Blepharoplasty Flashcards
A 50-year-old woman is scheduled to undergo transcutaneous blepharoplasty. Fat transposition and canthopexy are planned. The inferior oblique muscle of the eye is most vulnerable to injury when dissecting between which of the following structures?
A) Central fat compartment and lateral fat compartment
B) Lateral fat compartment and orbicularis retaining ligament
C) Medial canthal tendon and medial fat compartment
D) Medial fat compartment and central fat compartment
E) Orbicularis retaining ligament and arcus marginali
D) Medial fat compartment and central fat compartment
The inferior oblique muscle of the eye can be found between:
The inferior oblique muscle of the eye can be found between the medial fat compartment and the central fat compartment.
The inferior oblique muscle of the eye is most vulnerable when:
When performing either excision or manipulation of the medial and central fat compartments, the inferior oblique muscle is vulnerable to injury. These injuries include resection, cauterization, scarring, hemorrhage, edema, and suture injury while repairing the septum orbitali.
A transition of less than ______ of the inferior oblique muscle won’t cause permanent diplopia
One study suggested that transection of less than 50% of the inferior oblique muscle will not cause permanent diplopia.
Orbicularis retaining ligament anatomy
The orbicularis retaining ligament is a structure that originates along the orbital rim and inserts into the overlying orbicularis oculi muscle. Laterally, it contributes to the lateral canthal ligament.
Arcus marginalis anatomy
The arcus marginalis is the periosteal extension of the septum orbitale as it attaches into the orbital rim.
A 50-year-old woman is scheduled to undergo transcutaneous lower eyelid blepharoplasty for periorbital aging. Which of the following is the most likely complication 3 months postoperatively? A) Chemosis B) Infection C) Lacrimal system dysfunction D) Lagophthalmos E) Lower eyelid malposition
E) Lower eyelid malposition
Most common complication following lower blepharoplasty
The most common complication following lower blepharoplasty is lower eyelid malposition.
Predisposing factors for lower eyelid malposition following lower blepharoplasty
Predisposing factors for malposition that should be indentified preoperatively include malar hypoplasia, globe proptosis, high myopia, laxity of the lower eyelid, and thyroid ophthalmopathy.
A 69-year-old woman comes to the office for consultation regarding lower eyelid blepharoplasty. Physical examination shows a negative canthal tilt. Snap-back testing of the lower eyelid shows8 mm of distraction. Transcutaneous lower blepharoplasty with fat transposition is planned. Which of the following is the most appropriate surgical choice to avoid postoperative malposition of the lower eyelid? A) Horizontal wedge excision B) Lateral canthoplasty C) Orbicularis repositioning D) Posterior lamellar graft E) Tarsorrhaphy
B) Lateral canthoplasty
Protection against postblepharoplasty malposition of the lower lid in patients with severe lower 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 atlower level than medial canthus), who also require lateral eyelid resuspension.
Protection against postblepharoplasty malposition of the lower lid in patients with mild lower eyelid laxity
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 forthis condition.
Protection against postblepharoplasty malposition of the lower lid in patients with minimal lower eyelid laxity
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.
A 50-year-old woman comes to the office because of numbness of the skin of the right central forehead 10 weeks after undergoing upper eyelid blepharoplasty. The procedure involved transpalpebral resection of the medial brow depressor muscles. Injury to which of the following nerves is the most likely cause of this patient's condition? A) Abducens B) Oculomotor C) Supraorbital D) Supratrochlear E) Zygomaticotemporal
D) Supratrochlear
A 4-year-old boy is referred for evaluation because of a 6-month history of bilateral epiphora. Examination shows that the eyelashes are rubbing against the inferior corneas bilaterally. Which of the following is the most likely cause of this patient’s condition?
A ) Abnormal attachment of the orbital septum
B ) High-riding tarsal plane
C ) Laxity of the lateral canthal tendons
D ) Laxity of the tarsal plate
E ) Redundancy of skin and orbicular muscle of the eye
E ) Redundancy of skin and orbicular muscle of the eye
Epiblepharon
Epiblepharon is characterised by a congenital horizontal fold of skin near the margin of the upper or lower eyelid caused by the abnormal insertion of muscle fibres. This extra fold of skin redirects the lashes into a vertical position, where they may contact the globe. This is found most commonly in Asian individuals, especially children.
Most common cause of epiblepharon
The mostcommon cause of epiblepharon is excess pretarsal skin and orbicular muscle at the lower eyelid margin.
Epiblepharon usually affects the lower eyelids, is more common in people of Asian descent, and is accentuated on downward gaze.
A 66-year-old man is referred for evaluation of left eyelid ptosis. He reports decreased vision in the left eye only, which bothers him throughout the day. Physical examination shows mild-to-moderate left eyelid ptosis and elevation of the left supratarsal crease. Brow position and function and pupillary size are normal bilaterally. Which of the following is the most likely diagnosis? A ) Congenital ptosis B ) Facial nerve injury C ) Horner syndrome D ) Myasthenia gravis E ) Senile ptosis
E ) Senile ptosis
Senile ptosis is characterized by:
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.
Most common cause of ptosis in the elderly
Senile ptosis
What is necessary to correct senile ptosis?
Levator plication or advancement is required for correction.
Congenital ptosis
Congenital ptosis is seen in young patients who have moderate-to-severe ptosiswith absence of the eyelid crease and poor levator function. Upper eyelid frontalis sling is sometimes required for correction.
Horner syndrome
Horner syndrome is marked by ptosis, miosis, and anhidrosis. It occurs after loss of sympathetic innervations of the superior cervical ganglion.
A 45-year-old woman comes to the office for consultation regarding lower eyelid blepharoplasty. Physical examination shows prominent eyes; exophthalmos is suspected. Measurement of the distance between the anterior border of the globe and the most anterior point of which of the following aspects of the orbital rim is most appropriate to confirm this diagnosis? A ) Inferior B ) Lateral C ) Medial D ) Radix E ) Superior
B ) Lateral
Enopthalmos definition (mm)
The Hertel exophthalmometer measures the distance between the anterior border of the globe and the most anterior point of the lateral aspect of the orbital rim. Enophthalmos is defined as less than 14 mm
Which of the following anatomical events occurs during eyelid closure?
A ) The lacrimal canaliculi occlude
B ) The lacrimal diaphragm returns to a relaxed position
C ) The lacrimal puncta close
D ) The lacrimal sac collapses
E ) The nasolacrimal duct shortens
C ) The lacrimal puncta close
During eyelid closure,the lacrimal puncta close because of simple forced position.
Evolution of the lacrimal sac during eyelid opening/blinking
Upon eyelid closure, tears are milked lateral to medial. The deep heads of the preseptal muscles contract, shortening the canaliculi and closing their ampullae. Simultaneously, the deep heads of the preseptal muscles that are attached to the fascia of the sac (lacrimal diaphragm) pull the sac laterally. This creates negative pressure and results in the opening of the sac.
As the eyelids reopen, the lacrimal diaphragm returns to its relaxed position, creating sufficient pressure to propel the tears into the nasolacrimal duct. The canaliculi reopen at this phaseto allow collection of more tears.
A 65-year-old man has involutional ptosis of the left upper eyelid. Which of the following is the most important factor to consider when determining the appropriate management?
A ) Amount of brow ptosis
B ) Amount of excess eyelid skin
C ) Degree of levator function
D ) Distance between the tarsal edge and the brow
E ) Position of the supratarsal fold
C ) Degree of levator function
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.
Involutional ptosis is caused by
Involutional (senile) 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.
Levator function with involutional ptosis
Involutional (senile) 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 ___________ determines the required degree of correction for senile ptosis
The degree of levator function determines the required degree of correction.
Poor levator function and correction of senile ptosis
With a poor levator function (0 -6 mm of excursion), frontalis suspension isrequired.
Moderate levator function and correction of senile ptosis
With a moderate function (6 -10 mm), levator resection (shortening) is required.
Excellent levator function and correction of senile ptosis
For patients with excellent levator function (> 10 mm), aponeurotic surgery is appropriate
Which of the following structures is incised during the transconjunctival approach to lower eyelid blepharoplasty? A ) Capsulopalpebral fascia B ) Inferior rectus sheath C ) Lower eyelid tarsus D ) Orbicularis oculi E ) Orbital septum
A ) Capsulopalpebral fascia
Transconjunctival approach to blepharoplasty
The transconjunctival approach to blepharoplasty involves incision through the middle of the lower conjunctiva at the inferior aspect of the lower eyelid tarsus, which is then carried through the capsulopalpebral fascia.
Advantage of the transconjunctival approach to blepharoplasty
The primary advantage of this approach is that it avoids skin incisions and transection of the orbital septum and orbicularis muscle, resulting in a reported decrease in lower eyelid retraction
In a 45-year-old woman who is undergoing correction of lateral orbital fullness, which of the following is most likely to increase the risk of postoperative dryness of the eyes?
A ) Correction of brow ptosis
B ) Removal of the central preaponeurotic fat
C ) Removal of retro-orbicularis oculi (ROOF) fat
D ) Resection of the Eisler fat pocket
E ) Resection of a prolapsed lacrimal gland
E ) Resection of a prolapsed lacrimal gland
Causes of lateral orbital fullness
Causes of lateral orbital fullness, which may contribute to an unfavorable result after upper blepharoplasty, include prominence of the superolateral orbital rim, brow ptosis, excess retro-orbicularis oculi fat, lacrimal gland ptosis, and excess periorbital fat.
Treatment of lacrimal gland ptosis
Lacrimal gland ptosis, if encountered, can be corrected by resuspension of the gland with sutures extending from the pseudocapsule of the gland to the periosteum at the arcus marginalis of the orbital rim. The lacrimal gland is a major contributor to tear production and resection should be avoided.
Retro-orbicularis oculi fat anatomy
Retro-orbicularis oculi (ROOF) fat lies deep to the orbicularis oculi and superficial to the orbital septum.
Eisler fat pocket anatomy
The Eisler fat pocket, bordered by the lacrimal gland, orbital rim, orbital septum, and lateral canthal tendon, is an additional accessory fat pad in the lateral compartment of the upper lid and does not enter the surgical field during standard blepharoplasty.
A 65-year-old woman is scheduled for a brow lift procedure. She has a 10-year history of osteopenia. Her brow is approximately 8 mm inferior to the supraorbital rim on the right and 6 mm inferior to the supraorbital rim on the left. Scalp thickness is 4 mm. Which of the following techniques for rejuvenation of the forehead is contraindicated in this patient?
(A) Endoscopic brow lift fixed with cortical tunnels
(B) Endoscopic brow lift fixed with an Endotine 3.5 forehead device
(C) Endoscopic brow lift fixed with Mitek anchors
(D) Open brow lift using a coronal approach
(E) Open brow lift using an anterior hairline approach
(B) Endoscopic brow lift fixed with an Endotine 3.5 forehead device
In a recent cadaveric study comparing various methods of forehead fixation, neither cortical tunnels at 45-degree angles nor Mitek anchor screws penetrated the inner table, whereas the Endotine 3.5 post and titanium miniscrews both penetrated regions of the skull that were found to be thin (lateral and posterior to the coronal suture)
Entodine 3.5 forehead device
This device consists of a 1-mm-thick polylactic acid platform with tines that project 3.5 mm from the platform. A second-generation device consisting of a 0.5-mm L‑lactide/glycolide rapidly absorbing copolymer with variably projecting tines was introduced in 2003. Endotine fixation provides rapid and secure multipoint fixation and is designed to minimize complications such as alopecia and pain.
Entodine 3.5 forehead device contraindications
Contraindications to the use of Endotine forehead fixation include thin cranial bones (the post extends 3.95 mm) and a thin, atrophic scalp. Endotine forehead fixation also should not be used when internal fixation is otherwise contraindicated (eg, infection) and in patients with a known allergy or foreign-body sensitivity to plastic biomaterials.
A 59-year-old woman comes to the office for consultation regarding rejuvenation of the periorbital region. She is most concerned with bulging of orbital fat in the upper and lower eyelids. She says she wants “itall removed.” Which of the following is the most likely long-term outcome of excessive fat removal in this area? (A) Cadaveric appearance (B) Ectropion (C) Enophthalmos (D) Negative vector deformity (E) Tear trough deformity
(A) Cadaveric appearance
Removal of excessive fat from the eyelids may improve the convexity of the periorbital region temporarily, but it can cause a cadaveric appearance over the long term.
Correction of the tone of the lower eyelid with tightening of the muscle and canthal tendon, combined with correction of the tear trough deformity by fat repositioning over the orbital rim, will lead to a smooth lower eyelid-cheek junction.
A 46‑year‑old woman is undergoing blepharoplasty of the lower left eyelid. During removal of adipose tissue, the muscular structure indicated by the arrow in the photograph is inadvertently cauterized. To test the function of the structure, the patient should be asked to move her left eye in which of the following directions? (A) Downward (B) Downward and outward (C) Inward (D) Upward and inward (E) Upward and outward
(D) Upward and inward
Injury to the inferior oblique muscle remains an infrequent but potentially debilitating complication of lower blepharoplasty. During transcutaneous blepharoplasty, the inferior oblique muscle is susceptible to injury because of its intimate association between the medial and central compartments.
Most frequently injured extraocular muscle following transcutaneous blepharoplasty.
The inferior oblique muscle is reported to be the most frequently injured extraocular muscle following transcutaneous blepharoplasty.
Action of superior rectus
Upward and outward
Action of inferior rectus
Downward and outward
Action of inferior oblique
Upward and inward
Action of superior oblique
Downward and inward
Action of middle rectus
Inward
Action of lateral rectus
Outward
A 48-year-old man comes to the office six days afterundergoing bilateral transcutaneous lower eyelid blepharoplasty because he has diplopia and pain in the left orbit. Injury to the left inferior oblique muscle is suspected. Which of the following findings will confirm the diagnosis?
(A) Absent depression,extorsion, adduction of the left eye
(B) Absent elevation, intorsion, adduction of the left eye
(C) Absent extorsion, elevation, and abduction of the left eye
(D) Absent intorsion, depression, and abduction of the left eye
(B) Absent elevation, intorsion, adduction of the left eye
A 55‑year‑old woman who underwent an upper and lower blepharoplasty procedure via a subciliary approach five years ago comes to the office for consultation regarding dry eyes. She says that the symptoms are worse in the left eye and that she has to tape her eyes closed before sleeping to minimize dryness. Physical examination shows prominent globes with 1 mm of scleral show on the left and no scleral show on the right. Severe bilateral lid laxity is noted, along with 8 mm of anterior distraction of the lower lids. Snap-back test is greater than one second. Schirmer’s test indicates adequate tear production. Results of thyroid testing are within normal limits. Which of the following is the most appropriate management of this patient’s symptoms?
(A) Full-thicknessskin grafting to the lower eyelid
(B) Lateral canthotomy and canthoplasty
(C) Lateral tarsorrhaphy
(D) Suspension via a sub-orbicularis oculi fat (SOOF) lift
(E) Wedge resection lower lid tightening
(B) Lateral canthotomy and canthoplasty
The main symptom of dry eyes in the patient described is not likely caused by poor tear production but by accelerated evaporative loss from poor tone of the lower eyelids.
Which of the following structures of the eye acts as a suspensory system for the globe? (A)Lockwood ligament (B) Medial canthal tendon (C) Orbital septum (D) Superior oblique tendon (E) Whitnall ligament
(A)Lockwood ligament
