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André Camirand MD, Jocelyne Doucet IL*, June Harris MD**
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* Mrs. Doucet is our head nurse, who participates both in creating our research protocols and in the scientific evaluation
of our techniques and results
** Dr. Harris is an Associate Professor of Anatomy Faculty of Medicine, Memorial University of Newfoundland St. John's, Newfoundland
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This work is being submitted to the " Plastic and Reconstructive Surgery " Journal, September 1996
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Abstract
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We describe in detail the anatomy and function of the " Lockwood suspensory ligament " and the interrelated function of the orbital contents responsible for the intraorbital position of the eyeball and fat.
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With age, or because of genetic disposition, the eyeball descends reducing the space between it and the floor of the orbit. This will inevitably cause forward projection of the extraconical orbital fat creating herniated fat pads and resulting in enophthalmia. Based on the volume of the bony orbit and its contents, it is likely that relocating, rather than removing, herniated fat pads will greatly improve and prevent the enophthalmia of aging and give the globe a position and a projection of youth.
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Based on the results of surgery using the capsulopalpebral flap, it is likely that a descended Lockwood suspensory ligament, rather than a weakened orbital septum, is the cause of herniated fat pads and enophthalmia. We feel neither a weakened orbital septum nor an overabundance of orbital fat nor a shallow orbit is responsible for either of these conditions.
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We give a detailed description of how to raise the globe, preserve and relocate herniated fat pads, and manage and prevent enophthalmia and obtain a beautiful youthful looking eye.
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Key Words : herniated fat pads, enophthalmia, orbital septum, Lockwood suspensory ligament, capsulopalpebral fascia
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Anatomy
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The cone-shaped bony orbit has an average depth of 40mm, an average width of 40mm and an average height of 35 mm. The orbital cavity has an average volume of 30cc.
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Contained within this nonstretchable bony cavity are an eyeball of 10cc and an optic nerve and conical extraocular muscles which total a volume of 10cc. There remains a volume of 10cc for the intraorbital fat, which can be divided into intramuscular and extramuscular fat. There are 7-8cc of intraconical or intramuscular fat leaving about 2-3cc for the extramuscular fat located in the anterior orbit. We believe it is the movement of extramuscular fat anteriorly out of the orbit which creates herniated fat pads and enophthalmia.
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| Fig. 1. Anatomy of the capsulopalpebral fascia and lockwood's suspensory ligament. Parasagittal section to show anterior orbital structures: 1, superior rectus muscle; 2, levator muscle; 3, conjoining of superior rectus mulcle with levator muscle sheath; 4, Tenon's capsule; 5, suspensory ligament of superior fornix; 6, Whitnall's ligament; 7, frontalis muscle; 8, brow fat pad; 9, orbital orbicularis; 10, arcus marginalis; 11, orbital septum; 12, preaponeurosis; 13, preseptal orbicularis; 14, postorbicularis fascia; 15, levator aponeurosis; 16, superior conjunctival fornix; 17, Müller's muscle; 18, conjunctiva; 19, superior tarsus; 20, pretarsal orbicularis; 21, inferior tarsus; 22, musculocutaneous retractor insertion; 23, conjunctiva; 24, inferior conjunctival fornix; 25, Tenon's capsule; 26, inferior orbital septum; 27, Lockwood's ligament; 28, inferior tarsal muscle; 29, suspensory ligament of inferior fornix; 30, inferior oblique; 31, capsulopalpebral fascia; 32, inferior rectus muscle. |
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The volume of the orbital fat reduces with age but otherwise is constant and is almost never, if ever, in excess. An excess would produce exophthalmia since the size of the bony orbit does not change. This volume is not influenced by diet and remains obvious in cachectic patients, in victims of concentration camps or in undernourished people; their herniated fat pads do not resorb.
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However, salt and water retention can increase orbital fat volume and, because the bony orbit is nonstretchable, herniated fat pads result. A similar phenomenon happens when one gets up in the morning (orthostatic). The orbicularis muscle contracts during facial expression giving a spontaneous and temporary physiological enophthalmia and herniated fat pads.
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The location of the extramuscular fat is mostly anterior to the vertical axis of the globe and behind the orbital septum (for instance the inferior rectus muscle lies directly on the bone of the floor of the orbit). The fat will be mobilized according to the position of the globe in the orbit. Herniation of fat in the lower lid, or excessive excision of lower lid fat can create an upper sunken lid because of the Rouleau phenomenon: the orbital fat rotates around the globe.
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In 1986, Manson (1) showed that removing 2.5cc of intramuscular fat lowers the globe 1mm and moves the globe backward by 2mm; herniated fat pads will therefore inevitably create enophthalmia. Before herniation the extraconical fat is an intraorbital structure and decreasing the volume of intraorbital fat, whether it is intra- or extraconical, has the same end result: enophthalmia. By removing 6.8cc of intraorbital fat the eyeball will move backward by 9mm and downward by 6mm, proving the inefficiency of the Lockwood suspensory ligament without the orbital fat (1) .
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In 1988, Oliveri (3) claimed to reduce the protrusion of the globe by 5mm after removing 6cc of fat in exophthalmic patients.
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In 1991, Pearl (4) demonstrated that he could reduce exophthalmia by 1.5mm when 1cc of fat was removed from the orbit.
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Vistness (5) has demonstrated that an intraorbital catheter inflated with 1cc will create a marked exophthalmia. If one reduces 1 cc of extraconical herniated fat back into the bony orbit, inevitably it will mobilize the globe. We must conclude that any modification of the soft tissue content of the nonstretchable bony orbit will influence the location of the globe and of the extramuscular fat because we feel the universally weak orbital septum will never offer much resistance.
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| Fig. 2. Claudal anatomy of the capsulopalpebral ligament and that of Lockwood's suspensory ligament attached to the lateral retinaculum. |
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Manson (1, 2) demonstrated that excision of herniated fat pad (extraconical fat, but also extra orbital fat) does not mobilize the globe. This is true provided no pressure is applied on the globe as the conservative excision is performed. If pressure is applied on the globe, one aggravates the hernia and the enophthalmia. If all of this herniated fat was excised while the globe is pressed upon, then the resulting enophthalmia would be permanent. One should avoid this maneuver.
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As Dr. Manson or anyone, removes properly herniated fat pads (without pressure on the globe) true the position of the globe in the orbit will not change. However if the herniated fat was relocated in the non-stretchable cone-shaped orbit (as if reduced with fingers) inevitably the globe has to move up and anteriorly. This is the location the globe had in the orbit before the extraconical fat would move out of the orbit.
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We fully agree with Dr. Manson and we add that the herniated fat pad was intraorbital before herniating and inevitably as it herniates, it mobilizes the eyeball within the orbit. Relocating rather than removing this 1 cc or so of herniated fat inevitably will mobilize the globe in the orbit and give back its location of youth. As a corollary, one must conclude that if there is an extraconical fat hernia, there is a displacement of the globe in the orbit.
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| Fig. 3. As the globe comes down the lower orbital fat herniates anteriorly. |
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Orbital septum
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If the septum is torn as in orbital floor fractures, or lacerated by trauma or surgery, one never suffers from herniated fat pads nor from change in position of the globe in the orbit, even if the septum is never sutured. This confirms that the orbital septum is always a thin, weak and stretchable membrane that cannot contain the orbital fat or the normal position of the globe in the bony orbit. From our experience and observation contrary to what has been said, we must conclude that the orbital septum, no matter how strong, healthy or intact it is, is not responsible for preventing herniated fat pads or enophthalmia.
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| Fig. 4. The viellard ascète of Picasso shows low brow, enophthalmia, sunken eye lids, and herniated lower fat pads. |
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Lockwood Suspensory Ligament
The Lockwood suspensory ligament is the thickening of the capsulopalpebral fascia which is the anterior continuation of the inferior rectus sheath (Fig. 1) . It is attached to the medial and lateral retinacula (Fig. 2) and inserts into the inferior tarsus, the orbicularis oculi muscle and the skin (Fig. 1) . This ligament could be the most important structure maintaining suspension of the globe in the orbit but the presence of fat is essential for its efficiency (1) .
This sling or hammock-like structure will suspend the eyeball even if the maxilla is excised surgically or if the orbital floor is traumatically destroyed. This ligament is suspended from both the lateral and medial canthus. It's average length is 43 mm, has a width of 3-5 mm and is 1 mm thick.
The medial canthus is thicker and stronger than the lateral canthus and does not stretch as easily. Unlike the medial canthus which is immobile the lateral canthus is a dynamic and mobile structure. Because of the weight of the cheek, premalar fat pad and downward dynamic pull of the vertical fibers of the orbital orbicularis muscle, the lateral canthus will stretch (6) and descend more than the medial canthus with aging. We believe age, a genetically-determined lower location of the attachment of the lateral canthus off the orbital rim, or a congenital weakness or elongation of Lockwood's ligament of the lateral canthus will bring the globe down in the orbit. This will cause a forward projection of the orbital fat, despite the presence of a so-called "strong" orbital septum. In fact, herniated fat pads can manifest at a very young age. |
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| Fig. 5. Results, after an upper and lower blepharoplasty. One can easily notice the enophthalmia, the scleral show, the antimongoloid slant, and the low brow. |
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| Fig. 6. (left and right) Lower lid pseudodermachalasis, herniated fat pad, and almost a scleral show managed by lateral canthopexy 1 year postoperatively. |
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Pathophysiology
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As we age, the lateral canthus descends or stretches and we consequently lose the mongoloid fissure and almond-shaped eye of youth and beauty (6) . We eventually get a scleral show and possibly ectropion, a predominantly lateral pseudodermachalasis, herniated fat pads and enophthalmia.
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As the lateral canthus descends with age, the Lockwood suspensory ligament, which is attached to it, descends and inevitably so does the globe. This will reduce the space between the globe and the floor of the nonstretchable cone-shaped bony orbit. The extraconical fat has to be projected forward (Fig. 3) no matter how strong and healthy the orbital septum is and, as an immediate consequence, we get herniated fat pads of this lower lid and enophthalmia. Because of the extraorbital migration of the extraconical fat and because of involution of the orbital fat with age, the Lockwood suspensory ligament is less efficient (1) and the inevitable enophthalmia of aging results. The most eloquent example of this is the " vieillard ascète " of Picasso (Fig. 4) .
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I have had many patients consult me because the traditional blepharoplasty gives them " sunken eyes ". In magazines we can see famous movie stars with sunken eyes, which are very similar to those of the works of Picasso; this is the result when a total of 2-3cc of fat is removed from the upper and lower eyelids. Remember that removing this volume of fat that was intraorbital* causes the globe to descent by 1mm and move backward by 2mm (1) . If instead it is relocated (7, 8) , the opposite effect will occur. Iatrogenically, one can aggravate a premature enophthalmia and in many cases it can create more wrinkling because the lower eyelid skin loses its support or lining. Patients often tell me that their eyes are different, they have new wrinkles and they look older. A fair percentage of these patients will suffer from scleral show (Fig. 5) , so their eyes have changed but they do not necessarily appear younger or prettier.
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One must remember that the 2-3cc of fat were never " in excess ". If patients were able to be examined as teenagers, before they developed herniated fat pads with age, they very likely did not have eXophthalmia. So the theory that herniated fat pads result from excess fat in the orbit is no more valid for us than that of a weakened orbital septum nor a shallow orbit as the cause of this evolution in our patients. To prove this point gentle pressure is applied on the herniated fat pads, they are relocated, the eye ball raises, the enophthalmia is eliminated and a beautiful projection of youth is produced as the globe rises and moves forward (7) . This simple procedure never produces eXophthalmia. However it can aggravate upper eye lid fat pad hernias if it was already present. If not it could improve a past blepharoplasty sunken upper lid.
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* Whether intraconical or extraconical, to us this distinction does not make any difference and we do not contradict Manson. More and more experts believe this distinction as arbitrary.
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If fat is herniated or removed excessively from the lower eyelid, one can get a sunken upper eyelid because the upper eyelid fat will move backward -- the " Rouleau " phenomenon. This can be improved if enough fat is left in the lower eyelid and if it is relocated.
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Our only indication for lower lid fat pad removal would be exophthalmia, otherwise we prefer to preserve and relocate the fat of the herniated fat pads in order to improve the position of the globe in the orbit. This is accomplished by raising the lateral canthus (6) (canthopexy) and/or by reducing, or relocating, the fat and maintaining the reduction (or contention) of the herniated fat pad using the capsulopalpebral flap (7, 8) via a transconjunctival approach.
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Of course, a parsimonious removal of fat from the upper and lower eyelids could give a pleasing appearance to a patient but one must avoid applying pressure on the globe because it would aggravate the enophthalmia which would persist if the herniated fat was then excised. In our hands more satisfaction is gained by managing the underlying pathophysiology; specifically a reduced space between the globe and the floor of the orbit.
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| Fig. 7. Suturing the lower capsulopalpebral flap to the arcus marginalis to reduce and contain the herniated fat. |
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Management
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It seems clear to us that the only physiological management of herniated fat pads is to recreate the proper location of the globe and fat in the orbit. This can be done by 1- raising the Lockwood suspensory ligament and 2- relocating the herniated fat pad; preferably a combination of the two. We will discuss both approaches and give a detailed description of the surgical technique of relocating the herniated fat pad and on how to maintain the relocation with the help of a capsulopalpebral flap.
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A) Raising Lockwood Suspensory Ligament
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If a lateral canthopexy is properly executed (6) , as the canthus is raised, the eyeball moves upward and thereby increases the space between the globe and the orbital floor. The reason is that the Lockwood suspensory ligament is attached to the lateral canthus. Of course all skin, muscular and bony attachments must be freed. If only the lateral aspect is freed, the middle and medial parts of the commissure will not be raised (curved commissure) (7) and it will not look natural and beautiful. The canthus is attached to the superior and inferior tarsus which is then fixed to the orbital rim via the orbital septum. These inelastic structures must often be freed from the orbital rim in order to uniformly rotate the orbital commissure and obtain a good mongoloid fissure.
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This will somewhat relocate the fat pad (Fig. 6) , recreate the mongoloid fissure, redrape the pseudodermachalasis, cover the lower limbus and eliminate the risk of scleral show or ectropion. A peeling or laser resurfacing can at least temporarily help actinic and senile damage of the eyelid skin.
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If there was a real dermachalasis and good support following canthopexy, some skin could then be removed safely. Normally one would wait 3 months for the swelling to disappear allowing perfect judgment of the amount of eyelid skin to remove; however, this is only in a minority of cases. An obvious dermachalasis would require a concomitant skin excision but in our practice this is not usual.
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Of course not only is the skin scar eliminated but skin resection and orbital orbicularis muscle damage or denervation are avoided and orbital septum aggressions and cauterizations with their resultant linear scar retraction. These are the most common causes of scleral show and ectropion and they are virtually eliminated with our approach.
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B) Relocating and Containment (rather than Excision) of Herniated Fad Pads
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In 1919, Bourguet (9) from Paris performed transconjunctival fat pad relocation (not excision) and sutured the fat to the intraorbital tissues.
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However, it was Rafael de la Plaza (10) of Madrid who contributed the most to fat pad reduction. In 1988 he demonstrated a percutaneous approach to reduce the herniated fat pads and maintain their reduction by attaching the capsulopalpebral fascia to the arcus marginalis.
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Mendelson (11) of Australia published (1993) subsequently followed a large series of patients operated by de la Plaza's technique, proving the unequivocal duration of this management when it is properly done by a competent surgeon.
In 1993, in order to avoid a skin incision, pretarsal orbicularis weakness, downward linear retraction from surgical aggression at the level of the orbital orbicularis and septum, and scleral show, we described and started to use a transconjunctival approach to reduce the herniated fat pads of the lower eyelids. We used the lower orbital flap containing conjunctiva, inferior tarsal muscle and capsulopalpebral fascia attached to the lower arcus marginalis (orbital rim) to maintain the reduced fat pad (Fig. 7, 8, 9) . This technique relocated the herniated fat pad and raised and pushed the globe upward and forward, thus managing and avoiding enophthalmia.
Surgical Technique for Capsulopalpebral Flap
Using xylocaine, marcaine and epinephrine the lower eyelid is infiltrated. As for classical blepharoplasty 2 drops of local anesthetic are put on the cornea then a corneal lens is applied. For a better exposure the upper eyelid is sutured to the forehead above the eyebrow then the conjunctiva is infiltrated.
After removing the talc from the gloves, especially the index fingers, the arcus marginalis is palpated and, with sharp scissors, the conjunctiva, the inferior tarsal involuntary muscle and the capsulopalpebral fascia are opened opposite the arcus marginalis (lower than a transconjunctival blepharoplasty (Fig. 7) ) . This maneuver can be facilitated using a Desmarais or double prong hook to evert the lower eyelid. |
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| Fig. 8. Operating room dissection. (above) Showing arcus marginalis. (Center) Suturing lower capsulo- palpebral fascia to arcus marginalis. (below) The herniated fat pad almost completely relocated. |
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The incision done, the herniated fat pad can be seen between the upper palpebral flap and the lower orbital flap. Instead of excising the fat, a small coffee spoon or a similar instrument (i.e. freer) is used to replace the fat backward into the orbit thus exposing the arcus marginalis which (Fig. 8A) appears as a whitish band. The inferior oblique muscle can easily be seen and there is hardly any risk of damaging it since no fat resection is performed. We feel we reduce the risk of hematoma nor blindness - neither have ever been reported when fat pads are not removed.
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| Fig. 10. (Above) Preoperative with pressure on the globe, we aggravate enophthalmia would be permanent. (Center) Immediately postopera- tively, one can no longer produce enophthalmia or herniated fat pads. (Below) Two and a half years later, showing the result as permanent. |
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Before suturing the lower flap, the fat pad is slightly cauterized for three reasons: to make it fibrotic and therefore less fluid, to decrease the swelling due to salt and water retention or recumbency and, most importantly, to make it adherent to the intraorbital space. One must be parsimonious because decreasing the volume of fat (devascularization) would defeat the purpose of this procedure. Logically, if the inflamed, cauterized fat is relocated and maintained in the orbit with an external compression, for instance, steristrips for a 5 to 6 days, one could probably get as good a result as with the use of the capsulopalpebral flap, especially when canthopexy is done concomitantly. However, it is preferable to suture the lower orbital flap to the arcus marginalis (Fig. 7, 8) with 3 stitches or a continuous stitch using Bondex 4x0 and an HSM8 needle; this is a bloodless procedure.
Once done the retractor is removed and the following points are verified:
1. It is impossible to recreate enophthalmia with pressure on the eyeball (Fig. 10) .
2. It is impossible to herniate the lower eyelid fat pads with pressure on the eyeball (Fig. 10) .
3. The lower eyelid can be raised up to superior limbus.
4. There is normal upward movement of the globe.
Limitation in amplitude of the globe or the lower eyelid has never been seen either peroperatively or post-operatively.
Of course, there is a conjunctival gap of a few millimeters which is approximately the same as in conventional transconjunctival blepharoplasty. At first, a conjunctival flap was dissected from the inferior tarsal muscle with the aid of infiltration and a magnifying glass; this has since been demonstrated to be of no value and probable created unnecessary trauma. As in cases of conjunctival injuries, it reepithelializes in a few hours. In polytraumatic injuries involving the conjunctiva, this area is never repaired or grafted because of its great propensity to heal rapidly. We never experienced lower lid retraction nor interference with upward movement of the globe. |
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In order to avoid corneal dryness, the cornea is frequently irrigated with saline during this procedure.
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Unlike other techniques the orbital septum is freed at its lower orbital margin and there are no downward attachments; also the central capsulopalpebral fascia is freed from its lower attachment. This procedure is usually combined with a canthopexy. Because the inferior tarsal muscle is buttonholed, the pretarsal orbicularis muscle is unopposed and brings up the central part of the lower tarsus. This could explain why we never encountered any tethering of the detrusers. The lateral and medial attachments of the voluntary and involuntary muscles remain attached to the lower tarsus and there is no physiological impairment.
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Convalescence of Capsulopalpebral Flaps
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All of our patients are on antibiotic ointment for a few days and on artificial tears for a few weeks. During the first few postoperative days, patients can complain of diplopia because of intraorbital edema and globular displacement.
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| Complication |
No. of Cases |
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Failure |
6 |
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Conjunctivitis |
4 |
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Dryness |
3 |
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Granuloma |
2 |
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Skin laceration |
1 |
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Lower lid retraction (scleral show) |
Nil |
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Impaired lower lid movement |
Nil |
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Impaired eye lobe movement |
Nil |
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Diplopia |
Nil |
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Complications of Capsulopalpebral Flaps
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We used the capsulopalpebral flap on 46 occasions and got the following complications (see table 1) :
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Corneal and Conjunctival Irritation: Corneal and conjunctival irritation as well as dry eye syndrome are possible, but preventing corneal dryness with saline irrigation during surgery and postoperative artificial tears helps to circumvent this.
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Granulation: We had 2 conjunctival granulomas relieved by removing a stitch. The result was not adversely affected because fibrosis prevented a recurrence. Having replaced Polydeck with Bondex, this has not been observed since.
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Dissatisfaction: The lateral fat pad might not always be relocated to satisfaction and may require further coagulation. One must remember that the presence of this fat is essential to allow the Lockwood suspensory ligament maintain the intraorbital location of the globe as demonstrated by Manson (1) . If some of this fat is resected, Lockwood's ligament is not as efficient. We prefer to relocate it rather than excise it.
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Reoperation: Of course an improper technique can result in a failure but cannot worsen this condition; reoperation is indicated.
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Retraction: Theoretically the granulation from the conjunctival gap could cause long term retraction of the eyelid. The incision made opposite the arcus marginalis will reduce this gap and we do not dissect a conjunctival flap to cover this gap. After doing this technique for the past three years, we never noticed any interference with voluntary and involuntary lower eyelid movement nor interference of upper or lower movements of the eyeball.
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Recurrence: When we started using this approach, because of technical failures, we had 6 recurrent hernia in patients refusing a canthopexy which would have been of some benefit. These few recurrences were immediate. When properly executed we had no recurrences after 3 years.
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Skin Laceration: In one patient, we inadvertently lacerated the lid skin in exposing the arcus marginalis. It was of no consequence.
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Our results are both good and natural looking. None of our cases have shown disturbances of the voluntary nor of the involuntary inferior tarsal retractors.
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| Fig. 11. (left and right) Before and 1 year after relocating the herniated fat pad and using the capsulopalpebral fascia. The surgery was done almost 3 years ago, and there is no recurrence. |
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| Fig. 12. (Left) Preoperative and (right) almost 3 years relocating the herniated fat pad using the transconjunctival capsulopalpebral ligament. We consider the improvement permanent. |
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| Fig. 13. (Left) Preoperative and (right) almost 3 years relocating the herniated fat pad using the transconjunctival capsulopalpebral ligament. We consider the improvement permanent. |
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Discussion
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Using a perfectly performed canthopexy (6) and a transconjunctival suture of the capsulopalpebral flap to the arcus marginalis (7) , we manage and prevent enophthalmia, treat herniated fat pads and endow a youthful, mongoloid-looking eye without the inconveniences and risks of our conventional blepharoplasty. We are convinced that a weakened orbital septum is never the cause of herniated fat pads and its resulting enophthalmia in our patients, but rather it is the descent of the globe reducing the space between it and the orbital floor. We are also convinced that none of our patients with herniated fat pads have an excess of orbital fat because it would have been preceded by exophthalmia. Most importantly, we and our patients feel that the resulting appearance is more beautiful, more youthful and more natural-looking (Fig. 6, 11) compared to conventional blepharoplasty in our hands; in addition, we feel we reduce our incidence of complications.
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We improve, delay and likely prevent enophthalmia, one of the most obvious sign of an aging eye. With further research these techniques will be refined and made easier and might eventually complement or replace the traditional blepharoplasty.
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At the moment, we are working on a research protocol in which the HURTEL exophthalmometer would help us confirm and support with a more scientific documentation our delineated observations.
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| Fig. 14. Preoperative (above) and 8 weeks postoperative (below) views of a patient showing good movement of the lower lid and eyeball even in the presence of selling. |
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| Fig. 15. Two patients more than 2 years postoperatively demonstrating a cure of herniated lower lid fat pads, good movement of the lower lid, and good movement of the eyeball. |
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References
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- Manson PN, Clifford CM, Illif NT, Morgan R. Mechanisms of global support and posttraumatic enophthalmos: 1. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconst Surg. 1986; 77: 193-202.
- Wolf, A. Discussion: Transpalpebral Decompression of Endocrine Ophthalmopathy (Graves' Desease) by Removal of Intraorbital Fat: Experience with 147 Operations Over 5 Years. Plast Reconst. Surg. 1991; 87: 642.
- Oliveri N. Transpalpebral decompression of endocrine ophthalmopathy by removal of intraorbital fat.
Plast Reconst Surg. 1987; 627: 641, 1991.
- Pearl RM. Surgical management of volumetric changes in the bony orbit. Ann Plast Surg 1987; 19: 359-58.
- Vistness LM. Periorbital appearance as a function of orbital volume. Clinics in Plastic Surgery. 1993; Vol. 20, no. 2: 291-294.
- Camirand A. Canthopexy and transconjunctival blepharoplasty are preferable to lower blepharoplasty.
Can J Plast Surg 1993/94;1(4): 184-187.
- Camirand A, Doucet J. Reinforcing the orbital septum of the eye through a transconjunctival approach.
Oper Tech Plast Reconstr Surg 1994; 1 (3): 160-171.
- Camirand A, Doucet J. Surgical advances: a comprehensive approach to surgical rejuvenation of the eyes.
Aesth Plast Surg 1996;20: 15-22
- Bourguet J. Les hernies graisseuses de l'orbite, Bulletin Académique Médical, 1924
- De la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg 81 (5): 677, 1988.
- Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clin Plast Surg 20: 2: 323-330, 1993.
- Fogli A. Orbicularis muscleplasty and face lift: a better orbital contour. Plast Reconstr Surg 1995; 96 (7): 1560-1570.
- De la Plaza R, De la Cruz, L. New concept on blepharoplasty. Aesth Plast Surg 20: 221- 233, 1996.
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