An anatomical study of the junction of the orbital septum and the levator aponeurosis in Orientals

Microscopic Anatomy of Orbital Septum

PURPOSE

To study the microscopic anatomy of the orbital septum and evaluate its relationships with the adjoined structures.

METHODS

Histological evaluation of 11 upper eyelids (5 right, 6 left) from 10 Japanese cadavers (age range: 36-94-year-old, average: 71.1) was performed. The specimens were fixed in 10% formalin and stained with Elastica Van Gieson. Specimens were microscopically analyzed using different magnifications (20×, 40×, and 100×).

RESULTS

The orbital septum was the single fibrous layer in all the specimens, anteriorly separated from the retro-orbicularis fat pad capsule and posteriorly from the preaponeurotic fat pad capsule. At the junction of the orbital septum with the levator aponeurosis, the orbital septum proceeded towards the tarsal plate, and the preaponeurotic fat pad capsule reflected posteriorly.

CONCLUSIONS

The orbital septum is constituted of a single layer of fibrous tissue anteriorly separated from the retro-orbicularis fat pad capsule and posteriorly from the preaponeurotic fat pad capsule by the corresponding virtual spaces.

Orbital Septum in Lateral Canthus

PURPOSE

To disclose the precise attachment site of the orbital septum in the lateral canthus.

METHODS

Nine specimens of 7 Japanese cadavers aged 66 to 85 years at death were included. The attachment site of the orbital septum in the lateral canthus was grossly dissected. Two of the 9 specimens were exenterated and used to explore the anatomy from lateral and superior aspects, respectively.

RESULTS

The orbital septum in the lateral canthus attached slightly lateral to the outer edge of the lateral commissure with the levator aponeurosis and the lower eyelid retractors in the upper and lower regions, respectively. In addition, the orbital septum attached to the arcus marginalis with regard to the orbital bone. Fat tissue occupied the space between the orbital septum and the lateral retinaculum.

CONCLUSION

The orbital septum in the lateral canthus attached around the lateral commissure and the orbital rim.

Thin-Film Buckling Theory and Clinical Application of the Mechanism of Double Eyelid Formation

BACKGROUND

The mechanism underlying the formation of upper eyelid creases has been the subject of extensive study and ongoing debate. This research aims to elucidate the principles of upper eyelid creases formation, leveraging the membrane bending theory from engineering mechanics.

METHODS

We developed an anatomical model of the eyelid and implemented the finite element analysis. Preprocessing and mesh division were conducted using HyperMesh, followed by computational analysis with Abaqus. This approach enabled the observation of dynamic changes in the upper eyelid during eye opening and closing.

RESULTS

The study reveals that natural upper eyelid crease formation is influenced by multiple factors. These include the softer texture of the upper eyelid skin and the suborbicularis oculi fat, reduced rigidity at the eyelid crease, optimal contraction force of the upper eyelid, and the strategic placement of the pre-tarsal fat pad just above the eyelid crease.

CONCLUSIONS

Ultimately, our findings demonstrate the effectiveness of finite element analysis, grounded in membrane bending theory, in elucidating the dynamics of upper eyelid crease formation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Levator Extension Method for Correcting Double Eyelids in Elderly Asian Patients: A Reliable and Flexible Blepharoplasty Technique

Background

Conventional tarsal fixation techniques for creating a static double-eyelid fold frequently result in a nonmobile overdepression of the fold, which is particularly pronounced in elderly patients.

Objectives

We propose a novel surgical approach aimed at achieving better results with fewer complications. This approach involves imitating the natural double-fold physiology by employing a turn-over flap of the orbital outer septum and carefully managing the pretarsal soft tissue to create a double fold.

Methods

A total of 503 patients underwent double-eyelid surgery, involving a turn-over flap of the outer orbital septum and pretarsal soft-tissue management. The orbital septum was exposed and transversely opened superior to the incision margin and the pretarsal soft issue was removed as necessary. Turn-over flaps were trimmed and attached to the dermis and orbicularis oculi muscle of the lower flap. Patient follow-up occurred for 2 to 7 years (mean, 3.8 years).

Results

This surgical method achieves a double fold with shallow or moderate depth, creating a natural-appearing fold line. Of the 503 patients, 94% of respondents provided a satisfaction score of 4 and 5 points; 20 people provided a score of 3 points; 10 were dissatisfied. A review of the patient chart showed that there were no specific complications in >94% (473) of patients.

Conclusions

We proposed a double-eyelid surgery technique using the outer septum to control the depth and pretarsal soft-tissue management to minimize resistance in the creation of the double eyelid. Our method showed a high patient satisfaction rate and fewer complications in elderly Asians.

Small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique: A modified partial-incision double-eyelid blepharoplasty

BACKGROUND

The partial-incision double-eyelid surgery remains a popular esthetic procedure in Asia, most of the previous partial-incision double-eyelid operations involved resection of the pretarsal orbicular muscle, resulting in a depressed and firm eyelid crease. In order to create a more natural, dynamic, and durable double-eyelid crease with less visible scar and shorter postoperative recovery time, we describe a modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique for Chinese patients.

METHODS

A total of 132 patients who underwent bilateral modified partial-incision double-eyelid surgery were retrospectively reviewed. In this technique, three 2 mm incisions were designed, the orbicularis oculi muscle was preserved and conservatively dissected to expose the levator aponeurosis, and buried suture was used to fix the orbicularis oculi muscle to levator aponeurosis. The skin and orbicularis oculi muscle were then sutured together with the levator aponeurosis.

RESULTS

With a follow-up period of more than 6 months, most of the double eyelids were natural and dynamic, and the crease was stable. The majority of the swelling faded in 2 weeks and completely faded in the first month for most patients. The scars of the small incision became invisible after 3 months of recovery. One patient (0.8%) complained of bilateral fold disappearance. Asymmetries occurred in 4.5% (6 of 132) patients. 97.7% (129 of 132) patients were satisfied with the postoperative appearance. No severe complications were reported during the follow-up period.

CONCLUSION

The modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation double-eyelid blepharoplasty technique can create a more natural, dynamic, and durable double-eyelid crease with fast recovery and no visible scar or serious complications.

Sub-brow skin excision Combined with retro-orbicularis fat resection: A Technique for upper eyelid bulkiness and laxity correction

BACKGROUND

Many people are characterized by a swollen appearance and loose skin of upper eyelids, especially Asians. Retro-orbicularis oculus fat (ROOF) lying in the lateral canthus area is a critical factor of the bulkiness formation. Although several approaches have been reported, most of them intend to remove orbicularis muscle and preaponeurotic fat through a double-eyelid incision, leaving ROOF untreated. Consequently, an unnatural eyelid fold is formed and the lateral supraorbital region remains bloated .

METHODS

Sixty-seven patients underwent sub-brow skin excision combined with ROOF resection. The key point was to excise the loose skin and thick ROOF through an incision along with the lower 1/3 of the eyebrow. Surgical outcomes were evaluated 6 months postoperatively by the heights of the designed line from the palpebral margin to the pupil center (HPPC), medial cornea (HPMC), and lateral canthus (HPLC). The pinch test, photographs, and complications were also recorded.

RESULTS

The preoperative average HPPC, HPMC, and HPLC were 9.68 ± 1.73, 7.68 ± 1.24, and 6.82 ± 1.12 mm, while the postoperative average measurements were 7.25 ± 0.51, 5.99 ± 0.54, and 5.54 ± 0.61 mm, respectively. The result of the pinch test was improved and postoperative scarring was inconspicuous. Two patients had transient numbness in the eyebrow region that subsided within seven days. Two patients had slight asymmetry of eyebrow position but did not need a second operation.

CONCLUSIONS

Sub-brow skin excision combined with ROOF resection is an effective technique for improving upper eyelid bulkiness and skin excess with low revision rates.

Use of an Orbital Septum Flap for Correcting Severe Blepharoptosis

BACKGROUND

Several surgical procedures are available for the treatment of severe blepharoptosis with poor levator function. However, the procedures have advantages and disadvantages. Particularly, complications such as lagophthalmos and lid lag are commonly observed after conventional interventions. Thus, the present study aimed to introduce a surgical technique that uses an orbital septum flap without the orbital oculi muscle for the correction of severe blepharoptosis.

METHODS

The technique utilizes the orbital septum flap, which is connected with the frontalis muscle via the galea aponeurosis and frontal periosteum, to suspend the tarsal plate. In this case series, the technique was used for the correction of blepharoptosis in 16 eyes from 12 patients.

RESULTS

The margin reflex distance in all patients improved at 6 months after surgery. Two patients presented with lagophthalmos and three with mild recurrence. However, revision surgery was not required, and none of patients presented with lid lag.

CONCLUSIONS

For the correction of blepharoptosis, the use of the orbital septum flap without the orbital oculi muscle can be easily selected compared with other conventional methods that are more likely to cause overcorrection and closure disorders.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mini-Incision Eyelidplasty in Single Eye to Correct Congenital Upper Eyelid Crease Asymmetry

OBJECTIVE

This study aims to evaluate the clinical effect of mini-incision double eyelidplasty in single eye for correcting congenital upper eyelid crease asymmetry.

METHODS

Mini-incision double eyelidplasty was performed on 24 patients in single eye to treat congenital upper eyelid crease asymmetry between May 2016 and September 2018. The postoperative surgical results were classified as "excellent," "fair," and "poor." The subjective satisfaction and incidence of complications were documented.

RESULTS

The mean patient age at the time of surgery was 24.6 ± 3.1 years (21-28 years), and the mean follow-up time was 15.4 ± 8.7 (12-34 months). All patients showed "excellent" surgical outcomes according to symmetry of upper eyelid creases. All patients are "very satisfied" with the cosmetic outcomes. There were no cases of recurrence or other complications.

CONCLUSIONS

Mini-incision double eyelidplasty method in single eye was effective and endurable in the treatment of congenital upper eyelid crease asymmetry. The recovery rate was fast, and no cases of upper eyelid crease disappearance were observed in this study.

Role of Orbicular Oculi Muscle Resection in Double Eyelid Surgery to Correct Ptosis of Young Adults: A Retrospective Review in 121 Chinese Patients

BACKGROUND

A plump single eyelid with ptosis is the morphological feature of Asians. Orbicularis oculi muscle (OOM) technique can correct ptosis and get a good appearance.

METHODS

A retrospective study was conducted in 121 Chinese patients who underwent double eyelid surgery with medial epicanthoplasty using OOM resection technique from December 2016 to December 2019. Preoperatively, all the patients had good or excellent levator function while skin fold overlapping the upper eyelid margin was found. Palpebral fissure height, upper eyelid margin reflex distance, complications, and cosmetic results were evaluated. Comparisons were performed preoperatively and postoperatively.

RESULTS

The study included 121 patients. Mean follow-up time was 12.8 months (range, 6-32 months). Mean margin reflex distance increased from 1.96 ± 0.60 mm preoperatively to 3.74 ± 0.50 mm postoperatively (P < 0.001), mean palpebral fissure height increased from 6.31 ± 0.51 mm preoperatively to 8.33 ± 0.52 mm postoperatively (P < 0.001). Most patients obtained satisfactory results. Only 1 patient was under correction, 2 patients were with mild asymmetry 6 months postoperatively.

CONCLUSIONS

Ptosis of the upper eyelid can be corrected by the OOM resection technique without any procedure on levator muscle. This technique can be an alternative method for the correction of ptosis of the upper eyelid.

The anterior layer of the levator aponeurosis in blepharoptosis correction

BACKGROUND

Conventional aponeurotic surgery for blepharoptosis has many advantages, but there is a potential for recurrence and lagophthalmos. The anatomy of the levator palpebrae muscle is relatively well studied, but the relationship of levator aponeurosis with surrounding layers is still controversial. This study aims to prove the presence of an anterior layer of the levator aponeurosis in clinical cases and to describe a technique involving its use for obtaining predictable outcomes in blepharoptosis correction.

METHODS

Between January 2014 and October 2018, 173 patients with blepharoptosis underwent correction surgery that involved relocating the anterior layer of the levator aponeurosis. During this procedure, after retracting the preaponeurotic fat pad, we could identify the misinserted anterior layer of the levator aponeurosis on the floor of the fat pad. The anterior layer was divided and advanced with posterior layers to 2 mm below the upper margin of the tarsus. After surgery, patients were followed up for 1 year, and surgical outcomes were evaluated.

RESULTS

After 1 year of follow-up, 95.4% of the examined patients showed good long-term outcomes. Moreover, although 4% showed moderate outcomes and lost the double eyelid skin crease, there was no ptosis recurrence in these patients and no lagophthalmos occurred in any of the 173 patients.

CONCLUSIONS

The authors found the misinserted anterior layer of the levator aponeurosis at the floor of preaponeurotic fat pad in blepharoptosis patients. Relocation of the anterior layer can provide predictable outcomes without lagophthalmos in blepharoptosis correction.

Modified double-eyelid blepharoplasty with the combined partial- And minimal-incision method

BACKGROUND

Double-eyelid surgery remains a popular esthetic surgery in East Asian people. The partial-incision method provides the benefits of full-incision and nonincision techniques. It can create a predictable and durable double-eyelid crease.

AIMS

To create a long-lasting double-eyelid crease with a minimal scar, the author has described the modified partial incision technique with a small and minimal incision.

PATIENTS/METHODS

A preoperative design was developed with the patient in an upright sitting position. A partial incision was made between the medial limbus and the middle pupillary line; the minimal incision was made just adjacent to the lateral limbus. After local anesthesia, a strip of orbicularis oculi below the incision was dissected, and the pretarsal orbicularis oculi, anterior tarsal fascia and part of the anterior tarsal fat were removed. The skin, dermis and orbicularis oculi were sutured together with the pretarsal fascia.

RESULTS

From July 2016 to September 2018, 138 patients received a modified partial-incision double-eyelid surgery. A total of 119 patients were followed up. The postoperative shape and height were stable. Five patients developed loss of the unilateral fold (2.17%), and one patient complained of bilateral narrow eyelid folds (0.87%). No serious complications were noted.

CONCLUSION

The modified partial-incision technique for creating a double eyelid described here provides stable results with no visible scar and no serious complications.

The Eyelid Crease Height, Depth, and Shape: A Scoring System for Revisional Asian Blepharoplasty

This study reports on a series of challenging revisional Asian blepharoplasty cases with various suboptimal factors, including high or low crease height, shallow or deep crease indentation (depth), and suboptimal crease shape. The study also presents a simple scoring scale that combines these challenges into a composite score, which has helped in the management of these cases.

Methods

Data on 64 revisional cases were collected between January 1, 2006, and June 30, 2019, with 126 upper eyelids. These were cases with little skin remaining after previous surgeries, and each eyelid was scored based on a height, depth, shape scoring method. A composite score (H + D + S) is then summed up, which ranged from 1 to 10, with the higher number being the most challenging. The logic and rules behind this scoring scale are explained.

Results

Data regarding age, gender, and eyelid crease characteristics of the cases were collected; photographs, notes, and diagrams in the medical records were used to complete each eyelid's scoring. The age of the patients (57 women and 7 men) ranged from 21 to 74 years. The revision score distribution, age distribution, and averaged scores within each age group were investigated for those starting at 24 years or younger, and for each added decade until over 65 years. Patients with revisional effort scores of 5-8 were found in all age groups surveyed.

Conclusions

In this study, the author presents a practical scoring scale that recognizes the factors responsible for the suboptimal results in double eyelid plasty and helps clinicians in management, patient-counseling, and planning of surgical solutions.

Techniques, Principles and Benchmarks in Asian Blepharoplasty

Supplemental Digital Content is available in the text.

Background:

Asian blepharoplasty is a deceptively simple procedure where the goal is to create an upper lid crease. The author presents a retrospective self-analysis of 362 cases performed over the past 12 years.

Methods:

362 cases that fits the inclusion criteria were tabulated into spreadsheet data format. Recorded were age, gender, date of service and follow-ups, whether the AB performed was for primary or revisional purpose; the preoperative lid crease status, the patient-chosen crease height as well as shape preferred. Intraoperative observation included presence or absence of preaponeurotic fat, whether partially resected, or reposited were noted.

Results:

Of 362 patients (724 upper lids), primary AB constituted 81% (295) and revisional AB contributed 19% (67). The gender distribution was 87% female (315) and 13% male (47). The age distribution ranged from 12 to 75 years. The crease height selected ranged from 6.0 to 8.0 mm, with the median being 7.0 mm. Of the crease shape chosen, parallel shape was 65% (236) and nasally-joining crease shape was 35% (126).

Conclusions:

Asian blepharoplasty via trapezoidal debulking of preaponeurotic platform is a safe, effective and anatomically-based technique that does not involve the use of permanent buried sutures. The article discussed the 5 essential factors (aponeurotic attachment, selective block clearance of preaponeurotic space, precise positioning of the crease formation loci, detection of latent droopy eyelids and avoidance of Faden-like suture effect) and the author’s benchmarks to achieve a better success rate. Results for primary and revisional Asian blepharoplasty, strategies and potential pitfalls are presented. (http://links.lww.com/PRSGO/B141)

Local retro-orbicularis oculus fat (ROOF) resection in upper blepharoplasty: A retrospective evaluation study of 65 bilateral upper blepharoplasties

BACKGROUND

Puffy upper eyelids are normal in Asians, and full-incision blepharoplasty is commonly performed to remove some orbital fat to ameliorate the problem, but not all patients would exhibit obvious improvement. Local retro-orbicularis oculus fat (ROOF) is a layer of fibrofatty soft tissue that lies much deep into the orbicularis oculi in the upper eyelid, which is an important factor in the formation of puffy upper eyelids. This study was carried out to evaluate the clinical application (including the evaluation of photographs for the thickness of upper eyelid) of upper blepharoplasty combined with ROOF resection for correcting puffy upper eyelids.

METHOD

A total of 65 patients (5 males, 60 females) with puffy upper eyelids recruited from October 2015 to October 2016 were included in the study. Full-incision blepharoplasty combined with partial ROOF resection was performed on all patients. The thickness of soft tissue in the upper eyelid was measured by ultrasound biomicroscopy preoperatively and at 12 months postoperatively.

RESULT

All patients underwent surgery successfully, and 62 patients (124 eyes) were followed up for 12-15 months (mean 13.8 ± 2.7 months). Before the surgery, the thickness of the ROOF was 0.35 ± 0.12 mm on the left and 0.42 ± 0.08 mm on the right. Twelve months postsurgery, the thickness of the ROOF was 0.18 ± 0.03 mm on the left and 0.20 ± 0.02 mm on the right. During the follow-up period, all patients were satisfied with the esthetic effect, and no severe postoperative complications were observed.

CONCLUSION

Puffy upper eyelids can be corrected effectively by local ROOF resection in esthetic blepharoplasty.

Aponeurosis of the levator palpebrae superioris in Chinese subjects: A live gross anatomy and cadaveric histological study

An accurate understanding of the anatomy of the levator palpebrae superioris aponeurosis (LPSA) is critical for successful blepharoplasty of aponeurotic ptosis. We investigated the macroscopic and microscopic anatomy of the LPSA.This prospective live gross anatomy study enrolled 200 adult Chinese patients with bilateral mild ptosis undergoing elective blepharoplasty. Full-thick eyelid tissues and sagittal sections from the eyelid skin to the conjunctiva were examined with Masson trichrome staining or antismooth muscle actin (SMA) immunohistochemistry.Gross anatomy showed that the space between the superficial and deep layers of the LPSA could be accessed after incising the overlying superficial fascia, by retracting the white line. Adipose layers were clearly observed in 195 out of 200 patients with bilateral mild ptosis, among which 180 cases had the superficial layer connected to the uncoated adipose. Fifteen cases had the superficial layer connected to the smoothly coated layer, and 5 cases had the superficial layer directly connected to the deep loose fiber, almost without adipose. In previously untreated patients, the LPSA space was located beneath the intact orbital septum. In those with previous surgeries, it was beneath the superficial layer of the LPSA, underlying the destructed orbital septum. Cadaveric histology showed that the deep layer of the LPSA extended into the anterior layer of the tarsal plate and the superficial layer reflexed upward in continuity with the vertical orbital septum. An occult space existed between the 2 layers of the LPSA, with a smooth lining on the deep layer. The superficial layer of the LPSA was SMA-immunonegative but the deep layer was slightly immunopositive for SMA. An occult anatomic space exists between the superficial and deep layers of the LPSA, in proximity to the superior tarsal plate margin. Recognition of the more anatomically significant LPSA deep layer may help improve the aesthetic outcome of blepharoplasty.

Subclinical Ptosis Correction: Incision, Partial Incision, and Nonincision: The Formation of the Double Fold

Surgery to create eyelid folds accounts for the highest percentage of surgeries in Asians and Koreans who receive the surgery on the upper eyelid 2 to 3 times during their lifetimes for functional or cosmetic reasons. Patients are generally satisfied with the results-the eyes becoming brighter and bigger via the improvement of pseudoptosis by fold creation. The recent trend is to seek the "perfect" eye: a vertically and horizontally big palpebral fissure with more than 90% cornea showing. Surgery of the levator aponeurosis-Müller muscle complex is required to expose the cornea, except in those patients who inherently have good levator-Müller function. However, many complications occur during surgeries of the levator aponeurosis-Müller muscle complex, which increase the reoperation rate. Here, the authors briefly summarize recent experiences correcting subclinical ptosis using the nonincision, incision, and partial incision methods.

Surgical anatomy of the superior orbit on ultra-high-resolution MRI at 9.4 Tesla

BACKGROUND

A good understanding of the anatomical details is required to ensure optimal results during surgery of the orbit. Several indications for orbital surgery require biopsy, resection, or reconstructive procedures. The intricate relationships between the orbital septum and adjacent structures of the upper orbit can cause difficulties in interpreting the surgical anatomy of this region. The purpose of this study was to acquire further insight into the anatomy of the superior part of the orbit, with special attention paid to the orbital septum.

METHODS

An ex-vivo study was performed using magnetic resonance imaging (MRI) at 9.4 Tesla (isotropic resolution = 20 μm) on six human cadaver specimens to examine the superior-medial half of the orbit. To visualise the posterior layers of the upper orbit, a dissection of three of the orbits was performed prior to the MRI examination, and a flexible PVC sheet was introduced above the levator muscle.

RESULTS

The technique enabled a visualisation of anatomically important landmarks of the anterior and posterior parts of the upper orbit at a resolution near histological levels; to the authors' knowledge, this visualisation has not been reported previously. A posterior continuation of the orbital septum, which forms a distinct anatomical structure, is revealed.

CONCLUSIONS

The posterior aspect of the orbital septum separates the levator muscle and the orbital fat pad. Between these two structures, a surgical corridor is formed using MRI, enabling alternative access to the superior part of the orbit; this alternative access might be less invasive because the orbital septum remains undamaged.

Three mini-incision double-eyelid blepharoplasty

Although there are many procedures reported in the literature regarding the partial incision double-eyelid blepharoplasty, the current methods still have potential problems such as unstable and limitation of application. In this study, the authors developed a 3-mini-incision technique that minimizes tissue injury and provides a tough connection between the levator aponeurosis and skin. With this method, 3 minute incisions (3-4 mm) are made in the upper eyelid. Through these incisions, the whole strip of pretarsal orbicularis oculi muscle under the inferior incision line and the excessive fat can be removed. This technique gives a stable and natural-looking supratarsal fold, with invisible scar, minimal complications, and a short recovery period; and can be applied to patients with fatty eyelids. This method has the benefits of both nonincisional and full-incisional techniques, and avoids the disadvantages of the current partial incisional methods.

Surgical anatomy of the upper eyelid relating to upper blepharoplasty or blepharoptosis surgery

Eyelid anatomy, including thickness measurements, was examined in numerous age groups. The thickest part of the upper eyelid is just below the eyebrow (1.127±238 µm), and the thinnest near the ciliary margin (320±49 µm). The thickness of skin at 7 mm above the eyelashes was 860±305 µm. The results revealed no significant differences among the age groups. Fast fibers (87.8±3.7%) occupied a significantly larger portion of the orbicularis oculi muscle (OOM) than nonfast fibers (12.2±3.7%). The frontalis muscle passed through and was inserted into the bundles of the OOM on the superior border of the eyebrow at the middle and medial portions of the upper eyelid. Laterally, the frontalis muscle inserted about 0.5 cm below the superior border of the eyebrow. Fast fibers occupied a significantly larger portion of the OOM than did non-fast fibers. The oculomotor nerve ends that extend forward to the distal third of the levator muscle are exposed and vulnerable to local anesthetics and may be numbed during blepharoplasty. The orbital septum consists of 2 layers. The outer layer of loose connective tissue descends to interdigitate with the levator aponeurosis and disperses inferiorly. The inner layer follows the outer layer, then reflects and continues posteriorly with the levator sheath. Widths of the tarsal plate at its lower border, mid-height, and upper border were 21.8±1.8, 16.2±1.6, and 8.3±1.0 mm, respectively. The widths of the levator aponeurosis were 32.0±2.2, 29.2±3.5, and 27.2±3.9 mm, respectively. Below the levator, the "conjoint fascial sheath" (CFS) is attached to the conjunctival fornix. The CFS was 12.2±2.0 mm anteroposterior length and 1.1±0.1 mm thick. The shape was equilateral trapezoid with a longer base anteriorly. The superior palpebral muscle was trapezoidal. The lengths of its sides were 15.58±1.82 and 22.30±5.25 mm, and its height was 13.70±2.74 mm. The width of the levator aponeurosis was approximately 4 mm wider than the superior palpebral muscle.

Double-eyelid surgery using septoaponeurosis junctional thickening results in dynamic fold in asians

Background:

To avoid a static double-eyelid fold characterized by nonmobile overdepression of the fold, we propose a new surgical approach of using septoaponeurosis junctional thickening (SAJT) to create a dynamic fold.

Methods:

Six hundred eighty patients underwent double-eyelid surgery using the SAJT fixation technique. The orbital septum was exposed and transversely opened superior to the incision margin. The lower septal stump was trimmed to expose the SAJT. The dermis and orbicularis oculi muscle of the lower flap of the upper eyelid were attached to the SAJT. Patients were followed for 2–8 years (mean, 3.6 y). Anatomic study with 28 upper eyelids from 28 Korean adult cadavers was performed to confirm the histological structure of the SAJT.

Results:

This technique created a dynamic fold. When the eyes were open, the fold depth was moderate. When the eyes were closed, the fold site was smooth and not depressed. The surgery had a 95% patient satisfaction rate (365 responded as satisfied and 236 responded as very satisfied). Postoperative complications included partial or complete loss of the double-eyelid line in 14 and 4 cases, respectively, hypertrophic scar formation in 7 cases, and asymmetric fold in 8 cases.

Conclusions:

The authors introduce a double-eyelid surgery technique using the SAJT. This SAJT fixation technique creates a dynamic double-eyelid fold. Our study showed a high patient satisfaction rate and that the resulting fold mimics the movement of the congenital supratarsal fold in Asians.

Supplemental Digital Content is available in the text.

Surgical approach to the superior mid-orbit

Access to the superior mid-orbit is required for procedures on the levator muscle in the correction of upper eyelid ptosis and in surgery aimed at local lesions in this region. The purpose with this human cadaver study was to clarify the anatomical substrate for a surgical approach to the levator muscle and the upper mid-orbit structures, in which the orbital septum and the retroseptal fat pad is not harmed during surgery. Macro-anatomical dissections and histological examinations were performed on five human orbits from three formalin embalmed cadaver heads. It was found that the orbital septum extends posteriorly from its junction with the levator aponeurosis. This posterior continuation of the orbital septum encloses the superior orbital fat pad and separates this from the anterior surface of the levator muscle. In between the orbital septum and the levator, there is a dissection space that provides a minimal invasive access corridor to the structures in the upper mid-orbit.

Removal of a large amount of pretarsal tissue through three mini incisions in the construction of a double eyelid

BACKGROUND

The surgical procedure aimed at constructing the upper eyelid crease is the cosmetic operation most commonly requested by Asian patients. The incisional approach leaves a permanent crease, but the swelling period can last longer than 3 months, and a distinct scar usually is unavoidable. Many mini-incisional techniques with incisions of varying sizes and locations have been developed, but the removal of pretarsal tissue has not been sufficient because these procedures wipe out only small pockets of soft tissue immediately inferior to skin for placement of the suture. Thus, the formed double eyelid may not be durable. The technique the authors introduce is a modified mini-incisional technique that combines the benefits of both the incisional and the usual mini-incisional methods.

METHODS

Three 3- to 4-mm mini-incisions were made on each upper eyelid. The orbicularis muscle was isolated carefully from the skin and then cut off as much as possible in three directions: down (toward the palpebral margin), left, and right. Finally, the three incisions were sutured, and a vivid fold was created. This technique was applied for 110 patients. The follow-up period ranged from 3 to 12 months. The patients were welcomed for further treatment if any problems occurred at any time. An extra 3 years of follow-up evaluation was applied for 24 patients (46 cases) to assess the long-term maintenance of the fold.

RESULTS

This study enrolled 110 patients (212 cases). A natural-looking skin fold appeared after the edema period. The scar was not obvious. Disappearance of the fold was not found in any case during 3-12 months (mean, 9 months) of follow-up evaluation. Obvious shifting of the fold was found in four cases during the additional 3 years of follow-up evaluation, but disappearance of the fold was not found in any case.

CONCLUSION

This modified technique was found to be successful in developing a natural-appearing, long-lasting suprapalpebral fold with an inconspicuous scar. It combines the best of both the open and usual mini-incisional techniques. Because a large amount of pretarsal soft tissue is removed, the double fold is less likely to fade away.

LEVEL OF EVIDENCE V

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Oriental upper blepharoplasty

Aesthetic surgery of the upper eyelids is a very common procedure performed in cosmetic practices around the world. The word blepharoplasty, however, has a different meaning in Asia than it does elsewhere. Orientals have different periorbital anatomic characteristics, their motivations for seeking eyelid treatment are different, and operative techniques have been adapted consequently. There are also many eyelid shapes among Orientals, mostly with regard to the presence and location of the supratarsal fold and/or presence of an epicanthal fold. The surgeon must therefore master a range of surgical procedures to treat these variations adequately. It is critical to know the indications for each blepharoplasty technique as well as their complications to select the right surgery and avoid unfavorable results. Epicanthoplasty performed on the right patient can greatly improve aesthetic results while retaining ethnic characteristics. This article will discuss Oriental eyelid characteristics, preoperative patient assessment, commonly used corrective techniques for the "double-eyelid" creation, and complications and how to avoid them.

Asian blepharoplasty--an overview

Asian blepharoplasty has evolved over the years as greater understanding of the differences between the Asian and Caucasian eyelid anatomy has led to the development of modified techniques for upper lid blepharoplasty. The aim of Asian upper blepharoplasty is to create a pleasing and permanent upper lid crease. This article reviews the differences in the anatomy and the various techniques currently employed.

High-resolution magnetic resonance imaging of the upper eyelid: correlation with the position of the skin crease in the upper eyelid

PURPOSE

The position and appearance of the upper eyelid crease is one of the challenges in eyelid surgery. The aim of this study was to compare the clinical appearance of the upper eyelid crease with its anatomy, including the position of the levator, the septum, and the orbital fat as determined by Magnetic Resonance Imaging (MRI).

MATERIALS AND METHODS

Oculoplastic examination was performed in normal volunteers of the same age with different appearances of the upper eyelid. MRI (Intera 1.5 T, Philips, the Netherlands) was carried out with both head and surface coils in all volunteers. Subjects were asked to keep their eyes closed during the whole procedure, thus reducing artefacts due to eyeball movements. The protocol lasted 8 minutes and included a multiplanar scout to obtain T1-weighted 3D-images. Thin sagittal T2 sequences were obtained along the plane of the optic nerve and focused on both orbits, allowing a precise analysis of the orbital content and eyelid anatomy.

RESULTS

Six volunteers were included in this prospective study, three of Caucasian origin and three of North African, Central African and Asian origin, respectively. We distinguished two appearances of the crease: in some cases, the superior eyelid sulcus was convex, while in other cases it was concave. The superior eyelid fold was either high or low. Two Caucasian subjects had a deep, concave superior eyelid sulcus with a high crease. This crease appearance was correlated with a short concave appearance of the septum, which pulled back the pre-aponeurotic fat. The non-Caucasian volunteers all had a convex superior eyelid sulcus. The orbital septum insertion was low on the levator aponeurosis, and the orbital fat pad drooped onto the levator muscle, accounting for the convexity of the upper eyelid sulcus. A skin fold was formed by redundant skin over the crease.

CONCLUSIONS

MRI provides excellent images and allows a good analysis of the upper eyelid components. It permits a detailed analysis of the architecture for a better understanding of its appearance and of the crease position, although further investigation with a larger number of volunteers is required.

Histological analysis of the lower-positioned transverse ligament

The lower-positioned transverse ligament (LPTL) had been thought to run parallel to the junction between the orbital septum and the levator aponeurosis (junction). However, its true course was disclosed as crossing the junction. Since earlier histological studies were undertaken before the precise course was elucidated, it was uncertain whether the true LPTL was adequately disclosed. Therefore, we examined ten upper eyelids of 6 Asian patients who underwent blepharoptosis repairs. The LPTL and the tissue running parallel to the junction were harvested intraoperatively. Light-microscopically, the LPTL contained looser and thinner collagen bundles and less elastic fibres than the parallel tissue. Electron-microscopically, collagen microfibrils in the LPTL had almost the same periodicity and thickness as those in the parallel tissue. The LPTL is a loose and inelastic structure, which at a light microscopic level is completely different from the parallel tissue; however, the differences could not be verified by electron microscopy.

Rectus abdominis muscle free flap harvest by laparoscopic sheath-sparing technique

Previous reports of endoscopic rectus abdominis muscle harvest have described techniques that are hampered by the need for anterior rectus sheath division or mechanical devices to maintain the optical cavity. The authors report the first successful clinical case of a laparoscopic sheath-sparing rectus abdominis muscle harvest for free tissue transfer. It offers considerable advantages over the traditional open method and, with the help of an experienced laparoscopic surgeon, it should add little to operative time.