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Facial Plastics & Trauma > Eyelid defects, blepharoplasty, brow lift, Chin, Forehead > Flashcards

Eyelid defects, blepharoplasty, brow lift, Chin, Forehead Flashcards

1
Q

√What are the layers of the upper eyelid? What are their innervations?

A
  1. Skin
  2. Orbicularis oculi muscle (VII)
  3. Preseptal fat
  4. Orbital septum
  5. Orbital fat (preaponeurotic fat) (x2)
  6. Levator aponeurosis / Levator Palpebrae Superioris (Superior division of CNIII oculomotor nerve - which retracts the eyelid)
  7. Muller muscle above that connects to Superior tarsal plate below (sympathetic innervation)
  8. Conjunctiva

SOS Fuck AMC
Skin
Orbicularis Oculi Muscle
Septum
Fat (orbital)
Aponeurosis
Muller muscle above (tarsal plate below)
Conjunctiva

https://entokey.com/wp-content/uploads/2016/07/DA1-DB5-DC3-C72-FF1.gif

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2
Q

√What are the layers of the upper eyelid at the LID MARGIN?

A
  1. Skin
  2. Orbicularis oculi muscle
  3. Tarsal plate
  4. Conjunctiva
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3
Q

What are the layers of the lower eyelid?

A

Similar to the upper eyelid, similar layers but different muscles

  • Skin
  • Orbicularis Oculi (VII)
  • Orbital Septum
  • Orbital fat pads (x3)
  • Capsulopalpebral fascia (extension of inferior rectus)
  • Tarsal plate (connects with inferior tarsal muscle) - sympathetic innervation
  • Conjunctiva
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4
Q

√What is the function of the tarsal plate?

A

The tarsal plates serve as the main structural component of the eyelids. They are made of dense connective tissue and contain the Meibomian glands and eyelash follicles.

Kevan FP Page 56

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5
Q

√Describe the upper and lower orbital fat pads / fat compartments.

A

UPPER LID (x2):
1. Medial fat pad (more white)
2. Central fat pad (more yellow)
- Lacrimal gland lies lateral
- Medial and central fat pads are separated by the superior oblique

LOWER LID (x3):
1. Medial fat pad
2. Central fat pad
3. Lateral fat pad
- Medial and central fat pads are separated by the inferior oblique
- Central and lateral fat pads are divided by the arcuate expansion of the lockwood suspensory ligament

https://eyewiki.org/w/images/1/thumb/3/33/OASC1b.jpg/574px-OASC1b.jpg

Kevan FP Page 57

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6
Q

Describe the Lockwood suspensory ligament

A

Hammock-like ligament that suspends the eye inferiorly in the globe, preventing downward displacement to the floor of orbit.

The globe is also supported by the medial and lateral check ligaments, septum, and adipose tissue.

Insertion: Whitnall tubercle on the lateral orbital wall.

The arcuate expansion of Lockwood ligament typically defines the boundaries of the middle and lateral fat pads of the lower lid and inserts on the inferolateral orbital rim.

https://eyewiki.aao.org/Suspensory_Ligament_of_the_Eye_(Lockwood%E2%80%99s_Ligament)

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7
Q

Describe the arterial and venous and lymphatic supply of the eye

A

FINISH

Corliss Lecture

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8
Q

Describe all the ligaments of the eye

A
  1. Medial and lateral canthal ligmanets
  2. Whitnall’s: Suspends the lacrimal gland, superior oblique tendon, levator
  3. Lockwood’s: Made of fascia from inferior rectus and inferior oblique; suspends orbit; over time weakens –> eye pushes down and causes pseudoherniation of fat

Corliss lecture

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9
Q

Describe the innervation of the lid muscles

A

FINISH***

Mueller - norepinephrine stimulated

Upneeq eye drops

Corliss Lecture

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10
Q

Describe 6 features of Asian vs. Caucasian eyelids

A

Oriental eyelids have:
1. Medial epicanthal folds
2. Upslanting palpebral fissures (open space between the eyelids)
3. More subcutaneous and pre-tarsal fat
4. 50% have absent tarsal crease (single eyelid) - Single eyelid (absent tarsal crease) have a pre-tarsal fat pad (not present in caucasions).
5. Short tarsus (3mm vs. 10mm)

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11
Q

Why do 50% of asians have a single eyelid (absent tarsal crease)?

A

Primary insertion of the levator aponeurosis into the orbital septum occurs closer to the eyelid margin, resulting in an absence of tarsal crease

Levator aponeurosis does not extend through orbital septum towards the skin, instead terminates on superior tarsus

To recreate, suture levator aponeurosis to lower skin edge through standard blepharoplasty approach

Kevan FP Page 35
Vancouver 380

See Corliss’ lecture

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12
Q

What are two types of blepharoplasty that creates a supratarsal crease for asians?

A
  1. SUTURE TECHNIQUE
    - Placing intradermal sutures to anchor the subcutaneous tissue or orbicularis muscle to the aponeurosis or tarsal plate
    - Advantage: Simple, easy to perform, no scar, short recovery time
    - Disadvantages: High failure rate, stitch knots can be visible when eyes are closed
  2. RESECTION TECHNIQUE
    - Excising a strip of eyelid
    - Incise orbital septum +/- lipectomy
    - Orbicularis is sutured to levator aponeurosis

INCISIONLESS METHODS:
1. Epicanthopexy
2. Mustarde and Johnson’s Double Z-plasty

Dermis has to attach the septum or past the septum in order to get the crease

Vancuver 381

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13
Q

What are the borders for submental liposuction?

A
  1. SCM to SCM
  2. Mandible to cricoid
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14
Q

What are Ellenbogen’s 5 features of an aesthetic neck?

A
  1. Distinct inferior mandibular border with no jowl overhang
  2. Subhyoid depression
  3. Visible thyroid bulge
  4. Visible anterior border of the SCM
  5. Cervicomental angle between 105 to 120 degrees
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15
Q

Discuss the 4 main order of operations for a submentoplasty

A
  1. Submental liposuction first (to allow visualization of skeletonized platysma)
  2. Platysmaplasty (approximate medial borders of platysma)
  3. Chin implantation if needed (done via submentoplasty incision)
  4. Rhytidectomy (shouldn’t do this before platysma, because makes it harder to reapproximate platysma)
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16
Q

List the steps of the submentoplasty procedure (7)

A
  1. Incision 1-2mm posterior to submental crease, around 2cm long
  2. Undermine flaps (subcutaneous plane!)
  3. Dissection extends to anterior border of the SCM bilaterally
  4. Dissection does NOT extent past mandible to minimalize risk of injury to marginal mandibular nerve
  5. Once submental region has been undermined, the following steps can be done:
    a/ Liposuction - make sure liposuction aperture pointed deep away from dermis to avoid contour irregularity
    b/ Subplatysmal lipectomy (level Ia only)
    c/ Platysmalplasty (suture anterior margins of platysma)
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17
Q

List 11 complications of submentoplasty, differentiating early and late complications

A

Early:
1. Hematoma
2. Seroma
3. Sialocele
4. Infection
5. Contour irregularity
6. Marginal mandibular nerve injury

Late:
7. Scarring
8. Platysmal banding
9. Irregular neck contour
10. Hypertrophic/keloid scars
11. Cobra deformity
- Submental concavity + platysmal banding resulting in a hooded neck appearance like a cobra
- Caused by excessive submental fat excision AND/OR prominent platysma bands (especially if platysmaplasty was not done)

Kevan FP Page 52

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18
Q

Define a Witch’s chin

A

Witch’s chin = senile chin deformity
- Caused by weakening of the muscular attachments of the mentalis and depressor labii inferioris
- Results in the soft tissue pad of the chin falling below the mandibular line and a crease forming in the submental area

https://www.researchgate.net/profile/Anthony-Benedetto/publication/232037766/figure/fig51/AS:671518728126483@1537113949542/Depressor-labii-inferioris-and-platysma-can-interlace-their-fibers-in-some-individuals.jpg

Kevan FP Page 53

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19
Q

List 3 options for chin augmentation

A
  1. Mentoplasty (soft tissue) with chin implant
  2. Genioplasty (osseous)
  3. Non-invasive chin implantation (fillers) - just temporary, gives more 3D control over chin shape
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20
Q

Describe the Mentoplasty with Chin implant for chin augmentation. What is the overall procedural steps and what are some considerations to note when performing this?

A
  • Intraoral or submental incision
  • Mentalis muscles are divided to enter a dissection plane superficial to periosteum
  • Implant is placed in a supraperiosteal plane centrally and a subperiosteal plane laterally (subperiosteal plane improves fixation but has bony erosion, so therefore only do subperiosteal laterally)
  • Mental nerve must be identified and preserved
  • Mentalis muscle must be re-approximated

Kevan FP Page 54

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21
Q

Describe the Genioplasty for chin augmentation. What is the overall procedural steps and what are some considerations to note when performing this?

A
  • Horizontal bony osteotomy + plate fixation
  • Osteostomy is done below the tooth roots
  • If only AP advancement is needed, a horizontal osteotomy is done
  • If vertical movement (shortening) is also needed, an oblique osteotomy is made
  • Mobilized segment is repositioned and fixed with plates
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22
Q

List 11 possible complications of chin augmentation

A
  1. Scarring (can be intraoral or extraoral)
  2. Mental nerve injury
  3. Hematoma
  4. Implant migration
  5. Implant extrusion
  6. Infected hardware, need for removal
  7. Unsatisfactory cosmesis
  8. Witch’s chin
  9. Mentalis dyskinesis
  10. Bony erosion with implants
  11. Malunion/non-union in the context of osseous genioplasty
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23
Q

Discuss 4 types of implant types used in facial reconstruction. What facial sites are they commonly used at? What occurs at the tissue interface when these implants are placed? What are their advantages and disadvantages?

A
  1. SILASTIC (Polydimethyl-Siloxane)
    - Tissue interface: forms a fibrous capsule
    - Common sites: Chin, malar, nasal
    - Advantages: Can be carved, easily removed
    - Disadvantages: Bone resorption, hard to get exposure
  2. GORE-TEX (Fibrillate expanded polytetrafluoroethylene; ePTFE)
    - Tissue interface: Limited tissue ingrowth
    - Common sites: lips, nose
    - Advantages: Comes in sheets or tubular
    - Disadvantages: Can be palpable
  3. MEDPOR (High density polyethylene)
    - Tissue interface: Fibrovascular ingrowth
    - Common sites: Malar, orbit, chin, nasal, auricular reconstruction
    - Advantages: Versatile, resistant to infection
    - Disadvantages: Difficult to remove
  4. HYDROXYAPATITE (Bone source)
    - Tissue interface: Osseointegration
    - Common sites: Craniofacial, forehead
    - Advantages: Comes as a paste, can be molded
    - Disadvantages: Exposure or infection
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24
Q

Describe the ideal female and male eyebrow shape

A

FEMALE:
- Gently curving arc
- Should lie slightly above the supraorbital rim
- Landmarks:
a/ Medial brow limit: Line from alar facial groove to medial canthus
b/ Lateral brow limit: Line from alar facial groove to lateral canthus
c/ Peak: Traditionally at the lateral limbus (where the iris ends and sclera begins). More contemporarily, preference is for peak to be at the lateral canthus

MALE:
- Less curved, broader brow
- Should lie at the supraorbital rim
- Thick, flat, without lateral tapering
- Peak should be at the midpupillary line

Kevan FP Page 55

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25
Q

What is the blood supply to the forehead?

A
  1. ECA –> Superficial temporal artery –> supplies the zygomaticotemporal area
  2. ICA:
    a/ Ophthalmic artery
    b/ Supratrochlear artery
    c/ Supraorbital artery

https://www.researchgate.net/profile/Gregory-Tsoucalas/publication/339597319/figure/fig1/AS:864076787875840@1583023368026/Supratrochlear-artery-and-topographic-anatomy-A-presentation-of-supratrochlear-artery-and.png

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26
Q

What is the nerve supply to the forehead? (and label)

A

MEDIAL:
1. Supraorbital nerve (V1)
2. Supratrochlear nerve (V1)

LATERAL:
1. Lacrimal nerve (V1)
2. Zygomaticofacial nerve (V2)
3. Auriculotemporal nerve (V3)

https://pocketdentistry.com/7-the-head-by-regions/

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27
Q

Name the brow elevator muscles (and label)

A

Only ONE brow elevator = FRONTALIS

Origin: Posteriorly from the galea aponeurotica, which corresponds with the hairline on the surface.
Insertion: Inferomedially, the muscle interdigitates with fibers of procerus muscle, while more inferolaterally, it has attachments to the orbicularis oculi and corrugator muscles

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28
Q

Name the brow depressor muscles (and label them)

A

4 Brow Depressors
1. Corrugator Supercilii (vertical glabellar wrinkles)
2. Procerus (horizontal glabellar wrinkles)
3. Depressor supercilii
4. Orbicularis oculi (Crow’s feet)

Kevan FP Page 56

https://plasticsurgerykey.com/wp-content/uploads/2017/02/gr1-48.jpg

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29
Q

Name the 3 parts of the orbicularis oculi muscle

A
  1. Orbital Orbicularis = superficial/overlying to orbital bone, joins depressor supercilli
  2. Preseptal orbicularis = superificial to orbital septum (winking/voluntary)
  3. Pretarsal orbicularis = superficial to tarsal plate (blinking/involuntary)
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30
Q

List the orbital bones (and label them)

A

7 bones
1. Frontal
2. Maxillary
3. Zygomatic
4. Palatine
5. Ethmoid
6. Lacrimal
7. Sphenoid

https://images.ctfassets.net/u4vv676b8z52/2h7UGbxlinGUDwGTkVmroA/0aaeff0025e6a426480b0f8f32367dce/orbital-bones-illustration-678x446.gif

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31
Q

List the foramina of the orbit and what passes through them?

A
  1. OPTIC CANAL
    - Optic nerve
    - Ophthalmic artery
    - Central retinal vein (runs in optic nerve)
    - SNS to the orbit
  2. SUPERIOR ORBITAL FISSURE (contents of cavernous sinus, except V2)
    - CNIII (oculomotor)
    - CNIV (trochlear)
    - CNVI (abducens)
    - V1 (branches: nasociliary, lacrimal, and frontal)
    - Superior and inferior ophthalmic veins
  3. INFERIOR ORBITAL FISSURE
    - V2 (infraorbital nerve, zygomatic nerve)
    - Infraorbital artery and vein
    - Parasympathetic innervation to lacrimal gland

Figure 1: https://www.nature.com/articles/s41598-022-05178-y

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32
Q

What is the Annulus of Zinn? What passes through it?

A

Annulus of Zinn = tendinous insertion of the 4 rectus muscles within the orbit

Structures passing outside annulus of Zinn:
1. Almost everything from superior orbital fissure except CNIII and Nasociliary V1
a/ Lacrimal branch of V1
b/ Frontal branch of V1
c/ Trochlear nerve CN4
d/ Superior ophthalmic vein
e/ Inferior ophthlamic vein

Structures passing through Annulus of Zinn:
Optic Canal (pretty much everything):
1. Optic nerve
2. Ophthlamic artery
3. Central retinal vein
4. SNS fibres to orbit

Superior orbital fissure:
1. Oculomotor nerve (superior and inferior branch)
2. Nasociliary branch of V1
3. CNVI (abducens)

Figure 1: https://www.nature.com/articles/s41598-022-05178-y

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33
Q

Describe the eyelid retractor muscles and their innervation

A

Upper lid:
1. Levator palpebrae superioris (CNIII)
2. Muller’s Muscle (sympathetic innervation)

Lower lid:
1. Capsulopalpebral fascia (extension of inferior rectus; CNIII)
2. Inferior tarsal muscle (analogue to Muller’s muscle; sympathetic innervation)

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34
Q

What muscles are responsible for eye closure (eyelid protraction), and their innervation?

A

Orbicularis Oculi (CNVII)
- Pretarsal segment most important for blinking

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35
Q

What are the Meibomian glands?

A

Small oil glands that line the eyelid margin and secrete oil that coats the eye surface

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36
Q

What are the components of the tear film?

A

Three components of the tear film:
1. Lipid layer (from Meibomian glands)
2. Aqueous layer (from Lacrimal glands)
3. Mucin (from Goblet cells)

Kevan FP Page 58

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37
Q

Which muscles are important in the lacrimal excretory pump?

A
  1. Horner’s muscle (Deep head of pre-tarsal orbicularis oculi)
  2. Superficial head of the pretarsal orbicularis oculi
38
Q

At rest, what is the ideal lid position with respect to the iris?

A

Upper: Covers 1-2mm of superior iris
Lower: Sits 1mm below inferior edge of iris

39
Q

What is the ideal Marginal reflex distance for the eye?

A

Marginal Reflex Distance = Distance between the eyelid margin and the central corneal light reflex. A light is directed at the patient’s eyes and the patient is directed to look at the light in primary position.

MRD1 = Distance between upper eyelid margin to the light reflex in primary position.
- Used to assess upper lid ptosis.
- Normal = 4-5mm
- Distance between optimal MRD (4-5mm) and actual level determines the degree of ptosis

MRD2 = Distance between central corneal light reflex and lower eyelid margin

MRD1 + MRD2 = interpalpebral distance (opening of the eye).
- Average distance (palpebral fissues) ~9mm

https://eyewiki.aao.org/Margin_to_Reflex_Distance_1,2,3

40
Q

How do you measure levator function? How to you measure the results and what is normal vs. abnormal?

A
  • Hold brow in place to isolate eyelid retractors from frontalis muscle
  • Ask patient to close eye or look far down to measure lower limit
  • Have patient perform an extreme upgaze to measure upper limit
  • Measure difference with measuring tape

Interpreting results:
- Normal maximal excursion ≥ 15mm
- 12-15mm = good function
- < 9mm = poor function
- If levator function is abnormal, must consider something other than acquired ptosis

Congenital ptosis = levator muscle does not function properly
Acquired ptosis = levator aponeurosis has become dehiscent, or has lax insertions to the anterior tarsal plate

Kevan FP Page 59

41
Q

What is Temporal hooding? What are the mechanisms responsible?

A

Temporal Hooding = Drooping of the lateral upper eyelid skin (different than ptosis, which is determined by MRD1 - need to pull back the hooding sometimes to measure the MRD)

Causes:
1. Ptosis of the lateral brow - caused by weak adhesion of the superficial and deep temporal fascial layers
2. Lacrimal gland prolapse
3. Excess skin of the upper lid

42
Q

Why is the central/medial brow less prone to ptosis?

A

Stabilized by the supraorbital and supratrochlear neurovascular bundles

43
Q

What are the essential elements of a pre-operative assessment for upper blepharoplasty?

A

SAFE:
- Can they be satisfied?
- Anxieties
- Fears
- Expectations

History:
- Ocular history: Previous eye surgeries, history of glaucoma, cataracts, sicca symptoms/syndromes (autoimmune dx with lymphocytic infiltration of the salivary and lacrimal glands)
- Previous blepharoplasty (scar tissue limits degree of revision)
- Connective tissue disorder
- Bleeding diathesis
- Smoking history
- Motivation - functional vs. cosmetic
- Medications: ASA, antiinflammatories, OTCs, steroids, warfarin

Physical Examination:
- Ophtho assessment: visual fields and visual acuity
- Cranial nerves
- Periocular exam
a/ symmetry
b/ brow position
c/ eyelid skin
d/ upper eyelid height + crease
e/ fat prolapse
f/ levator function + ptosis (MRD1)

Upper blepharoplasty - want to know if its brow problem or eyelid skin problem to identify
Brow
Eyelid skin
Eyelid fat
Eyelid margin

44
Q

What are two tests of lower eyelid laxity and function? What differentiates the two?

A
  1. Snap Test (or Snap-back test) - pulling lid down
  2. Distraction Test - pullind lid out
45
Q

What does the medial and lateral canthal tendons attach to?

A

Medial canthal tendon: Attaches to the frontal process of the maxilla, the lacrimal groove, and the tarsus of each eyelid

Lateral canthal tendon: Attaches to the upper and lower tarsal plates, which attaches to Whitnall’s tubercle inside the orbital rim deep to the septum.

46
Q

Describe the snap test or snap-back test. How do you perform it? What is the grading system of the results?

A

Test of lower eyelid laxity

How to perform the test:
1. Gently pull lower lid DOWN towards the orbital rim, and release (snap back)
2. Slower return to position suggests canthal laxity

Grading:
- Grade 0: Normal lid that returns to position immediately after release (within 1 second)
- Grade 1: 2-3 seconds
- Grade 2: 4-5 seconds
- Grade 3: More than 5 seconds but does return to position with blinking
- Grade 4: Never returns to position and continues to hang down in frank ectropion after the snap back test

47
Q

Describe the Distraction test of lid function. How is it performed and how are the result interpreted?

A

Measure of lower lid laxity

How its performed:
1. Grasping the lower lid and pulling OUT (lower lid pulled away from the globe), and measuring the distance
2. ≥6-10mm indicates laxity (Bailey’s says 10mm)

Kevan FP Page 60

48
Q

What are the indications for a blepharoplasty?

A

FUNCTIONAL:
- Impaired vision secondary to overhanging lid skin or brow ptosis
- Visual field defect: Superotemporal skin excess or large medial upper fat pad
- Asthenopia - sagging skin on to eyelashes causing frequent blinking and eye fatigue
- Interference with optical correction secondary to bulging fat pads contacting eye glasses
- Full thickness skin graft donor site
- Steatoblepharon

COSMETIC:
- Pseudoherniations (most common reason)
- Dermatochalasia
- Hypertrophy of orbicularis muscle (secondary to blepharospasm or excessive squinting)
- Festoons
- Blepharochalasia

49
Q

Differentiate between orbital fat pseudoherniation, dermatochalasia, blepharochalasia, and festoons. What is the most common indication for lower lid blepharoplasty?

A

ORBITAL FAT PSEUDOHERNIATION
- aka. Palpebral bags, or Steatoblepharon
- Bulging of orbital fat seen within a weak orbital septum or with relaxation of the Lockwood ligament
- The most common indication for lower eyelid blepharoplasty

DERMATOCHALASIA:
- Excess skin of the eyelid, most common secondary to age and sun exposure
- Not to be confused with blepharochalasia

BLEPHAROCHALASIA:
- Rare, recurrent inflammatory disorder of the eyelids characterized by recurrent edema
- Orbicularis hypertrophy - increased thickness of the pre-septal or pre-orbital portions of the orbicularis oculi. Often mistaken for orbital fat pseudoherniation.

FESTOONS:
- Redundant folding of orbicularis oculi that hangs in a hammock-like fashion from canthus to canthus.

Drooping skin = dermatochalasia
Drooping fat = Orbital fat pseudoherniation/steatoblepharon
Drooping orbicularis muscle = Festoons

Kevan Page 62

50
Q

How do you address pseudoherniation of fat?

A
  • Can be addressed through both transconjuctival or subciliary incision. Transconjunctival is favoured as produces no scar
  • Fat can be excised, lasered, cauterized or redraped (moving the orbital fat inferiorly from nasal and medial compartment)
  • Redraping is done to address a tear trough deformity
51
Q

Define Scleral Show

A

The amount of white (sclera) measured between the inferior limbus of the iris and lower lid margin while the head is positioned in the Frankfurt horizontal plane.

52
Q

Define Orbital Vector

A

Relationship between the anterior most point of the cornea projects and the inferior orbital rim

Negative Vector: Inferior orbital rim is behind anteriormost point on cornea (eye is in front)

Positive Vector: Inferior orbital rim is in front of anteriormost point on cornea (eye is behind)

Clinical significance:
- Negative vector - higher risk of ectropion (predicts ectropion)
- With a positive vector - tightening the lower brow will cause less spillover onto the maxilla

53
Q

Define lower lid laxity. What are 3 subtypes of lower lid laxity?

A

Excess horizontal eyelid as a result of aging, measured with snap test or distraction test.

Blepharoplasty in these patients requires adjunctive procedures to support the lower lid.

Subtypes of lower lid laxity:
1. Ectropion = outward turning of the eyelid margin away from the globe
2. Entropion = Inward turning of the eyelid margin towards the globe
3. Tear trough deformity = Soft tissue surface depression seen along the medial inferior orbital rim. Often accentuated by orbital fat pseudoherniation

54
Q

Define the Arcus Marginalis and Double Convexity Deformity

A

Arcus marginalis = confluence between orbital septum and periosteum

Double Convexity Deformity: Deformity that results from descent of the suborbicularis orbital fat (SOOF) below the arcus marginalis and/or weakening of the orbital septum above the arcus (that contains the SOOF)
- Below arcus = SOOF sags
- Above arcus = Orbital septum sags

Double convex deformity is an indication for fat repositioning when doing a lower lid blepharoplasty or mid-face lift

https://img.medscapestatic.com/pi/meds/ckb/75/10275tn.jpg

https://i0.wp.com/plasticsurgerykey.com/wp-content/uploads/2019/05/f009-003-9780323297554.jpg?w=960

55
Q

Define Malar Mounds

A

The soft tissue convexity formed between the zygomatic ligament (McGregor’s patch) and the Orbicularis retaining ligament

As aging occurs, because both of these are true retaining ligaments and fixed in place, accumulation of fat here causes a contour deformity between the eyelid and cheek

Kevan FP Page 63

56
Q

What is Schirmer’s Test? How is it performed? What is the interpretation?

A

Schirmer’s Test: Test for dry eyes, and risk for potential exacerbation following ptosis surgery

Method: Strip of filter paper is placed inside the lateral lower eyelid, and assessed for how much of the paper gets wet

Interpretation:
- Abnormal if < 5mm in 5 minutes (aqueous tear deficiency)
- OR if < 50% of contralateral side (when doing facial nerve functioning testing)

57
Q

What are things that should be evaluated when planning an upper lid blepharoplasty?

A
  • Brow ptosis, possible need for browplasty?
  • Skin type determines aggressiveness of resection
  • Presence of Lagophthlamos (inability to close eyelids completely)
  • Test for presence of Bell’s phenomenon (defensive rolling of eye upward on side with incomplete eyelid closure)
  • Position of the super crease (10-12mm in women, 7-8mm in men)
  • Make incision 8-10mm from tarsal plate
  • Leave 20-24mm from lashes –> brow to reduce chance of lagophthalmos
58
Q

When considering upper blepharoplasty, what other adjunctive procedure should you also consider and assess for?

A

Brow lift

  • If don’t with blepharoplasty, the brow lift should be done first to avoid lagophthalmos
  • Upper blepharoplasty does not correct an asymmetric or ptosis brow
59
Q

How do you prevent lagophthalmos when performing an upper blepharoplasty?

A

Keep ≥20mm of skin between the upper lid and brow

  • Upper limit of the amount of skin excised should preserve a remaining 20mm of upper eyelid height
60
Q

Where should the incisions be in an upper blepharoplasty? What is the plane of dissection?

A

Incision:
1. Inferior incision 8mm above the eyelid margin
2. Must maintain 12mm of infrabrow skin. Failure to do so can affect lid closure and cause eyelid margin malposition

*Makes sense 8+12 =20mm which is the minimum remaining height post-blepharoplasty to avoid lagophthalmos.

Plane of dissection = skin muscle flap

61
Q

How can you determine the amount of upper lid skin that should be removed in an upper blepharoplasty?

A

Pinch Test: Fine non-toothed forceps grasp redundant skin above the crease to determine the upper incision line without affecting eyelid closure

62
Q

What are the different types of Blepharoplasty?

A
  1. Upper Lid Blepharoplasty
    a) Transcutaneous
  2. Lower Lid Blepharoplasty
    a) Transcutaneous (via subciliary incision) - addresses fat and skin
    b) Transconjunctival - addresses fat only
    i/ Pre-septal
    ii/ Post-septal
63
Q

What are the different approaches of transcutaneous upper blepharoplasty?

A
  1. Skin flap
  2. Skin + muscle flap
  3. Skin, muscle, + fat flap
64
Q

How much skin should you take for upper blepharoplasty? What are the safety landmarks

A

6mm from the nasal bone prominence (angular vein is in that location so don’t want to go too medial)

10mm from the tarsus to brow
or 20mm from the margin to the brow

Medial incision = medial punctum
Lateral incision = don’t go past the orbital rim

Corliss’ lecture

65
Q

Discuss the Transconjunctival approach to lower lid blepharoplasty. What are the indications, advantages, and disadvantages? General procedure considerations?

A

Fat only (not skin)

Indications:
1. Younger patients, with isolated steatoblepharon (and no excess skin or muscle)
2. Patients who do not want an external scar
3. History of hypertrophic/keloid scarring

Procedure:
1. Incision is made 2mm inferior to the tarsal plate
2. Two general approaches: Pre-septal vs. Post-Septal

Pre-septal:
- Incision 2mm on the inferior aspect of the tarsal plate
- Dissect through the avascular plane between the orbicularis oculi and septum; mainly used for orbital fracture repair
- Advantages:
– Better visualization of fat pads
– Less risk to inferior oblique muscle
– Allows same direction of approach to fat pads as with a trancutaneous technique
- Disadvantages: Takes longer to perform

Post-Septal:
- Incision 4mm below the inferior tarsal margin.
- Go behind septum to directly approach the orbital fat, so the orbital septum s not violated
- Advantages: Faster technique, more direct approach to fat pads vs. pre-septal
- Disadvantages: Increased risk to inferior oblique

Kevan FP Page 64
Vancouver 382

66
Q

What is Steatoblepharon?

A

Prominence of eyelid fat pads due to prolapsed fat and/or lacrimal gland.

67
Q

Discuss the Transcutaneous/Subciliary approach to lower lid blepharoplasty. What are the indications, advantages, and disadvantages? General procedure considerations?

A

Indications:
1. Addresses fat + skin, as opposed to fat only
2. Preferred in patients with anterior lamellar pathology (e.g. dermatochalasia, or festoons in addition to steatoblepharon)

Procedure:
1. Incision is made 2mm inferior to the lower lid margin
2. Can raise a skin only flap, or raise a skin-muscle flap (skin + orbicularis muscle) - muscle flap is standard

Kevan FP Page 64

68
Q

What cosmetic eye problems can be addressed with blepharoplasty?

A
  1. Steatoblepharon
  2. Dermatochalasia
  3. Festoons or Orbicularis Hypertrophy (by resecting part of the orbicularis muscle)
69
Q

Differentiate ectropion from Lagophthalmos

A

Ectropion = outward turning of eyelid
Lagophthalmos = failure of complete eye closure

70
Q

What are 4 causes of ectropion post-lower lid blepharoplasty?

A
  1. Overaggressive skin resection (major cause)
  2. Failure to address lower lid laxity (major cause)
    - This would be found with snap or distraction test
    - If identified, a lid shortening procedure should be done (e.g. canthoplasty or canthopexy - take the lateral canthus and sling it up to make the canthus more tight and reducing risk of blepharoplasty)
  3. Scar contracture
  4. Post-operative edema
  5. Inflammation of fat pocket
  6. Downward displacement of skin/muscle
71
Q

What are the reasons for ptosis post-blepharoplasty?

A
  1. Lid edema
  2. Hematoma
  3. Levator aponeurosis dehiscence/injury
  4. Mixxed diagnosis of Horner’s syndrome
72
Q

What are 23 possible complications of blepharoplasty? List the top 3 most common first

A
  1. Milia (most common) - small epithelial remnants trapped in the incision manifesting as small white nodules. Can be excised in clinic with an 18G needle
  2. Dry eye symptoms (second most common)
  3. Retroorbital hematoma (most feared), external bleeding
  4. Pre-septal hematoma
  5. Infection
  6. Lagophthalmos (inability to completely close eye)
  7. Ectropion
  8. Entropion
  9. Excess remaining skin
  10. Adverse cosmesis (e.g. asymmetry)
  11. Corneal ulceration
  12. Vision loss
  13. EOM injury (especially superior and inferior oblique muscles)
  14. Ptosis
  15. Scleral show
  16. Chemosis
  17. Contous irregularity/asymmetry
  18. Subconjunctival ecchymosis
  19. Scarring
  20. Blindness
  21. Epiphora
  22. Corneal abrastion
  23. Patient unsatisifed
73
Q

Describe the emergency management of a retrobulbar hematoma

A
  • Average orbital volume = 26cc (confined cavity)
  • Volume of 4cc = 16% (6mm proptosis)
  1. Urgent Ophthalmology consult
  2. HOB elevation
  3. IV Mannitol 20% over 20-30 min (100g in 500cc bag)
    - Fast acting, dehydrates vitreous and fat
    - 1mg/kg IV over 30 mintutes
  4. Acezolamide 500mg IV q2-4h
    - Slower onset of action
    - Decreases aqueous humor production
    - Sulfa drug - watch for allergies!
  5. Steroids (controversial)
  6. Lateral canthotomy and cantholysis + definitive orbital decompression (external ethmoidectomy vs. endoscopic)
  7. Release incision sutures
  8. DO NOT SEARCH FOR VESSEL, OR CAUTERIZE BLINDLY

“OHH SHIT”
Ophtho
HOB elevation
How is vision (IOP)
Set up lateral canthotomy + cantholysis
Help relieve pressure (open sutures)
IV meds (mannitol, acetazolamide, steroids)
Timolol drops

74
Q

What are the most common injured muscles in blepharoplasty?

A

Upper lid: Superior oblique
Lower lid: Inferior oblique

Risk of diplopia with injury
Located between the fat pockets, and therefore are at high risk of injury

75
Q

What are the absolute indications for a lateral canthotomy and cantholysis in an anesthetized patient?

A
  1. IOP > 40mmHg in an anesthetized patient (normal 15mmHg)
76
Q

Define Tarsal plate Show (TPS) and Brow Fat Span (BFS). What is the significance of their ratio?

A

Tarsal Plate Show (TPS) = Distance from lashline to the upper lid crease

Brow Fat Span (BFS) = Distance from crease to inferior edge of brow

TPS + BFS = Distance from lid to brow

TPS:BFS Radio
- Youthful ratio = 1:1.5 medially and 1:3 laterally
- With aging, bone and soft tissue loss around eye decreases BFS, therefore TPS relatively increases and the ratio goes up.
- E.g. with age - 1:1 medially and 1:2 laterally, for example
- This may give illusion of brow ptosis when the overall distance from brow to lashline (TPS+BFS) is the same

77
Q

List the 7 different types of brow lifts

A

A. Forehead lifts:
1. Coronal Forehead Lift
2. Pre-trichial forehead lift
3. Midforehead lift

B. Brow lifts:
1. Midforehead Brow lift
2. Direct Brow Lift
3. Browpexy

C. Temporal Lift

78
Q

Describe the three types of forehead lifts, their indications, procedure considerations, advantages and disadvantages

A

Coronal Forehead Lift
- Used for total forehead and brow elevation
- Incision follows the shape of the hairline, travels within the hair bearing scalp, and starts at root of helix bilaterally
- Subgaleal dissection - eventually periosteal to find the foramen
- Advantages: Treats all aspects of aging forehead and brow
- Disadvantages: Elevates hairline, limited use in men, elongated scar, vertically elevates upper third of face, possible prolonged hyperesthesia of the scalp, less fine-tuning of brow position

Pre-Trichial Forehead Lift
- Used for patients with high hairline as this does NOT elevate hairline further
- Incision placed either at junction of forehead and hairline, or just within the hairline
- Incision is beveled to allow hair growth through incision
- Incision follows an irregular pattern to mask scar
- Subgaleal dissection - eventually periosteal to find the foramen
- Advantages: No vertical forehead lengthening, preserves hairline, treats all aspects of aging forehead and brow
- Disadvantages: Visible exposed scar, hyperesthesia of scalp

Midforehead Lift
- Used in patients with a PROMINENT forehead crease
- Incision placed into a transverse forehead rhytid
- Subcutaneous dissection

79
Q

Describe the three types of non-forehead brow lifts, their indications, procedure considerations, advantages and disadvantages

A

Midforehead Brow Lift
- Same as a midforehead lift (incision into a prominent forehead crease) except with TWO incisions that DO NOT CROSS MIDLINE
- Does not address forehead and glabellar rhytids, but allows access to the brow to address ptosis
- Advantages: Preserves hairline, corrects brow asymmetry, improved fine-tuning of brow position
- Disadvantages: Exposed scar, avoid in oily thick skin

Direct Brow Lift
- Used in patients with facial paralysis OR older patients with busy eyebrows
- Incision placed within the brow
- Fine scar may be visible
- Advantages: accurate brow elevation, preserves forehead/scalp sensation, preferred if patients have abundunt or thick brown hair, immediate scar camouflage, corrects brow asymmetry
- Disadvantages: Treats brows only, possible exposed scar

Browpexy
- Brow elevation done in conjunction with blepharoplasty
- Elevation is done via the same blepharoplasty incision
- Brow fat and orbicularis are elevated and suspended to periosteum via incision
- Massry also described an external browpexy performed with a small 8mm incision at the central superior brow
- Advantages: Small incision, good for brow ptosis
- Disadvantages: Possible prolonged eyelid edema, brow asymmetry, unsatisafactory results

Kevan FP Page 66

80
Q

Describe the Temporal Lift and Endoscopic brow lift for brow lift, its indications, procedure considerations, advantages and disadvantages

A

Used in patients with an adequate medial brow and a ptotic lateral brow

Similar principles to an endoscopic brow lift, except dissection does not proceed medially past the supraorbital neuvascular complex

Endoscopic Brow Lift
- Done via 5 incision ports (midline, bilateral paramedian, bialteral temporal)
- Paramedian incisions used if bone fixation is done. If only lateral brow elevation is required, these are omitted
- NOT for high hairlines, male pattern baldness, thick or tight skin
- Advantages: Less invasive small incisions, good scar camouflage, high preserved hairline, no vertical forehead lengthening, treats most aspects of aging forehead and brow
- Disadvantages: Less fine-tuning of brow position, contour irregularities in scalp because of paramedian bony fixation

Need to release the muscles and ligaments of the brow depressors.

Plane - right on periosteum. In the forehead lift, you start subgaleal and then you go to the periosteal plane and find the foramina of the neurovascular bundles

Kevan FP Page 67

81
Q

What is the arcus marginalis release technique for lower lid blepharoplasty?

A

Acrus Marginalis = confluence between orbital septum and periosteum.

Release allows for orbital fat to descend over maxilla.

By repositioning attachment of the arcus marginalis, allows for the lower lid fat to soften the transition from the orbit to the cheek

Kevan FP Page 67

82
Q

List 10 complications of brow/forehead surgery

A
  1. Hematoma
  2. Hypertrophic scar/keloid scarring
  3. Scalp hypoesthesia
  4. Temporal branch injury
  5. Elevation of hairline (especially with coronal approach)
  6. Lagophthalmos
  7. Ectropion
  8. Asymmetry
  9. Adverse cosmesis
  10. Alopecia
83
Q

What do you do if you suspect an orbital hematoma?

A
  1. Lateral canthotomy and cantholysis
  2. Adjunctive measures:
    a/ Elevate head of bed
    b/ Orbital massage
    c/ Mannitol
    d/ Steroids
    e/ Diuresis
  3. Contact ophthalmology
84
Q

What are the effects of aging on the periorbital region?

A

Lateral Hooding
***

85
Q

Young patients have more fat - so when you do blepharoplasty need to be careful not to age them too much - sometimes can do some fat grafts to give them fullness

A

FINISH

86
Q

Need to ask about dry eye symptoms and history of lasik (which can cause you to have worsening dry eye symptoms)

A

FINISH

87
Q

What is the safest way to expose and remove fat from the lower lid?

A

Sharply incise orbital septum, tease out the fat, clamp the fat, cauterize it, and check for hemoastasis before you let the fat retract back (unclamp but hold it so that it doesn’t retract back)

Need to cauterize it so that it won’t retract back in and bleed, causing a retroorbital hematoma

88
Q

What are the options for ectropion repair?

A
  1. Canthoplasty/canthopexy
  2. Spacer graft ± skin graft (usually graft use things like fat, etc.)
  3. Midface suspension
89
Q

What are the options for ptosis correction?

A
  1. Muller-Conjunctival resection ± tarsus
  2. Levator resection
  3. Frontalis sling
90
Q

What are the surgical adjuncts for periorbital rejuvination?

A
  1. Botox/Dysport
  2. Filler
  3. Fat grafting
  4. Laser resurfacing (CO2) - good for a few wrinkles with minimal laxity
  5. Peels

Facial Plastics & Trauma (9 decks)

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