Essentials of Aesthetic Surgery

472
Part VII Facial Surgery
• Depending on the limited amount of skin that needs to be removed, the excision of
soft tissues can be performed in an elegant, trapezoidal block.25-27

clearing of a greater surface of the aponeurosis.

fold.

treatment through the tissue planes.

beveled passage through the orbicularis oculi allows a triangular cross segment
of orbicularis oculi and some septal to be cleared.
Crease is primarily based on the central upper tarsal height.
Shape chosen is included in the design.
After the crease incision (lower incision line) and upper incision have been made
through the skin using a surgical blade, the next step is a superiorly-beveled traverse
through the upper incision’s orbicularis oculi and orbital septum to the preaponeurotic
space (Fig. 36-7).
Müller muscle
Levator muscle
Conjunctiva
Upper incision
(with removal
of skin)
Lid crease incision
Orbital septum
Triangular debulking
(of soft tissue without
skin removal)
Trapezoidal debulking of
preaponeurotic platform
The concept of trapezoidal and triangular debulking of eyelid tissues as applied in Asian
upper blepharoplasty.26,27
The strip of myocutaneous tissues backed by the orbital septum (in most cases) is then
rotated forward and trimmed along the superior tarsal border toward the lid crease
incision, using light application of monopolar cautery on cutting mode with good
control of vascular oozing.

crease incision and superior tarsal border.
The wound-injury involvement of the layers is staggered and distributed.

473
Chapter 36 Asian Blepharoplasty
SENIOR AUTHOR TIP: With this beveled approach, access through the skin, orbicularis
oculi, and orbital septum allows en bloc removal, preventing the need to excise
each individual layer, as well as allowing graded handling of the preaponeurotic fat,

The tissue planes are reset appropriately through release of any constraining surgical
drapes.
The upper edge of the incision wound will fall in place naturally without exaggerated
wound tension over the aponeurotic tissue along the superior tarsal border; the crease
invagination is easily observed intraoperatively even before closing the wound edges.

strands of the levator aponeurosis, and back to skin as interrupted sutures.
The wound is further approximated with a running 7-0 suture.
NOTE: The orbicularis oculi muscle, orbital septum, and preaponeurotic fat pad are
intentionally not embedded in the crease wound, further reducing the incidence of
malformation of the crease and suboptimal results. In this technique, buried sutures are
not used, and all sutures are removed at 1 week.
SENIOR AUTHOR TIP: The elegance of the beveled approach is that instead of
removing a square or rectangular cross sectional block (preaponeurotic skin, orbicularis
oculi, and possibly fat), a beveled approach through orbicularis removes a smaller
amount of these tissue layers. Fat excision is minimal to prevent a sunken sulcus. This
preserves more of the orbicularis oculi than traditional excision and allows clearing of a
greater surface of the aponeurosis. In most cases, a small amount of skin is necessarily
removed to reduce the lid fold.
This technique has the following

• Allows a tension-free closure

13

• Aims to preserve and even enhance the biodynamics of tissue layers

13 (consisting of
preaponeurotic fat, fourth layer) to exist between the anterior and posterior
lamella.

interphase of activated levator–Müller muscle with a relaxed skin-orbicularis oculi
(lid fold).

functional unit, innervated by the facial nerve branches.

there are movements at the boundary between the levator muscle and the
preaponeurotic fat pad in front, as well as co-contraction of the Müller muscle.

each other.

474
Part VII Facial Surgery
Rather than rely on suture compression or ligation of upper lid tissues with permanent
sutures, it creates a more favorable anatomic environment for a crease to form
naturally.
It avoids encircling sutures (temporary or permanent) on any muscles by using

redirecting it toward the skin along the superior tarsal border, and dissolvable suture
materials are not used.
All sutures are removed at 1 week. The concept and technique are equally applicable to
revisions.28
NONINCISIONAL TECHNIQUES


Combines suture apposition and scarring to create the palpebral crease

Determine the fold height
• Position relative to the epicanthal fold
• Desires of the patient
• Personal aesthetics
Eversion of lid and measurement of tarsal height with calipers
Mark desired fold (usually at or slightly inferior to the superior margin of the tarsal
plate), following natural curve of upper eyelid
Mark incision/suture line
• Width of marking should be at or slightly less than tarsal width for younger patients.
• Width of marking should be slightly wider than tarsal width for older patients.
Single or multiple buried suture technique
• Single suture29 (Fig. 36-8)
A
Stab incision
B
C
Design of the position and conjunctival passage of the suture. A, The two points of
B, The points of entry of
the suture are marked with methylene blue. C, The lid is everted and a double-armed 6-0 Prolene
suture is inserted through the conjunctiva.

475
Chapter 36 Asian Blepharoplasty
D
E
One end of the double-armed suture is passed back through the lid, entering
through the same needle hole on the conjunctival surface and exiting through the stab incisions
in the skin. E, The other end of the suture is passed back to the skin.

palpebral crease with the steps of stabbed incisions. Technically one is no longer
in a nonincisional technique, as these stab incisions are closed also with 6-0 nylon/
polypropylene.
• Suture inserted through conjunctiva, entering and exiting through same hole
• Passes through full thickness of lid
• Enter and exit through same skin incision so needles come through stab incision
together
• Knot tied and released to bury it subcutaneously
• Essentially is a buried, full-thickness, horizontal mattress suture
• Alternatively, can do multiple through-and-through mattress sutures
21 (Fig. 36-9)
A
B
C
Single buried suture
Skin/soft tissue
closure
D
Passing back of the suture is completed.
B, One needle is passed subcutaneously to exit
through the other stab incision, and the two ends of
the suture are tied securely and singly. C, A single 6-0
Prolene stitch is used to close each stab incision. D, A
cross section of the upper eyelid shows the position of
the single stitch permanently in place.

476
Part VII Facial Surgery
A
B
C
D
The closed technique is commonly used in Asia for lid surgery in those without fat
A, The top of the tarsus is
B, Tiny incisions
will allow knots to bury deep beneath skin. C, Nonabsorbable sutures, placed through the lid, run
subconjunctivally on the deep side of the upper tarsus and exit and travel subdermally to create
D, Sutures securely tied and cut. This
technique is especially useful when combined with frontal lifting.
Continuous buried tarsal suture21,30,31 (Fig. 36-10)
• Equidistant incisional dots are marked along marked fold.

oculi muscle.

and traverses medial stab incision with deep bite through superior tarsus, exiting
and reentering the next lateral stab incision.

lateral end.

exposure through conjunctiva.

until both ends exit laterally.


(Fig. 36-11).

477
Chapter 36 Asian Blepharoplasty

stitch technique. Incisional dots are marked at
points through both threads reenter at lateral
ends and the knot is tied. B, Cross section of a
continuous buried tarsal stitch.
A
A
I
H
H
G
G
F
F
E
E
D
D
C
C
Tarsus
Knotted
Knotted
B
B
A
B
SENIOR AUTHOR TIP: The frequent association of secondary consecutive ptosis when

pressure on the surgeon to prophylactically perform a mild ptosis correction. Conjointly
this is achieved either by tucking the levator aponeurosis in incisional methods, or by
passing one to three buried suture sets even higher above the superior tarsal border
(by several millimeters) to create a skewed, posteriorly directed and upwardly beveled
passage across the thickness of the upper lid, causing a plication or tucking of the
levator aponeurosis and Müller muscle.
NOTE:







Cross section showing placement of a
buried suture that encircles the orbicularis oculi, levator
aponeurosis, and underlying Müller muscle. It is a suture
loop of 7-0 nylon or polypropylene. Often, a small
fragment of preaponeurotic fat pad and orbital septum
may be inadvertently included in the ligature.

478
Part VII Facial Surgery
1
2
3
4
A´
A
B´
B
In buried suture methods, three double-armed 6-0 or 7-0 nylon are typically used.

passage involves everting the upper lid margin and passing it subconjunctivally for 3-4 mm at
a level typically several millimeters above the superior tarsal border ). The second passage is
trans-lid and directs one needle toward the skin side along the path of B aiming just over
the upper border of the tarsus. Similarly, for the other arm of the suture, the third passage
goes from If each suture thread is tied on the skin at this moment, it will be a full-thickness
compression ligature encompassing (plicating) the Müller muscle, the levator aponeurosis, and
orbicularis oculi muscle in a posterosuperiorly biased fashion along the axis of the levator muscle’s
B
and Essentially, the second needle exiting the skin at is repassed subcutaneously to join
B,

contraction in the width of levator aponeurosis at the two locations of Traditionally,
the suture methods use three sets of these sutures, one each at the medial third, central third, and

SENIOR AUTHOR TIP: Three sets of these buried sutures means that three encircling
loops are placed around the levator/Müller muscle layers from the subcutaneous
plane from the front skin surface. Patients who have these procedures often have an
exaggerated stare or an elevated upper lid margin; in essence, a prophylactic correction
has been included. It may also be marketed as a form of ptosis repair. This is a classic
example of an overdiagnosed condition (ptosis) with overprescribed countermeasures,
sometimes in an overcomplicated fashion.
EPICANTHOPLASTY


• Flaps designed to pull skin medially
• Requires exercising caution, because it may produce hypertrophic or unsightly
scarring
(Fig. 36-14)

479
Chapter 36 Asian Blepharoplasty
Published techniques for correcting Asian epicanthal folds. A,
method. B, C, D, Jordan’s
E, Yoon’s “one-armed jumping man” method. F,
method. G,
A
B
C
D
E
F
G
COMPLICATIONS
ASYMMETRY
Common source of dissatisfaction in 13%-35%20
Minimized by consistent and meticulous technique

crease and may be alternative to reoperation for patients with asymmetrical creases.32

480
Part VII Facial Surgery





MULTIPLE UPPER EYELID FOLDS
From scar tissue adhesions and/or overresection of underlying tissues
May require surgical release of adhesions with interposition of tissue (orbital fat,
orbicularis oculi)33
PTOSIS OR LID RETRACTION
Ptosis may be a result of hemorrhage into Müller muscle.

RELAPSE
More common in suture techniques and in bulkier lids
• Rates range from 2.9% to 4.5% in experienced hands and with good patient
selection.
29,30

Allow 3-6 months to pass
SCARRING/DIMPLING
Scarring is usually more of a problem with epicanthoplasty than with blepharoplasty.

Dimpling results from subdermal suture.

• Suture removal after 3 months may be required.
TOP TAKEAWAYS

Asians lack a palpebral fold, because the levator does not penetrate the septum

subcutaneous tissue.

Trapezoidal debulking of preaponeurotic tissues allows precise, physiologic, and
on-plane debulking and requires the fewest steps of all upper blepharoplasty
techniques.
REFERENCES
1. Shirakabe Y, Kinugasa T, Kawata M, et al. The double-eyelid operation in Japan: its evolution
as related to cultural changes. Ann Plast Surg 15:224, 1985.
2. Sayoc BT. Plastic construction of the superior palpebral fold. Am J Ophthalmol 38:556, 1954.
3. Millard DR Jr. Oriental peregrinations. Plast Reconstr Surg (1946) 16:319, 1955.

Bull 25:257, 1960.
5. Cho M, Glavas IP. Anatomic properties of the upper eyelid in Asian Americans. Dermatol Surg
35:1736, 2009.

481
Chapter 36 Asian Blepharoplasty




Plast Reconstr Surg 107:1665, 2001.
10. Sayoc BT. Absence of superior palpebral fold in slit eyes; an anatomic and physiologic explana-
tion. Am J Ophthalmol 42:298, 1956.

12. Morikawa K, Yamamoto H, Uchinuma E, et al. Scanning electron microscopic study on double
and single eyelids in Orientals. Aesthetic Plast Surg 25:20, 2001.
13. Chen WP. The concept of a glide zone as it relates to upper lid crease, lid fold, and application
in upper blepharoplasty. Plast Reconstr Surg 119:379, 2007.
14. Collin JR, Beard C, Wood I. Experimental and clinical data on the insertion of the levator pal-
pebrae superioris muscle. Am J Ophthalmol 85:792, 1978.

1984.

comparison to the Caucasian eyelid. Arch Ophthalmol 117:907, 1999.
17. Siegel R. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg 13:263, 1984.
18. Kim DW, Bhatki AM. Upper blepharoplasty in the Asian eyelid. Facial Plast Surg Clin North Am
15:327, 2007.
19. Chen WP. Asian blepharoplasty. Update on anatomy and techniques. Ophthal Plast Reconstr
Surg 3:135, 1987.
20. Johnson CC. Epicanthus and epiblepharon. Arch Ophthalmol 96:1030, 1978.
21. Flowers RS. Asian blepharoplasty. Aesthet Surg J 22:558, 2002.
22. Yoon KC, Park S. Systematic approach and selective tissue removal in blepharoplasty for young
Asians. Plast Reconstr Surg 102:502, 1998.

24. Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty. Clin Plast
Surg 20:193, 1993.
25. Siegel RJ. Contemporary upper lid blepharoplasty—tissue invagination. Clin Plast Surg 20:239;
discussion 245, 1993.
26. Chen WP, ed. Asian Blepharoplasty and the Eyelid Crease, ed 3. Philadelphia: Elsevier Sciences,
2016.
27. Chen WP. Concept of triangular, trapezoidal, and rectangular debulking of eyelid tissues: ap-
plication in Asian blepharoplasty. Plast Reconstr Surg 97:212, 1996.
28. Chen WP. Beveled approach for revisional surgery in Asian blepharoplasty. Plast Reconstr Surg
120:545; discussion 553, 2007.
29. Baek SM, Kim SS, Tokunaga S, et al. Oriental blepharoplasty: single-stitch, nonincision tech-
nique. Plast Reconstr Surg 83:236, 1989.
30. Wong JK. A method in creation of the superior palpebral fold in Asians using a continuous
buried tarsal stitch (CBTS). Facial Plast Surg Clin North Am 15:337, 2007.


12:269, 2010.
32. Choi HS, Whipple KM, Oh SR, et al. Modifying the upper eyelid crease in Asian patients with


Reconstr Surg 127:1323, 2011.

482
Soft tissue depressions at the lid-cheek junction represent some of the most

The term
development of 1
Contemporary use of the term refers to a variable spectrum of soft
tissue deformities across the lid-cheek junction that are a direct result of the interplay
of complex, age-related changes that occur in the lower lid and midcheek.
• Correction of these deformities may therefore include procedures directed at
rejuvenating both the lower lid and midcheek areas depending on their severity.
TERMINOLOGY2
Natural sulcus directly overlying the medial one third of the inferior
orbital rim.
• “Tear trough deformity” refers to a prominent nasojugal groove.
Prominent depression at lid-cheek junction inferolateral to
nasojugal groove.

Region of cheek medial to a line extending from the frontal process of the
zygoma to the oral commissure and from the lower lid to the nasolabial fold.
• Prezygomatic part: Overlies the skeleton of the midcheek.
• Infrazygomatic part: Covers the vestibule of the oral cavity.
Association of several anatomic characteristics giving rise to a
prominent tear trough (Fig. 37-1).
• Herniation of orbital fat
• Tight attachment of the
orbicularis retaining ligament
along the arcus marginalis
• Malar retrusion
GRADING SYSTEM
An objective system for grading
the severity of deformity has
been proposed by Barton et al.
3
• More severe deformities are
characterized by changes
not limited to the nasojugal
groove.



Herniation
of fat
Malar retrusion
Tight attachment of
retaining ligament
Tear trough triad.

483
Chapter 37 Correction of the Tear Trough Deformity
Grading System for Tear Trough Deformity


No medial or lateral lines indicating the arcus marginalis or the orbital rim
Contour is smooth and youthful; no transition at the orbit-cheek junction
0
Medial line or shadow is mild or subtle


I


II
Orbit-cheek junction shows a severe prominence, with an obvious step between orbit
and cheek
III
CLASSIFICATION OF MIDFACE MORPHOLOGY

junction and midface.4

Minimal
lower lid
aging
TYPE I
Minimal descent
of lid-cheek
junction
TYPE II
Moderate upper
lid aging with
brow ptosis
Lid-cheek junction
below orbital rim
Nasolabial fold
TYPE III
Upper lid aging
with mild ptosis
Lower lid laxity—
“round eye”
(scleral show)
Nasojugal groove
Malar bag
Tear trough
TYPE IV
ANATOMIC CONSIDERATIONS CONTRIBUTING TO DEFORMITIES AT

Periorbital and midcheek anatomy has been reviewed in detail in Chapter 22.
MEDIAL FAT PAD
Bulge extends anteriorly in a position superior to the inferiomedial orbital rim.
• Visually, this creates an apparent increase in the depth of the nasojugal groove.

484
Part VII Facial Surgery
Inferior descent is limited by the tight, direct attachment of the orbicularis to the
medial orbital rim.
SENIOR AUTHOR TIP: The medial fat pad can be quite vascular and care must be taken
in the dissection of this fat pad to prevent vascular injury that retracts into the orbit,
which can result in a retrobulbar hematoma.
CENTRAL FAT PAD
Inferior descent over the central orbital rim is not restricted and therefore occurs
progressively.

millimeters.

well as the length of the nasojugal groove.
With increasing magnitude of descent, a sulcus develops lateral and inferior to the
central fat bulge—the
• Palpebromalar groove creates a visible demarcation of the lid-cheek junction
laterally.
SENIOR AUTHOR TIP: The medial and lateral fat pads are separated by the “arcuate

medially to the medial canthal tendon. It is a retroseptal structure which functions to
prevent overaction of the inferior oblique muscle.
FESTOONS
Can be multifactorial
Skin and skin/muscle festoons can be addressed by redraping the skin and/or
skin/muscle in a more anatomic position.

orbitomalar retaining ligament with the subdermal collagen as the direction of the

SENIOR AUTHOR TIP: It is very important to identify festoons and their etiology prior
to surgery so that they can be addressed and patient expectations for swelling in this
area can be properly addressed.
INDICATIONS AND CONTRAINDICATIONS
Main indication is the presence of enough deformity so that surgery may make a
8

and .4
• Patients who have these characteristics should be discouraged from injectables
alone, as they are highly likely to have an undesirable result.

485
Chapter 37 Correction of the Tear Trough Deformity
Nonsurgical management with injectables is a good option for to tear
trough deformities, but patient selection is paramount.9
NONSURGICAL AND SURGICAL TREATMENT OPTIONS
PREOPERATIVE EVALUATION FOR NONSURGICAL AND SURGICAL TREATMENT
Consideration of perorbital form and function, along with anatomy and patient
expectation, must be balanced with protecting lid function.10

• The distance from the pupil to the lower eyelid margin (MRD-2)
• The distance from the pupil to the tear trough
• The width of the tear trough
• The intercanthal angle
These quantitative measurements can allow for objective preoperative and post-
operative assessment and allow for more predictable results.11
SENIOR AUTHOR TIP: Assessment of lower eyelid laxity via the snap test is important
in assessing whether lower eyelid tightening, and/or shortening, should be performed
at the time of blepharoplasty surgery.
INFORMED CONSENT FOR NONSURGICAL AND SURGICAL TREATMENT
Managing patient expectations cannot be overstated.

Correction, not elimination of the defect, should be properly emphasized.
If injectables are selected, a discussion about embolization should be included in the
consent.12
NONSURGICAL TREATMENT

NOTE:



• Visible, mild to moderate tear trough deformity


• Minimal downtime
• Cost
• Minimally invasive

6-9 months.
14

• Temporary8
• Does not address skin pigmentation, wrinkles, or redundancy
• Very small but serious risk of vision loss
15

486
Part VII Facial Surgery

• With patient in upright position, mark area to be injected and provide local
anesthesia.
• Injection of material deep to dermis either in the orbicularis or at the
using parallel feathering technique to treat the area of
deformity
• To prevent bumps, injection should only be performed when the needle is being
withdrawn and never when stationary.
• Injection should cease before retracting the needle from the dermis.
TIP:
long periods of time (1 year) if untreated. It may also lead to persistent discoloration
of the lower lid.


• Bruising
• Irregularities

TIP:
injection of hyaluronidase (75 units in 3 cc of local anesthetic).
NONVASCULARIZED FAT GRAFTING
Injection of fat grafts has been reported and is extremely technique sensitive.
Irregularities may be permanent.

weight gain.
SURGICAL TREATMENT
Historically the deformity was treated by excision of herniating fat.

displacement have altered treatment philosophies.
is preferred over fat excision in younger
patients.
may be necessary in older patients or those with an increased
volume of orbital fat.
16

17,18
• Barton has substantiated the role of the septal reset in management of tear trough
deformities.19
• Care must be exercised to prevent lower eyelid malposition which is a well-known
sequelae of the

487
Chapter 37 Correction of the Tear Trough Deformity
TIP: When performing the septal reset procedure, it is helpful to have the lower eyelid
on stretch during the suturing of the orbital septum to its new position to prevent
excessive shortening of the middle lamella and minimize risk of lid malposition.

Browlift
dissection
Lateral orbit/temple elevated
using browlift procedure
Lower lid
suspended using
blepharoplasty
procedure
A
B
C
A, Trim overlap. B, Cut only as
necessary to close gap. C, Suture to orbit rim.
For mild deformity with vector positive or vector neutral orbits
Visible depression over the arcus marginalis can be improved approximately 50% by
release of the orbicularis retaining ligaments and orbicularis redraping.



Moderate to severe deformity: Vector negative orbits with tear trough triad

488
Part VII Facial Surgery
Sub Orbicularis Oculi Fat (SOOF) pad suspension from the arcus marginalis in
conjunction with septal reset, or by itself, can improve
the lid-cheek junction.
• Provides removal of redundant skin, redraping
of the orbicularis, and redraping of intraobital
fat across the orbital rim for correction of the
deformity.
21
Comprehensive technique to address changes at the
eyelid-cheek junction as well as repositioning ptotic
midface soft tissues.
Slightly higher incidence of complications (lateral
orbital skin excess, deformities of the lateral canthus,
and lower lid malposition) than traditional lower
blepharoplasty techniques.
Careful attention to lower lid laxity, orbit vector status,
and lower lid supporting techniques (canthopexy) are
critical to successful outcome.

Initially described by Flowers,1 due to the thin tissue qualities, grafts in the tear trough
may be palpable and create visible irregularities.
TOP TAKEAWAYS

Management of tear trough deformities requires an intimate knowledge of


treatment options with the patient.

Patients should be educated that improvement in the contours and not
complete elimination is the goal.

Patients should be informed that pigmentation characteristics of the skin may
not be changed but improving the contours will improve shadowing that can

REFERENCES
1. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 20:403,
1993.

Plast Reconstr Surg 110:885, 2002.
3. Barton FE, Ha R, Awada M. Fat extrusion and septal reset in patients with the tear trough triad:
a critical appraisal. Plast Reconstr Surg 113:2115, 2004.
Repair septal
hernia
Advance arcus
marginalis
(septum plus fat)
Septal reset.

489
Chapter 37 Correction of the Tear Trough Deformity
4. Hester TR Jr, Codner MA, McCord CD, et al. Evolution of technique of the direct transblepha-
roplasty approach for the correction of lower lid and midfacial aging: maximizing results and
minimizing complications in a 5-year experience. Plast Reconstr Surg 105:393; discussion 407,
2000.
5. Haddock NT, Saadeh PB, Boutros S, et al. The tear trough and lid/cheek junction: anatomy and
implications for surgical correction. Plast Reconstr Surg 123:1332, 2009.

stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and
the lateral suborbital trough deformity. Plast Reconstr Surg 106:479; discussion 467, 2000.
7. Mendelson BC. Discussion: Fat extrusion and septal reset in patients with the tear trough triad:
a critical appraisal. Plast Reconstr Surg 113:2122, 2004.
-
const Surg 120(6 Suppl):74S, 2007.
9. Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr
Surg 125:699, 2010.
10. Jindal K, Sarcia M, Codner MA. Functional considerations in aesthetic eyelid surgery. Plast
Reconst Surg 134:1154, 2014.

cheek junction. Plast Reconstr Surg 128:775, 2011.
12. Bailey SH, Fagien S, Rohrich RJ. Changing role of hyaluronidase in plastic surgery. Plast Reconstr
Surg 133:127e, 2014.

Reconstr Surg 120(6 Suppl):74S, 2007.
14. Donath AS, Glasgold RA, Meier J, et al. Quantitative evaluation of volume augmentation in

Surg 125:1515, 2010.

review of the world literature. Dermatol Surg 41:1097, 2015.

17. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast
Reconstr Surg 96:354, 1995.
18. Hamra ST. The role of septal reset in creating a youthful eyelid-cheek complex in facial rejuve-
nation. Plast Reconstr Surg 113:2124, 2004.
19. Barton FE, Ha R, Awada M. Fat extrusion and septal reset in patients with the tear trough triad:
a critical appraisal. Plast Reconstr Surg 113:2115, 2004.
20. Barton FE. Eyelids. In Facial Rejuvenation. New York: Thieme Publishers, 2008.
21. Hester RT, Codner MA, McCord CD, et al. Evolution of technique of the direct transblepharo-
plasty approach for the correction of lower lid and midfacial aging: Maximizing results and
minimizing complications in a 5 year experience. Plast Reconstr Surg 105:393, 2000.

490

performing blepharoplasty surgery.
Classically, lateral canthopexy was reserved for or with

is the most common complication of lower lid
blepharoplasty.1

of mechanical distraction secondary to cicatricial and gravitational forces, and
attenuation of lid supporting structures.
• Secondary forces result from eyelid edema, hematoma, chemosis, and disruption of
orbicularis innervations.

blepharoplasty in the appropriate patient.2,3
Contemporary blepharoplasty techniques aim to correct more than merely skin laxity
and therefore have the potential for increased distracting forces on the lower lid.
• These techniques should be used in conjunction with the consideration of routine
lateral canthopexy.
4
TERMINOLOGY

often through the existing upper and lower blepharoplasty

component of the lateral canthal tendon from the
orbicularis muscle. A double-armed suture is placed from
the lower blepharoplasty incision and passes superolateral
to the internal orbital rim periosteum above Whitnall
tubercle and exits the lateral upper eyelid incision. This
direction can be vectored according to the patient’s unique
presentation and orbital morphology.
Tightening of the lateral canthus while
of the canthus to the orbital rim
Tightening or repositioning the lateral canthus using transection
or resection and to the orbital rim

491
Chapter 38
TIP: These terms are sometimes used interchangeably and a canthopexy, as originally
described by Flowers et al,5 was a simple suture canthal suspension without any release.
A canthoplasty was used to indicate surgical division of the lateral commissure in


in primary cosmetic lower blepharoplasty.
ABSOLUTE INDICATIONS FOR LATERAL CANTHOPEXY
Any procedure attempting to correct a preexisting lower lid
deformity, even in a situation of primary blepharoplasty without prior surgery, should
incorporate a lateral canthopexy.
• Scleral show between the lower lid margin and inferior limbus may indicate lower lid
deformity.
• Canthal dystopia where the lateral canthal position is caudal to the lid margin and/or
medial canthus.



Manual anterior distraction of the lid from the globe


its normal position. Delayed return or persistent eversion indicates lid laxity.
RELATIVE INDICATIONS FOR LATERAL CANTHOPEXY
Any blepharoplasty procedure involving more than isolated transconjunctival fat
removal or isolated minimal skin excision
PREOPERATIVE EVALUATION
6
1. Vector analysis
2. Tarsoligamentous integrity
3. Scleral show
4. Canthal tilt
5. Distance from lateral canthus to orbital rim soft tissue
6. Midface projection and position
7. Vertical restriction
CHARACTERIZATION OF LOWER LID DEFORMITY
Understanding the cause of a lower lid deformity is essential in selecting a lateral
canthopexy technique.
Results from acquired laxity of the normal lower lid support
mechanism


lid support to prevent deformity postoperatively.

492
Part VII Facial Surgery
Results from contractile forces of the scarring process; may

of the lid from
its retracted position.

(transosseous) to counteract the forces of scarring and prevent recurrent
deformity.
TECHNIQUES
SUPERFICIAL RETINACULAR LATERAL CANTHOPEXY
Involves tightening lateral retinaculum to superomedial aspect of lateral orbital rim 6
(Fig. 38-2)

rim
Suture

tendon

• Does not disinsert lateral canthus
• May raise position of lateral canthus
SENIOR AUTHOR TIP: I originally described this form of lateral retinacular (canthal)

eyelid surgical procedures utilizing, in most situations, existing upper and lower eyelid

the retinacular orbicularis muscle, to allow mobilization of a portion of the tendon
rather than a simple suture canthopexy without release that was typically temporary
at best. The release allows for further mobilization as well as the ability to suspend the
orbicularis muscle separately and more securely with separate vectoring. This provides
both canthal suspension and stabilization that allows for the appropriate orbicularis
suspension that improves lower eyelid/cheek junction deformities and also provides
additional lower eyelid support allowing for appropriate skin resection while avoiding
lower eyelid malposition.
Unlike what has been a concern regarding lateral canthal procedures when one
considers them all “the same,” they certainly are not and suspension procedures like

stabilization during the healing phase of blepharoplasty and the eyelid position and
canthal tilt more commonly return to the preoperative state in a matter of weeks.

493
Chapter 38
IN INE CANTHOPEXY
Involves tightening lateral canthus directly to Whitnall tubercle2 (Fig. 38-3)
In-line lateral canthopexy.
Aperture width restored

In-line plication of
lateral canthal tendon
to Whitnall tubercle
• Does not alter position of lateral canthus
TIP:

orbicularis suspension) or release are performed simultaneously.
TRANSCANTHO ANTHOPEXY
Similar to in-line canthopexy, this is a temporary lid stabilization technique (Fig. 38-4).
Transcantho-
canthopexy.
ORBICULARIS SUSPENSION
Although not truly a canthopexy, this maneuver, in addition to redraping the ptotic

composite facelifting and midface lifting techniques
8 (Fig. 38-5).

494
Part VII Facial Surgery

orbicularis. B, The pennant flap is then used to provide upward mobilization of the ptotic
orbicularis, tunneled deep to the lateral canthus and then anchored with permanent suture to the
superomedial aspect of the lateral orbital rim periosteum.
A
B
SENIOR AUTHOR TIP: Orbicularis suspension should be considered as an integral
component of comprehensive lower blepharoplasty as it accomplishes a combination


TRANSOSSEOUS CANTHOPEXY

ectropion
• Canthal anchoring suture is passed through a burr hole in the lateral orbital rim and
secured to the deep temporal fascia
7 (Fig. 38-6).
In-line drill hole
through orbital rim
Suture to
temporalis fascia
Transosseous canthopexy is reserved mostly for constructive/secondary lower

cannot be achieved with standard canthoplasty or canthopexy.

495
Chapter 38
SENIOR AUTHOR TIP: Originally popularized by Flowers, “drill hole” canthopexy was

the “bone” was required where a greater canthal deformity existed. This, however, did


and failure.
HORIZONTAL LOWER LID SHORTENING
9 (Fig. 38-7)
A
B
C
Horizontal lid shortening.
TARSAL STRIP RELEASE
The tarsal strip anchors the tarsus to the periosteum of the inferolateral orbit.
It is located inferoposterior to the lateral canthal tendon.

2
SENIOR AUTHOR TIP: This maneuver is more often required in scarred and cicatrized
situations where release is necessary for mobilization of the lower eyelid. However, it

in primary blepharoplasty.
CANTHOPLASTY CONSIDERATIONS

procedures.10
Standard canthal anchoring techniques may result in upward

and to accommodate

496
Part VII Facial Surgery
Deep-set eye.
TIP: Deep-set or enophthalmic eyes present a unique challenge since the lateral
commissure is usually at or near the orbital rim that requires supraplacement for any
lower eyelid support that further narrows the vertical palpebral aperture, and the
exaggerated (usually temporary) canthal tilt frequently lasts longer than one would
expect.
Standard canthal anchoring techniques may result in downward
clotheslining of lower lid. This creates retraction of the lid, scleral show, and
enlargement of the lateral triangle (Fig. 38-9).
Supraplaced canthoplasty.
TIP: Prominent eyes (i.e., high myopia, thyroid exophthalmos, large negative vectors)

lateral orbital tubercle). A more lateral placement of the suspension suture more often
allows suspension without “clotheslining.”
to accommodate

497
Chapter 38
POSTOPERATIVE CARE
Patients should be advised to expect a temporary change in the canthal positions,

Patients should be counseled that they will look presentable 2-3 weeks after surgery.

Ophthalmic antibiotic ointment should be used for routine incision care.
COMPLICATIONS
Most common
• Scleral show
• Ectropion

Chemosis: Also common and will usually resolve spontaneously
See Chapter 35 for complete list of complications.
TOP TAKEAWAYS

Canthopexy or canthoplasty should be considered a routine component in
aesthetic blepharoplasty procedures.

Critical evaluation of each patient’s periorbital morphology, lower lid laxity, and

anchoring procedure.
REFERENCES
1. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 20:417, 1993.

canthopexy. Plast Reconstr Surg 103:2042, 1999.
3. Trussler AP, Rohrich RJ. MOC-PSSM CME article: Blepharoplasty. Plast Reconstr Surg 121(1
Suppl):S1, 2008.
-
sary? A 30-year review. Plast Reconstr Surg 128:265, 2011.
5. Flowers RS, Nassif JM, Rubin PA, et al. A key to canthopexy: the tarsal strap. A fresh cadaveric
study. Plast Reconstr Surg 116:1752, 2005.
6. Tepper OM, Steinbrech D, Howell MH, et al. A retrospective review of patients undergoing
lateral canthoplasty techniques to manage existing or potential lower eyelid malposition: iden-

7. Barton FE. Eyelids. In Barton FE, ed. Facial Rejuvenation. New York: Thieme Publishers, 2008.
8. Hamra ST. The role of septal reset in creating a youthful eyelid-cheek complex in facial rejuve-
nation. Plast Reconstr Surg 113:2124, 2004.
9. Hester TR Jr, Douglas T, Szczerba S. Decreasing complications in lower lid and midface rejuve-
nation: the importance of orbital morphology, horizontal lower lid laxity, history of previous
surgery, and minimizing trauma to the orbital septum: a critical review of 269 consecutive
cases. Plast Reconstr Surg 123:1037, 2009.

2003.

498
DEFINITION
Blepharoptosis is drooping of the upper lid margin to a position that is lower than normal.
(Normal upper lid position is at the level of the upper limbus.)
ANATOMY1

superioris muscle
Orbital septum

aponeurosis
Tarsus
Superior tarsal muscle
(Müller muscle)

Normal
lid fold
A

superioris muscle


aponeurosis
Superior transverse
ligament (Whitnall)
Medial
horn
C

Fatty degeneration of levator
palpebrae superioris muscle
Normal edge
of medial horn
Degeneration of
medial horn
D

PTOSIS
Orbital septum
Tarsus

dehiscence and retraction
B
High lid fold
LEVATOR APONEUROSIS

Orbicularis oculi, dermis, tarsus

499
Chapter 39 Blepharoptosis
Superior division of oculomotor nerve (CN III)
Provides 10-12 mm of eyelid elevation
Develops in the third gestational month from the superior rectus muscle
Anterior lamella of the levator muscle forms aponeurosis
Posterior lamella of the levator muscle forms Müller muscle
Approximately 2-5 mm above the tarsus the anterior portion of the levator aponeurosis
joins the orbital septum.
MÜLLER MUSCLE
Posterior lamella of levator muscle
Superior border of tarsus
Sympathetics
Provides 2-3 mm of eyelid elevation
FRONTALIS MUSCLE
Galeal aponeurosis
Suprabrow dermis
Frontal branch of facial nerve
Elevates brow and upper eyelid skin
ETIOLOGIC FACTORS/PATHOPHYSIOLOGY
TRUE PTOSIS

PSEUDOPTOSIS: CONDITIONS THAT MIMIC TRUE PTOSIS
Retraction of contralateral lid can give appearance of ptosis on

Downward rotation of the globe with accompanying lid movement




CONGENITAL PTOSIS
Developmental dysgenesis in the levator muscle
Idiopathic persistent ptosis noticed shortly after birth
Usually not progressive



Decreased levator excursion

Ptotic eyelid generally higher than the normal eyelid during downgaze
Inheritance pattern unclear

500
Part VII Facial Surgery
TIP: History alone usually can distinguish congenital from acquired ptosis, but if there
is a question, lagophthalmos on downward gaze is characteristic of congenital ptosis,




•



•
and phimosis
•

•



ACQUIRED PTOSIS

•




•


Traumatic
•
• Allow recovery of myoneural dysfunction, resolution of edema, and softening of
scar (approximately 6 months).
• This can occur after cataract surgery from dehiscence of levator aponeurosis.

• Paralyzes levator muscle
• Paralyzes Müller muscle
•




• Upper lid tumors
• Severe dermatochalasis (excessive upper lid skin), brow ptosis

501
Chapter 39 Blepharoptosis
EVALUATION
DETERMINATION OF CAUSE
Congenital or acquired
TIP:
which is more commonly seen with congenital cases.
DEGREE OF PTOSIS
Always compare with contralateral side.
Measure amount of descent over upper limbus.
• 1-2 mm: Mild
• 3 mm: Moderate
• 4 mm or more: Severe

Degree of Ptosis





1-2 mm
3 mm

LEVATOR FUNCTION
Measure from extreme downward gaze to extreme upward gaze while immobilizing the
brow.

5-10 mm: Fair
<5 mm: Poor
Levator Function

Good




5-10 mm
0-5 mm
PREOPERATIVE EVALUATION FOR DRY YE SYMPTOMS
(see Chapter 34)
Upward rotation of globe when eyes forcibly opened, corneal
protective mechanism during sleep
Advanced ophthalmologic
tests useful to further characterize causes of dry-eye symptoms
TIP: General rule: If contact lenses can be worn, then tear production is adequate.
Scleral show or lower lid laxity—patient more prone to

position or tone in conjunction with ptosis correction

502
Part VII Facial Surgery
TIP: All ptosis procedures cause lagophthalmos; therefore dry-eye symptoms must
be evaluated preoperatively.
CONTRALATERAL EYE

4

• Severe ptosis on one side creates impulse for bilateral lid retraction. Therefore, if the

which may reveal ptosis of the contralateral side.

• Attempt to reveal contralateral ptosis.

tipped applicator to alleviate ptosis; then examine for contralateral ptosis.
LID CONTOUR AND LID CREASE
Evaluate contralateral lid contour and lid crease to determine proper postoperative lid

OCULAR EXAMINATION
Assess general ocular visual function and consider ophthalmologic consultation for
formal examination.

COMPLICATING ISSUES

• Postoperative lagophthalmos with corneal exposure may threaten vision.

• This is seen in congenital cases. Ptosis repair can cause lid eversion.

• Medial horn of levator aponeurosis is commonly dehisced and creates temporal shift
of tarsus. Ptosis repair must recenter tarsus.

• Correction of ptosis in the severe eye can unmask ptosis in the contralateral eye.

• Ptosis gives illusion of narrower intercanthal distance; if widened preoperatively,
patient should be informed about possible appearance of telecanthus
postoperatively.
ANESTHESIA FOR PTOSIS REPAIR
IV sedation with local anesthetic
Useful for mild to moderate degrees of ptosis correction in cooperative patients
Most amenable to anterior-approach levator surgery
Allows active patient participation with eye opening and closure so that precise
correction can be achieved

503
Chapter 39 Blepharoptosis
TECHNIQUE
Inject local anesthetic (use sparingly).
Expose aponeurosis.
Place key sutures.
Have patient sit upright and focus on premarked spot on distant wall.
Adjust key sutures until ptosis is corrected at appropriate level.
TIP:
results.
CHOICE OF SURGICAL PROCEDURE
Algorithm for ptosis repair.

or advancement
Frontalis suspension
Aponeurotic repair
5-10 mm function
usually congenital/myogenic
Patient with Blepharoptosis
Evaluate levator function
<5 mm function
usually congenital/traumatic

usually involutional
If of levator excursion (excellent), then or
If of excursion (moderate), then or advancement
If of excursion (poor), then required
TIP: In patients with mechanical ptosis, treat contributing factor(s) (e.g., brow ptosis,
upper lid tumor).


which gives 0.5-1 mm of temporary lid elevation. If using epinephrine with
monitored anesthesia care, the operated side should be slightly overcorrected to
compensate for postoperative relaxation of Müller muscle.
FASANELLA ERVAT PROCEDURE
Conjunctival approach to excise tarsus, Müller muscle, and conjunctiva
Should be considered only when levator function is excellent with minimal ptosis
Avoids external incision—therefore cannot alter supratarsal crease
Somewhat less predictable than external approaches

504
Part VII Facial Surgery
A
B
C
D
E
The Fasanella-Servat (tarsal-conjunctival müllerectomy) procedure is indicated for
patients with good levator excursion and mild ptosis.


Appropriate candidates for surgery were tested with instillation of 2.5% phenylephrine
hydrochloride drops into the conjunctival sac.
Phenylephrine-stimulated contraction of the sympathetically innervated Müller muscle
provided an excellent guide to the results of Müller muscle–conjunctival resection10
(Table 39-3).
3.5-4.5 mm of folded Müller muscle conjunctiva complex is resected using a
noncrushing vascular clamp. This corresponds to the 7-9 mm resection length
determined by the phenylephrine evaluation.
Double-armed catgut is placed in a running horizontal mattress fashion and then
inserted from the conjunctiva through the external lid and tied loosely over the tarsal
plate.
Phenylephrine Response Guideline


Excessive lid elevation
7-7.5
Perfect height
8
Inadequate lid elevation
9
No response
Müller muscle–conjunctival resection not indicated
LEVATOR APONEUROSIS ADVANCEMENT11
Useful for mild to moderate ptosis
Amenable to monitored anesthesia technique

505
Chapter 39 Blepharoptosis
7 (Fig. 39-5)
• Incise skin at desired supratarsal fold.
• Expose orbital septum and distal
levator aponeurosis beneath

• Incise septum and retract preapo-
neurotic fat to expose the aponeurosis,

• Incise distal aponeurosis at the superior tarsal border, and dissect it free from Müller
muscle.
• Place a central-lifting suture: Double-arm 6-0 suture passed into superior tarsus and
levator aponeurosis. Tarsus will need to be recentered in cases of temporal displacement.
Patient with Involutional Ptosis
Determine the degree of ptosis
and verify good levator function
Moderate-severe ptosis

Minimal-moderate ptosis
Posterior MMCR
Adjunctive procedures
under local anesthesia
General anesthesia


+
+
Any other adjunctive
plastic surgery
procedures (e.g.,
blepharoplasty)
Algorithm for treatment of involutional ptosis. (MMCR, Müller muscle–conjunctival
resection.)
Dissection of the levator
aponeurosis.

muscle and
aponeurosis
Müller
muscle
Superior
arcade
Orbital
septum
Superior
tarsal plate
B
Orbital
septum

muscle and
aponeurosis
Orbicularis
oculi muscle
A

muscle and
aponeurosis
Double-arm
suture raises
superior tarsal
plate
Superior tarsal
plate
Müller
muscle
C

506
Part VII Facial Surgery
TIP: In general, 4 mm of levator advancement is needed for every 1 mm of ptosis
correction.
TIP: If this patient is under general anesthesia, a gapping method can be applied, in
which an advancement is performed until upper and lower eyelids are separated by an
amount corresponding to preoperative levator excursion.
• If levator excursion is 8-10 mm, upper lid should be slightly lower than the upper
limbus after advancement; if it is 6-8 mm, it should be at the limbus; if it is 4-6 mm,
it should be slightly higher than the limbus.
• Additional medial and lateral sutures are placed.

orbicularis.
Alternatively, levator aponeurosis advancement can be performed by exposing levator
muscle above Whitnall ligament and resecting muscle in ratio of 4:1 for desired
correction.
11

aponeurosis, performed concurrently with aesthetic facial procedures under general
anesthesia.
12
EXTERNAL LEVATOR RESECTION
Best used when levator function is fair

Conjunctiva
Clamp
Suture to
tarsus

Conjunctiva is then dissected free from the overlying levator complex. It should be dissected in
the fornix and reattached to the superior edge of the tarsus with absorbable sutures. This is then
resected.
TIP: Carraway and Vincent11 espouse levator advancement over external levator
resection because of improved results with less morbidity.

1. Incise skin and orbicularis muscle at the desired supratarsal crease.
2. Expose superior border of the tarsus.
3. Incise full-thickness through superior tarsal attachments and place ptosis clamp.
4. Dissect levator and Müller muscle complex from conjunctiva and orbital septum/
preaponeurotic fat; cut medial and lateral horns as necessary.

507
Chapter 39 Blepharoptosis
5. Remove full-thickness of levator aponeurosis/muscle and Müller muscle.
6. If there are 1-2 mm of ptosis with 8-10 mm of levator function,
resect 10-12 mm; if there are 2 mm of ptosis with 5-7 mm of levator function,
resect 18 mm.
7. Use the gapping method.
LEVATOR REINSERTION
Only useful in true levator dehiscence, which is likely only after trauma
Involves resuturing the dehisced end to the tarsus
Uncommon procedure because of uncommon indication
FRONTALIS SUSPENSION
Required if levator function
(<5 mm) (congenital cases, neurogenic
cases)
Can provide 1 cm of excursion; good
result in straightforward gaze; may
produce lagophthalmos while asleep,
which requires ointment or nighttime
patching
Incorporates a sling (fascia lata,
temporalis fascia, homograft fascia,
silicone strips, Gore-Tex) from frontalis
to lid
• If eyes are dry preoperatively
proceed with caution. Consider use
of biologic or alloplastic material so
level can be adjusted.
For unilateral congenital cases, bilateral
suspension performed to improve
symmetry

• Harvest 3 mm fascia lata strip.
• Use three supralash incisions at medial, central, and lateral limbus and three brow
incisions.
• Thread fascia submuscularly from upper lid to brow.


entropion seen with Crawford procedure
COMPLICATIONS12
Undercorrection
Overcorrection
Excessive lagophthalmos
Corneal exposure or keratitis, dry-eye syndrome
Eyelid contour abnormality, temporal overcorrection
Eyelid crease asymmetry
Fascia lata
A frontalis sling tethers the upper
eyelid to the frontalis muscle above by way of
alloplastic or autologous material beneath the
orbicularis oculi muscle.

508
Part VII Facial Surgery
Eyelash ptosis or lash abnormalities
Entropion or ectropion/eversion of the upper lid
Extraocular muscle imbalance
Conjunctival prolapse
TOP TAKEAWAYS

Congenital ptosis usually requires frontalis suspension.

Acquired ptosis is most often involutional.

For correction of involutional ptosis, use levator advancement with monitored
anesthesia and advance approximately 4 mm for every 1 mm of desired lid
elevation.
REFERENCES

2008.
2. McCord CD. The evaluation and management of the patient with ptosis. Clin Plast Surg 15:169,
1988.
3. McCord CD. Evaluation of the ptosis patient. In McCord CD Jr, Codner MA, Hester TR, eds. Eyelid


the importance of Hering’s test. Plast Reconstr Surg 108:1527, 2001.
5. Carraway J. Correction of blepharoptosis. In Achauer BM, Eriksson E, Guyuron B, et al, eds.

6. Carraway JH. Cosmetic and function considerations in ptosis surgery: the elusive “perfect”
result. Clin Plast Surg 15:185, 1988.
-

2012.

Thieme Publishers, 2008.

82:775, 1988.

using Müller’s muscle-conjunctival resection. Plast Reconstr Surg 130:799e, 2012.

77:394, 1986.
12. de la Torre JI, Martin SA, De Cordier BC, et al. Aesthetic eyelid ptosis correction: a review of
technique and cases. Plast Reconstr Surg 112:655, 2003.
13. McCord CD Jr. Complications of ptosis surgery and their management. In McCord CD Jr, Codner

1995.

509
The human “middle of the face,” often called is a loosely applied anatomic term
that mainly focuses on the soft transition from the lower eyelid inferiorly toward the
rounder, upper cheek as it transitions into the lateral face, upper lip, and soft tissue of the
nasal sidewall. Thus a problem arises when any anatomic component within this
region begins the aging process.
HISTORY
In the early twentieth century, surgical procedures to address facial aging consisted of skin

RENAISSANCE ERA S 1
Early 1970s: Skoog2
dissection.
1976: Mitz and Peyronie3

These advances improved the appearance of the lower third of the face and neck, but
not the midface.
DIFFERENT PLANES OF DISSECTION ERA 1
Craniofacial surgeons, like Tessier,4 introduced subperiosteal approaches to better
reposition facial soft tissues.
• “Mask lift”: subperiosteal dissection of the malar region, zygomatic arches, and
orbital region
• Soft tissues dissected and redraped over the facial skeleton to rejuvenate the face
1984: Psillakis5 attempted to reposition/elevate the soft tissues of the orbital and

aponeurosis of the temporalis.
1990: Hamra6 introduced the deep plane rhytidectomy, combining a Skoog-type
sub-SMAS dissection over the zygomaticus musculature and medially to fully release


1992: Hamra7
“composite rhytidectomy.” Through a transblepharoplasty incision, the orbicularis oculi
was undermined, and this plane was connected to the facelift dissection plane. This

repositioned, addressed the three major areas of soft tissue ptosis.

510
Part VII Facial Surgery
1992: Barton8 provided a better understanding of the sub-SMAS plane and its
relationship to the nasolabial fold. Anatomically, within the medial cheek the SMAS
becomes the investing fascia of the zygomaticus major and minor.

the deepened nasolabial fold.
• He recommended that, to address the fold, medial to the zygomaticus musculature
the dissection must transition to skin–subcutaneous tissue plane to release the

1993: Owsley9 malar fat pad as a “discrete area of bulky subcutaneous
fat, which overlies the maxillary zygomatic region.” The fat pad is triangular in shape
and has its base at the nasolabial fold. He advocated dissecting below the fat pad to
completely mobilize it and then suspending it under tension to the subcutaneous fascia
over the malar eminence with a vector perpendicular to the nasolabial crease (Fig.
40-1).
Malar fat pad
Elevation and mobilization of the malar fat pad.
ADVANCED TECHNIQUES ERA 2
1992: Terino10 described his concept of addressing the “fourth plane.”
• Advocated the use of alloplastic facial augmentation in conjunction with concepts of
facial zonal anatomy to address volume loss in the midface
1993: Flowers11 describes the tear trough deformity and used alloplastic implants for
volumetric correction.
1994: Coleman12
and suspend?”

region through fat grafting
1994: Facial surgeons, including Fuente del Campo,13 Isse,14 and Ramirez,15 started to
incorporate the endoscope into facial rejuvenation.
• 1995: Ramirez described six types of procedure combinations for rejuvenation of
the upper and middle third of the face.
• Types four through six addressed the midface and consisted of full open, full
endoscopic, and biplanar combined procedures.

511
Chapter 40 Midface Rejuvenation
VECTORS AND VOLUME ERA RESENT 1
Concepts of volume management of the midface and correct vector of elevation/pull
15,16 described a volumetric approach to midface rejuvenation, both in the
subcutaneous and subperiosteal plane.

region.
Vectors of pull in rejuvenative surgery were reassessed, and a more
direction of pull was advocated, especially for procedures addressing the
midface.
PERTINENT ANATOMY
BASIC DEFINITION OF THE MIDFACE
Portion of the cheek medial to a line extending from the frontal process of the
zygoma to the oral commissure and from the lower lid above to the nasolabial fold
below
17
Anatomically, the midface thus encompasses complex relationships of the lower lid, the
nasolabial fold, the upper lip, and the malar eminence/cheek.
BASIC ANATOMY

• Main determinant of contour of the midface, although the thickness of the soft
tissue component is important, especially with changes in aging
• Serves as platform for attachment of the overlying ligaments and muscles, which
support the midface soft tissues
• Upper/outer prezygomatic portion: Overlies the body of the zygoma

cavity









elongates, becomes
narrower, and displaces inferiorly



• SMAS


the zygoma and mandible


region

512
Part VII Facial Surgery

• Midface retaining ligaments20 (Fig. 40-2)
Retaining ligaments of the midface and orbit.
Temporal
ligamentous
adhesion
Adhesions
Temporal branches
of facial nerve
Supraorbital ligamentous
adhesion
Zygomatico-
temporal nerve
Inferior
temporal
septum
Sentinel vein
Lateral brow thickening
of periorbital septum
Lateral orbital thickening
of periorbital septum
Periorbital septum
Thickenings
Septum
Zygomatic branch
of facial nerve
Temporalis
muscle
A
Lower lid bulge
Malar bag
Orbitomalar
ligament
Suborbicularis
oculi fat
Orbitomalar
ligament
Zygomaticocutaneous
ligament
B
21


(see Chapter 43)

overlying muscles of facial expression
• Complex facial anatomic structure
• Prominence adds to aged appearance
• Contributes to midface aging
• Surgical correction is complex and controversial
as to the ideal procedure.
(see Chapter 37) (Fig. 40-3)
• Also known as nasojugal groove

• Medial aspect of the lower eyelid
• Becomes more prominent with loss of cheek
volume and descent of midface structures;
groove often accentuated by herniated orbital fat


of the orbital rim after descent of the malar
fat pad.
Tear trough
Herniation of
orbital fat
Tear trough.

513
Chapter 40 Midface Rejuvenation
of the inferomedial orbicularis oculi,
levator alaeque nasi, and levator labii superioris, which is located inferior to
the orbital rim and becomes apparent with volume loss in this area.

• Orbicularis oculi


tissues of the eyelids
TIP: Repositioning the lateral canthus and orbicularis oculi muscle, thus shortening
the apparent length of the lower eyelid, is crucial to re-creating a youthful appearance
of the periorbital region and midface.


• Risorius: Important for smiling

• Orbicularis oris
• Masseter

18 (Fig. 40-4)
Superficial temporal artery
Occipital artery
Posterior auricular artery
Vertebral artery
Facial artery
Maxillary artery
Transverse facial artery
Supratrochlear artery
Common carotid artery
External carotid artery
Internal carotid artery
Superior thyroid artery
Inferior thyroid artery
Inferior labial artery
Superior labial artery
Submental artery
Angular artery
Mental artery
Deep cervical artery
Blood supply.
• Mainly from branches of the

periorbital region
• Facial artery
• Internal maxillary artery

514
Part VII Facial Surgery
• Infraorbital artery





• Transverse facial artery


• Sensory: Branches of CN V2 (trigeminal)





enter near inferior lateral aspect entering on the posterior aspect of the muscle.

midcheek, which passes deep to the zygomaticus major.



APPLIED ANATOMY
The midface is divided into an and a segment.
segment is called the midcheek.22
• Midcheek is the portion of the midface on the anterior aspect of the face, extending
from the lower eyelid caudally to the nasolabial groove and upper lip22 (Fig. 40-5, ).
• The aesthetically pleasing fullness of the youthful cheek is produced by the midcheek.
As a person ages, changes in the midcheek reveal that it comprises three distinct
anatomic structures22 (Fig. 40-5, B).

2. Malar segment
3. Nasolabial segment
Subcutaneous compartments of the midcheek.
Anterior
aspect
Lateral
aspect
A
Nasolabial
Malar
Lid-cheek
Palpebromalar groove
Nasojugal groove
Midcheek groove
B

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Chapter 40 Midface Rejuvenation

during the aging process is important to adequately correct changes that occur over
time.

segments become separated by
22
1. superolaterally
2. Medially
3. Inferolaterally
These three grooves intersect to form an 22
• The midcheek groove runs essentially parallel to the nasolabial fold; cephalically, it
extends into the nasojugal groove.
• The palpebromalar groove extends laterally toward the lateral canthus at the
cephalic limit of the midcheek.



Epidermal thinning and the development of rhytids

Descent of soft tissues from attenuation of ligamentous structures, causing the
development of prominent grooves and a gaunt look from volume loss
Changes in the skeletal support structure of the midface

and
• May be the creating individual variation of facial appearance
Studies have shown the of the midface with age.
• Pessa et al23 suggested that age-related changes in bone structure led to posterior
retrusion of the inferior orbital rim and the anterior maxilla.
• Using facial CT scans to assess midface skeletal changes in male and female patients,
Mendelson et al
24 found that the angle between the anterior maxilla and the orbital

• Yet, in contrast to previous reports, Mendelson found that the inferior orbital rim

appearance of the
lid-cheek junction, as described by Jelks et al.
25
• Shaw and Kahn26
glabellar and maxillary angles with increasing age.
• These studies all contrast the earlier notion that facial skeletal aging changes
consisted of growth and expansion with advancing age.
• Recent data intuitively make sense, because these skeletal structures serve as the
foundation of the midface soft tissues and the site of attachment of the muscles
of the lower lid and upper lip and the supporting/retaining ligaments of the
midface.
• Pessa et al
23 and Mendelson et al24 showed greater changes in maxillary angles in
males during aging. The posterior displacement of the anterior maxilla leads to loss
of soft tissue support, which, in addition to soft tissue volume loss, accentuates the
aging changes in the midface.
• Skeletal support loss could explain the descent of the malar fat pad/soft tissues

structure.

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Part VII Facial Surgery



1. Skin
2. Subcutaneous tissue
3. Musculoaponeurotic layer

5. Fixed periosteum and deep fascia
Anatomic structure of the midface can be equated with that of the scalp22 (Fig. 40-6).
Zygomatic branch of facial nerve
Parotid duct
Lower buccal branch of facial nerve
Upper buccal branch of facial nerve
Upper mandibular branch
of facial nerve
Premasseter space
Mandibular ligament
Masticator space
Key masseteric cutaneous ligaments


musculoaponeurotic layer to the skin.






• In the midface and cheek, within the
SMAS layer. These muscles have more attachments to the overlying skin than to the
underlying skeletal structures.
TIP: Intuitively, this makes sense, because the action of these muscles produces our
facial expressions rather than movement of joints.

layer. In the scalp this loose areolar layer acts as a simple glide plane. In the midface
it retains this function but also contains the which serve

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Chapter 40 Midface Rejuvenation
Midface retaining ligaments
• Orbicularis retaining ligament

• Upper masseteric ligament
Within level four between the retaining ligaments are large areas where there

of the mimetic muscles.
22
• The of these spaces is formed by the
• The is formed by the
form the

the vascular structures.
In the midface, the soft tissues overlie free space more than solid skeletal bone.
22 (Fig. 40-7):
1. Preseptal
2. Prezygomatic
3. Masticator
4. Oral cavity
Preseptal
Prezygomatic
Oral cavity
Masticator
Upper masseteric ligament
Zygomatic ligament
Orbicularis retaining ligament
Four major midface spaces.
The ligaments fan out within the SMAS layer forming a perpendicular network of the
retinacular cutis.

• As the face ages, facial bulges
lose their strength, allowing the soft tissues overlying the facial spaces to become
distended. The strong ligamentous attachments to the dermis resist this distension
and appear on the skin as deep grooves.
22
• These changes, coupled with the well-documented skin changes of aging, produce
the characteristic aging of the midface.

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Part VII Facial Surgery
ASSESSMENT OF THE MIDFACE

the face”27
Facial aging is the result of several factors, including:
• Skin laxity
• Ptosis of soft tissues
• Volume loss within the soft tissues
• Changes within the skeletal structure of the facial bones
28
Hester and Szczerba19 within the
midface during the aging process:
1. Gradual ptosis of the cheek skin below the inferior orbital rim with descent of the
attenuated lower eyelid skin, creating a skeletonized appearance with infraorbital
hollowness
2. Descent of the malar fat pad, with loss of the malar prominence
3. Deepening of the tear trough
4. Exaggeration of the nasolabial fold
Anatomic components of lower lid and midface aging include19 (Fig. 40-8):
Midsagittal anatomy of the midface. A, Youthful midface. B, Aged midface. ( ,
Suborbicularis oculi fat.)
Orbitomalar
ligament
Orbital septum
Zygomaticus major muscle
SOOF
Zygomaticocutaneous
ligament
Orbitomalar
ligament
Orbital septum
Zygomaticocutaneous
ligament
Malar fat pad
A
B


• Descent of the lid-cheek junction
• Horizontal laxity of the tarsal plate component of the lower eyelid
• Descent of the cheek fat pad with laxity of the orbitomalar ligament

• Some degree of deepening of the nasolabial fold

structures of the midface, as described previously, lead to the observed midface
changes of the aging process.

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Chapter 40 Midface Rejuvenation


The classic loss of cheek volume is the result of three processes18,29
1. Displacement (inferiorly) of soft tissue from ligamentous attenuation
2. Soft tissue and fat atrophy

SURGICAL PRINCIPLES
One of the greatest paradigm shifts in the approach to facial rejuvenation, in particular
of the midface, occurred with the realization that simply undermining and redraping

of the face (i.e., soft tissue and facial skeletal support) did not adequately rejuvenate
the midface.
Recent advances, in particular the developments described by surgical anatomists, have
led to a better understanding of midface rejuvenation, including:
• Dissection planes
• Volume augmentation
• The concept of vectors and direction of lift
30
Mendelson31 has advocated the following principles as paramount in achieving lasting
results in addressing midface aging:
• Adequate release of soft tissues
• Appropriate vectors of elevation

The concept of in facial anatomy refers to the retaining ligaments of the face,
which attach the dermis to the underlying facial skeleton, as previously described.
• Functionally, these ligaments compartmentalize the face.
31


compartments.
• Surgical correction requires application of anatomically derived surgical principles
which facilitates
redraping and elevating of the soft tissues along appropriate vectors to achieve a
more youthful position and appearance
31 (Fig. 40-9).
Zygomaticocutaneous
ligament
Masseteric
cutaneous ligament
Superior
temporal septum
Orbicularis
retaining ligament
Regions of the face.

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Part VII Facial Surgery

compartment, which allows complete repositioning of the soft tissues.
• Use of multiple sutures within a compartment decreases the load exerted on any

31 (Fig. 40-10).
Repositioning using
multiple vectors
Principle of correction
of laxity of the lower lid.


potential distortion on the appearance of the face.
CHARACTERISTICS OF THE IDEAL MIDFACE LIFT
Ramirez32 described the following
procedure:
• Provides volumetric remodeling of the cheek
• Allows management of the skeletal foundation by augmentation or reduction
without additional incisions or alternative plane of dissection

of alternative grafts
• Corrects the fat pad herniation of the lower eyelid
• Corrects the V deformity of the eyelid-cheek interface

• Potential for treating the skin layer in the same operative setting without the risk of
skin necrosis or delay in healing
• Minimizes facial edema
• Minimizes facial numbness
• Minimizes facial nerve injury
OPERATIVE TECHNIQUES
FAT GRAFTING see C
Often used as an adjunct to a midface lift to address loss of volume
Anatomic areas within the midface that often need soft tissue augmentation include:
• Tear trough and infraorbital area
• Malar eminence
• Submalar region
• Nasolabial crease
The two most common areas that require volume augmentation are the
(to re-create a youthful convex appearance) and the