior to the orbital septum can produce forces in any of these spaces and accounts for the small but definite risk of orbital hemorrhage or even blindness when addressing anterior orbital fat during a surgical procedure. The blepharoplasty surgeon should be well versed in the acute treatment of orbital hemorrhage.

Preseptal (extraorbital) fat

The preseptal, or extraorbital, fat represents retro-orbicularis oculi fat (ROOF), which may accumulate outside the orbital rim on the inferior lateral brow and upper malar areas.

Upper eyelid retractors

The levator palpebrae muscle is the upper eyelid retractor and originates from the lesser wing of the sphenoid, extending anteriorly along the superior orbit. The levator condenses approximately 14–20 mm above the superior border of the tarsus into Whitnall’s ligament. Anterior to Whitnall’s ligament, the levator forms a bilamellar aponeurosis that joins with the septum to insert into the tarsus. A lateral horn divides the lacrimal gland into the palpebral and orbital lobes and contributes to the lateral retinaculum. A medial horn inserts into the lacrimal crest. The posterior lamella of the levator aponeurosis contains Müller’s muscle.

Lower eyelid retractors

The capsulopalpebral fascia forms the lower eyelid retractors. This fibroelastic tissue originates from the inferior rectus and oblique muscles, fuses into Lockwood’s ligament, and inserts approximately 5 mm below the inferior tarsus.

Lateral canthus

The lateral canthus partitions into an anterior and posterior leaflet. The anterior leaflet inserts onto the orbital rim periosteum, and the posterior leaflet inserts onto the lateral orbital tubercle (Whitnall’s), approximately 3 mm behind the orbital rim. The lateral canthus lies approximately 6 mm below the lacrimal gland fossa and is the culmination of the lateral canthal retinaculum, which consists of the lateral horn of the levator palpebrae superioris, preseptal and pretarsal orbicularis oculi, Lockwood’s ligament, and the check ligament of the lateral rectus muscle.

The ideal position of the lateral canthal tendon is 10–15° above the medial canthal tendon. All key elements of the lateral retinaculum must be addressed before mobilizing the lateral canthus for any repositioning or tightening procedures. Fig. 14.7A shows a patient with lateral canthal effacement and displacement after three blepharoplasties; she also had levator dehiscence, upper lid ptosis, and ectropion of the lower lid. Fig. 14.7B demonstrates correction of the lateral canthus, lid ptosis, and ectropion with levator advancement and canthoplasty.

Figure 14.7, (A) Patient with lateral canthal effacement with displacement laterally and inferiorly. (B) Patient after correction with lateral canthal tendon resuspended helping to correct lower eyelid ptosis.

The treating surgeon should also note the position of the lateral canthus as a three-dimensional construct. The structure is supporting the eyelids laterally hanging in space. The lateral commissure (angle) lies within millimeters of the orbital rim and disruption of this anatomy can be noted in the repeat blepharoplasty patient. This disruption is especially notable after failed lateral canthopexy or canthoplasty procedures ( Fig. 14.8 ).

Figure 14.8, The upper and lower eyelids are suspended in space and can be thought of as completing a sling between the medial and lateral canthal tendons. Even millimeters of displacement of the position of the point where the lateral canthal tendon joins with the tarsal plates and orbicularis muscle can disrupt the position and function of the upper and lower eyelids. Note the three-dimensional construct of the eyelids’ supportive structures and orbital bony confines. The eyelids are effectively hanging in space, suspended medially and laterally.

Medial canthus

The medial canthal tendon inserts into the bony orbit with three leaflets: anterior and posterior horizontal leaflets and a vertical leaflet. The medial canthal tendon is the culmination of the medial canthal retinaculum, the confluence of the deep head of the pretarsal orbicularis, the orbital septum, the medial end of Lockwood’s ligament, the medial horn of the levator aponeurosis, the check ligaments of the medial rectus muscle, and Whitnall’s ligament. The upper, lower, and common lacrimal canaliculi are closely approximated to the medial canthal retinaculum and care must be taken to ensure their integrity when altering its position ( Fig. 14.9 ).

Figure 14.9, In (A) note the medial canthal tendon is the culmination of the medial canthal retinaculum, the confluence of the deep head of the pretarsal orbicularis, the orbital septum, the medial end of Lockwood’s ligament, the medial horn of the levator aponeurosis, the check ligaments of the medial rectus muscle, and Whitnall’s ligament. As seen in (B) , care must be taken when repositioning the medial canthal tendon to preserve this confluence and reposition the entire structure as a whole. The medial canthus’ three bony attachments, upper and lower canaliculi, and lacrimal fossa are all in close proximity.

Corneal protection

In any surgery involving the eyelids, corneal protection is necessary. Protective lenses are a routine part of any blepharoplasty procedure as these lenses function to prevent desiccation and injury to the cornea which can result in devastating consequences. Additionally, care must be taken to avoid corneal abrasions which may be incurred with any internal sutures; all knots should be buried or placed externally as to avoid inadvertently scratching the cornea as the sensitive corneal tissue will only tolerate opposition with conjunctival or mucosal tissues.

Pathophysiology and anatomical changes of the aging eyelid

In performing blepharoplasty, it is essential to have a full understanding of how normal periocular anatomy changes with aging to select the right procedure for each patient. Especially important to understand is the fact that eyelids are a functional component of the larger face and their function is directly affected by anatomical neighbors. Specifically, as the upper lid is connected to the eyebrow and the lower lid to the cheek, as we age all of these tissues simultaneously undergo a predictable pattern of anatomical change related to loss of intrinsic support and gravitational forces.

With aging, the eyebrow, which is composed of skin, muscles (procerus, corrugator supercilii, depressor supercilii, frontalis, and orbicularis oculi), galea, and the brow fat pad (ROOF) undergoes attenuation of its ligamentous attachments which leads to eyebrow ptosis and descent onto the upper eyelid. This condition is termed dermatochalasis. Additionally, with aging the orbital septum develops laxity and the orbital fat pads protrude anteriorly (steatoblepharon), which lowers the upper eyelid fold position. The ligamentous attachments to the lacrimal gland (Soemmering’s ligaments) may also become attenuated leading to gland ptosis. While a low or absent upper eyelid fold is a component of age-related pathophysiology in occidentals, it is anatomically physiologic in Asian individuals wherein the levator fibers insert into the pretarsal skin more caudally, if at all. Furthermore, with aging the levator aponeurosis may attenuate or dehisce from its insertion site in the skin, leading to upper eyelid drooping, termed blepharoptosis, associated with elevation or loss of the upper eyelid fold. The levator muscle has tethering attachments to the overlying orbital fat pads and thus dehiscence of the levator aponeurosis can result in fat pad retraction and a superior sulcus deformity.

In the lower eyelid, the thin skin is prone to developing dermatochalasis with aging due to decreasing levels of collagen and elastin. With aging, the orbital septum develops laxity and the inferior orbital fat pads protrude anteriorly; the suborbicularis oculi fat (SOOF) may also contribute to lower eyelid fullness above the orbitomalar ligament and tear trough deformity in the nasojugal groove. In addition, the medial canthal tendon can become attenuated with age, which leads to inferior and lateral displacement of the lacrimal puncta resulting in inferior and medial descent of the tendon, which results in a further decrease in lateral canthal inclination. Descent of the lateral canthal tendon also shortens the intercommissure distance leading to horizontal lower eyelid laxity. Over time, this is exacerbated by downward distraction forces from the cheek and may result in malposition, causing conditions such as increased scleral show, ectropion, or entropion ( Fig. 14.10 ).

Figure 14.10, The lower eyelid is held against the globe by intrinsic support provided by the tarsal plate, canthal tendons, and orbicularis muscle sling. In normal function the net vector of these forces is posterior and superior. Any forces that increase extrinsic distraction forces such as senescence, surgery, lasers, or trauma can disrupt the normal apposition of the lower eyelid to the globe. The lower lid position is determined by a balance of two opposing forces which may be affected by senescence and/or procedures.

Midface aging also results in descent of the malar fat pads causing prominence of the orbital rims and bulging of the prezygomatic space from edema (malar mounds) or orbicularis oculi muscle redundancy (festoons). These two conditions can be very difficult to treat and may cause significant patient distress and consternation for the surgeon.

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