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Plastic Surgery - Breast/Aesthetics > Periorbital Region, Blepharoplasty, Brow Lift - Board Review > Flashcards

Periorbital Region, Blepharoplasty, Brow Lift - Board Review Flashcards

1
Q

What are the goals of blepharoplasty?

A
  1. Treating upper and lower eyelid laxity and ptosis
  2. Preservation of upper orbital fullness and defined upper eyelid crease
  3. Preserving smooth transition between cheek and lid junction while restoring the youthful eye
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2
Q

What is blepharochalasis?

A

Rare inherited disorder characterized by repetitive episodes of eyelid edema and subsequent levator dehiscence and ptosis

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3
Q

What is dermatochalasis?

A

Loosening of the eyelid skin with fat protrusion

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4
Q

Describe senile ptosis.

A

Most common type of ptosis seen in the elderly. It is caused due to the dehiscence of the levator aponeurosis. There is elevated tarsal crease (greater than 7 mm), thinned upper eyelid, and lid droop with downward gaze.. Treatment is levator advancement or plication.

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5
Q

Best test for ptosis. Describe it.

A

Marginal reflex distance 1 (MRD1) test. The distance between the upper lid margin (orbital rim) and the corneal reflex when the eye is in the primary position. The normal value ranges between around 4.0 and 4.5 mm.

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6
Q

What is entropion?

A

Inward rotation of the eyelid margin

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7
Q

What findings make up Horner’s syndrome?

A

Blepharoptosis, pupil miosis, facial anhidrosis

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8
Q

Where is the apex of the brow?

A

Lateral limbus of the eye in forward gaze

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9
Q

How many bones make up the orbit? What are they?

A

7; Sphenoid, Frontal, Zygomatic, Ethmoid, Lacrimal, Maxilla, Palatine.

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10
Q

Where does the nasolacrimal duct drain?

A

Beneath the inferior turbinate.

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11
Q

What is analogous to the levator palpebrae superioris aponeurotica in the lower eyelid?

A

Capsulopalpebral fascia

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12
Q

In the setting of normal facial proportions, what distance best approximates the intercanthal distance?

A

Orbital fissure width

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13
Q

What anatomical event happens during eyelid closure?

A

The lacrimal puncta closes.

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14
Q

What are the layers of the eyelid?

A

Skin, orbicularis oculi muscle, retro-orbicularis oculi fat (ROOF), orbital septum, sub-orbicularis oculi fat (SOOF), levator muscle, Mueller’s muscle and conjunctiva

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15
Q

What muscles are responsible for medial brow retraction?

A

Corrugator, depressor supercilii, and less orbicularis oculi

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16
Q

What is the anterior lamella

A

Skin and orbiculularis oculi muscle

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17
Q

What separates the anterior and posterior lamella of the eyelid?

A

The orbital septum which originates at the arcus marginalis (periosteal thickening along the orbital rim)

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18
Q

What are the fat compartments of the eyelid?

A

Upper: Central and nasal
Lower: Nasal/medial, central, lateral

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19
Q

What branches of the external carotid artery supply the lid?

A

Facial, internal maxillary, superficial temporal

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20
Q

What branches of the internal carotid artery supply the eyelid?

A

Dorsal nasal, supratrochlear, supraorbital, lacrimal, and terminal branch of the ophthalmic

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21
Q

What separates the medial and central fat pad in the lower eyelid?

A

Inferior oblique muscle. When performing excision or manipulation between these fat pads, it is at risk for injury.

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22
Q

What is the posterior lamella

A

Lower lid: conjunctiva and capsulopalpebral fascia

Upper lid: conjunctiva and Mueller’s muscle

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23
Q

What is the Tarsoligamentous sling?

A

tarsal plate, medial and lateral canthal tendons, capsulopalpebral fascia and conjunctiva

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24
Q

What autologous structure is useful in the reconstruction of the posterior lamella?

A

Hard palate mucosal graft

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25
Q

What is the innervation of the eyelid?

A 
Infraorbital nerve (V2) and infratrochlear nerve, zygomatiofacial = lower eyelid
Lateral palpebral branch of the infraorbital and lacrimal nerve from V1, infratrochlear = upper eyelid
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26
Q

What nerve can be found adjacent to the sentinel vein?

A

Temporal branch of the facial nerve

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27
Q

What is the composition of the tear film?

A

Inner Mucin (goblet cells), middle aqueous (lacrimal glands), outer lipid (meibomian glands)

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28
Q

Dysfunction of what can lead to dry eyes?

A

Meibomian glands (secrete lipids that prevent tear film evaporation)

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29
Q

What is the anatomic basis for tear trough deformity?

A

Tear trough ligament is an osteocutaneous ligament from the medial portion of the maxilla. It extends inferolaterally from the medial canthus to the midpupillary line where it connects to the orbicularis retaining ligament. This ligament is the basis for the deformity.

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30
Q

What is the lymphatic drainage for the eyelid?

A 
Medial = submaxillary lymph nodes
Lateral = parotid lymph nodes
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31
Q

What is the function of the procerus?

A

continuous with the frontalis muscle, inserts into the nasal bone to create horizontal rhytids of the glabella

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32
Q

What are the key elements for evaluation of the forehead?

A

Brow position, brow bone prominence, fat excess or deficiency, glabellar and forehead furrows

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33
Q

What are the key elements for evaluation of the Midface?

A

Vector analysis, tear trough deformity, malar bags, cheek ptosis, skin quality and excess

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34
Q

What are the key elements for evaluation of the Orbit?

A

Orbit, visual acuity, visual fields, EOM testing, eye performance, canthal tilt, levator function, upper and lower eyelid laxity, orbicularis oculi hypertrophy, lower eyelid malposition, lacrimal gland ptosis, upper eyelid ptosis, skin quality and excess, post-septal fat herniation

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35
Q

What does an exophthalmometer measure?

A

Distance between the anterior border of the globe and the most anterior point of the lateral aspect of the orbital rim.

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36
Q

What is the definition of enophthalmos and exophthalmos (by measurement)?

A

Enophthalmos is defined as less than 14mm on enophthalmometer; midrange is 15-18mm and exophthalmos is greater than 18mm

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37
Q

How do you evaluate levator function?

A

Measure the amount of lid excursion with the brow and frontalis muscle held in neutral position. Normal function is >10mm. Moderate function is 5-10mm. Poor function is <5mm

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38
Q

What are the markings for upper blepharoplasty?

A

Women 8-10mm from lid margin, Men 7mm
10mm from normal brow margin
5-6mm from lash margin at lateral canthus

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39
Q

What is unique about the Asian eyelid?

A

Lack of insertion of the levator aponeurosis into the upper lid dermis causing a lack of supratarsal fold.

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40
Q

Describe the markings for lower blepharoplasty.

A

From level of the lateral canthus, a line is extended inferiolaterally for approximately 6-10mm within a prominent crows feet crease. Approximately 10mm of skin is preserved between the lateral extension of the upper and lower blepharoplasty incisions.

41
Q

Describe the technique for transconjunctival blepharoplasty.

A

The orbital fat can be removed by a trans-septal approach that divides the conjunctiva, capsulopalpebral fascia, and septum or retroseptal incision through the conjunctiva and capsulopalpebral fascia leaving the septum intact. If the midface needs to be accessed or redraping of fat is planned, the orbitomalar ligament must be released. The orbitomalar ligament attaches the orbicular muscle to the orbital rim. It separates the lower eyelid from the midface.

42
Q

Describe the objective of canthopexy/canthoplasty.

A

Suturing the tarsal plate and lateral retinaculum to the periosteum of the lateral orbital rim thereby tightening the lower lid tarsoligamentous structure. Patients with lid distraction >6mm require lateral canthotomy and canthoplasty.

43
Q

Discuss postoperative blepharoplasty care

A

Head elevation and ice application x 48 hours. Ophthalmic antibiotic ointment applied along the suture line and the globe to prevent or reduce tear film loss. Sutures, including the Frost suture (to brow), are removed 5-7 days post surgery. Avoid makeup and contacts x 2 weeks.

44
Q

What is lagophthalmos?

A

Inability to close eye

45
Q

What is the Schirmer’s test and what is considered abnormal?

A

Schirmer’s test is used to determine whether the eye produces enough tears to keep it moist. The test is performed by placing filter paper inside the lower lid of the eye. After 5 minutes, the paper is removed and tested for its moisture content.; Less than 10mm

46
Q

What is the mucous spot test?

A

A subjective measure of dry eye, absence of a film layer on the eye indicating chronic dry eye

47
Q

What sites are involved in a zygomaticomaxillary complex (ZMC) fracture?

A
  1. Zygomaticofrontal
  2. Zygomaticomaxillary
  3. Zygomatic arch
  4. Inferior orbital floor
  5. Anterior wall of the maxilla
48
Q

What is the cause of classic congenital ptosis?

A

Inadequate/nonexistent levator function

49
Q

What is a cause of pseudoptosis?

A

Enophthalmos

50
Q

What is the most appropriate procedure for congenital ptosis?

A

Frontalis sling

51
Q

What is the classic treatment for senile ptosis?

A

Levator advancement/reinsertion

52
Q

In senile ptosis, what happens to the supratarsal crease?

A

The crease becomes cephalically displaced because of adhesion between the aponeurosis and the dermis. The superior crease moves with attenuation of the aponeurosis.

53
Q

What is the most commonly injured muscle in a blowout fracture?

A

Inferior oblique, the only EOM to insert on the bone directly

54
Q

What is the globe malposition associated with orbital blowout?

A

Enophthalmos

55
Q

How much of the eyelid can be sacrificed and primarily closed?

A

Up to 25% total lid loss

56
Q

Should the lacrimal gland be excised if ptotic?

A

no

57
Q

What reconstructive technique is typically used for central (full thickness) upper eyelid with 50% defect?

A

Semicircular skin/muscle flap rotation or Tenzel flap

58
Q

What flap is commonly used for total lower eyelid loss

A

Mustarde flap - large skin muscle cheek rotation flap

59
Q

What is the most common and second most common skin cancers on the eyelid?

A

BCC (#1) and SCC (#2)

60
Q

What is a Huges flap?

A

A tarsoconjunctival flap from the upper eyelid, used to reconstruct >50% lower lid defects, for posterior lining only.

61
Q

What is the recovery rate for Bell’s Palsy?

A

84%

62
Q

What fascia is commonly used to perform frontalis sling?

A

Tensor fascia lata

63
Q

If myasthenia gravis is suspected, what test should be performed?

A

Tensilon test - edrophonium injection leading to short-term improvement in ptosis

64
Q

When do the symptoms occur with myasthenia gravis?

A

Later in the day

65
Q

What is chemosis?

A

Edema of the eyelid

66
Q

Discuss management of postoperative chemosis?

A

Liberal ophthalmic ointments/drops. Severe chemosis that herniates through the palpebral fissure requires more aggressive ointment/drop application and patching the eye for 24-48 hours, apply gentle pressure with ACE to decrease swelling. Can be surgically drained.

67
Q

Symptoms of retrobulbar hemorrhage/hematoma

A

Progressive eye pain alone or with scintillating scotomas (flashes and sparkles), hemianopsia or amaurosis fugax (window shade), Early discharge from the eye after blepharoplasty, perioperative/post-operative vomiting and coughing.

68
Q

Management of retrobulbar hematoma

A

Rapid surgical decompression and lateral canthotomy, administration of mannitol, acetazolamide and oxygen

69
Q

Discuss the etiology of diplopia following blepharoplasty

A
  1. Usually temporary 2/2 to edema
  2. Permanent diplopia can occur from thermal injury to the inferior oblique or superior oblique muscles
  3. Strabismus surgery may be required if persistent
70
Q

What is the most common complication after lower blepharoplasty?

A

Lower eyelid malposition

71
Q

Discuss the management of lower eyelid malposition

A
  1. Mild malposition may contribute to lagophthalmos and corneal exposure. May require bandage contact lenses to protect the cornea and conservative massage of the lower lid margin until 6 weeks post op
  2. Lower lid ectropion or persistent lid malposition following 2-3 months of conservative management may require placement of a posterior lamella spacer graft or lateral canthoplasty
72
Q

What is the most common cause of post surgical lower ectropion?

A

Combination of lower lid laxity with scarring/traction on the capsulopalpebral fascia-septum interface

73
Q

What is the most common complication after Asian blepharoplasty?

A

Asymmetry

Others complications: fold loss, suture extrusion, epicanthal scarring

74
Q

What is the preferred treatment for lower lid ectropion?

A

Canthoplasty with capsulopalpebral spacer graft (Alloderm, autologous dermis, palate mucosa, etc)

75
Q

What does correction of ptosis in one eye do in a bilateral case?

A

Correction will make the non-corrected side MORE ptotic due to unequal innervation - Hering’s law

76
Q

What is the normal brow position?

A

Men typically have a low straight brow at the level of the upper orbital rim, women have slightly higher brow with an arch or peak 2/3 of the way across the horizontal axis

77
Q

What are the indications for surgical rejuvenation of the upper face?

A

Soft tissue ptosis of the forehead, eyebrow, temporal region, forehead height disparities, permanent static glabellar and forehead lines

78
Q

What muscles are innervated by the frontal branch of the facial nerve?

A

Frontalis, corrugator, procerus, depressor supercilii

79
Q

What is the origin and insertion of the corrugator muscles?

A

Origin: frontal bone near the superiormedial orbital rim lateral to the origin of the procerus
Insertion: dermis of the forehead skin above the middle third of the eyebrow

80
Q

What is the result of the division or resection of the corrugator muscles?

A

They cause medial and vertical rhytids. Division will diminish wrinkling in glabella. Brows can spread and widen. Over-resection can lead to contour depression and strange appearance with animation

81
Q

What nerve is encountered and preserved during resection of the medial aspect of the corrugator muscles?

A

Supratrochlear nerve

82
Q

What is the origin of the procerus?

A

Paramedian location over the nasal bones inferior and medial to the origin of the corrugator muscles. They are responsible for medial brow depression and horizontal rhytids in the glabella

83
Q

What is brow strain and what is it a sign of?

A

State of chronic frontalis muscle contraction and brow elevation. Common causes are upper lid ptosis and/or dermatochalazia

84
Q

Describe the retaining ligaments of the brow and temple.

A

Supraorbital ligamentous adhesions traverse the horizontal aspect of the upper orbital rim. They terminate laterally into the temporal ligamentous adhesion (TLA) a dense ligamentous adhesion over the upper lateral aspect of the orbital rim and temple adjacent to the sentinel vein.

85
Q

Describe the fascial layers of the temple.

A

Scalp
Superficial temporal fascia (aka temporopareital fascia, gala aponeurotica); contiguous with the SMAS
Superficial layer of the deep temporal fascia
Deep layer of the deep temporal fascia
Temporalis muscle

86
Q

What is the innervation of the frontalis and corrugators?

A

Frontal branch of the facial nerve

Corrugator also innervated by buccal branch

87
Q

What are the sensory nerves of the forehead

A

Major: Supratrochlear and supraorbital nerves
Minor: lacrimal and zygomaticotemporal

88
Q

What is the surgical significance of the temporopareital fascia and its relation to the frontal branch of the facial nerve?

A

The frontal branch of the facial nerve begin deep to the SMAS at the level of the upper border if the zygomatic arch and traverses the temporopareital fascia 1cm above the upper border of the arch to run within the TPF.

89
Q

Describe an alternate surgical approach for corrugator resection if a brow lift is not being performed.

A

Upper blepharoplasty incision, dissection deep to the orbicularis and superfiical to orbital septum then medially over the orbital rim toward the vicinity of the supratrochlear neurovascular bundle

90
Q

What are the relative contraindications for an endoscopic brow lift?

A

High hairline with overly convex shaped forehead

91
Q

What is the normal height of the forehead?

A

Measured from the most cephalic portion of the brow to the hairline. 4-5cm for young women. Aging causes lengthening due to receding hairline and brow descent

92
Q

How can a high forehead be corrected?

A

Scalp advancement procedure; pretrichial zigzagged incision that continues into the scalp at the temples. Scalp is advanced and secured and the intervening forehead skin is resected

93
Q

Describe the significance of the sentinel vein in endoscopic brow lift.

A

Avoid injury and bleeding, denotes location (within 1cm) of the frontal branch, it is surrounded by dense TLAs that should be released so adequate lifting of the temporal brow can be accomplished

94
Q

What is an alternative to endoscopic, hairline or coronal brow lift?

A

Direct excision of a deep mid forehead rhytid or direct open browpexy via upper brow hairline incision (best in older men). Internal brow pexy via upper bleph incision

95
Q

What are the indications for a temporal lift?

A

Lateral brow ptosis, temporal soft tissue ptosis, excess lateral orbit skin, or excess skin bunching over the zygoma from facelift

96
Q

What is the plane of dissection in an endoscopic brow lift?

A

Subperiosteal over the frontal bone and deep to the temporopareital fascia over the temple. Superior temporal septum must be released to achieve continuity between these planes.

97
Q

What is the most likely cause of unilateral brow paralysis after blunt dissection endoscopic brow lift?

A

Traction injury in the region of the sentinel vein. Usually temporary. Can use botox on the contralateral side while it regenerates.

98
Q

What are some options for achieving brow support during an endoscopic brow lift?

A

Unicortical tunnel with suture tie through, unicortical screw to scalp fixation, endotine device, lactosorb (resorbable unicortical screw with suture pilot hole)

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