The Anatomy and Clinical Application of Preorbital Septum Fiber

Cause Analysis and Surgical Treatment of Aponeurotic Ptosis With Upper Eyelid Depression

BACKGROUND

Ptosis and upper eyelid depression were previously diagnosed as 2 separate diseases. The authors found that in patients with aponeurotic ptosis accompanied by upper eyelid depression, the main cause of upper eyelid depression was impaired dynamic transmission of the levator aponeurosis.

OBJECTIVE

To analyze the causes of upper eyelid depression in patients with aponeurotic ptosis accompanied by upper eyelid depression and to introduce the best treatment methods.

METHODS

The authors enrolled 15 eyes (11 patients) with aponeurotic ptosis accompanied by upper eyelid depression from October 2021 to August 2022. The authors analyzed the causes of upper eyelid depression in those patients and performed aponeurotic ptosis correction surgery and orbital septum fat release surgery. After 6 to 12 months of follow-up, the authors reviewed the patient's medical records and photographs to evaluate the treatment outcomes.

RESULTS

After surgery, ptosis was corrected and upper eyelid depression significantly improved in all the patients. One patient had poor eyelid morphology and upper eyelid depression due to habitual brow lifting, which was relieved after an injection of botulinum toxin into the frontalis muscle. One patient had overcorrection of the upper eyelid depression on the affected side and no other complications.

CONCLUSION

The main cause of upper eyelid depression in patients with aponeurotic ptosis is impaired dynamic transmission of the levator aponeurosis. Aponeurotic ptosis repair surgery and orbital septum fat release surgery are simple surgical procedures that restore the normal anatomy and physiology of the upper eyelid and maintain the normal structure of the eyelid, with good post-operative outcomes.

Release of fibrous web bands between the preaponeurotic fat pad and Levator aponeurosis in subclinical blepharoptosis correction during double-eyelid blepharoplasty

BACKGROUND

Double-eyelid blepharoplasty is a popular cosmetic procedure in Asia; however, there are some drawbacks to this procedure for mild blepharoptosis. Enhancing movement of the levator aponeurosis can correct blepharoptosis through the release of fibrous web bands present between the preaponeurotic fat pad and levator aponeurosis.

AIM

To improve our understanding of the anatomical link between the levator aponeurosis and orbital septum fat and to introduce that the release of the link can provide favorable results in double-eyelid blepharoplasty.

PATIENTS/METHODS

We included patients with latent ptosis or subclinical blepharoptosis who underwent double-eyelid blepharoplasty with the release of fibrous web bands between June 2021 and March 2023. Mild ptosis was corrected following complete release of the fibrous bands beneath the preaponeurotic fat pad. Patients were followed up for 4-12 months postoperatively, and surgical outcomes were evaluated. Patient demographic variables and photographs were collected pre- and postoperatively. Patients, surgeons, and laypersons were asked to evaluate the outcomes postoperatively. The Friedman's nonparametric (for repeated measures) two-way analysis of variance was used for statistical analyses.

RESULTS

Outcomes were assessed in 45 individuals with an average monitoring period of 6.9 months. There were no cases of incomplete eyelid closure or upper eyelid ectropion. Over 50% of the surgical outcomes were deemed "satisfactory" by each of the three groups in relation to the widening of the eyelid fissure. Most of the examined patients demonstrated favorable long-term results.

CONCLUSIONS

Fibrous web bands are implicated in subclinical or mild blepharoptosis. The release of fibrous web bands between the preaponeurotic fat pad and levator aponeurosis can provide favorable results in double-eyelid blepharoplasty.

Correction of Sunken Upper Eyelid in Asian Blepharoplasty Based on Anatomical and Histological Study of Orbital Fat Fascia Flap

OBJECTIVES

To explore the clinical application of orbital fat fascia flap in the correction of sunken upper eyelid in Asian blepharoplasty based on anatomical and histological research.

METHODS

Observe the histological structure of the orbital fat and its fascia vascularity through cadaver anatomy and histological sections of 10 cadavers. Based on the anatomical and histological characteristics of orbital fat, 36 patients with mild to moderate sunken upper eyelids were corrected by transposition of orbital fat fascia flap with preservation of fascia vascular pedicle. During the operation, the lateral part of the central cellulite of orbital fat was separated longitudinally and transferred to the sunken place to correct the sunken upper eyelid.

RESULTS

Anatomy and histology show that the orbital fat was located between the anterior layer of the levator aponeurosis and the posterior layer of the orbital septum and was separated into fat lobules by many fibrous septa. The blood vessels move forward from back to front along the orbital fat interlobular septum, and the blood vessels in the capsule below the orbital fat are abundant. Clinical results showed that the shape of the sunken upper eyelid was significantly improved in 35 cases after correction with this method during the postoperative follow-up from 9 months to 18 months. The mean sunken depth improved from 6.2mm (±1.0 mm) preoperatively to 2.2mm (±0.9 mm) at the last follow-up with a statistical significance. And only 1 case had partial depression in the unilateral eyelid and received autologous granular fat transplantation with satisfactory postoperative results.

CONCLUSION

The transposition of orbital fat fascia flap with longitudinal separation and preservation of fascia vascular pedicle can better correct the sunken upper eyelid during blepharoplasty, and the long-term effect is stable, which is worthy of clinical promotion.

LEVEL OF EVIDENCE IV

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Category of upper eyelid morphology and the preferred double eyelid shape in Asians according to questionnaire survey

BACKGROUND

The morphological classification of the upper eyelid in Asian people is complex and diverse and usually not consistent with what we know well.

AIMS

To improve the classification of upper eyelid morphology and investigate the preferred double eyelid shape by Asian people.

METHODS

An investigation of 640 patients' preferences for double eyelid shape was conducted, and the pre- and post-operative effects were assessed. The shapes of the natural eyelids of 247 people (485 eyes) who provided real photographs of the eyelids were counted. The chi-square test was used to analyze the differences.

RESULTS

There were 10 eyelid shapes: single eyelid, parallel-shaped double eyelid, fan-shaped double eyelid, parallel fan-shaped double eyelid, opened fan-shaped double eyelid, crescent-shaped double eyelid, hidden-shaped double eyelid, horizontal-shaped double eyelid, triangle-shaped double eyelid, and multiple-fold eyelid. The difference in the shape of the natural eyelid between males and females was statistically significant (p < 0.05). The most popular eyelid shapes were single eyelid (24.9%), open fan-shaped double eyelid (21.0%), fan-shaped double eyelid (16.3%), and hidden-shaped double eyelid (12.6%). Men and women preferred a parallel fan-shaped double eyelid (18.0%), a parallel-shaped double eyelids (17.0%), and an open fan-shaped double eyelids (18.1%).

CONCLUSIONS

The most popular upper eyelid shapes were single eyelid, open fan-shaped double eyelid, and fan-shaped double eyelid. The parallel fan-shaped, parallel-shaped, and open fan-shaped double eyelid were favored by men and women.

Anatomic and Magnetic Resonance Imaging-Based Correction of Upper-Eyelid Depression and Blepharoptosis in Senile Patients

In senile patients with sunken superior sulcus, involutional ptosis, and higher eyelid crease, a single operation to correct depression or ptosis cannot achieve good results. We demonstrated the anatomy of periorbital septum fibers, which may contribute to the levator muscle's volume depletion and dynamic power transmission disorder, and described a procedure for correcting upper-eyelid depression and blepharoptosis in senile patients. The fibrous webs in these patients connected the posterior aspect of the orbicularis and the orbital septum and extended to the orbital fat and levator aponeurosis. These fibers were dissected to release the periorbital septal fibers, and the orbital septal fat flap was transferred to the depressed region. Advancement or plication of the levator aponeurosis was performed in patients with uncorrected blepharoptosis after the procedures described above. The technique was applied to 13 Chinese patients (25 eyes) between May 2021 and April 2022. Postoperative magnetic resonance imaging revealed that the preaponeurotic fat was displaced forward and down to the upper margin of the tarsus, and the curvature of the upper-eyelid depression was significantly improved. Moreover, the superior sulcus deformity improved, the ptosis was corrected, and the uppermost crease decreased in all patients. No recurrence of ptosis or abnormal adhesion was observed. We believe this is the first study using magnetic resonance imaging to evaluate eyelid anatomy and the effects of surgery in this patient group. Releasing periorbital septum fibers is crucial for correcting a portion of the sunken eyelid and ptosis in Asians.