JC Blepharoplasty.pptx oral and maxillofacial surgery

Blepharoplasty

1. JOURNAL CLUB( Topic- Blepharoplasty) Presented by Dr Yashobanta Biswal Guided By Dr Ashish sharma Dr Himanshu Bhutani

2. Introduction The signs of periorbital ageing include dermatochalasis, skin hooding of the upper eyelids, lacrimal gland prolapse, adipose prolapse, and lateral canthal descent and orbital septum diastasis. All of these deformities can be addressed through upper and lower blepharoplasties with arcus marginalis release, lateral canthopexy, sub-periosteal midface rhytidectomy with temporal suspension of the malar mound and SOOF repositioning.

3. In the following report the technique and the authors’ experience in the rejuvenation of the periorbital and midface region are presented. There were a total of 20 patients in this series. Sixteen were female and 4 were male. All the patients were followed-up on a monthly basis after surgery for the first 6 months. They were then seen at 1 year post-surgery. All of the patients were evaluated by the senior author

4. P eriorbital and midfacial rejuvenation can be achieved via upper and lower blepharoplasties, lateral canthopexies and sub-periosteal midface rhytidectomy. The early signs of ageing of the periorbital area and middle facial third include attenuation of the orbital septum with pseudoherniation of periorbital fat with minimal muscle and skin excess.

5. There are 3 important layers or so called lamellae composing the eyelids. The skin of the eyelid and the underlying orbicularis oculi muscle makes up the anterior lamella . The orbital septum and the retractors compose the middle lamella , and the conjunctiva of the lower eyelid composes the posterior lamella . It is important to understand which layer is involved and needs correction while evaluating the eyelid deformities.

6. Patient selection and follow-up The proper candidates for sub-periosteal midface rhytidectomy and upper and lower blepharoplasties are individuals with isolated periorbital and midfacial ageing such as blepharochalasis , blepharoptosis, excess skin and fat, lateral canthal descent, orbital festooning, tear through deformities, deep melojugal folds, deep nasolabial folds and malar deficiency secondary to descent of the malar soft tissues due to ageing. These patients may not be candidates for formal, preauricular rhyti - dectomy or sub-periosteal mask facelift.

7. However, these above features may be present in patients with other stigmata of facial ageing, such as mandibular jowls, submental lipomatosis, platysmal diastasis, etc. In these patients besides the periorbital and midface rejuvenation a formal cervicofacial rhytidectomy is advisable. In this series, all of the patients were followed up monthly after surgery for the first 6 months and then were re-called after 12 months. All of the patients were eval- uated by the senior author.

8. Surgical technique Upper eyelid blepharoplasty The caudal incision is curvilinear and located at the expected position of the natural lid crease (1 mm cephalic to the upper tarsal plate). Laterally, the incision is carried beyond the lateral orbital rim in a natural skin crease within a crowfoot rhytid. The location of the incision is dictated by the amount of skin that needs to be excised .

9. The incision follows a ‘lazy-S’ and should incorporate more skin laterally and centrally to allow for superior elevation of the upper eyelid in these locations, which is considered to be a sign of youth and is desirable by the patients. It is important that the medial extent of the incision allows for good access to the medial fat compartment. Once the skin incision is completed, the excess skin and orbicularis oculi muscle are removed. This exposes the orbital septum and the protruding orbital fat compartments.

10. The septum may be opened through its full length when necessary. It allows access to the central and the nasal fat pad as well as to the lacrimal gland. Great care should be taken to avoid injury to the lacrimal gland. Adequate amount of fat is then excised from the central and nasal compartments. Applying gentle traction on the fat while carefully applying pressure on the globe and cauterizing its base to ensure haemostasis performs this.

11. Aggressive fat excision should be avoided to prevent a skeletonized or hollow appearance postoperatively. The excised skin, muscle and fat removed are kept on moist gauze to ensure equal excision bilaterally unless there are asymmetries noted preoperatively. The muscle is then reapproximated using 3–4 interrupted fastabsorbing sutures. Finally, the skin is closed using a few 6-0 Prolene interrupted sutures.

12. Lower lid blepharoplasty The lower blepharoplasty may be performed through standard subcilliary or crease incisions or transconjunctival if no skin needs to be removed. Prior to the application of the corneal shield, topical anesthetic is applied. The lower lid is then adequately anesthetized. A 5-0 silk suture is place at the level of the grey line to allow for retraction of the lower lid. Usually, the skin incision is stepped through the skin and muscle. It is important that adequate cuff of muscle is left on the tarsus to minimize postoperative lower eyelid retraction.

13. Preseptal dissection is then performed caudally using a combination of sharp and blunt dissection. Once the dissection is carried to the inferior orbital rim, the orbital septum is incised along the length of arcus marginalis , which exposes the 3 fat compartments ( Fig. 3 ).

14. Fat is then carefully removed as per the presurgical plan. The fat is gently teased, clamped and the base cauterized to ensure haemostasis . Most of the time minimal fat removal is necessary if at all. What is needed is mostly repositioning of the orbital fat, which had prolapsed through weakened orbital septum

15. The orbital fat is repositioned laterally and superiorly, thus recreating the gentle ‘S’- shaped malar contour characteristic of the youthful individuals in a profile and 3/4 view. One should try to avoid excessive resection of orbital fat since this leads to hollowed-out unnatural orbital appearance. Once adequate sculpting of the lower eyelid fat pads is performed, the wound is ready for closure. If the procedure is done transconjunctival there is usually no need for suturing of the conjunctiva.

16. Transblepharoplasty subperiosteal midface rhytidectomy This can be done either through lower lid blepharoplasty incision or through transconjunctival approach. Once the rim is reached, an incision is carried to the bone along the full length the anterior aspect of the inferior orbital rim. Using a periosteal elevator, wide sub-periosteal dissection is performed in a caudal direction to reach the maxillary alveolus, the piriform rim medially and the zygomatic buttress extending to the lateral orbital rim laterally ( Fig. 4 )

17. Great care is taken to avoid injury to the infraorbital, zygomatico - facial and zygomaticotemporal neurovascular bundles during the dissection ( Fig. 5 ). The so-called zygomatic mound should be completely free for superior and lateral repositioning. Two 2-0 Mersilene sutures are passed through the base of the midface dissection ( Fig. 6 ).

18. The first one is passed through the paranasal periosteum and musculature, while a second is passed through the malar area. The zygomatic mound is then resuspended superolaterally to the deep temporal fascia through the lateral aspect of the upper eyelid incision through a subcutaneous tunnel between the upper and lower blepharoplasty incision ( Fig. 7 ).

19. At this point it should be apparent that the cheek mound has been elevated and the nasolabial folds have been improved as compared to the non-operated side. The suspension sutures have to be firmly attached to the immobile deep temporal fascia. Care is to be taken not to carry the medial suspension suture too close to the medial aspect of the lower eyelid since this may interfere with the function of the eyelid postoperatively.

20. T he lateral canthal complex can also be resuspended superiorly to provide for rejuvenation of the eyelids. This is done with 4-0 Mersilene sutures placed subcutaneous at the area of the lateral retinaculum through the lower blepharoplasty incision and transported through the same subcutaneous tunnel to the superior blepharoplasty incision and tightened at the lateral orbital periosteum, which completes the lateral canthopexy. Steristrips , antibiotic ointment and cheek supporting dressings are applied at the end of the procedure.

21. Results In the majority of the patients there was pronounced oedema postoperatively, which subsided on an average of 6 weeks. This was of concern to some of the patients. We think that this prolonged oedema is due to the interruption of the lymphatic drainage due to the extensive dissection of the lateral orbital region. Most of the patients also experienced transitory decreased sensation in the dis- tribution of the infraorbital nerve. However, all recovered without residual deficit. All of the patients were satisfied with the outcomes of surgery ( Figs. 8–13 ).

22. Discussion The rejuvenation of the midface can be achieved through different approaches. For example, via standard preauricular rhytidectomy the McGregor’s fat pad can be resuspended and the nasolabial folds flattened through the action of the supero -lateral vector of suspension. The midface can also be quite effectively addressed through coronal incision during an open forehead lift or mask facelift This can also be accomplished endoscopically through minimal access incisions.

23. The authors believe that the subperiosteal midface rhytidectomy combined with lower and/or upper blepharoplasties are effective procedures for the rejuvenation of the midface and the periorbital region in the properly selected individuals.

24. A im The aim of this randomized controlled trial was to assess the patient- reported outcomes (PROs) of two different surgical upper blepharoplasty techniques.

25. Methods Study population All consecutive healthy White European patients between the ages of 30 and 70 years, who consulted the Department of Oral and Maxillofacial Surgery at the University Medical Center Groningen for an upper blepharoplasty between Feb- ruary 2018 and October 2019, were invited to participate. Patients were included if they showed dermatochalasis of both upper eyelids and an upper eyelid blepharoplasty was indicated.

26. Patients were excluded if they suffered from severe hollowing of the upper eyelid area (including A frame deformity), had a history of ocular or orbital trauma, a history of eyelid or eyebrow region surgery, had been subjected to other cosmetic surgical or nonsurgical procedures, had ophthalmic disease, or suffered from blepharoptosis.

27.   Study design A prospective, single centre , double-blind randomized controlled trial investigating PROs of upper blepharoplasties was designed. The study protocol was approved by the Institutional Review Board of the University Medical Center Gronin - gen (METc2017/451) and registered in the Netherlands Trial Register (ID NL7886). Written informed consent was obtained from all study participants. The 2010 CONSORT statement was applied in the reporting of this study.

28. Blinding and randomization ( Fig. 1 )

29. Eligible participants were assigned randomly to either treatment group A ( resec - tion of skin only) or group B (resection of skin and a strip of underlying orbicularis oculi muscle). Only the surgeons knew which treatment group the patient had been assigned to until the completion of the trial. Participants were informed about both surgical procedures, but did not know which treatment they had undergone, and received identical information about the postoperative course of events.

30. Outcomes Demographic data were recorded including age, sex, medical history, and use of medication. The severity of the dermato chalasis was assessed before upper blepharoplasty and categorized according to a four level photo numerical severity scale using anatomical cut off points: normal if the upper eyelid skin was not touching the eyelashes, mild if the upper eyelid skin was touching the eyelashes, moderate if the upper eyelid skin was hanging over the eyelashes, and severe if the upper eyelid skin was hanging over the eye . The tissue removed was weighed per eye and the weight recorded in grams.

31. PROs were obtained at baseline and at 6 and 12 months after the surgical upper blepharoplasty by means of validated FACE-Q questionnaires . The questions refer to the eyes in general, but also to the upper eyelids, forehead and eyebrows, overall face, age appearance appraisal, age appraisal, social functioning, and satisfaction with the outcome. Scale scores range from 0 (worst) to 100 (best), except for the age appraisal scale. Scarring was assessed at 12 months after surgery with the Patient and Observer Scar Assessment Scale (POSAS, version 2.0/NL)

32. Surgical procedure Preoperatively, with the patient in an upright position, the surgeon used a marking pen to draw the incision lines on the skin of the eyelids. The lid crease incision was marked first, by generally following the eyelid crease of the upper eyelid. A pinch technique was used to assess the maximum amount of skin to be removed. The patients were asked to close their eyelids gently. A pair of smooth forceps was used to grasp the excess skin above the eyelid crease incision until the eye- lashes began to rotate upwards. This was considered to be the maximum amount of skin that could be removed safely.

33. Approximately 1.7 ml of Ultracaine DS Forte (40 mg articaine , 10 mg epinephrine per millilitre ) local anaesthetic was injected subcutaneously per eye. After incising the skin with a scalpel, the excess skin was removed. Cauterization was used to achieve haemostasis . The group B participants then underwent subsequent removal of an ad ditional strip of the underlying orbicularis oculi muscle . The tissue removed was weighed per eye. The orbital septum was coagulated in order to create scarring and thereby to accentuate the eyelid crease better.

34. The muscle edges were approximated with two to three small bipolar coagulation spots. The skin was sutured with Ethilon 6–0 (Ethicon, Cornelia, GA, USA) intracutaneously in a running fashion and adhesive suture strips were placed. Photographs of the surgical tech- nique are shown in .

35. The participants were asked to avoid heavy lifting, sudden bending, and strenuous sporting activities for 7 days following the procedure. The patients were seen 7 days postoperatively to remove the suture strips and sutures, and after 2, 6, and 12 months to be examined and evaluated for potential complications.

36. When indicated, i.e. when a significant amount of protruding medial fat was present, the patients underwent removal of the protruding medial fat whereby the orbital septum was only opened medially to expose the fat. Pressing the globe gently made the fat protrude through the open septum. The capsules were opened and the pads were trimmed with bipolar coagulation to create the desired contour of the eyelid. All other treatment procedure steps were identical in groups A and B.

37. Statistical analysis FACE- Qscore differences between group A and group B were evaluated using gener - alized estimating equations (GEE). The GEE model included FACE-Q scores, base- line FACE-Q scores, sex, age, dermatochalasis severity score, and tissue removed during surgery. Pre- and post-blepharoplasty differ- ences were analysed using the Friedman test and pairwise comparisons were per- formed.

38. Results The characteristics of the patients included in groups A and B, depicted in Table 1 , were comparable at baseline.

39. Discussion No significant differences when comparing the skin-only excision technique with the skin/muscle excision were observed, except in the ‘satisfaction with the eyes’ questionnaire, which favoured the skin-only group

40. In the authors’ opinion, since the results are comparable, the least invasive method should be used. Additionally, when considering the eyes in general, the skin-only technique is preferable. The surgical technique may be tailored to the needs of the individual patient. The authors consider that the removal of a strip of orbicularis oculi muscle should not be a standard procedure but only performed on indication.

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