Eyelid defects, blepharoplasty, brow lift, Chin, Forehead

Question 1

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

Answer 1

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

Question 2

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

Answer 2

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

Question 3

√What are the layers of the lower eyelid?

Answer 3

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

Vancouver 380

Question 4

√What is the function of the tarsal plate?

Answer 4

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

Question 5

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

Answer 5

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

Question 6

√Describe the Lockwood suspensory ligament

Answer 6

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.

Made of fascia from inferior rectus and inferior oblique

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)

Question 7

√Describe the arterial and venous and lymphatic supply of the eye

Answer 7

ARTERIES:
1. Ophthalmic artery (ICA)
2. Angular artery (Facial - ECA)
3. Infraorbital artery (IMAX - ECA)

VEINS:
1. Cavernous sinus - for superior and inferior ophthalmic vein (w pterygoid plexus)
2. Pterygoid plexus - forms inferior ophthalmic vein and infraorbital vein
3. Facial vein

Corliss Lecture

Question 8

√Describe all the ligaments of the eye

Answer 8

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

Question 9

√Describe the innervation of the lid muscles

Answer 9

MOTOR:
1. Orbicularis CN7
2. Levator upper and lower lid retractors - CN3
3. Mueller muscle - smooth, NE stimulated - Sympathetics

Sensory:
V1 upper
V1/V2 lower

Corliss Lecture

Question 10

√Describe 5 features of Asian vs. Caucasian eyelids

Answer 10

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)

Question 11

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

Answer 11

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

Question 12

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

Answer 12

INCISIONLESS
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

INCISION
2. RESECTION TECHNIQUE
- Excising a strip of eyelid
- Incise orbital septum +/- lipectomy
- Orbicularis is sutured to levator aponeurosis
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

Question 13

√What are the borders for submental liposuction?

Answer 13

1. SCM to SCM
2. Mandible to cricoid

Question 14

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

Answer 14

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

Question 15

√Discuss the 4 main order of operations for a submentoplasty

Answer 15

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)

Question 16

√List the steps of the submentoplasty procedure (7)

Answer 16

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)

Question 17

√List 11 complications of submentoplasty, differentiating early and late complications 5 each

Answer 17

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

Question 18

√Define a Witch’s chin. Cause?

Answer 18

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

Question 19

Discuss the management options of a retrognathic chin 5

Answer 19

1. Filler
2. Chin implants (Alloplast, intraoral - bothersome sutures with geniobuccal scar contracture, intraoral contamination, or extraoral - external scar)
3. Sliding genioplasty (Indications - excess or insufficient vertical mandibular height, extreme microgenia, hemifacial atrophy, mandibular asymmetry, failed implant previously)
4. Distraction osteogenesis
5. Orthognahic surgery

Question 20

What are the contraindications to chin implants? 4

Answer 20

“CHIN”

C: Chin is too small (ie. severe microgenia)
H: Health of teeth (ie. significant periodontal disease)
I: Incompetence of lips (Labial incompetence)
N: Not enough vertical mandible height

Question 21

√List 3 options for chin augmentation

Answer 21

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

Question 22

√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? What plane? 4 total

Answer 22

• 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

Question 23

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

Answer 23

• 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

Question 24

√List 11 possible complications of chin augmentation

Answer 24

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
12. Tooth root injury?

Question 25

√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?

Answer 25

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

Question 26

√Describe the ideal female and male eyebrow shape

Answer 26

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 ## Footnote Kevan FP Page 55

Question 27

√What is the blood supply to the forehead? 4

Answer 27

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

Question 28

√What is the nerve supply to the forehead? (and label) 5 sensory

Answer 28

MEDIAL: 1. Supraorbital nerve (V1) 2. Supratrochlear nerve (V1) LATERAL: 1. Lacrimal nerve (V1) 2. Zygomaticofacial nerve (V2) 3. Auriculotemporal nerve (V3) ## Footnote https://pocketdentistry.com/7-the-head-by-regions/

Question 29

√Name the brow elevator muscles (and label)

Answer 29

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

Question 30

√Name the brow depressor muscles (and label them)

Answer 30

4 Brow Depressors 1. Corrugator Supercilii (vertical glabellar wrinkles) 2. Procerus (horizontal glabellar wrinkles) 3. Depressor supercilii 4. Orbicularis oculi (Crow's feet) ## Footnote Kevan FP Page 56 https://plasticsurgerykey.com/wp-content/uploads/2017/02/gr1-48.jpg

Question 31

√Name the 3 parts of the orbicularis oculi muscle

Answer 31

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)

Question 32

√List the orbital bones (and label them)

Answer 32

7 bones 1. Frontal 2. Maxillary 3. Zygomatic 4. Palatine 5. Ethmoid 6. Lacrimal 7. Sphenoid ## Footnote https://images.ctfassets.net/u4vv676b8z52/2h7UGbxlinGUDwGTkVmroA/0aaeff0025e6a426480b0f8f32367dce/orbital-bones-illustration-678x446.gif

Question 33

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

Answer 33

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 (follows zygomatic) ## Footnote Figure 1: https://www.nature.com/articles/s41598-022-05178-y

Question 34

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

Answer 34

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

Question 35

√Describe the eyelid retractor muscles and their innervation

Answer 35

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)

Question 36

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

Answer 36

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

Question 37

√What muscles are important in the lacrimal excretory pump?

Answer 37

1. Horner's muscle (deep head of pretarsal orbicularis oculi) 2. Superficial head of the pretarsal orbicularis oculi

Question 38

√What are the Meibomian glands?

Answer 38

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

Question 39

√What are the components of the tear film?

Answer 39

Three components of the tear film: 1. Lipid layer (from Meibomian glands) 2. Aqueous layer (from Lacrimal glands) 3. Mucin (from Goblet cells) ## Footnote Kevan FP Page 58

Question 40

√Which muscles are important in the lacrimal excretory pump?

Answer 40

1. Horner's muscle (Deep head of pre-tarsal orbicularis oculi) 2. Superficial head of the pretarsal orbicularis oculi

Question 41

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

Answer 41

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

Question 42

√What is the ideal Marginal reflex distance for the eye?

Answer 42

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 - Normal distance ~5mm MRD1 + MRD2 = interpalpebral distance (opening of the eye). - Average distance (palpebral fissues) ~9-10mm Limbus = junction of cornea and sclera ## Footnote https://eyewiki.aao.org/Margin_to_Reflex_Distance_1,2,3

Question 43

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

Answer 43

- 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 ## Footnote Kevan FP Page 59

Question 44

√What is Temporal hooding? What are 3 mechanisms responsible?

Answer 44

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

Question 45

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

Answer 45

Stabilized by the supraorbital and supratrochlear neurovascular bundles

Question 46

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

Answer 46

SAFE: - Can they be satisfied? - Anxieties - Fears - Expectations History: - Ocular symptoms: diplopia, blurred vision, recent changes, last ophthalmology visit - Ocular history: Previous eye surgeries, history of glaucoma, cataracts, sicca symptoms/syndromes (autoimmune dx with lymphocytic infiltration of the salivary and lacrimal glands) - Surgical history: Previous blepharoplasty (scar tissue limits degree of revision), Other surgeries or laser surgery, or orbital injury - Medical history: Hyperthyroidism (upper lid retraction), Hypothyroid (lower lid puffiness), Connective tissue disorder, Bleeding diathesis, Sjogren's disease, SLE, GPA, Hypothyroid (lower lid puffiness), HTN - Medications: ASA, antiinflammatories, OTCs, steroids, warfarin - Smoking history - Motivation - functional vs. cosmetic 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

Question 47

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

Answer 47

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

Question 48

√What does the medial and lateral canthal tendons attach to?

Answer 48

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.

Question 49

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

Answer 49

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

Question 50

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

Answer 50

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, review course 8) ## Footnote Kevan FP Page 60

Question 51

√What are the indications for an upper blepharoplasty? 5 fx 5 cosmo

Answer 51

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

Question 52

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

Answer 52

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 ## Footnote Kevan Page 62

Question 53

√How do you address pseudoherniation of fat?

Answer 53

- 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

Question 54

√Define Scleral Show

Answer 54

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.

Question 55

√Define Orbital Vector

Answer 55

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

Question 56

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

Answer 56

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

Question 57

√Define the Arcus Marginalis and Double Convexity Deformity

Answer 57

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 ## Footnote 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

Question 58

√Define Malar Mounds

Answer 58

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 ## Footnote Kevan FP Page 63

Question 59

√What is Schirmer's Test? How is it performed? What is the interpretation?

Answer 59

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)

Question 60

√What are the physical exam requirements for a blepharoplasty assessment?

Answer 60

1. Brow - assess position (low, high, aesthetic), symmetry 2. Eye exam: pupils, EOM, vision, visual fields 3. Eyelid symmetry, supratarsal crease, ptosis (upper lid covering 2-3mm of limbus) 4. Skin assessment - redundant, fat, muscle 5. Lower lid tests: snapback test, distraction test, assess canthal laxity (is lid shortening needed?)

Question 61

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

Answer 61

- 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

Question 62

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

Answer 62

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

Question 63

√How do you prevent lagophthalmos when performing an upper blepharoplasty?

Answer 63

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

Question 64

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

Answer 64

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

Question 65

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

Answer 65

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

Question 66

√What are the different types of Blepharoplasty?

Answer 66

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

Question 67

√What are the different approaches of transcutaneous upper blepharoplasty?

Answer 67

1. Skin flap 2. Skin + muscle flap 3. Skin, muscle, + fat flap

Question 68

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

Answer 68

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 ## Footnote Corliss' lecture

Question 69

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

Answer 69

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 ## Footnote Kevan FP Page 64 Vancouver 382

Question 70

√What is Steatoblepharon?

Answer 70

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

Question 71

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

Answer 71

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 ## Footnote Kevan FP Page 64

Question 72

√What cosmetic eye problems can be addressed with blepharoplasty?

Answer 72

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

Question 73

√Differentiate ectropion from Lagophthalmos

Answer 73

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

Question 74

√What are 6 causes of ectropion post-lower lid blepharoplasty?

Answer 74

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 SOLIDE

Question 75

√What are the reasons for ptosis post-blepharoplasty? 4

Answer 75

1. Lid edema 2. Hematoma 3. Levator aponeurosis dehiscence/injury 4. Mixxed diagnosis of Horner's syndrome

Question 76

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

Answer 76

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

Question 77

√Describe the emergency management of a retrobulbar hematoma

Answer 77

- 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 3. Acezolamide 500mg IV q2-4h - Slower onset of action - Decreases aqueous humor production - Sulfa drug - watch for allergies! 4. Steroids (controversial) 5. Lateral canthotomy and cantholysis + definitive orbital decompression (external ethmoidectomy vs. endoscopic) 6. Release incision sutures 7. 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

Question 78

√What are the most common injured muscles in blepharoplasty?

Answer 78

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

Question 79

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

Answer 79

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

Question 80

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

Answer 80

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

Question 81

√List the 7 different types of brow lifts

Answer 81

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

Question 82

√What are the muscles from superfiical to deep forehead rhytidectomy?

Answer 82

1. Frontalis 2. Corruagtor 3. Procerus 4. Orbicularis

Question 83

√What are the muscles from superficial to deep mid-eyebrow?

Answer 83

1. Skin 2. Orbicularis 3. Galea enveloping frontalis 4. Frontalis 5. Deep galeal layer 6. Galea fat pad (brow fat) 7. Corrugator (within brow fat) 8. Deep galea layer 9. Glidine plane space 10. Periosteum ## Footnote Vancouver 387

Question 84

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

Answer 84

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

Question 85

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

Answer 85

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 ## Footnote Kevan FP Page 66

Question 86

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

Answer 86

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 ## Footnote Kevan FP Page 67

Question 87

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

Answer 87

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 ## Footnote Kevan FP Page 67

Question 88

√List 10 complications of brow/forehead surgery

Answer 88

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

Question 89

√What do you do if you suspect an orbital hematoma?

Answer 89

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

Question 90

√What are the effects of aging on the periorbital region?

Answer 90

Temporal Lateral Hooding Dermatochalasia (Excess skin) Festoons Fat pseudoherniation Orbital hypertrophy

Question 91

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

Answer 91

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

Question 92

√What are the options for ectropion repair? 3

Answer 92

1. Canthoplasty/canthopexy - secure the lateral canthus to the lateral orbital rim in order to prevent downward displacement of lateral canthus with the septal reset (prevention) 2. Spacer graft ± skin graft (usually graft use things like fat, etc.) 3. Midface suspension ## Footnote Corliss lecture

Question 93

√What are the options for ptosis correction? 3

Answer 93

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

Question 94

√What are the surgical adjuncts for periorbital rejuvination?

Answer 94

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