Blepharoplasty 01-22 Flashcards

Question

A 16-year-old girl comes to the clinic because she is dissatisfied with the asymmetric appearance of her breasts. Physical examination shows the right nipple-areola complex is more superiorly located and the breast volume is small. There is absence of the right anterior axillary fold. Which of the following other physical examination findings is most likely? A) Accessory nipple B) Microtia C) Right clubfoot D) Scars consistent with repaired cleft lip E) Shortened right-hand digits

Answer 1

The correct response is Option E. The chest findings described are consistent with Poland syndrome with absence of the sternocostal head of the pectoralis major muscle. Poland syndrome can be associated with hand abnormalities, including shortened digits. Cleft lip, accessory nipple, clubfoot, and microtia are not known to be associated with Poland syndrome.

Answer 2

The correct response is Option E. Eyelid muscles are innervated by the facial nerve (cranial nerve VII), the oculomotor nerve (cranial nerve III), and sympathetic nerve fibers. Sympathetic fibers contribute to upper eyelid retraction by innervation of the superior tarsal muscle, also known as the Müller muscle. Sympathetic fibers also innervate the inferior tarsal muscle, contributing to lower lid retraction. The superior tarsal muscle was stimulated by the epinephrine of the local anesthesia, causing temporary mild upper lid retraction. The oculomotor nerve (cranial nerve III) innervates the main upper eyelid retractor, the levator palpebrae superioris muscle, via its superior branch. Oculomotor nerve is one of the four cranial nerves that transmit parasympathetic fibers. The facial nerve (cranial nerve VII) innervates the orbicularis oculi, frontalis, procerus, and corrugator supercilii muscles, and supports eyelid protraction. The temporal and zygomatic branches of the facial nerve supply the orbicularis oculi, the main eyelid protractor. The facial nerve also supplies the corrugator supercilii and the procerus, both of which secondarily contribute to upper eyelid protraction.

Answer 3

The correct response is Option E. This patient's lower eyelid deformity is most likely caused by shortening of the posterior lamella. The lower eyelid is formed by the anterior, middle, and posterior lamellae. The anterior lamella consists of skin and orbicularis oculi muscle. The orbital septum comprises the middle lamella. The posterior lamella, or capsulopalpebral fascia, is comprised of the tarsus muscle, lower lid retractors, and conjunctiva. Injury or scarring of any of these structures can result in malpositioning of the lower eyelid, as seen in this patient. Shortening and scarring of the posterior lamella and septum are most common. Entrapment of Lockwood's ligament would lead to a loss of globe support, and inferior displacement of the cranial bone grafts and orbital floor would result in dystopia. Scleral show and ectropion resulting from excess skin excision are more typical of cosmetic blepharoplasty than internal fixation. Periorbital fat atrophy can result in scleral show and a change in globe position but rarely causes ectropion in patients with traumatic orbital injuries.

Answer 4

The correct response is Option C. Intercanthal distance most closely approximates orbital fissure width. Normal facial values are often described as proportions rather than absolute numbers. Many texts describe normal intercanthal distance as between 30 and 35 mm, but some studies have shown intercanthal distances of up to 40 mm in healthy cohorts. Thus, using the facial features as referents can be helpful. The face is often divided into fifths for analysis of width, and the intercanthal distance represents one fifth, as does the orbital fissure width. The nasal bone width is narrower than the intercanthal distance, and the eyebrow length extends lateral to the lateral canthus, representing greater than a fifth of the facial width. Subnasale, stomion, and menton distances are most often used to calculate facial height proportions. Although there is no reason why, theoretically, a measurement of facial height could not correspond to a measurement of facial width, these values do not.

Answer 5

The correct response is Option E. The elevation of these tissues near the eyelid margin forces an upward and inward rotation of the lower lashes. A common result of this rotation is contact between the lower eyelashes and the cornea or inferior bulbar conjunctiva. Laxity of the tarsal plate may be seen as an atrophic change in adults with involutional entropion. Laxity of the canthal tendons is an involutional change and would not be expected in children. Abnormal septum attachments may occur as a postoperative or posttraumatic complication but are unlikely the cause of eyelash malposition.

Answer 6

The correct response is Option B. The inferior oblique muscle is the most commonly injured extraocular muscle during lower blepharoplasty and lies between the nasal and central fat pads. Injury can lead to diplopia typically seen postoperatively between 1 and 6 weeks. Initial treatment is conservative. Surgical repair can be attempted only after improvement stops. Inferior oblique muscle is not found in the other locations. The arcuate expansion of Lockwood ligament is located between the central and lateral fat pads.

Answer 7

The correct response is Option B. This major (greater than 75%) defect of the lower eyelid has been categorized as a zone II defect by Spinelli and Jelks. The most appropriate method of reconstruction is the cheek advancement flap with a nasal septal cartilage and lining graft for internal lining. The cheek advancement flap can be elevated widely and rotated without tension to provide anterior coverage of the defect, while the composite graft is used for lining and support of the lower eyelid. Cantholysis, lateral canthotomy, and primary closure are most useful for defects that are less than 50%. Similarly, the Hughes tarsoconjunctival flap is best used in defects that are less than 50%, as larger flaps would result in significant deformity of the upper eyelid. Composite grafts from the ear are rarely used for lower eyelid reconstruction because the tissues are usually thicker than the lower eyelid and may be associated with partial or complete graft loss. Forehead flaps can be used for medial eyelid or canthal defects but are tertiary options in reconstruction of lateral lower eyelid defects.

Answer 8

The correct response is Option A. The medial orbital wall is comprised primarily of the orbital plate of the ethmoid bone. This bone is made up of a horizontal or cribriform plate, a midline perpendicular plate that forms the nasal septum, and symmetric lateral masses. The outer wall of each lateral mass is the medial orbital wall, the inner walls are the sidewalls of the nasal Knowledge of the anatomy of the medial orbital wall is important when diagnosing and treating extensive orbital blowout fractures, which often include the orbital floor. These fractures can extend to involve the inferomedial hillock and central section of the medial orbital wall; if this occurs, the orbital contents may be displaced into the maxillary and ethmoid sinuses. If the anatomic volume of the bony orbit is not restored surgically, the patient may develop posttraumatic enophthalmos and diplopia. This will most likely occur in those patients who have an increase in bony orbital volume of greater than 5%. The lacrimal and palatine bones give off smaller contributions to the medial orbital wall, as does the lesser wing of the sphenoid bone. The orbital floor is comprised of the maxilla medially and the zygoma anteriorly.

Answer 9

The correct response is Option E. The most common cause of epiblepharon is excess pretarsal skin and orbicularis oculi muscle at the lower eyelid margin. In this congenital anomaly, a fold of skin and underlying orbicularis muscle override the eyelid margin, often pushing the cilia against the globe. The eyelid margin and tarsus are stable and maintain the proper orientation. Epiblepharon usually affects the lower eyelids, is more common among Asians, and may be accentuated on downward gaze. Most cases resolve with facial growth during childhood. Surgical correction is needed when the lashes cause significant corneal injury. Epiblepharon requires resection of the redundant pretarsal skin and orbicularis muscle as well as placement of sutures between the tarsal plate and the subcutaneous tissue to create adhesions. Taping of the lower eyelid is not practical in a child. Nighttime lubrication of the eyes is not sufficient treatment because the lashes continue to cause damage during the day, which may cause permanent corneal scarring. Lateral tarsal strip and repositioning of the eyelid margin are a common treatment for ectropion. Reinsertion of the retractors at the base of the tarsus and subtotal excision of the preseptal orbicularis are the treatment of choice for involutional entropion with horizontal laxity from the tarsus, vertical laxity due to attenuation or disinsertion of the lower eyelid retractors or orbital septum, and migration of the preseptal orbicularis in the pretarsal position.

Answer 10

The correct response is Option A. Blepharoplasty is the most common facial cosmetic procedure performed on people of Asian descent. Unlike blepharoplasty in Caucasian faces, the goal of Asian blepharoplasty is to create a supratarsal fold. Asian eyelids are characterized by several key elements including absent or low lid crease, shorter tarsus, descending pre-aponeurotic fat, and minimal or absent connection between the levator aponeurosis and the upper lid dermis. The mainstay of surgical correction is creation of a permanent fixation point between the levator muscle and the supratarsal dermis and subdermal structures. The most common complication after Asian blepharoplasty is asymmetry. It is important to remember that unlike Caucasian blepharoplasty, the motivation for Asian blepharoplasty is less frequently rejuvenation. Rather, Asian patients are typically younger and desire creation of a supratarsal fold or correction of a preexisting fold asymmetry. Asymmetry is a common preoperative finding and should be well documented and discussed with the patient before surgery. Small differences in positioning of the newly created crease can be very obvious to both patient and surgeon. When recognized immediately after surgery, early revision should be considered. Other complications unique to Asian blepharoplasty include fold loss, suture extrusion, and epicanthal scarring. Lagophthalmos, which most often results from overresection of upper eyelid skin, is less frequent in Asian blepharoplasty because skin excision is typically more limited, particularly in a younger patient undergoing a partial incision technique. Fold loss may result from a technical error in securing the layers of dermis, epidermis, or levator aponeurosis, or from placing too few sutures. Revisional surgery would be required to correct this problem. Suture extrusion is not uncommon, given that permanent sutures are used for fixation. Meticulous placement of clear 7-0 nylon and trimming of suture ends will minimize the risk of this complication. If a suture becomes exposed in the first few months postoperatively, removal should be deferred until scarring is mature and fixation is more tenacious. Epicanthoplasty is commonly used is Asian patients with epicanthal folds undergoing blepharoplasty. Various techniques, including Y, W, and modified Z-plasties, have been reported. The epicanthal region is prone to hypertrophic scarring, particularly in Asians who have thick dermis.

Answer 11

The correct response is Option B. This patient has traumatic aponeurotic ptosis, which is characterized by the physical examination findings of good levator function, elevation of the eyelid crease, and the ability to visualize the shadow of the iris with eyelid closure (positive Nesi sign). In this type of ptosis, the levator aponeurosis is detached from the tarsal plate. Early reattachment of the levator is most likely to produce the best result. Patients with botulinum toxin-induced ptosis will have a more prominent decrease in levator function. In patients with mechanical, myogenic, or neurogenic ptosis, the shadow of the iris cannot be visualized through the eyelid.

Answer 12

The correct response is Option D. This patient has developed nasolacrimal duct obstruction as a complication following open reduction and internal fixation of a comminuted naso-orbital ethmoid fracture. The level of obstruction must be determined in order to correctly bypass the stricture or damaged portion of the lacrimal system. This can be accomplished by various methods, including canalicular injection and/or intubation, fluorescein staining of the eye, and radiologic testing. Dacryocystorhinostomy is used for correction of nasolacrimal duct obstruction. Many methods of dacryocystorhinostomy have been described. The single lacrimal flap technique, as well as other techniques that do not involve flaps, has produced long-term patency rates of 90%. Conjunctivodacryocystostomy and conjunctivodacryocystorhinostomy are procedures used for reconstruction in a patient who has obstruction at the canalicular level. Conjunctivorhinostomy is used in patients who have absence or obliteration of the tear sac. Dacryocystostomy involves intubation of the tear sac, which would not be beneficial in this patient.

Answer 13

The correct response is Option B. Ectropion involves eversion of the eyelid margin; it frequently occurs in the lower eyelid as a result of the pull of gravity on the unsupported eyelid tissue. It is usually the result of mechanical (involutional or senile), cicatricial, or neurogenic causes. This patient has classic cicatricial ectropion, which has resulted from abnormally healing burn wounds. The ectropion has occurred as a result of scar contracture of the anterior lamella of the lower eyelid, leading to excessive scleral show and exposure keratopathy. Full-thickness skin grafting is recommended to replace lost tissue and prevent secondary contracture. In addition, complete release of contracted soft tissues and use of added supporting materials such as cartilage should be considered. Scar massage and intralesional injection of a corticosteroid would not improve a fixed, foreshortened lower eyelid. Neurogenic ectropion is best treated by correction of the associated upper eyelid lagophthalmos using inserted prosthetic devices (eg, gold eyelid weights). In patients with involutional ectropion, there is progressive laxity of the lower eyelid; the lower eyelid retractors or capsulopalpebral fascia becomes disinserted from the inferior border of the tarsal plate. Corrective surgical procedures include lateral canthoplasty, lateral wedge excision, and the Kuhnt-Szymanowski technique, which involves excision of a full-thickness wedge from the region of the lateral canthus. The skin excision is then hidden under a subciliary incision.

Answer 14

The correct response is Option D. A child with congenital tearing is likely to have a nasolacrimal duct problem. Punctual agenesis, lacrimal sac fistula, and other rare abnormalities should be ruled out with dye disappearance testing, which usually is markedly asymmetric in a nasolacrimal duct problem. Generally, a nasolacrimal duct problem should be treated with massage and antibiotic drops until the child is age 12 to 13 months. For about 70% of children with tearing at age 6 months, this conservative treatment leads to resolution by age 12 months. If tearing persists, probing of the nasolacrimal duct should be performed. The longer probing is delayed beyond age 13 months, the greater the number and complexity of the procedures needed to successfully treat congenital dacryostenosis. Therefore, initial probing and irrigation should be performed before age 13 months. Observation alone is not appropriate because it delays treatment, which increases the number and complexity of the procedures required. Massage with antibiotic ointment is not appropriate for this 13-month-old girl, although it could have been done before age 12 months. If probing is unsuccessful, Silastic intubation should be done. Dacryocystorhinostomy is reserved for those rare cases that do not respond to Silastic intubation. Typically, the Jones test is not needed to make the diagnosis. The Jones I test involves instillation of fluorescein dye into the conjunctival sac. A cotton pledget is placed inside the nose close to the orifice of the nasolacrimal duct. Staining of the pledget, a positive test result, indicates that flow through the lacrimal system is uninhibited. A negative result on the Jones I test indicates obstruction but does not localize it in the upper or lower system. In the Jones II test, the punctum is anesthetized and dye is inserted through an irrigation cannula. Then the system is irrigated with saline. If dye is collected from the nose, a positive test result, the nasolacrimal duct is partially obstructed, but the upper system from the conjunctiva to the lacrimal sac is not obstructed.

Answer 15

The correct response is Option D. Bilateral blepharoplasty with fat pad removal and ptosis repair using levator advancement will address this woman's visual field defect and mild ptosis. These procedures are used for patients with normal levator function (defined as greater than 10 mm). Bilateral upper eyelid blepharoplasty alone or in conjunction with fat pad removal would not correct the ptosis, while repair of the ptosis only would not address the visual field obstruction. This patient has a common problem that requires thorough preoperative evaluation. Visual field obstruction is evaluated clinically and verified using standard visual field testing. Examination of levator function involves stabilizing the brow and measuring the excursion of the upper eyelid margin from downward gaze to upward gaze with the eyes fixed on a distant point. The normal distance between the upper and lower limbi across the pupil is 11 mm. The upper limbus should rest 2 mm below the superior edge of the iris and 2 mm above the superior edge of the pupil. Division of Muller's muscle would not correct the ptosis. The Fasanella-Servat procedure is used to correct minimal ptosis but is a more difficult, complicated procedure than levator plication. Accessibility to involved structures is limited with this procedure. Bilateral blepharoplasty combined with fat pad removal and ptosis repair using a fascial sling is recommended to correct congenital ptosis, defined as ptosis of more than 4 mm and levator function of less than 5 mm. Resection of the levator muscle is excessive and unnecessary in patients with minimal acquired ptosis.

Answer 16

The correct response is Option B. Blepharophimosis syndrome, which is classified according to three types, is a form of congenital ptosis. Patients with blepharophimosis syndrome, type 1 have large epicanthal folds with epicanthus inversus, horizontally shortened eyelids, and severe ptosis. Patients with type 2 have telecanthus, absence of the epicanthal folds, severe bilateral ptosis, absence of levator function, and skin shortage involving all four lids. Blepharophimosis syndrome, type 3 involves absence of epicanthal folds, telecanthus, an antimongoloid slant of the palpebral fissures, severe ptosis, mild orbital hypertelorism, and skin deficiencies. As with many congenital syndromes, the malformations are isolated. Forehead and ear anomalies are also common. Although epicanthus and epiblepharon comprise a portion of this patient's condition, the presence of severe congenital ptosis leads to a diagnosis of blepharophimosis syndrome type 1. Surgical correction of blepharophimosis syndrome involves repair of the epicanthal folds and correction of eyelid ptosis. Levator resection, medial canthoplasty, and fascial suspension techniques have all been used in combination to correct the abnormalities. A five-flap technique that combines double Z-plasties and a Y-to-V flap is most often used for repair of the epicanthal folds. Ideally, the canthus should lie halfway between the pupil and the center of the nasal bridge following all repair procedures. Blepharochalasis and blepharospasm are not seen in patients with blepharophimosis syndrome.

Answer 17

The correct response is Option A. The inferior oblique muscle is a thin, narrow skeletal muscle near the anterior margin of the floor of the orbit. This extraocular muscle is attached at its origin, maxillary bone, and the posterior, inferior, lateral surface of its insertion, and eye. The inferior oblique muscle receives its innervation by the inferior branch of the oculomotor nerve. This muscle moves the eye by extorsion, elevation, and abduction. The primary action of the inferior oblique muscle is extorsion/external rotation; secondary action is elevation; tertiary action is abduction. This muscle serves as the primary partition between the medial and central fat compartments of the lower eyelid. Careful identification and preservation of the muscle is important during lower eyelid surgery. In this case, the surgeon likely injured the muscle when having difficulty with fat resection of the medial fat pad. The inferior rectus muscle is responsible for depressing, adducting, and extorting the eye. The orbicularis oculi muscle is responsible for closing the eye. The superior oblique muscle is responsible for intorsion, depression, and abduction. The superior rectus is responsible for elevation, adduction, and intorsion.

Answer 18

The correct response is Option A. Cicatricial ectropion is best treated by full-thickness skin grafting to replace the skin deficit. A tarsal support procedure, such as a lateral canthoplasty, may be needed to fully restore the tone and position of the eyelid. Depending on their thickness and distribution, scars may be released by incision or excision. Cicatricial ectropion can be prevented by early surgical intervention with burn excision and grafting, thereby avoiding the need for late reconstructive procedures. Most burn reconstruction should be delayed until scars have matured sufficiently, usually by one year after injury. Earlier intervention is needed when a vital skin function is impaired, such as corneal protection. Eyelid massage and corticosteroid injection are appropriate for minor scarring and scleral show after blepharoplasty but are unlikely to provide the rapid and complete relief needed for this patient. Scarred skin does not expand effectively, limiting the role of tissue expansion in this patient. A tarsoconjunctival flap is useful for posterior lamella reconstruction of a full-thickness deficit of greater than 50% of the lower eyelid. The radial forearm free flap may replace a broad area of cheek injury, although the flap tissue is too bulky for effective eyelid skin replacement.

Answer 19

The correct response is Option D. This defect requires prompt surgical correction, because allowing the wound to granulate would result in a severely dysfunctional eyelid. With such a defect, a Hughes tarsoconjunctival flap is best used for reconstruction. This reconstruction involves taking a tarsoconjunctival flap from the upper eyelid, leaving 3 to 4 mm of the upper tarsus intact, and advancing the remaining tarsus and conjunctiva to the lower eyelid defect. This provides the posterior lamella of the eyelid. The anterior lamella is reconstructed by advancement of a skin-muscle flap from the lower eyelid or cheek. Direct closure with cantholysis is appropriate for defects of less than 25% of the eyelid. The Cutler-Beard flap, which uses skin and muscle from the lower eyelid, is inappropriate for a patient with a lower eyelid defect. Because this patient=s defect affects more than 50% of the lower eyelid and because the eyelid requires a supportive base, a skin graft or composite contralateral lower eyelid graft would not provide adequate support.

Answer 20

The correct response is Option A. In one study of 80 patients undergoing reconstruction of orbital blowout fractures and fractures of the zygomaticomaxillary complex via a preseptal transconjunctival approach, ectropion was not identified as a complication. Only one case of transient entropion was identified, and only 2% of patients in this study reported any complications. Another study of 35 patients who were undergoing secondary orbital procedures reported that 4% of these patients subsequently developed ectropion. In a third study of 400 patients, one patient was identified as having ectropion. In contrast, the rate of ectropion in patients undergoing the traditional subciliary approach to reconstruction has been shown to be as high as 25%.

Answer 21

The correct response is Option B. The Jones I dye test involves the instillation of fluorescein dye into the conjunctival sac. A cotton pledget is placed inside the nose close to the orifice of the nasolacrimal duct; staining of the pledget, also known as a positive test, indicates that flow through the lacrimal system is uninhibited. In patients who have both a positive Jones I test and epiphora, hypersecretion of the lacrimal gland is the most likely cause. Negative findings on the Jones I test are indicative of obstruction; however, the test does not localize the obstruction to the upper or lower system. With the Jones II dye test, the punctum is anesthetized and dilated, and an irrigation cannula is inserted; the system is then irrigated with saline. If dye-stained fluid is collected from the nose, which indicates a positive test, there is partial obstruction of the nasolacrimal duct; the upper system, from the conjunctiva to the lacrimal sac, is not obstructed. If no dye-stained fluid is found in the nose (a negative test), but there is reflux through the opposite canaliculus, obstruction of the lower system, and not the upper system, can be diagnosed. In contrast, if findings on the Jones II test are negative, and there is reflux through the irrigated canaliculus, the obstruction can be localized to the upper system. Therefore, a patient who has negative findings on the Jones I dye test but positive findings on the Jones II dye test has a partial obstruction of the nasolacrimal duct. The nasolacrimal duct empties into the inferior meatus; in contrast, the posterior ethmoid air cells empty into the superior meatus and are not connected to the lacrimal system.

Answer 22

The correct response is Option C. Involutional ptosis, the most common type of acquired eyelid ptosis, is caused by a defect in the levator aponeurosis that occurs with stretching and allows downward positioning of the tarsal plate. Involutional ptosis is associated with good-to-excellent levator function, a high supratarsal crease, and thinning of the eyelid tissues above the tarsal plate. The degree of levator function determines the required degree of correction. With a poor levator function (0 €“6 mm of excursion), frontalis suspension is required. With a moderate function (6 €“10 mm), levator resection (shortening) is required. For patients with excellent levator function (\> 10 mm), aponeurotic surgery is appropriate. The amount of brow ptosis will help determine whether additional corrective procedures are necessary. The amount of excess skin and the distance between the tarsal edge and the brow indicate the amount of excess skin to be excised in a blepharoplasty. The position of the supratarsal fold indicates the cause of ptosis and is useful in determining placement of corrective incision.

Answer 23

The correct response is Option A. This 58-year-old man has findings consistent with blepharochalasis, a condition of unknown cause that results from a developmental deficiency of elastic tissue within the eyelids. It most often occurs during early adulthood. Patients with blepharochalasis, or dermatopysis palpebrum, have recurrent episodes of mild to moderate, painless edema of the eyelids. Over time, the episodes become more frequent, resulting in a permanent "baggy" appearance of the eyelids with thinning and wrinkling of the eyelid skin. Herniation of orbital fat occurs, leading to an exacerbation of symptoms. Excision of redundant tissue is indicated for management of visual obstruction. Patients with dermatochalasis have occasional episodes of visual obstruction resulting from excess eyelid skin. Dry eye syndrome is caused by corneal exposure following blepharoplasty and manifests as pain, dryness, and blurred vision. Pachydermoperiostosis, or idiopathic hypertrophic osteoarthropathy, is a familial condition of unknown cause characterized by progressive enlargement of the eyelids, hands, feet, and toes. The conjunctivae are covered by hypertrophic papillae. Ptosis and visual obstruction are common. Senile ptosis results from progressive attenuation of the levator aponeurosis. Levator advancement is appropriate management.

Answer 24

The correct response is Option A. Transconjunctival blepharoplasty with the skin pinch technique has a low rate of scleral show, compared with rates seen in studies of the transcutaneous blepharoplasty using a skin-muscle flap. However, because it uses a transconjunctival approach to the fat compartments of the lower eyelid, access is not improved but can be challenging, particularly for the lateral fat pad. This is considered a disadvantage of the transconjunctival method. Skin resection is believed to be more thorough with the skin pinch method than with the classical skin-muscle flap. The incidence of middle lamellar scarring with the technique is believed to be less, since the orbicularis oculi muscle is not violated. Performance of canthopexy is not changed by the selection of this technique.

Answer 25

The correct response is Option A. Through a transconjunctival approach, the dissection begins in a preseptal plane and is then converted into a supraperiosteal dissection over the anterior orbital rim until the levator labii superioris is visualized. This ensures release of the tear-trough ligament and entrance in the premaxillary plane. Orbicularis oculi is the muscle that is released and is found more superficial, as are the zygomaticus major and minor, and levator labii superioris alaeque nasi.

Answer 26

The correct response is Option A. The most likely diagnosis in this patient is a corneal abrasion. The cornea is highly innervated (300 to 400 times greater than skin) and any abrasion is associated with marked pain and epiphora. Topical anesthetic eye drops, such as proparacaine hydrochloride or tetracaine hydrochloride, can both treat the pain and be diagnostic. In the setting of a corneal abrasion, the patient would get relief within minutes after application and a formal ocular examination would then be possible. Treatment for a corneal abrasion would include symptom control with topical anesthetics as needed and prophylactic topical antibiotics. Eye patches should be avoided since they can decrease oxygenation of the cornea. Similarly, contact lenses should be omitted until the cornea is fully healed. The cause of corneal abrasions is any mechanical injury during induction, preparation, surgery, and emergence. Particular care should be taken by all team members during the entire surgery and up until the moment when the patient is coordinated enough to touch their face. A time that is particularly dangerous is the cleaning of the face at the end of surgery. Camouflaging an acute pain episode with narcotics, without establishing and treating the root cause, is not sound medical care and can lead to a missed diagnosis with associated harm. A return to the operating room, as a first step in management, is not indicated in this clinical scenario. If possible, an ophthalmological examination is best performed with an awake patient. Both forehead feminization and lower blepharoplasty can lead to a retrobulbar hematoma, which may present similar to a corneal abrasion. Physical examination can distinguish between the two entities since a retrobulbar hematoma would present with proptosis. However, a canthotomy involves only the release of the lateral canthus without severance of the lateral canthal tendon that is found more posterior. This incision would inadequately treat a retrobulbar hematoma. If topical anesthetic eye drops do not have an effect, then further escalation of care is warranted. If an acute retrobulbar hematoma is suspected, a canthotomy and cantholysis can be indicated. This is a procedure that can be done at bedside should the patient be unable to immediately return to the operating room. It is important that this is done properly and that the lateral canthal tendon is entirely released so that the retrobulbar pressure is released.

Answer 27

The correct response is Option B. Causal factors leading to ectropion include horizontal laxity of the eyelid (involutional), vertical shortening of the anterior lamella of the eyelid (congenital or cicatricial), paralysis of the orbicularis oculi muscle (secondary to paralytic entropion) causing loss of eyelid muscular tone, and neoplasia within the lower eyelid pulling or forcing the eyelid away from the globe. Physical examination findings of abnormal snap-back test and distraction test in the patient described suggest abnormal horizontal lid laxity.

Answer 28

The correct response is Option A. Intraocular pressure is similar to compartment syndrome in that an excessive amount of pressure on the optic nerve resulting from bleeding or edema can increase intraorbital pressure and ultimately lead to blindness. An acute increase in intraorbital pressure can occur following orbital fracture repair, blepharoplasty, or other surgical procedures. Physical examination in an affected patient will show visual loss associated with a pupillary defect, such as a loss of pupillary reaction to light. Increased intraocular pressure can be measured at the bedside using a tonometer. Lateral canthotomy, or release of the lateral canthal tendon, should be performed immediately to relieve pressure and restore sight. Any proptosis that is present will be accentuated immediately after surgery and can thus be diagnosed at this time; it can be measured to confirm adequate release of the check-rein ocular support. Surgical exploration can also be performed after lateral canthotomy to control any persistent bleeding. In contrast, eyelid structures such as the levator aponeurosis, orbicularis oculi muscle, and tarsal plate do not need to be released. Because these structures lie external to the support sling created by the lateral canthal tendon and Lockwood's suspensory ligament, they already have at least partial mobility. Tenon's capsule covers the globe and extraocular muscles, creating a barrier between these structures and the orbital fat. The lower portion of the capsule comprises Lockwood's suspensory ligament. Because of their position proximal to the globe, it is more prudent to detach the lateral canthal tendon from the bony rim in order to allow for advancement of the intraorbital contents. Surgical detachment of the lateral canthal tendon will disrupt the globe only minimally. Any loss of lower eyelid height can be restored later with lateral canthopexy.

Answer 29

The correct response is Option D. The orbitomalar ligament attaches the orbicular muscle of the eye to the orbital rim. It separates the lower eyelid from the mid face. Release of this structure is required to obtain access to the mid face when approaching it from the lower eyelid. The capsulopalpebral fascia inserts on the inferior border of the tarsus. It makes up the anterior superior portion of the lower eyelid retractors distal to the Lockwood ligament. The capsulopalpebral fascia is divided during the transconjunctival incision. This affords access to the lower eyelid for the blepharoplasty procedure. The Lockwood ligament is a fascial thickening that supports the globe. It surrounds the inferior rectus and inferior oblique muscles and fuses with the capsulopalpebral fascia. It is analogous to the Whitnall ligament in the upper eyelid. The orbital septum acts to contain the orbital contents. It attaches inferiorly to the periosteum at the arcus marginalis and superiorly to the eyelid margin. A transconjunctival blepharoplasty can be performed by a pre- or postseptal approach. The parotid masseteric fascia is within the mid face. It is distal to the orbitomalar ligament when approached from the eyelid. It does not need to be released to access the mid face.

Answer 30

The correct response is Option C. Recent articles have greatly improved our understanding of the anatomy of the lower eyelid, tear trough, pre-zygomatic space, and the ligaments in the orbital area. The tear trough ligament is a true osteocutaneous ligament between the palpebral and orbital portions of the muscle. It extends inferolaterally from the medial canthus to approximately the mid-pupillary line, where is connects with the bilayered orbicularis retaining ligament. Recent anatomic dissection work has shown that this ligament is the anatomic basis of the tear trough deformity. Fillers should be placed inferior to the tear trough ligament; placing them superiorly will only serve to emphasize lower eyelid fat, and will emphasize the tear trough deformity.

Answer 31

The correct response is Option C. The layers of the eyelid are the conjunctiva, MÃ¼ller muscle, levator muscle, orbital fat, orbital septum, retro-orbicularis oculi fat, orbicularis oculi muscle, and skin. The MÃ¼ller muscle lies below the levator insertion to the superior border of the tarsus and is visualized during the levator muscle repair. The conjunctiva is located deep to the MÃ¼ller muscle and should not be visualized during the muscle reinsertion to the tarsus. The orbital septum and retro-orbicularis oculi are anterior and superior to the levator tendon. The Whitnall ligament is also superior to the levator tendon. The capsulopalpebral fascia is the extension of the lower eyelid retractors and fuses at the inferior aspect of the lower eyelid tarsus.

Answer 32

The correct response is Option B. The inferior oblique muscle is the most commonly injured extraocular muscle during lower blepharoplasty and lies between the nasal and central fat pads. Injury can lead to diplopia typically seen postoperatively between 1 and 6 weeks. Initial treatment is conservative. Surgical repair can be attempted only after improvement stops. Inferior oblique muscle is not found in the other locations. The arcuate expansion of Lockwood ligament is located between the central and lateral fat pads.

Answer 33

The correct response is Option C. Protection of the ocular surfaces is the primary goal in managing the cicatricial ectropion of the lower eyelid in the patient described. The patient €™s lower eyelid lacks height. Scarring between the capsulopalpebral fascia (lower eyelid retractors) and the orbital septum because of trauma or following aggressive lower eyelid blepharoplasty can cause vertical contracture of the lower eyelid, resulting in corneal exposure. Lower eyelid position can only be restored by placement of an autogenous or alloplastic spacer graft (hard palate, donor sclera, auricular cartilage, tarsus, and others), as in the postoperative image shown. In conjunction, eyelid-tightening procedures such as lateral canthopexy and canthoplasty address horizontal skin laxity. Complete tarsorrhaphy is not an option for a young and active patient. It is an acceptable temporizing solution in cases of paralytic ectropion. Pentagonal wedge resection of the lower eyelid is an adjunct procedure for cases of lower eyelid laxity with horizontal skin excess. Punctal occlusion of the lower eyelid would alleviate the dryness caused by the increased exposure but would not restore normal anatomy of the lower eyelid in the patient described. Repair of the lower eyelid retractors in conjunction with lateral canthal resuspension is used to correct lower eyelid entropion. The procedure would not address the scarring present in the patient described.

Answer 34

The correct response is Option A. This patient has ectropion with eversion of the lower eyelid. In general, ectropion is classified as involutional, cicatricial, or neurogenic. The patient described has a cicatricial ectropion. At three weeks into the postoperative period, the wounds are still in the active phase of healing. Over the next six to nine months, as the collagen with the scar remodels, the lid may return to a more normal position. Therefore, during this time frame, the ectropion should be managed with scar tissue massage and a regimen to prevent complications related to dry eyes, such as tear supplementation and eye patching. Surgical intervention is warranted if there is no improvement after this time frame or if conservative therapy is ineffective and there is a risk of visual compromise. Injection of a corticosteroid can reduce inflammation and soften the scar, allowing the eyelid to return to a better position. However, use of corticosteroids in the lower eyelid is not advocated because of the risks of tissue atrophy and skin discoloration. Lysis of scar adhesions and the placement of an interpositional graft are indicated for cases of midlamellar scar. Placing upward traction on the eyelid can identify scar contracture in this location. If adequate skin is present, the lower eyelid should reach at least the level of the midpupil. If this movement is restricted, midlamellar scarring is likely. Lateral canthopexy is indicated for lower eyelid malposition associated with lower eyelid laxity. Excision of the scar and skin grafting are indicated for ectropion secondary to cutaneous deficiency. Excision of the scar and cheek advancement with a lateral canthopexy would not be a primary reconstruction procedure for this lesion.

Answer 35

The correct response is Option C. A skin graft from the contralateral upper eyelid should be used for full-thickness coverage of this patient's defect. Because older patients typically have dermatochalasia, there is often sufficient skin in the unaffected upper eyelid that can be harvested and used to cover small skin deficits. A cross-lid flap is more appropriate for coverage of a full-thickness defect. Grafts harvested from the retroauricular and supraclavicular regions are better used for skin grafting of the face due to their optimal color match; however, this skin is often too thick for use in the upper eyelid. Wedge resection is an excessive, unnecessary procedure.

Answer 36

The correct response is Option D. This patient is at increased risk for the development of ectropion of the lower eyelid, eversion of the lid margin away from the globe. The snap-back test can be used to assess horizontal laxity of the eyelid. After being pulled away from the eye, the time it takes for the lid to resume a normal position is measured. The result is graded from 0 (time indicating normal tone and laxity) to IV (time indicating loss of tone and severe laxity). Different lateral canthopexy and canthoplasty procedures have been described to prevent malposition of the lower eyelid and can be performed adjunctly with shortening of the lower eyelid. These procedures include repositioning of the inferior limb of the lateral retinaculum on the orbital rim; suturing of the lateral orbicularis oculi muscle to the orbital rim; suspension of a deepithelialized lower eyelid dermal pennant on the orbital rim; and suspension of a lateral orbit periosteal pennant on the orbital rim. All of the procedures commonly suspend or support the lateral canthus. Ectropion of the lower eyelid may also result from vertical deficiency of the anterior lamella of the lid. Cicatricial changes with consequent vertical lid shortening may result from skin disease, trauma, and previous surgical procedures. Local therapy such as pressure and massage may be used to treat mild cicatricial changes. Further therapy to augment the anterior lamella with a full-thickness skin graft may also be required. The use of tarsorrhaphy is a temporary means to protect the cornea from exposure. The suture itself will not prevent lower eyelid malposition. The tarsoconjunctival flap, which is elevated from the upper eyelid, may be used to reconstruct defects of the lower eyelid. In this case, there is no such defect.

Answer 37

The correct response is Option E. Extending the skin incisions too far medially can create a webbing of the nasal skin. Carrying the incision medially does not promote inadequate skin excision, lagophthalmos, or retrobulbar hematoma. Injury to the lacrimal system is unlikely to occur with a more medial incision.

Answer 38

The correct response is Option D. The most likely cause of numbness in the patient described is injury to the supratrochlear nerve. The supratrochlear nerve courses superiorly through the corrugator muscle and innervates the central forehead skin. It is subject to injury during muscle interruption via either of the transpalpebral, coronal, or endoscopic approaches. The abducens nerve is motor to the lateral rectus muscle of the globe and is not within the operative field. Although it can be injured distal to its exit from the frontal bone, the deep branch of the supraorbital nerve provides sensation to the frontal periosteum. The frontal branches of the facial nerve are motor only to the frontalis muscle. The oculomotor nerve would not result in these findings, as it does not supply sensation to the forehead. The zygomaticotemporal nerve renders sensation to the lateral orbital-forehead skin and is located far lateral to the medial brow depressors.

Answer 39

The correct response is Option A. The tear film is comprised of three layers: an outer lipid layer, a middle aqueous layer, and an inner mucin layer. The meibomian glands produce the outer lipid layer, which prevents tears from evaporating. Thus, meibomian gland dysfunction can lead to dry eyes. Anatomically, Meibomian glands appear posterior to the tarsal plate with an opening at the eyelid margin. The aqueous layer lubricates the eye and helps clear debris. The mucin layer, closest to the cornea, both nourishes the cornea and allows smooth distribution of tears. Although sebum is often confused with meibum, or meibomian gland secretions, it is not the same. Sebum blockage of the meibomian glands can cause meibomian gland dysfunction. Thus, sebum is incorrect because while sebum can block the Meibomian glands, it is specifically the Meibomian gland dysfunction which causes the dry eye.

Answer 40

The correct response is Option E. The most appropriate answer is thyroid eye disease, or thyroid ophthalmopathy. This is the most common cause of proptosis and diplopia in adults. It affects women approximately 4 to 6 times more frequently than men. Puffy, swollen eyelids, injected conjunctivae, eyelid lag, and proptosis are common in thyroid ophthalmopathy. Optic neuritis is typically associated with visual loss, which is not a symptom in this scenario. Similarly, myasthenia gravis is associated with eyelid ptosis, worsening toward the end of the day—which is not a symptom in this scenario. Although both allergic conjunctivitis and Sjögren syndrome could cause conjunctival injection, neither would be associated with proptosis or eyelid lag. Vision loss, due to compression of the optic nerve, can occur in the most severe cases. Fortunately, this

Answer 41

The correct response is Option D. This patient who has ptosis of 3.5 mm with good levator function (greater than 10 mm) is best managed with repositioning of the levator aponeurosis. In patients who develop ptosis following an operative procedure or trauma, multiple etiologic mechanisms, including neurologic, myogenic, and mechanical, may be the cause. Because injuries to the levator complex may be concealed by acute edema, the surgeon should allow for resolution of the edema, myoneural recovery, and scar softening. After this has occurred, the degree of ptosis and the extent of levator function can be measured in order to determine the appropriate surgical procedure. Advancement of MŸeller's muscle will not correct 3.5 mm of ptosis. Eyebrow suspension is most appropriate for patients who have poor levator function (less than 4 mm) and greater than 3 mm of ptosis. The Fasanella-Servat procedure shortens the lower components of the eyelid (ie, the tarsus, conjunctiva, and MŸller's muscle). The modification of this procedure spares the muscle and is best for patients who have levator function of greater than 10 mm and ptosis of less than 2 mm. Levator resection is reserved for those patients who have levator function between 4 mm and 10 mm, and ptosis of greater than 3 mm.

Answer 42

The correct response is Option E. Senile ptosis is characterized by dehiscence of the levator aponeurosis, the most common cause of ptosis in the elderly. Elevation of the supratarsal crease is seen. Levator plication or advancement is required for correction. Congenital ptosis is seen in young patients who have moderate-to-severe ptosis with absence of the eyelid crease and poor levator function. Upper eyelid frontalis sling is sometimes required for correction. Facial nerve injury results in brow ptosis but not blepharoptosis. Horner syndrome is marked by ptosis, miosis, and anhidrosis. It occurs after loss of sympathetic innervations of the superior cervical ganglion. The eyelid crease is usually not affected. Myasthenia gravis may cause unilateral or bilateral ptosis that is exaggerated with fatigue. The condition typically affects young women or elderly men. Pharmacologic testing establishes the diagnosis.

Answer 43

The correct response is Option A. Ptosis of a mild to moderate degree is a common finding following blepharoplasty; common causes include postoperative edema of the eyelids and hemorrhage into MŸller's muscle. Because these complications generally resolve spontaneously over time, reassurance and observation with frequent follow-up examinations are most appropriate. Eyelid massage and stretching exercises are effective for management of early ectropion of the lower lids. Phenylephrine eyedrops are only indicated if the ptosis is caused by Horner's syndrome. Although operative exploration is warranted in patients who have eyelid discrepancies following blepharoplasty, it would not be useful in this patient who did not initially undergo repair of the levator mechanism. Instead, surgical treatment in this patient should be delayed for two to six months to allow for spontaneous recovery.

Answer 44

The correct response is Option C. This patient has classic signs of blepharoptosis secondary to acquired dehiscence of the levator aponeurosis, such as high eyelid crease, excellent levator function, and an MRD of 0 mm. The MRD quantifies the distance between the lid margin and the pupillary reflex. To correct this blepharoptosis in the most anatomically correct fashion, surgery should be done to reanastomose the dehisced end of the levator aponeurosis to the superior aspect of the tarsus. The other surgical options are used for different indications. A Fasanella-Servat procedure takes a posterior conjunctival approach to correct mild ptosis without levator disinsertion. Plication of the levator muscle alone does not provide long-lasting results and is a valid option only if the distal end of the muscle is not dehisced. Resection of the orbicularis muscle will not correct the ptosis. Unilateral frontalis suspension is the procedure of choice for patients with absent levator function and severe ptosis.

Answer 45

The correct response is Option A. This 58-year-old man has findings consistent with blepharochalasis, a condition of unknown cause that results from a developmental deficiency of elastic tissue within the eyelids. It most often occurs during early adulthood. Patients with blepharochalasis, or dermatopysis palpebrum, have recurrent episodes of mild to moderate, painless edema of the eyelids. Over time, the episodes become more frequent, resulting in a permanent "baggy" appearance of the eyelids with thinning and wrinkling of the eyelid skin. Herniation of orbital fat occurs, leading to an exacerbation of symptoms. Excision of redundant tissue is indicated for management of visual obstruction. Patients with dermatochalasis have occasional episodes of visual obstruction resulting from excess eyelid skin. Dry eye syndrome is caused by corneal exposure following blepharoplasty and manifests as pain, dryness, and blurred vision. Pachydermoperiostosis, or idiopathic hypertrophic osteoarthropathy, is a familial condition of unknown cause characterized by progressive enlargement of the eyelids, hands, feet, and toes. The conjunctivae are covered by hypertrophic papillae. Ptosis and visual obstruction are common. Senile ptosis results from progressive attenuation of the levator aponeurosis. Levator advancement is appropriate management.

Answer 46

The correct response is Option A. In this patient who has undergone upper eyelid blepharoplasty, the persistent upper eyelid fullness is most likely a result of descending lacrimal glands. Appropriate management of this condition can include resuspension of the glands, which has been advocated by some surgeons. However, excision of the glands is not recommended because it may result in the development of keratoconjunctivitis sicca. Eyebrow ptosis would most likely be seen over the entire eyebrow, not just the lateral third. Lateral fat compartments are found in the lower eyelids but not in the upper eyelids. Although subcutaneous fat deposits can cause lateral fullness of the eyelids, they typically pass beyond the region of the canthus. Bony prominences would most likely involve the entire eyebrow.

Answer 47

The correct response is Option A. The incision for a retroseptal approach is usually placed 4 to 5 mm below the tarsal border, or about 8 mm for the lid margin. The plan of dissection for a retroseptal approach is, by definition, deep to both the orbicularis muscle and septum. Because the fat pads are retroseptal, modification does not require entry through the septum when a retroseptal approach is used. The preseptal approach is typically chosen for modification of the lid-cheek junction, and facilitates fat pad redistribution and access to the midface. The retroseptal approach is used for reduction of fat pads only. The inferior oblique muscle is located between the central and medial compartments of fat. Multiple authors have shown that is it indeed safe to perform skin resurfacing with either chemical peel or laser simultaneously with a transconjunctival blepharoplasty.

Answer 48

The correct response is Option B. A patient who undergoes blepharoplasty and ptosis repair in the context of a compensated brow ptosis is likely to experience worsened brow ptosis after the procedure. Evaluation of the blepharoplasty patient requires careful examination of the entire upper third of the face. Patients may have, in addition to excess upper eyelid skin, an eyelid ptosis. In addition to identifying the ptosis, it is important to recognize compensated brow ptosis. A compensated eyelid ptosis occurs when the patient uses the frontalis muscles to raise the eyebrows, which results in a functional improvement in visual fields. This is most easily identified by having the patient close her eyes, and evaluate the automatic raising of the eyebrow on eyelid opening. In this case, the change in the position of the brow on downward gaze and on frontal gaze indicates a compensated brow ptosis. After ptosis repair and blepharoplasty, brow ptosis can become more manifest as the need for compensation decreases.

Answer 49

The correct response is Option C. Tears are a trilaminar fluid. The precorneal layer is formed by mucin-secreting goblet cells in the conjunctiva. This inner layer of the tear film covers the cornea and promotes the dispersion of the overlying aqueous layer. The lacrimal gland secretes the middle layer. This aqueous layer is made of water and proteins. This layer promotes osmotic regulation and the control of infectious agents. The meibomian glands produce the outer lipid layer. This oil layer helps to prevent the evaporation of the tear film. As a result, dysfunction of the meibomian glands can lead to dry eyes.

Answer 50

The correct response is Option D. This patient has developed nasolacrimal duct obstruction as a complication following open reduction and internal fixation of a comminuted naso-orbital ethmoid fracture. The level of obstruction must be determined in order to correctly bypass the stricture or damaged portion of the lacrimal system. This can be accomplished by various methods, including canalicular injection and/or intubation, fluorescein staining of the eye, and radiologic testing. Dacryocystorhinostomy is used for correction of nasolacrimal duct obstruction. Many methods of dacryocystorhinostomy have been described. The single lacrimal flap technique, as well as other techniques that do not involve flaps, has produced long-term patency rates of 90%. Conjunctivodacryocystostomy and conjunctivodacryocystorhinostomy are procedures used for reconstruction in a patient who has obstruction at the canalicular level. Conjunctivorhinostomy is used in patients who have absence or obliteration of the tear sac. Dacryocystostomy involves intubation of the tear sac, which would not be beneficial in this patient.

Answer 51

The correct response is Option D. This patient who has ptosis of 3.5 mm with good levator function (greater than 10 mm) is best managed with repositioning of the levator aponeurosis. In patients who develop ptosis following an operative procedure or trauma, multiple etiologic mechanisms, including neurologic, myogenic, and mechanical, may be the cause. Because injuries to the levator complex may be concealed by acute edema, the surgeon should allow for resolution of the edema, myoneural recovery, and scar softening. After this has occurred, the degree of ptosis and the extent of levator function can be measured in order to determine the appropriate surgical procedure. Advancement of MŸeller's muscle will not correct 3.5 mm of ptosis. Eyebrow suspension is most appropriate for patients who have poor levator function (less than 4 mm) and greater than 3 mm of ptosis. The Fasanella-Servat procedure shortens the lower components of the eyelid (ie, the tarsus, conjunctiva, and MŸller's muscle). The modification of this procedure spares the muscle and is best for patients who have levator function of greater than 10 mm and ptosis of less than 2 mm. Levator resection is reserved for those patients who have levator function between 4 mm and 10 mm, and ptosis of greater than 3 mm.

Answer 52

The correct response is Option A. In one study of 80 patients undergoing reconstruction of orbital blowout fractures and fractures of the zygomaticomaxillary complex via a preseptal transconjunctival approach, ectropion was not identified as a complication. Only one case of transient entropion was identified, and only 2% of patients in this study reported any complications. Another study of 35 patients who were undergoing secondary orbital procedures reported that 4% of these patients subsequently developed ectropion. In a third study of 400 patients, one patient was identified as having ectropion. In contrast, the rate of ectropion in patients undergoing the traditional subciliary approach to reconstruction has been shown to be as high as 25%.

Answer 53

The correct response is Option C. The primary factor contributing to the patient's concern is the relationship of the orbital malar ligament, orbital septum and retroseptal orbital fat. Release of the orbital malar ligament and fat repositioning offers the best option for improvement. The retroseptal fat compartments appear to be full so that fat injection alone would risk creating unwanted prominent fullness in the area. Skin resection should be conservative after fat repositioning to avoid lower lid malposition. Phenol-croton oil peeling is an effective treatment for aging changes but would not correct the anatomical relationships that underlie this patient’s chief concern. Botulinum toxin type A injections would not adequately address this patient's concerns.

Answer 54

The correct response is Option B. Complications arising as a result of blepharoplasty can be categorized as early (occurring during the first postoperative week), intermediate (occurring between the first and sixth postoperative weeks), and late (occurring after the sixth postoperative week). Among the intermediate post-blepharoplasty complications, lower eyelid malposition is the most commonly reported. It results from the imbalance in tension between the anterior and posterior lamellae. Widely regarded predisposing factors include: negative vector in which the orbital rim is retropositioned relative to the vertical plane of the cornea, excessive skin resection, aggressive imbrication of the orbital septum, thyroid ophthalmopathy (e.g. Graves disease) with exophthalmos, excessive and/or persistent edema, and hematoma. Horizontal laxity of the tarsoligamentous sling is the most likely predictor of lower eyelid malposition after lower eyelid blepharoplasty. It reflects the loss of normal upward, posterior, and superior tension across the lower eyelid margin. When this condition exists, manifested by a "snap test" in which the lid can be manually distracted anteriorly more than 8 mm away from the globe, surgical correction of horizontal eyelid laxity should be addressed during the lower eyelid blepharoplasty. This is accomplished with a tarsal strip procedure or similar form of canthoplasty. The euthyroid status with or without globe retropositioning of this patient confers less risk than hyperfunctioning thyroid conditions such as Graves in which exophthalmos increases the potential for lower eyelid malposition. A retropositioned globe will not affect the lower lid as much as the upper lid. Medical conditions such as glaucoma do not influence lower eyelid position.

Answer 55

The correct response is Option B. Chlorhexidine is a known ocular irritant at 4% strength and can cause severe corneal damage and corneal toxicity, especially if inadvertently left to dwell in the eye during a procedure. Thus, products like hexachlorophene and chlorhexidine gluconate should be avoided in and around the eye. Dilute chlorhexidine at 0.04% can be safely used as an eye treatment and is clinically prescribed for acanthamoeba keratitis, associated with contact lens use. 5% Povidone-iodine is available in a sterile ophthalmic variety and is used for ophthalmic procedures. 10% Povidone-iodine may also be used around the cheeks, brows, and eyelids. Unscented baby shampoo with a sterile rinse can be used for those with povidone-iodine allergies. While chloroxylenol is a mild eye irritant, it can be used with care around the eye.

Answer 56

The correct response is Option A. The findings seen in this patient are consistent with retraction of the lower eyelids, a common complication following surgery of the lower eyelids and midface. Lower eyelid retraction is defined as inferior malpositioning of the lower eyelid margin without eyelid eversion. Affected patients have round, sad-looking eyes, scleral show, and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. Ocular lubricants typically provide only minimal relief. Potential causes of lower eyelid retraction include scarring between the orbital septum and capsulopalpebral fascia, laxity of the lateral canthal tendon, and descent of the structures of the midface. Appropriate management is based on patient findings, which may include relaxation of the tarsal margin, skin shortening, and/or deep lamellar scar contracture.

Answer 57

The correct response is Option D. This 68-year-old woman has substantially diminished elasticity of the skin of the lower eyelids. Because of this, she is at increased risk for development of ectropion postoperatively if blepharoplasty with skin excision is performed alone and the laxity of the lower eyelid skin is not corrected. Therefore, the most appropriate management is lower eyelid blepharoplasty combined with lateral canthopexy, which will decrease the laxity of the lower eyelids and lower the risk for ectropion. Injection of botulinum toxin will not rejuvenate the lower eyelids, and carbon dioxide laser resurfacing of the lower eyelids will only increase the risk for ectropion if canthopexy is not performed concomitantly. Transconjunctival blepharoplasty alone will not correct the excessive skin of the lower eyelids.

Answer 58

The correct response is Option A. Minimal lagophthalmos in the postoperative period following blepharoplasty is not uncommon and generally self-correcting. Minimal lagophthalmos may persist but is often asymptomatic owing to compensatory blinking and increased tear production, both of which are the result of the mild exposure and resulting corneal stimulation. Laser-assisted in situ keratomileusis (LASIK) procedure involves creation of a corneal flap that interrupts the long ciliary nerves of the ophthalmic division of the trigeminal nerve. The interruption of these nerves results in decreased sensation to the cornea and a decreased corneal reflex arc. Patients with compensated exposure from blepharoplasty may lose the compensatory blink in reaction to corneal irritation following LASIK. This may cause dry-eye symptoms. With time, the corneal reflex arc improves, and the transient neurotrophic keratopathy and dry-eye symptoms improve. The other options are unlikely to cause her symptoms of dry eyes.

Answer 59

The correct response is Option D. This patient has traumatic ptosis as a complication of prior surgical procedures. At the time of debridement, either a portion of the levator muscle was excised or the muscle function is limited by scar tissue. In either case, the function as shown in the photographs is minimal, and the ptosis is best managed by a frontalis suspension procedure. It is generally agreed the fascia lata is the material of choice for the sling. Alloplastic materials, such as silicone slings, can also be used but have a risk of extrusion and infection. The advantage of alloplastic sling reconstruction is that there are no risks to the donor site. The Fasanella-Servat procedure involves excision of a portion of the conjunctiva, tarsus, orbital septum, levator aponeurosis, and Müller muscle. It can be used in cases of mild ptosis (1-2 mm). Levator function must be present. The Kuhnt-Szymanowski procedure is used to correct lower eyelid ectropion. It involves a wedge excision of the lower eyelid. Levator advancement surgery could possibly be used in this case if, during exploration of the eyelid, the levator was noted to be present and not compromised by scar. However, in this case, the levator mechanism was likely excised in the process of debriding the wound tract and inflammatory tissue. Therefore, in light of the degree of ptosis, the noted limited elevation of the upper eyelid, and the mechanism of injury, frontalis suspension is a better choice for ptosis repair in this patient. With no evidence of muscle function, it is unlikely that adhesions alone are the cause of restricted eyelid movement. Therefore, lysing the scar would likely be inadequate treatment.

Answer 60

The correct response is Option E. The best option for this patient is a conjunctivotomy to drain the fluid. She may also benefit from a lateral tarsorrhaphy. Chemosis can be classified as mild, moderate, or severe based on the degree of conjunctival prolapse between the eyelids. This patient had moderate chemosis based on significant conjunctival prolapse but maintaining the ability to close her eyelids. Chemosis may develop intraoperatively and can be treated with conjunctival plication. It typically occurs within the first postoperative week. Initial treatment for mild chemosis includes lubricating drops and/or tobramycin/dexamethasone drops, which aim to decrease inflammation and potential infection. Moderate chemosis may benefit from the addition of eye patching. After chemosis has been present for 2 to 3 weeks, the inflammatory phase has likely passed, as confirmed in this patient by the whitish appearance of the conjunctiva on examination. Anti- inflammatory medications, whether topical or oral, are no longer beneficial. Patients are likely to benefit from conjunctivotomy to drain the fluid that has accumulated. Oral steroids, such as methylprednisolone, are not indicated until after attempted treatment with conjunctivotomy and lateral tarsorrhaphy. REFERENCES: 1. McCord CD, Kreymerman P, Nahai F, Walrath JD. Management of postblepharoplasty chemosis. Aesthet Surg J. 2013;33(5):654-61. doi: 10.1177/1090820X13487016. Epub Jun 6 2013. 2. Woo KI, Choi CY. High-frequency radiowave electrosurgery for persistent conjunctival chemosis following cosmetic blepharoplasty. Plast Reconstr Surg. 2014;133(6):1336-1342. doi: 10.1097/PRS.0000000000000175 3. Weinfeld AB, Burke R, Codner MA. The comprehensive management of chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg. 2008;122(2):579-586. doi: 10.1097/PRS.0b013e31818001d0

Answer 61

The correct response is Option D. Dry eye syndrome (dysfunctional tear syndrome) is a problem of tear deficiency and eye discomfort that may result in damage to the cornea. Combining upper and lower eyelid blepharoplasty relative to staged upper and lower eyelid surgery presents a greater risk for dry eye syndrome due to orbicularis oculi dysfunction after surgery. Women on hormone replacement therapy also have a higher risk for developing dry eye syndrome after blepharoplasty. Eye lubrication before and after surgery needs to be strongly considered. Patients with prior laser vision correction should wait at least 6 months before pursuing blepharoplasty because of the effects on corneal sensation and tear production. In this case, the patient’s Lasik procedure 1 year prior would not impair her surgical outcome with upper and lower eyelid blepharoplasty. Chemosis is characterized by conjunctival swelling and irritation after blepharoplasty surgery, requiring lubrication after surgery. Some surgeons advocate treatment of this condition with steroid drops. Eyelid malposition is more likely in patients with a negative vector, defined as those with a maxilla that does not project beyond the orbital rim. It is also common in patients who have poor eyelid tone, diagnosed by snap test or evident as ectropion. Major adverse postoperative events such as bleeding and loss of vision are rare. Bleeding is more risky with uncontrolled hypertension. Smoking history, diabetes, and hypothyroidism are not directly associated with specific complications of blepharoplasty.

Answer 62

The correct response is Option A. The medial orbital wall is comprised primarily of the orbital plate of the ethmoid bone. This bone is made up of a horizontal or cribriform plate, a midline perpendicular plate that forms the nasal septum, and symmetric lateral masses. The outer wall of each lateral mass is the medial orbital wall, the inner walls are the sidewalls of the nasal Knowledge of the anatomy of the medial orbital wall is important when diagnosing and treating extensive orbital blowout fractures, which often include the orbital floor. These fractures can extend to involve the inferomedial hillock and central section of the medial orbital wall; if this occurs, the orbital contents may be displaced into the maxillary and ethmoid sinuses. If the anatomic volume of the bony orbit is not restored surgically, the patient may develop posttraumatic enophthalmos and diplopia. This will most likely occur in those patients who have an increase in bony orbital volume of greater than 5%. The lacrimal and palatine bones give off smaller contributions to the medial orbital wall, as does the lesser wing of the sphenoid bone. The orbital floor is comprised of the maxilla medially and the zygoma anteriorly.

Answer 63

The correct response is Option D. Both the Fasanella-Servat procedure and the levator aponeurosis reinsertion can accomplish good surgical results and are accurate methods for the correction of mild to moderate ptosis. However, one of the major disadvantages of the Fasanella-Servat procedure is that it does not address excess skin of the eyelid fold. Dry eyes, incomplete correction, overcorrection, and eyelid asymmetry are possible complications of both procedures.

Answer 64

The correct response is Option E. The orbicularis retaining ligament or the orbital malar ligament is a bilaminar membrane that spans from the periosteum of the inferior orbital rim to the fascia on the underside of the orbicularis. During aging, this ligament accentuates the orbital malar depression and restricts the orbital fat from blending with the sub oribularis oculi fat (SOOF). This patient presents with a prominent orbitomalar sulcus and tear trough deformity. Release of the medial portion of the orbicularis oculi muscle and the orbicularis retaining ligament allows fat transposition over the orbital rim, thus softening and improving this deformity. This procedure can be performed through either a transcutaneous or transconjunctival approach. The capsulopalprebral fascia is a retractor of the lower eyelid. It is incised during a transconjunctival fat excision. It is not incised in a transcutaneous approach. The inferior oblique tendon of the inferior oblique muscle should be protected during lower eyelid surgery. Lockwood’s ligament is a supportive structure of the globe. The inferior limb of the lateral canthal tendon is not released for fat transposition. It may be released for canthal support and repositioning.

Answer 65

The correct response is Option C. Blepharoptosis occurs as a result of acquired or congenital causes. Among the former causes is the most common one, involutional (senile), as well as traumatic, mechanical, neurogenic, and myogenic. The latter category includes myogenic or neurogenic causes only. Because surgical correction is the only effective, definitive therapy for acquired ptosis, it is important for the clinician to be able to differentiate between the causes. The involutional variety is due to attrition or dehiscence of the levator aponeurosis from the anterior upper part of the tarsal plate. Diagnosis of ptosis is confirmed when there is less than 2.5 mm of distance between the upper eyelid margin and the papillary light reflex. Physical findings that support the diagnosis of involutional ptosis include a lid drop during downgaze, a higher than normal upper lid crease, visibility of the eye through the thinned upper eyelid, and preservation of good levator excursion (greater than 10 mm). Rating the degree of ptosis is based on the upper eyelid margin to pupillary light reflex distance: greater than 4 mm is considered normal. Excess upper eyelid skin can obstruct visual field; however, it is not indicative of involutional ptosis.

Answer 66

The correct response is Option D. The most appropriate treatment is orbital decompression for retrobulbar hematoma. Most complications after blepharoplasty are correctable and minor. However, postoperative bleeding into the orbit causes a retrobulbar hematoma. With a large enough hematoma, orbital pressure increases, causing increased swelling, eye pain, and proptosis. With continued pressure, the optic nerve is compressed, leading to reduction in vision and ultimately blindness. The cause of a retrobulbar hematoma is bleeding within the orbit. As such, the blepharoplasty technique would be one in which the orbital septum was opened. Nevertheless, this complication must be considered in all blepharoplasty patients. The treatment for retrobulbar hematoma is emergent orbital decompression. The incision needs to be opened and the orbital space accessed for the hematoma and soft tissues to decompress and alleviate traction or pressure on the optic nerve. A lateral canthotomy is done as well to ensure maximal decompression. In the past, mannitol has been given as a diuretic for reduction of edema, but also as a free radical scavenger in hopes of protecting the optic nerve from compressive ischemia. Lasix is often administered as a quick controllable diuretic to lessen edema. This is a very rare complication of blepharoplasty. Mejia et al. surveyed plastic surgeons in the United States and Great Britain and derived data from over 750,000 blepharoplasties. In this study, 25 patients had permanent visual loss and 14 had temporary loss of vision. The overall incidence of visual loss due to retrobulbar hematoma was 0.0052% or one in 20,000 cases, with permanent loss occurring in 0.0033% or one in 30,000. Symptoms as noted above occurred in all patients within the first 24 hours, and hypertension was found to be the most common risk factor. All patients will develop postoperative swelling and ecchymosis to varying degrees. Head elevation and ice packs are appropriate for standard swelling noted without findings of orbital pain, proptosis, or changes in vision. Tarsorrhaphy is useful for patients with lagophthalmos or ectropion but has no role in globe protection for acute proptosis in the above setting. Lasix infusion is part of the treatment for retrobulbar hematoma, but as a stand-alone therapy it is inadequate. Provision of more pain medication is inappropriate in the presence of pain and reduced vision and will only serve to mask some symptoms related to the hematoma.

Answer 67

The correct response is Option B. Lateral canthal support can treat preexisting lower eyelid laxity and can help protect against postblepharoplasty malposition of the lower eyelid. The choice of treatment can be determined by the extent of eyelid laxity. For severe lower eyelid laxity (greater than 6 mm of eyelid distraction), a lateral canthoplasty with lateral cantholysis allows for increased superior mobility and precise positioning of the lower canthal tendon inside the orbital rim. While horizontal wedge excision of the lower eyelid addresses the horizontal lower eyelid laxity, it is not recommended in negative canthal tilt patients (lateral canthus at lower level than medial canthus), who also require lateral eyelid resuspension. Mild eyelid laxity (1 to 2 mm of eyelid distraction) can also be addressed with orbicularis repositioning. A posterior lamellar graft would not be an appropriate treatment for this condition. In minimal cases of eyelid laxity, temporary external support of the lower eyelid with a tarsorrhaphy stitch at the lateral limbus can help protect the cornea and prevent early cicatricial ectropion.

Answer 68

The correct response is Option B. The patient shown in the photograph has minimal exophthalmos and moderate scleral show. Such clinical findings, as well as proptosis, hypotonia of the lower eyelids, and maxillary hypoplasia, are significant predictors of dry eye syndrome, while low tear film is less predictive of dry eye syndrome. Therefore, appropriately cautious management is critical in patients who have these anatomic findings and are considering blepharoplasty. Surgery can still be performed with the necessary modifications and adequate ocular protection. One study reported that 65% of patients who developed dry eye syndrome following blepharoplasty had normal findings on preoperative Schirmer's testing. This patient would not be at risk for diplopia, which is more closely related to edema, hematoma, and wound infection. Entropion occurs as a result of damage to the ciliary margins of the eyelid resulting from an excessively close incision (leading to angulation of the upper border of the tarsal plate) or spasm of the upper portion of the orbicularis oculi muscle. However, this patient's findings are not indicative of postoperative entropion. Development of hematoma is rarely predictable. The findings are not consistent with ptosis, which can be worsened postoperatively if it is not identified before the procedure.

Answer 69

The correct response is Option B. Frontalis suspension is the most appropriate procedure for correction of the poor levator function and severe ptosis seen in this 6-year-old boy. Appropriate preoperative evaluation should be performed in any patient with ptosis to classify the type and severity of the ptosis and the amount of levator function. Ptosis is classified as congenital or acquired. Patients with congenital ptosis often have poor function of the levator muscle, characterized by absence of eyelid excursion and a static eyebrow. In acquired ptosis, levator function is typically moderate to good. The amount of levator function is critical to determine the appropriate surgical correction. Blepharoplasty is appropriate in patients with excess skin and fat around the eyelids, but not in patients with true ptosis. Placement of gold weights in the eyelids is indicated for patients with facial paralysis to assist with eyelid closure. Plication and/or resection of the levator muscle is appropriate for patients who have moderate ptosis and levator function that is rated as fair to good.

Answer 70

The correct response is Option A. The findings in this patient are most consistent with dehiscence of the levator aponeurosis, which is the most common cause of ptosis in elderly persons. Attenuation of the levator aponeurosis typically results. Levator advancement is performed for correction. Facial nerve injury is a sequela of trauma and may be characterized by eyebrow ptosis. Horner's syndrome occurs as a result of sympathetic denervation of the superior cervical ganglion. It is characterized by ptosis, myosis, and anhidrosis. The eyelid creases and levator muscle are typically unaffected. Unilateral or bilateral ptosis secondary to myasthenia gravis is exacerbated with fatigue and can present in young women and elderly men. Neostigmine testing is used to establish the diagnosis. Periorbital fat atrophy results in pseudoptosis and enophthalmos of the globe.

Answer 71

The correct response is Option E. The zygomaticofacial nerve provides sensory innervation to the lateral fat pad of the lower eyelid. Branches of the trigeminal nerve provide sensation to the face. The infraorbital nerve, the second branch of the trigeminal nerve, supplies innervation to the lower eyelid, cheek, and upper lip. The lateral palpebral branch of the lacrimal nerve, a branch of the infraorbital nerve, supplies sensory innervation to the superior lateral portion of the upper eyelid. The infratrochlear nerve provides sensory innervation to the medial aspect of the upper and lower eyelid. The lacrimal nerve provides sensation to the upper eyelid through the first branch of the trigeminal nerve. The facial nerve is a motor nerve to the face and is not responsible for sensation in the face.

Answer 72

The correct response is Option B. The finding of a negative vector places the patient at an elevated risk for lower lid malposition and ectropion. The negative vector refers to the anatomic relationship on lateral view of the maximum projecting point of the globe and the maximum projecting point of the infraorbital malar prominence. If the globe projects less than the malar prominence, a negative vector exists. Conversely, if the malar prominence projects more than the globe, a positive vector exists. The negative vector finding indicates potentially deficient globe and lid support based on skeletal anatomy. Such patients will often have minor scleral show or lateral lid lag. It is important to recognize these findings prior to blepharoplasty surgery in order to surgically address the risks of ectropion via primary lid suspension during the blepharoplasty. Occasionally, lower lid blepharoplasty may be avoided if a negative vector is present and other conditions such as dry eye exist. Other findings or conditions that are associated with postoperative ectropion and lower lid malposition are: orbicular weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, and eyelid laxity. Excessive or prominent middle lamellar scarring can occur after surgery, which can also lead to lid malposition. Lagophthalmos is the inability to lower the upper lid fully and is a negative consequence of upper blepharoplasty due to excessive tissue resection or fibrosis. Enophthalmos is interior retraction or displacement of the globe related to increased orbital volume. This is unrelated to lower blepharoplasty surgery. Proptosis is an external displacement of the globe giving the appearance that the eyeball is extruding from the obit. This is most often associated with Graves disease, head trauma, and increased intracranial pressure. It can also be due to a retrobulbar hematoma after blepharoplasty, which is a surgical emergency due to the risk of blindness. Dystopia refers to malposition of the globe related to skeletal changes of the orbit. This would not be a result of blepharoplasty, but can occur after facial trauma or facial tumor resection.

Answer 73

The correct response is Option E. The most common complication following lower blepharoplasty is lower eyelid malposition. Lower eyelid malposition ranges from mild scleral show to severe cicatricial ectropion. Malposition of the lower eyelid results from abnormal downward forces on the eyelid. Excessive scarring, over-resection of skin, imbrication of the orbital septum, orbicularis paralysis, edema, and hematoma can all produce lower eyelid malposition. Predisposing factors for malposition that should be indentified preoperatively include malar hypoplasia, globe proptosis, high myopia, laxity of the lower eyelid, and thyroid ophthalmopathy. Postoperative mild scleral show can often be managed with massage and topical lubrication. However, severe ectropion may require scar release, skin grafting, or a lower eyelid tightening procedure such as a canthoplasty. Chemosis is a postoperative sequela, but it usually resolves in 6 weeks. Infection of the lower eyelid following blepharoplasty is rare given that the eyelid is well vascularized. Lacrimal system dysfunction is rare and often returns to normal without surgical intervention. Lagophthalmos can occur following upper blepharoplasty and can lead to postoperative pain, guarding, or incomplete eyelid closure. Lagophthalmos is usually temporary and resolves with lubrication and eyelid massage.

Answer 74

The correct response is Option A. Intraocular pressure is similar to compartment syndrome in that an excessive amount of pressure on the optic nerve resulting from bleeding or edema can increase intraorbital pressure and ultimately lead to blindness. An acute increase in intraorbital pressure can occur following orbital fracture repair, blepharoplasty, or other surgical procedures. Physical examination in an affected patient will show visual loss associated with a pupillary defect, such as a loss of pupillary reaction to light. Increased intraocular pressure can be measured at the bedside using a tonometer. Lateral canthotomy, or release of the lateral canthal tendon, should be performed immediately to relieve pressure and restore sight. Any proptosis that is present will be accentuated immediately after surgery and can thus be diagnosed at this time; it can be measured to confirm adequate release of the check-rein ocular support. Surgical exploration can also be performed after lateral canthotomy to control any persistent bleeding. In contrast, eyelid structures such as the levator aponeurosis, orbicularis oculi muscle, and tarsal plate do not need to be released. Because these structures lie external to the support sling created by the lateral canthal tendon and Lockwood's suspensory ligament, they already have at least partial mobility. Tenon's capsule covers the globe and extraocular muscles, creating a barrier between these structures and the orbital fat. The lower portion of the capsule comprises Lockwood's suspensory ligament. Because of their position proximal to the globe, it is more prudent to detach the lateral canthal tendon from the bony rim in order to allow for advancement of the intraorbital contents. Surgical detachment of the lateral canthal tendon will disrupt the globe only minimally. Any loss of lower eyelid height can be restored later with lateral canthopexy.

Answer 75

The correct response for Item 88 is D and for Item 89 is C. Horner syndrome is marked by ptosis, miosis, and anhidrosis. It occurs after loss of sympathetic innervations of the superior cervical ganglion. The eyelid crease is usually not affected. Injury to the facial (VII) nerve results in brow ptosis, not blepharoptosis. Myasthenia gravis may cause unilateral or bilateral ptosis, which would be exaggerated by fatigue. The condition typically affects young women or elderly men. Pharmacologic testing establishes the diagnosis. Senile ptosis is characterized by dehiscence of the levator aponeurosis, which is the most common cause of ptosis in elderly individuals. Elevation of the supratarsal crease is seen. Levator plication or advancement is required for correction.

Answer 76

The correct response is Option A. Involutional entropion can be confused with involutional ectropion in the static state because of the associated lower eyelid laxity in both instances. The two conditions are completely distinguishable on animation of the orbicularis oculi muscle. Inversion of the lower eyelid occurs on attempted eyelid closure in cases of involutional entropion. Causal factors include orbicularis dysfunction with the preseptal portion overriding the pretarsal portion, upper eyelid €œclosure kick, € disinsertion of lower eyelid retractors, loss of horizontal and vertical eyelid support, and loss of orbital fat volume. Hertel exophthalmometry is an objective measure of globe position in relation to the orbit; although enophthalmos can be associated with entropion, the test cannot distinguish it from ectropion. Jones dye test is used to assess the lacrimal drainage system. Lower eyelid snap-back test indicates laxity in both entropion and ectropion. The Schirmer test is an objective measure of lacrimal secretory capacity only.

Answer 77

The correct response is Option C. The patient has 3.5 mm of ptosis of the left upper eyelid, which partially obstructs vision. Absence of the eyelid crease and 3 mm of levator function are highly suggestive of congenital ptosis. A frontalis sling of the left upper eyelid can correct these abnormalities by resetting the position of the affected eyelid. Observation is not appropriate because the partial obstruction of vision could lead to amblyopia in the left eye. Application of a patch is inappropriate because it would deprive the left eye of all visual input, exacerbating the problem. Resection of Müller’s muscle from the left upper eyelid is an acceptable treatment of a small amount of ptosis (such as 1 mm) in an adult but would not correct this severe ptosis. Levator resection and advancement of the upper eyelid are the most common method of treating levator dehiscence in adults but would not be appropriate to treat a child with minimal levator function.

Answer 78

The correct answer is option B. The capsulopalpebral fascia and the inferior tarsal muscle are retractors of the lower eyelid. Both structures attach to the inferior border of the tarsus. The inferior tarsal arises from the capsulopalpebral head of the inferior rectus muscle. Its function is analogous to the Müller muscle in the upper eyelid. The capsulopalpebral fascia is analogous to the levator aponeurosis of the upper eyelid. The capsulopalpebral fascia makes up the anterior superior portion of the lower eyelid retractors distal to the Lockwood ligament. The capsulopalpebral fascia is divided during the transconjunctival incision. This affords access to the lower eyelid for the blepharoplasty procedure. The lateral canthus anchors the lower lid to the lateral orbital bone. It is not necessary to release this to redrape orbital fat. The orbital septum acts to contain the orbital contents. It attaches inferiorly to the periosteum at the arcus marginalis and superiorly to the eyelid margin. A transconjunctival blepharoplasty can be performed by a preseptal or postseptal approach. The orbicularis retaining ligament (also known as the orbitomalar ligament) attaches the orbicularis oculi to the orbital rim. It separates the lower eyelid from the midface. Release of this structure is required to obtain access to the midface when approaching it from the lower eyelid. Reference(s): Pacella, S, Nahai FR, Nahai F. Transconjunctival blepharoplasty for upper and lower eyelids. Plast Reconstr Surg. 2010;125(1):384-392. doi:10.1097/PRS.0b013e3181c2a534 Rohrich RJ, Mahedia M, Hidalgo D, Shah N. The evolving role of blending of the lid-cheek junction in lower blepharoplasty. Plast Reconstr Surg. 2018;142(2):377-382. doi:10.1097/PRS.0000000000004593 Zide BM, Jelks GW. Surgical Anatomy of the Orbit. 1st ed. Raven Press;1985:28-30. Zoumalan CI, Roostaeian J. Simplifying blepharoplasty. Plast Reconstr Surg. 2016;137(1):196e-213e. doi:10.1097/PRS.0000000000001906

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Blepharoplasty 01-22 Flashcards

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