Blepharoplasty and Brow LIft Flashcards
1
Q
Define dermatochalasis and blepharaochalasis
A
- blepharochalasis - excess fat, skin and muscle in upper eyelid - inflammatory
- dermatochalaiss - only excess skin - laxity
2
Q
Define blepharoptosis and pseudoptosis
A
- blepharoptosis - upper lid margin inferior displcaed over limbus
- pseudoptosis - depression of upper lid secondary to enopthalmus/dermatochalasis
3
Q
Define the Shimer test, snap test and distraction test
A
- Schirmer test - to verify reflex and basic tearing, use 35x5mm filter paper, 5mins, normal is 10-30mm. Schirmer 1 test both reflex/basic, test 2 w tetracaine to eliminater relfexive response
- Snap test - lid pulled downward, if >1sec to return to position =laxity
- Distraction est - lid pulled away from globe, if can be distracted >6-10mm =laxity
4
Q
What are aesthetic measurments deifning an attractive periorbital region
A
- Intecanthal distance 1/5 of facial width
- Hairline to brow at pupil 5-6cm
- brow to midpupil 2.5cm
- pretarsal skin show 3-6mm
- lash line to upper tarsal crease 10mm
- brow to SOR 1cm
5
Q
Describe the anatomy of o.oculi
A
Pre-tarsal
- Medial - superficial head inserts on ant limb of MCT, deep head inserts on posterior crest posteriro to lacrimal sac
- Lateral - inserts with LCT onto Whitnalls tubercle
Pre-septal
- Medial - superficial heads inserts on ant limb of MCT, deep head inserts on posterior lacrimal crest w pretarsal OO
- Lateral - forms a raphe of fibers which insert directly into skin
Orbital
- MEdial - inserts onto SOR and IOR
- Lateral - lies superficial to frontalis, corrugator, ZM/m, lip and nasal levators
6
Q
Describe the sensory innervation in the periorbital region
A
- STN, SON (V1)
- Infratrochlear nerve (V1) (both upper and lower lids)
- lacrimal n (V1)
- Infraorbital (V2)
- Zygomaticofacial/zygomaticotemporal (V2)
7
Q
Describe the intra and extraorbital fat compartments
A
Post-septal (intraorbital)
- Upper (2) - medial pale yellow fat w medial palpebral artery + infratrochear n. Central butter yellow fat. Lacrimal gland lies laterally
- Lower (3) - medial pale yellow (separated by IO) central butter yellow (seperated by lateral extension of arcuate ligament) lateral butter yellow
Pre-septal (extraorbital) lies deep to orbicularis, anterior to septum
- Roof - Retro-orbicularis oculi fat
- SOOF - sub-orbicularis oculi fat
8
Q
What are the origins and insertios of the orbital septum
A
Origin: IOR and SOR - named arcus marginalis
Insertion - Upper lid - 15mm above uppe rtarsal birder
Insertoin - Lower lid - 5mm below lower tarsal border
9
Q
What forms supratarsal crease?
A
insertion of OO and fibrous levator aponeurosis into skin
10
Q
Describe your history and physical for patient presenting with periorbital complaints of againg
A
History
- Deformity, desires, expectations
- Ocular Hx: corrective lens/contact, dry sx, visual sx, last ophtho asx, cataract, glaucoma, Lasix surgery
- Symptom (ptosis/laxity) - onset, duration, progression, uni/bilat
- PMHx: HTN, thyroid, coagulative D, endocrine, meds/allergies
PE
- Visual Asx: pupils, EOM, VA, VFs, conjuntival ingection, fundoscopy, corneal reflex
-
Upper lid:
- Static - > lid position (ptosis/retraction), brow position, excess skin/muscle/fat, supratarsal crease
- Dynamic: levator fx, Bells, lagophthalmus, orbicularis fx
-
Lower lid:
- Static: malar bag, festoons, excess skin/muscle/fat, lip position (ectro/entro/scleral show)
- Dynamic: Snap and distraction test (laxity)
-
Globe:
- canthi
- exoph/enop, vertical dystopia
- Vector
- Proptosis
11
Q
What does negative vector predict
A
- risk of dry eye syndrome
- risk of ectropion
- may require canthoplasty as part of the procedure
12
Q
What are the principles and goals of blepharoplasty
A
- restore sharp crisp tarsal folds
- restore symmetry
- retain/restore lateral canthal angle
- reposition/remove poorly positioned skin/fat/muscle
13
Q
Describe the steps of the upper blepharoplasty
A
-
Marking
- w pt standing, at jx of lateral and central 1/3 , mark inferior extent of incision 9-12mm from the lash line, with gentle curve medial and lateral, stopping belore medial canthus
- pinch test to determine amount of skin removal
-
Skin excision/muscle
- incisions made and skin excsied
- if muscle excision, done next as small strip
- septum opened to remove medial fat pad which protrudes, minimal centrally
- careful hemostasis
- +/- anchoring stitches, ROOF excision, gland suspension
14
Q
Describe steps in Lower blepharoplasty
A
-
Marking
- subciliary - 1-2mm below lash line and lateral extensio into crease
- trasncutaneous (below vascular arcade through conj/CPF
- incise skin w scalpel puncture then scissors, step to then incise through muscle to reach septum
- May excise muscle
- open septum, release protruding fat
- release ORL, ZRL
- conservative skin excision
Modifications as per Dr. Ford
- +/- canthoplasty +/- o.oculi sling
- release tear through below rim supraperiosteal
- release ORL and ZRL below rim supraperios
- transpose medial fat below tear through depression
- excise post-septal lateral fat pad
- +/- resuspension of o.oculi to DTF
- temporary tarsorrhaphy at lateral limbus 5-0 nylon x1wk
- tear naturall q2h, lacrilube qhs
15
Q
List complications of blepharoplasty
A
Immediate
- corneal injury
- lacrimal injury
- diplopia
- blindness
- glaucoma
- OCR
- hematoma
- subscleral
- periorb
- retrobulbar
Early
- conjunctivitis
- keratoconj sicca
- ecchymosis
- chemosis
- lagophthalmus
- asymmetry
Late
- asymmetry, underover correction
- ectropion/entropion
- levator dysfx
- Lacrimal dysfx: epiphora/dry eye
16
Q
How do you manage chemosis
A
- Def: edema of conjunctiva
- Secoandry to lymphatic disruption - conj is drained by lympatics of eyelid
- Prevention is key
- intra-op BSS< HOB elevation, , normotensive anesthesia, minimal iV lfuid, limit exposure
- Treatment
- tears naturalle q2h, lacrilube qhs. if not resolving, tobradex or forte liquifilm, neo-synephrine, +/- patching/cold compress
- If not esolving 2wks - optho cnosults for oral steroids
17
Q
WHat is the incidence and management of retrobulbar hematoma?
A
- 0.04% - worse outcome - blindness 2’ compression with occlusio of CROA or optic nerve ischemia
- Clinical Hx
- pain
- loss of vision
- On exam
- proptosis
- ophthalmoplegia
- increased IOP >30 (papilledema)
- mydriasis
- gradual loss of VA
- Managment
- surgical emergency- evacuation
- HOB>30
- control pain/N/V
- remove sutures
- urgent lateral canthotomy, cantholysis
- mannitol 20%, 1-2g/kg IV over 1hr
- methylpredinosone 1G IV x1
- Timolol 0.5% 1-2gtt bid
- Diamox (CAI) 500mg IV then 250mg q4hr
- Ophtho consult
18
Q
What are indicaitions for emergent decompression for RB hematoma
A
- acute Visual loss with high IOP (consicous)
- proptosis, IOP >40 +/- RAPD (unconscious)
Technique
- lateral canthotomy/cantholysis (not if globe ruptre suspected)
- open surgical site if post op
- formal drainge
- look for active bleeder
- if not completely released, release arcus marginalis/orbital septum
- if not completely decompressed, outfracture alteal orb wall
19
Q
Describe how you would do a lateral canthotomy/cantholysis
A
- LA w needle directed away from the globe
- cut laterally between two lids
- inferolateral tension onlower lid away from glob
- blunt scissors to cut inferior crus of lateral canthus
20
Q
Describe the features of the asian upper and lower eyelid
A
- Upper lid
- absence of supratarsal
- medial epicanthal fold
- hooding caruncle
- narrow palpebral fissure
- Lower lid
- anterosuperior projection of intraobital fat
- absence of lower lid crease
21
Q
Describe correction of asian eyelid and epicanthal fold
A
- Open
- incision 5-6mm above midupil, 15mm in length
- excision of pretarsal o/oculi approx 2mm
- anchor lower skin dermis with suturing to levator insertion at upper tarsal border
- Closed
- sutures w prolene at level of new desired supratarsal crease
- Epicanthoplasty
- V-Wplasty
22
Q
Describe the anatomy of the brow musculature
A
Frontalis
- O: Galea
- I: interdigitates w corrugator, procerus, O/oculi
- N: CN7 frontal
- fx: only brow elevator
Corrugator - 2 heads: transverse and oblique
- O: trasnverse = medial SOR,
- I: trasnverse = superior/middle 1/3
- O: oblique = mediosuperior OR
- I: Oblique = medial brow dermis
- Fx: pulls brow medial and inferior
Procerus
- I: ULC, nasal root
- O: glabellar skin
- Fx; pulls brow medial and inferior
Depressor supercilli
- O: SOR
- I: medial brow dermis
- Fx: depresses
23
Q
What retaining ligaments must be released in a brow lift and where are they located
A
- Superior temporal fusion line : periosteum along superior temporal line of skull
- Zone of Adhrence: 6mm medial to STFL - where periosteum and galea are fixed
- Orbital ligament: along lateral orbital rim - fusion of TPF to LOR. At inferior most ZOA
- tethers the lateral brow to the Orbital rim
- fuses with orbital septum at thr im to make arcus marginalis
24
Q
What is the importance of the sentinel vein
A
Located 1.5cm superiolateral to LCT, perforating vein that enters TPF
- identifies location of Orbital ligament
- identifies nearby location of frontal branch - 1cm inferior and lateral to sentinal vein
25
Describe the anatomy of the sensory innvervation in the brow region and motor innervation
**Sensory**
* **SupraTrochlear**
* exits foramen 1.7cm from midline
* enters corrugator then frontalis
* **Supraorbital**
* ****exits foramen 2.7cm from midline
* DEEP br: runs between periosteum+galea medial to STL \>supplies frontoparital scalp
* SUPERFICIAL - pierces frontalis 2-3cm above rim -\>supplies forehead and anterio 1-3cm of scalp
\*\*bulf of corrugator muscle is interposed b/w ST and SO
**Motor**
* **CN7 frontal branch - supply superior OO, trasnverse corrugator, frontalis, procerus**
* CN7 zygomatic branch - supply medial and inferior OO, oblique corrugator, DS,
26
Describe the aesthetic features of a brow
* medial brow starts at vertical line w ipsilat ala and medial canthus
* lateral brow extends to oblique line with ipsilat ala and lateral canthi
* arches and peak is in line wiht lateral limbus
* women - brow lies above SOR, men it lies at SOR
* distance hairline to brow 6cm M, 5cm W
27
What are goals of brow lift
* correct brow ptosis and secondary lateral upper lid fullness
* correct trasnverse rhytids, glabellar rhytids and transverse nasal rhytids
28
Desribe P/E for consideration of brow lift
* Frontalis hyperactivity, brow ptosis
* Rhytids -trasnverse, vertical, horizontal
* Contour - SOR, frontal bossing
* Brow position/symmetry
* hairlines position
* Upper lid - presence of lateral fullness
* Lower lid - position, tone/laxity
29
Classify options for brow rejuvenation
**Non- Operative**
* botox
* fat grafting
**Operative**
* OPEN
* Incisions
* Hairline
* Coronal
* Bitemporal
* Supraciliary
* Midforehead
* trans-blepharoplasty
* limited scalp + trans bleph
* Plane of Dissection
* Subperiosteal
* Subgaleal
* Subcutaneous
* Endoscopic
* Plane of dissection
* Subperiosteal
* Subgaleal
30
What are the advantages/disadvantage of each plane of dissection
* Subperiosteal
* Ind: glabella rhytids, ptosis
* Adv: motion of all tissues in one
* Disadv: limited effect on rhytids
* Subgaleal
* Adv: direct visualization and excision of corrugatprs. Good effect on rhytids
* Disadv: sacrifice supraorbital nerve, indirect approach to rhytids
* Subcutaneous
* Adv: excellent for rhytids, can alter forehead height deformities
* Dsiadv: high risk of complx including alopecia, ischemia
31
What are methods of fixation?
* Suture
* tunnel in outer table cortex
* Screw/Anchor
* internal screw'Mitek anchor
* endotine (resorbable)
* Fibrin glue
32
With direct skin excision how much brow elevation per amoutn skin excised in achieved?
* Th closer to the brow, the greater the elevation
* Brow 1:1
* Hairline 1.5:1
* Coronal 2:1
33
What are 2 considerations whn selecting technique
* hairline
* rhytids
* Hairline
* if short forehead, can use coronal
* If high forehead, use hairline \*\* because dont want hairline to migrate any more back
* Rhytids
* method of myoplasty - direct excision or botox
* plane of dissection (subgaleal / subcut if deep significant rhytids
34
What are complications of a brow lift
* Flap necrosis
* hematoma
* elevation of hairline
* asymmetric dynamic motion of forehead
* Nerve injury (SON, CN7 frontal)
* Descent, inadequate lateral correction
* alopecia, poor scarring
*
35
Where is the SON most likely injured and how can this be avoided
* Coronal incision: where branch is cut as it travels in galeal plane
* Subgaleal dissection: where branch courses from periosteum to lie between periosteum and galea
To avoid injury - subperiosteal plane is safe as the nerve is above periosteum at all times
36
Which structures must be released with a brow lift
* ZOA
* Orbital ligament
* STL fusion plane at SOR
37
Which strucutres are a risk of injury during brow lift?
* Nerves
* CN7 frontal br
* SON: deep, superfcial, trunk
* STN
* Hair follicles
38
What are the indications, adv and disadvantage of
* Direct brow
* MIdforehead
* Hairline
* Coronal
* Trnasbleph
* Temporal
* Direct brow
* male balding, deep rhytids
* Adv: direct
* disadv: scar visible
* MIdforehead
* male balding, deep rhytids
* Adv: direct
* disadv: scar visible
* Hairline
* high hairline
* Adv: no movement of hairlines
* Disadv: visible scar
* Coronal
* Low hairline
* Adv: scar well hidden except if alopecia, will lengthen forehead
* Disadv: more excision for movement,
* Trnasbleph
* Ind: glabellar rhytids
* Adv: well hidden scar, direct corrugator excision
* Disadv: no improvement laterally (crows feet) or forehead trasnverse, or brow elevation
* Temporal
* Ind: lateral crow feet, lateral brow ptosis
* Adv: good treatment of lateral ptosis/rhytids, well hidden
* Disadv: no tx of midline forehead rhytds/glabella. risk of temporal nerve injury
39
Describe the coronal brow lift
* Incision - placed 7-9cm behind hairline from ear root to ear root (unless combo w facelift
* need ot have at leadt 5cm remaining of hair in front of incision once excision done
* Plane - subgaleal but trasnsition to subcutaneous in temporal region to avoid injury to temporla n
* SON - ID trunk, protect and release flap form SOR
* Corrugators - fter identifying SON, corrugators medial to this - direct excision
* Procerus - resect in mdline
* Frontalis - interrupted to its attchments in glabella region + resection
*
40
Describe the endoscopic brow lift
* Incisions 5 - midline, paramedian, temporal
* PLane: Subperiosteal from midline/paramedian
* Plane: Temporal - just above superficial leaflet of DTF - and dissect form lateral to medial to release STL, ZOA and orbital ligament
* Strucutres to ID
* SON - preserve and to ID corrugator
* corrugator - incise periosteum 2cm above SOR, medial to SON and resect
* Sentinal vein - to release ORL
* Fixation - suture/anchor
41
