Extended Blepharoplasty - Rawnsley Plastic Surgery

. -
State of the Art Review Series
Extended Blepharoplasty
Peter A. Adamson, MD,CCFP, FRCSC; Guy J. Tropper, MD, FRCSC; Becky L. McGraw, M D
patients, particularly the elderly or
male patient, have larm infraorbital
'lap us* In standard lower
b'eph*
pouches and marked skin redundancy
lntraarbital
eroplasty
to a leva'"low
with lax skin tone. Because the eupherim. This. technlque Is useful In tha mannism, 'The lid cannot hold up the
agement of Infraorbltal, or malar, bags
cheek," holds true, the standard conblephthat are seen In aa many as
servative approach to lower eyeIid
candidates. A concomitant eye
blepharoplasty i s Inadequate for manshortening procedure is trequsntly
agement of these patients. The exneeded to treat horizontal eyslld laxity.
Achievement of satisfactory results d*
tended blepharoplasty procedure is s
pends on the proper suspension of the
modification of lower eyelid blepharothe lateral canthal plasty that enables the surgeon to corskin-muscfe 'lap
perlosteumm Extended blspharoptasty Is
rect infraorbihl poaches and excessive
an innovative way ta Improve infraorbltal
skin
redundancy.
pouching, whlch Is. otherwise beyond the
Other
authors have recognized this
reach of the standard blepharoplasty procedure.
problem and proposed treatment rnethlarch oto,arvnso,
~~~d ~~k
surg. 0d8.I Furnasa described festoons of the
orbicularis oculi as a n occasional cause
1991;117:6Q6-609)
of baggy eyelids, and categorized them
into preseptal, orbital, and jugal. To
ewer
blepharoplastyean be a
correct such festcmns, he advocated the
procedure even for
us, of a suture suspending the myothe
surgeon*In the
cutarwo,s flap of the lower eyelid to
dard lower
blepharOplastyp
the periosteum of the lateral canthus.
judgment and emeriencepide
the
However, he limited the dissection of
with
to the extent of
the flap to the level of the infraorbibl
and fat excision-The potential for
rim. Consequently, any correction irnpostoperative
malpOsitionOr ecposed on the ''jugal festoons" was an
tropiOn imposes
On the
indirect effect Castanares3 proposed a
part of the surgeon.
some direct excision of the festoons, leaving
a facial scar, or a facial rhytidmbmy
Accepted for p u b l i d o n September 14, 1990.
tomake them le, apparent.
From the Department of Otolnq~gology-Head
Small,' in 1981, first described the
and ~~~k suwery,
Univcmjty of ~~~~~h
(ontario).
extended blepharoplasty. This inPresented in part at the American Academy of
volved dissection of the lower eyelid
Facial Plastic and Reconstructive Surgery East.
myocutaneous flap beyond the level of
ern Section, Toronto, Ontario,January %, 1989.
Reprint requests to PO Box 47, Suite 2707, TOthe infraorbi tal rim and on to the anronto Dominion Bank Tower, Toronto Dominion
terior maxilla, in order to correct large
Toronto. Ontario, Canada M5K lBT (Dr
cheek festoons. This present cornmuAdamson).
Extended blepharoplaaty Involvesex-
tending the dlssectlon of the skln-muscle
606
Arch Otolaryngol Head Neck Surg-Vol
1 17.
June 1991
nication outlines our techniqne of ex
tended blepharoplasty, and stre
the advantages i t offers to select pa.
tients without a significant incre
morbidity.
Our use of the technique ha
dirwted toward elimination of
sochdasis extending beyond
fraorbital rim. While the e
blepharoplasty procedure ma
formed alone, it is usually
with an u p p r eyelid blepharoplasty.
In this case, the upper eye
aroplasty is carried out first.
blepharoplasty directly approaches
extensive blephart>chalasis and ble
dress. Other indications fo
this technique include: or
struction with strengthe
lower eyelid to support
lower eyelid reconstru
Iarly in cases of p o s h
traumatic lower eyeli
rectjon of scleralsho
of thyroid ophthalmopathy; and reconstruction of the zygorna.'
Contraindication
Mepharoplasty are
standard blepha
Blepharoplasrj-Adamson
el
I
*&le
thyroid ophthaln~opathy.
,suspicion of thyroid dysfunction
i, for a thorough endocrinologic
\&ion. The prespnce o f xehthalrnia or proptosis should sug:
caution. ScEcral ahow
uld prompt the surReon to search
history of previous trailma or
~y to the eyelid. The structure
nsible for eyelid retraction
d k established, and this should
ressecl d u t i n ~surgery.
Fig l .-Extendad blephamplastyincision (sold line). It Is longer and sl~ghtfyhgher than the
standard blepharoplaslyincision (dashed line).
Fig 2.-Extent of udermhlng tor extended
blepharoplasty, into the lateral canfhsl area.
b l o w the infraorbital rim, sndovtn Ihe zygoma.
The short d a s b d line indicates the ~nfraorbitai
nm.
the surgwn should delineate the exof infraorbital pouch in^ below t h e
I infrsorbillal rim.This pouchinnmay
parate from t h e fatty palpebral
extending inlerolaterally over
The quality .of the skin, skin
tldq and the amount of f a t prolapsing
Fig 3,-Estimation of the redundant portion of
lhe lateral skin-muscle flea and ~ t sexclaim.
med on all patients. Each patient is
ferred for assessment by an ophthalst, and preoperative p h o w a p h i c
entation i s obtained.
Operative Technique
ure may be ~ r f o r r n e dunder
procedures. We routinely adethylprednisolone (120 r n ~ and
)
1 g) intravenously at the k i n -
is eqmtpd to allow adequate vaa-
UP
to the bevel of t h e lateral canthus,
'npisi~n13 apprnximatcly 8- to 4-mrn
"'than is ~ ~ n e r a l used
l y lor standard
A t the lateral aspect of t h e incision.
sharp scissors are u s 4 to spread t h e fihers
of the orhicuIarin ocuIi muscle With the
assistant exert in^ firm downward traction
on the skin of the chpek, s plan^ is easily
dissected between the orbicularis oculi and
t h s~u b j a c ~ n orbitnl
t
wpturn. Blunt disspction of this avascular plant? creates a composite musculocubneous flsp anteriorly.
Undermining is continued inferiorly into
the infraorbital region anterior to the zygoma, 1.0 to 2.0 cm helow, t h e orbital rim as
n d p d , as well ns lateral!y into the lateral
can thal reqian (Fin 2). This facilitates later
r d r a p a p ~of the Rap and tension-free
wountl closure. The blunt dissection minimizes trauma to the blood supply of the flap
and decreases t h e risk of darnakng the infraorhital nerve. After the undermining: is
complete. the musculocutaneous flap is elevated by incising t h e orbicularis oculi suppriorly along the subciliary incision.
W h i l ~retractors hold the flap inferiorly,
additional exposure of the f a t padsis gained
hy drawinp the lower eyelid superiorly with
a t e m p o r a v tarsal suture. Excision of a
small strip of orbital septum provides access to t h e p r o t u b r a n t fat. The f a t is gent l y t e a 4 from the surrounding tissue using hlnnt diswtion. One should avoid dam-
Ql~laryngo~
Head Neck ~ u r g - ~ o 1l I 7. June 1991
Fig 4.-Ofbicularis suspension suture anchwed la the lateral camhal penosteurn. The
dashed line indicales the ~nfrawbltalnm.
aging the vessels found medially in the
vicinity of the f a t pad. 'Fhe inferior oblique
is seen b t w e e n the medial and central fat
pad, and mustbe respected. Scissor excision
of f a t i s limited to that projectinq above the
level of t h e orbital rim and is p r d e d hy
injection of the base of the f a t ~ l o b uwith
l~
1-1
anesthetic, followed by bipotar rlectrocautery. Absolute bemostasis is sec.uwtl
with bipolar e3ectrocautery.
Laxity of the eyelid is frequently present,
particularly in this c a t q o r y of patient.
Horizontal laxity is attserrsPd with the pinch
test, in which the eyelid is distractd from
the g l o b and releaserl. The d e m of distraction and the abillity of the eyelid to snap
back into place are determined, Mild dep e e s of laxity may be adequately rnanaued
tients
may
hll of
qualifrr
were fl
t061
yeam.
En a
po~~
bib1 r
applie
iocrca
eyelid
* mu6
rim in
in the
redun*
tatera
than t
move
aroplr
my on
forme
fidenc
9utus1
short4
stancl
Fol
mantl
alent
dvet
FIQ 5 -A
Some
occur
4.4 year-old man w ~ t hrnfraorbltal pouchinq Top left. Preoperathve anreroposterior vrew Top rlyht,
Preoperative
rrghl lateral vtew Bottom left. One-year postoperatwe n n l e r ~ s t e r i o vrew
r
The procedure anvolved elevat~onof the flap 2 crn beyond the ~nfreorbaalrim, 6-rnm hrrzontal eyelid shwlenlng, and 8-mm
lateral sk~nexcism. Bottom right. Postoperat~ve
rtghi batera! view.
with the orbicularis suspension procedure
descdwd below. More Revere degrees of
laxity are treated with a lateral canthoplasty.' Extreme cases ot laxity may require a horizontal eyelid resection, such as
the mndified Rick procedure laterally, or
the Kuhnt-Szymanowski pentamnxl wdsx
excision a t the lateral limbus. Thp eyelid
margin is reappmximatd with 6-0 silk
everting sutures on the skin starting from
the p y Iine, while 5-0 polyglactin [Vieryl)
s u t u m are u s d to reestablish continuity of
the tarsat prate and pretarsal strip of the
orbicularis oculi.
R d r a p x g ~of the lower y e l i d musculocutanpous flap is accomplished in a suprolateral direction. The patient is instructed
to adopt a neutral gwe. Gentle distraction
on the chwk is used to simulate the eff& of
m.rrvity when t h e patient rcsumes an upright position. Care must be taken to avoid
inferior displacement of the lower eyelid
marpin during this maneuver. Scleral show
is unacceptable at this poin t, and an 0.5-rnm
overlap of the lower eyelid on the limbas is
808
Arch Otolaryngol Head Neck
preferred. Once estimation of the redundancy of the flap is confirmrd, the excess
skin and muscle is trirnmdl l ~ t e r a l l y(Fig
3). under mi sin^ of the skin around the [atera1 canthal part of the incision and flap
will allow better redrapage of t h e skin and
avoid standing tissue cones ( d o g e r s ) on
skin closure.
Proper suspension of the flap i s the most
important step of tbe procedure. A permanent horizontal mattress suture (4-0 Mersilene) is placed in the o r b i c ~ ~ l a roculi
i s and
the deeper dermis of the edg of the musculmltaneous flap, and then sutured to t h e
periosteum of the inner aspect of the lateral
mnthaP area (Fig 4). Two such suspension
sutures are placed to elevate the flap supetolaterally in order to remove all tension
from the infraciliary skin suture line. The
rest of the orbicularjs muscle is approximated lntetally with inverted 4-0 p l y & d i n (Vicryl)sutures. Interrupted, evertinp: 6-0 silk sutures maintain the undermined skin etlm together. The redundant
medial part of the flap is then trimmed and
Surq- .Val 1 1 7 . June 1991
too a1
the wound is c l o d with simple 6-0 silk so.
tures.
Postoperative care consists of head el*
vation and mntinuous application of icecold wet compressm for at least 24 hour?.
Generous usc of ophthalmic drops durinp
the day and ointment during the night adequatetv protects the curnea and c o n j u n ~
tiva. Patients are instructed to apply topical antibiotic ointment tothe woundstwoto
three times a day, until the sutures are removed on the fourth postoperative day. The
horizontal eyelid resection sutures (Eickot
Kuhnt-Szymanowski) are left in place fora
total of 7 days.
RESULTS
The senior author (P.A.A.) has ud
the extended hlepharoplasty technique for 3 years. The experience and
long-term results obtained from s e ~ f l
cases have been encouraging and suff
~ e s further
t
application of the tech
nique. Approximately 10% of the Ps'
Bkphamplasty-Adam*
L
$nkq presenting for
gay h candidates for
blepharoplasty
this technique.
111 of the patients in our series who
, Ualified for the extended approach
,pre men. Their ages ranged from 44
.o 61 years, with a n averapp age of 54
;ears.
In all patients, severe tower eyelid
*uching extended below the infraor;idrim. The extended technique was
,Jppliedwithout c a u s i n ~a significant
';ncreasein operative time, This lower
.?elid mymutanmus flap was elevakd
fs much as 2 crn below the infraorhital
+ in three patients and1 cm or more
in the others. On the a v e r w , 7 mm of
dundant skin was excised from the
'3t~ralaspect of the flap. This is more
'(ban the average of 2.5 mm that we re:move laterally in the standard bleph(roplasty pr0cedure.l More aggressive
"-nvocutaneous flap elevation was per&med in the later eases, ss more con!lidace in the orbicularis suspension
4uture was obtained. Horizontal eyelid
,shortening was performed in every indance, removing a s average of 4.9 mm.
Follow-up ranged from 6 to 15
months. Chemosis seemed more prevalent than in standard cases, but red v e d in all patients within 2 to 6 days.
hme degrw of minor dimpling may
occur if the suspension stitch is placed
too superficially in the dermis. This
can be corrected by skin undermining
during the surgery and with massaEe
postoperativelv. One patient presenting with scleral show preoperativelv
had persistent show postoperatively.
The patient was asymptomatic and
pleased with the result. All patients
were very satisfied with the improvement achieved. No patient suffered facial hypesthesia in the infraorbital
nerve distribution. None of the patients in this group suffered from dry
eye symptoms preoperatively or postoperatively. Figure 5 illustrates a rep-
resentative case.
COMMENT
Extended blepharoplasty utilizes
wider undermining of t h e standard
blepharoplasty musculmtaneous flap
in the region of the upper cheek and
zygoma. Redrapage of this larger flap
allows elimination of, or at least improvement in, the infraorbital pouches
t h a t cannot be addressed with sknd a d blepharoplasty techniques. This
redrapage often provides some lift and
smoothing of skin in the mid-cheek region, but should not h promoted as a
substitute for facial rllytidmtorny.The
patient should not be led to anticipate
significant improvement in the melolabial fold, even t h o u ~ hminor improvements may h noted.
Although relatively easy to descrik
and perform, extended blepharoplasty
calls for cautious and judicious application. The larger myocutaneous flap
and skin excision. especially in older
patients, constitutes a significant risk
for postoperative scleral show and dry
eye syndrome. Hence, great e m p h a s i ~
needs to Iw placed on the use of nonresorbable suspension sutures to secure
t h e flaps to the lateral canthal perios-
teurn.
Exknded bIepharoplasty is an innovative way to address edemabus
"bags" of skin or festaons of orbicularis oculi muscle extending below the
infsaorbihl rim It represents a raluahle modification of t h e standard
btspharoplasty procedure, and pmvides a significant improvement of infraorbital pouching not othenvise
available. Our exylerience has provided
us with @ results and justifies its
continued use.
S u m t e d readiape include the followi~in~:
1. Small RO.Extended lower lid blepharoplas?Arch C@h#holmd 19Nl$PI:14(n-I405 (The clasSIC description of extenrl~dhlepharoplasty.)
2 Holt JE. Holt G R . Hlephamplasty indimtions and prwwrative awwrment Arch OtoIuryRgd 19HT,:111:394-397.(A r ~ v i e wof the anatomy,pathology, and ~ n d m t i o n for
s hlepharoplasty, as well arr e d ~ m s s i o n of the complete
preoprative evaluat~onfor blepbaroplwty.)
References
1. Gonsalm-Ulhoa M,StevensE.The treatment
of plpebral bags. PI& &w&r ,%m. 1961;
w531-3%.
2 Furnae DW. F-na
o t orbicuIaria mnscle
u a c a w of
eyelids. PI& RrxoRslr Surg.
1Ivlg51~540-516.
3. Castanares S. A compariiron of blepharo-
plasty techniques. In: Masters F, Leai~JR.4
s
.
S m p ' u m a Aesthelic Su7g~ryof !he Fmce,
EwIi& and RWML St LOU~R,
MD:Cn' Mmby Go;
1972.
4. Small RG.Ext~ndedlower lid blepharoplasty. Awh Ophthalmd l!W1;9?1402-J405.
5. Holt SE, IJolt GR. Blepbaroplmty indics-
tiona and rxmprative assasment. Arch OIw
l
a
m 1985J11:394-X37.
6 McGraw RL, Adamson PA. Poet-blephpFasZy cctropioic prrventlon and management.
Presented at the Spring Meeting of the American
Academy of Facial Plastic and Rwnatnlctive
Surgery, Palm k w h , Fla. May d. 1%.
Facial Plastic Analysis and Discussion
Extended Blepharoplasty
Peter A. Adsinsan, MD, CCFP, FRCSC;Guy J. Tmpper, MD, FACSC;k k y L McGraw, M D
Dimmimi by Frank M.Kanaer, MD
P
m n t l y , there is no consensus amonR
Juveons when skin flaps or skin-muscle flaps should be utilized. Traditionally,
the skin-muscle flap hw k n used in patients in whom a small amount of excess
skin excision ((3 mm] in anticipated. If
larger amounts of skin needed to be removed, a skin flap was utilized. Many Burgeons, however, employ a skin-muscle flap
in all cases whileother suqpona prefer akin
flaps ia ail but the youngpatient with tight
skjn. In 1W7. Spiral attempkd a clinical
study to clarify the situation. In a group of
26 patientu ranging in aw from +%750 68
years old, he perlorrnd a skin-muscle Rap
on one lower lid and a skin flap on the contralateral lower lid. His operative m u k s
were assessed from color transparencies by
several plastic surgeons, residents, and students. The photographs were made from 3
to 12 months following surgery.Except for
one or two minor disparities, the observers
felt that there were no simificant variations betwwn the two eyes.
Adamson has chosen the skia-muscle
flap as his m e t h d of choice. This technique
trmthe pretarsal orbicularis oculi
muscle, an important component of lower
lid s u- m
- r t . The tarsolimmentous wmplex
is of particular surgical importance. It is
c o r n p a d of the pretaraal orbicularis oculi
muscle, the medial and lateral canthal Eendons, and the fibrous tarsal plate (tarsus).
Lower eyelid position and tone ate related
in p a t part to the integrity of the tarsolimrnentous complex. The increase in lower
lid laxity with a@ has been attributed to
stretching of the lateral canthal tendon.
Preservation of the p w h r s a l orbiealaris
oculi muscle with Its medial and lateral
tendons and the fibrous tarsal plate as a
single unit, the tarsolipmentous complex,
aids in resistina contractile forces placed on
the lower lid.
Persistent eyelid rnalpmition following
lower lid blepharoplaaky may result from
ovemalous excision of ukin or muscle, scar
610
Arch Otolarynool Head Neck Surq-Vol
often results in pulling or the lower lid
formation and contracturewithin the lower
margin downward, causing unacceptable
eyelids, adhesions of the orbital septum, or
scleral ehow, if not frank ectropion. An
dyxtonic muscle function of the orbicularis
ounce of p r w e n t i w is worth a pound of
oculi muscle. Eyelid rnalposition, therefore,
mre,especiably as it retates to the aesthetic
results when f o r m acting on the lower lid
unit of the eyelid, eye, and orbit.
in an inferior direction avercame the supAdamson has attempted to preaent an
pwt of the tarsoligamentous complex.
anatomic classification and treatment ot
Rees' believes that lid retraction is more
amthetic and functional eyelid abnorrnalifrequent after extensive skin undermining
than following the skin m u ~ l eflap tsch- ties in a well-organid outline. Skin flaps,
transconjunctival, and pre-excision technique. He feels that the skin flap has a tenniquesare not jncludedin this retrospctiw
dency to contract like a free skin maft does
study, yet wedgetecesections, lateral ranthcbut to a lesser extent, bston,'aa the other
tomies, and lateral suspension sutures are.
hand, believes that the m i b i l i t y of postIs too much surgery h i n e performed in atoperative scleral show i s reduced by utiliztempting to correct all the anatomic varia.
ing a skin flap and g m r u i n ~
the attachtions and perceived deformities of the aginu
ments of the orbicularis mli muscle to the
eyelid? Is it wer worth requiring a seoondtarsus and the orbital septum.
ary reconstructiveprmdure to repair comPreservation of t h e tarsoligamentous
plications that may have k n prevented bp
complex by placing the skin incision in a
a more conservative approach7 Are the
crease approximately 4 mrn below the
risks worth the rewards? These are the
lashes as advocated by MFCollough and
quedions that must be answered by each
English4 appears to offer few theoretical
one of us in eatahlishing wr surgical phia d v a n m s . Presefina the pretarsal skin
losophy.
adds little if any suppnrt to the lower lid.
This type of study enables surgeona ta
Furthermore, placement of the incision at
compare their aesthetic results with me&this lower level makes for a more visible
surable data concerninn complications
scar that can Iw difficulttocamtnrfla~e,even
function, and patient satisfaction. It can
with eyeliner.
The choioe of the best indicated s u r ~ i c a l hetg influence the evolution of our surgical
philosophy and techniqne, keep in^ routine
technique is subjective, influend by one's
from b e w m i n ~one's master in the ~ ~ ~ r s u i t
skill, training, knowledge and overall aesof improved functional and aesthitic rethetic judpnent. A s a rule, it is bast to 06sults.
b i n a maximal result with a minimum of
surgery,as complications oftenrise with an
FRANK
M. ~ M E RM D
increase in surgical intervention. A conserBeverly Hills, Calif
vative approach aids in preventing radical
alterations in the normal win^ eyelid.
References
Compmrnim must frequently be made he1. Spire M. tower blepharoplnaty: R clinical
tween the "ideal" eyelid and a more indistudy. Hasl B m d r S u q . 1977;',n:.S%a%.
vidualized surgical result. Gertain m d i horj2. RePs TD. Prprention of ectroplon
tions cannot be aiflificbntly i m p r o d or
mntal shorteninn of the lower lid during b h h sroplwtr;.Ann Pioxtic Strw. 1953.11:17-S.
than&
by lower lid bl~pharoplasty,For
3. Xston U. S k i n - ~ u s c l eflap lower It? blWhexample, rhytides of the lower lid skin can
aroplasty. Cha Plus! S I I ~ 19S:15.&708
J.
rarely be improved by blepharoplasty
4 ?vldklloughE(;, E n ~ l i z h.JT, Rtepharop!a51F
alone. attempt in^ to eliminate these wsinavoitl~naplastic qelids drrh i H n E n q ~ ~ l
Neck sllrl~lQRS:E14.M:M46
kles and fine l i n e by removal of excess skIn
117.
June 1991
Blepharoplasly-KaM