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André Camirand MD, Jocelyne Doucet RN*, 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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A detailed consideration is given to rejuvenation of the upper and lower eyelids and periorbital area using modern and physiological concepts, which are based on reversing the effects of aging. A revolutionary idea is proposed for the pathophysiology of herniated fat pads of the lower eyelids. This concept must be borne in mind when one considers managing and preventing enophthalmia. Techniques are also presented to improve the infraorbital sulcus, crow's feet and eyebrow ptosis during aesthetic surgery.
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Key Words : enophthalmia, herniated fat pads, infraorbital sulcus, canthopexy, capsulopalpebral fascia, SMAS
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Résumé
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Nous offrons avec détail une façon de rajeunir les paupières et la région péri-orbitaire. Ces méthodes physiologiques et modernes s'adresse directement au phénomène de vieillissement. Nous tentons d'expliquer la pathophysiologie des hernies graisseuses ainsi de l'enophthalmia du vieillissement et bien entendu comment y remédier sans les inconvénients des techniques conventionnelles. Nous discuterons également du sillon infra-orbitaire, de la ptose du sourcil ainsi que les pattes d'oies.
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Upper Eyelids
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When one considers rejuvenating the upper eyelids, one must understand that with aging, the eyebrow gravitates downward causing a pseudodermachalasis of the upper eyelids; this, in turn, is responsible for static crow's feet, a receding hairline and widening of the forehead. Because the eyebrow is low, in order to improve our appearance (in front of the mirror or when meeting someone) or to improve our field of vision, we raise our eyebrows. As a consequence, we hypertrophy our frontalis, procerus and corrugator muscles and develop forehead wrinkles .
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It is not advisable to excise skin and fat pads from the upper eyelids. This procedure simply reduces the distance between the eyebrows and the eyelashes, creates a " sunken eye " and an ugly contrast between the skin inferior to the eyebrows and that of the upper eyelids which are different in color, texture and thickness. In addition, it could prevent a possible brow lift because the patient would have lagophthalmia.
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TABLE 1: Aging Eye
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| 1. |
Brow gravitates downward causing: |
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- Pseudodermachalasis of the upper eyelids |
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- Corrugator, procerus and frontalis wrinkles |
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- Static crow's feet |
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- Widened forehead |
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- Reduced distance between the eyebrow and the eyelashes |
| 2. |
Lateral canthus gravitates downward causing: |
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- Decreased mongoloid slant |
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- Pseudodermachalasis of the lower eyelids |
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- Herniated fat pads |
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- Scleral show |
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- Enophthalmia |
| 3. |
Premalar fat pads gravitate downward (worsened by lower eyelid herniated fat pads) causing: |
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- Infraorbital sulci |
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A brow lift, on the other hand, will give a proper location and arch to the eyebrows, restore the original distance between the eyebrows and the eyelashes and eliminate the pseudodermachalasis of the upper eyelids. Furthermore, by doing an incision perpendicular to the hair follicles (1, 2) , one can get an invisible scar and narrow the forehead by advancing the hairline, thereby obtaining the beautiful facial harmony of youth (3, 4, 5) . A coronal approach would further widen the forehead thus breaking the harmony of the face. Even if I remove 1.5 - 2.5 cm of forehead skin, in addition to weakening the procerus, corrugator, frontalis and orbicularis oculi muscles, I still have to further raise the eyebrows in some patients after only a year. Since skin is never removed by an endoscopic approach, I never use endoscopy for this procedure. After three months, when most of the swelling is gone, one can then safely consider excising some skin from the upper eyelids*.
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* The skin resection is far less than in a conventional upper blepharoplasty, thereby reducing the contrast between the skin inferior to the eyebrow and the pretarsal skin. It will not lower the eyebrow.
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| Fig. 1. A patient after a conventional upper lower blepharoplasty showing (A) an antimongoloid slant; a striking contrast between the pretarsal skin and the skin inferior to the eyebrow; and (B) scleral show; a decreased distance between the eyebrow and eyelashes; and enophthalmia |
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| Fig. 2. Preoperative (A) and postoperative views (B) of a patient managed by a brow lift and a literal canthopexy |
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| Fig. 3. A patient following conventional upper and lower blepharoplasty (A) managed by brow lift and lateral canthopexy, thus eliminating the scleral show and producing an almond-shaped eye (B) |
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| Fig. 4. A patient with eyebrow ptosis and an antimongoloid fissure (A) who requested upper and lower blepharoplasty. Instead, she was managed by a brow lift and lateral canthopexy, thus eliminating the eyebrow ptosis and dynamic and static crow's feet and producing an almond- shaped eye (B) . The scar virtually invisible (C) |
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As the brow lift is being done, the herniated fat pads of the upper eyelids are exposed and coagulated to devascularize them, thus reducing their volume and creating fibrosis (to prevent some of the herniation and eliminate the risk of hematoma). This must be done parsimoniously. If the volume of the herniated fat pad is excessively reduced, we would get the illusion of a sunken eye and a premature aging of the eye. If this is the only periorbital surgery, a routine manipulation (incision, excision or coagulation) of the vertical fibers of the orbicularis oculi muscle should be done through the frontal approach. Continue the supraperiosteal approach to create a submuscular tunnel underneath the orbicularis oculi muscle according to the preoperative markings of the upper and lower limits of the dynamic crow's feet. Then, through the galea, create a subcutaneous (supramuscular) tunnel to easily manipulate (coagulate and incise) the vertical fibers of orbicularis oculi. Not only will this manage the dynamic crow's feet but it pulls up the tail of the eyebrow and prevents future downward pull thus giving a much longer lasting result.
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TABLE 2: Herniated Fat Pad of the Lower Eyelid - Pathophysiology
Lockwood suspensory ligament gravitates downward
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Space between the globe and the floor reduces
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Orbital fat projects anteriorly
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Orbital septum, orbicularis oculi muscle and skin stretch
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Enophthalmia develops
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Infraorbital sulcus deepens |
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Lower Eyelids
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The youthful-looking eye has a lateral canthus which is 2-3 mm above the medial canthus, giving a mongoloid fissure or almond-shaped eye. The lower eyelid covers the lower limbus by 1-2 mm. In addition, the Lockwood suspensory ligament (mainly) and the intraorbital fat (to a lesser degree) maintain the position of the eyeball in its normal upward and forward position within the orbit (Fig. 5) .
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With aging the lateral canthus gravitates downward creating a pseudodermachalasis, reducing the mongoloid fissure and creating herniated fat pads and scleral show. Removing skin will rarely improve this condition and there is a great risk of worsening the scleral show. Herniated fat pads result from a decreased space between the eyeball and the floor of the orbit. This, in combination with a non-stretchable, cone-shaped orbit, causes the orbital fat to be projected forward, stretching the orbital septum, the orbicularis oculi muscle and the skin. We have always been taught that with aging the inferior orbital septum becomes thin and weak and therefore stretches to cause herniated fat pads.
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TABLE 3: Causes of Enophthalmia
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| 1. |
Genetic or age-related lowering of the globe |
| 2. |
Herniated fat pads |
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Excision of herniated fat pads |
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Coagulation of orbital fat |
| 5. |
Resorption of orbital fat with age |
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The results of surgical interventions do not support this concept and it seems more reasonable to believe that the septum is always thin and weak so therefore cannot be the cause of hernias. From experience, every time the orbital septum is torn (for example, as a result of a fracture of the orbital floor) I have never seen a herniated fat pad, even if the septum was left open. It is also worth noting that lacerations of the lower eyelids are often deep enough to involve the orbital septum; closure of the skin does not include repair of the orbital septum, but these patients do not subsequently demonstrate evidence of herniated fat pads. Based on these observations, I propose that herniated fat pads result, not from an over-abundance of orbital fat* and subsequent stretching of the orbital septum, but from lowering of Lockwood's suspensory ligament and forward displacement of this fat. As the fat moves forward, there is an inevitable downward and backward displacement of the globe creating a " sunken eye " or enophthalmia. Moreover, the volume of orbital fat decreases with age. If the fat pads are excised aggressively, or with pressure placed on the eyeball, the enophthalmia is aggravated.
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* If ever a patient had an excess amount of intraorbital fat, they would have exhibited an exophthalmia. We have never observed this condition in any patient who had or did not have herniated fat pads.
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Coagulation of the orbital fat and resorption of the fat with aging also aggravate the enophthalmia.
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The space between the globe and the floor of the orbit can be decreased because of a genetic lengthening of the Lockwood suspensory ligament or because of its descent with the lateral canthus which gravitates downward with age. The Lockwood suspensory ligament, which determines the level of the globe, is attached to the lateral retinaculum (Fig. 6) .
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TABLE 4: Management and Prevention of Enophthalmia
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| 1. |
Raise the eyeball with a proper canthopexy |
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Reduce and maintain herniated fat pads with the capsulopalpebral fascia |
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Use the SMAS to buttress the lower herniated fat pads during a face lift |
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If a proper canthopexy (6, 7) is performed, the Lockwood suspensory ligament is raised; this increases the space between the globe and the floor of the orbit and reduces the herniated fat pads thus improving the enophthalmia. In addition, it recreates the mongoloid fissure of youth, covers the lower limbus and redrapes the wrinkled skin, which can be further improved by a concomitant chemical peeling or laser resurfacing. Of course, this procedure eliminates the risk of scleral show, retrobulbar hematoma and possible blindness, thus simplifying the informed consent.
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| Fig. 5. Schematic drawing of the anatomy of a youthful eyeball within the orbit. (1) Inferior tarsus (2) Conjunctiva (3) Müller's muscle (4) Capsulopalpebral fascia (5) Inferior orbital septum (6) Capsulopalpebral facia (7) Inferior oblique (8) Lockwood's ligament (9) Fascioseptal triangular space |
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| Fig. 6. View from underneath the eyeball to show the capsulopalpebral and Lockwood's suspensory ligament attached to both retinacula. Lockwood's suspensory ligament supports the eyeball in position within the orbit. |
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Another way of treating herniated fat pads consists of a transconjunctival approach (7, 8) opposite the arcus marginalis of the inferior orbital rim. Using this method the herniated fat pads are reduced, instead of excised, and the lower, or ocular, capsulopalpebral flap is sutured to the arcus marginalis (Fig. 7A, B and C) . This will not only maintain the reduced fat pads in place but it will also raise and project the eyeball forward, thereby treating and preventing enophthalmia. This procedure never interferes with eyelid or eyeball movement. A gap is created below the upper, or ciliary, flap but this gap is no larger than in conventional transconjunctival blepharoplasty and, in fact, re-epithelializes within a few hours. The use of the capsulopalpebral fascia using a cutaneous approach was first described by de la Plaza (9) of Spain as he sutured it to the arcus marginalis to manage herniated fat pads and improve enophthalmia. This technique was popularized by Mendelson (10) of Australia. We find it much simpler to use the conjunctival approach, a bloodless approach which avoids being surgically aggressive at the junction of the preseptal orbicularis muscle and the orbital septum. Such aggression can cause a linear and downward pull on the lid and is the most common cause of scleral show. Of course, excessive skin resection and excision or paresis of the pretarsal orbicularis muscle are other common causes.
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TABLE 5. To Improve the Infraorbital Sulcus
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| 1. |
Relocate premalar fat pad with the SMAS |
| 2. |
Reduce herniated palpebral fat pad by: |
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canthopexy |
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b) |
capsulopalpebral fascia |
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cutaneous approach (de la Plaza) |
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transconjunctival approach (Camirand) |
| 3. |
Other techniques: |
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a) |
Fill in defect with herniated fat pad (Loeb, Hamra) |
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Tear trough implant (Flowers) |
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Scleral Show
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The best management of scleral show is a lateral canthopexy, preferably with an incision of the capsulopalpebral fascia (done through the transconjunctival approach as in the management of herniated fat pads). In some cases, if this defect is still not corrected, one should graft some mucosa from the hard palate and suture it with plain or chromic catgut (11, 12, 13, 14) . This graft acts as a " spacer " and its height should be twice that of the preoperative amount of retraction, so as to overcorrect for resorption and shrinkage. Hard palate mucosa is chosen because it is composed of keratinized, stratified squamous epithelium unlike the rest of the oral mucosa (15) .
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We condemn the use of tarsorrhaphy, skin grafting and wedge resection as these procedures never improve, and may worsen, the condition.
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| Fig. 7. With age, because of lowering of Lockwood's suspensory ligament, the eyeball moves down and back and the orbital fat projects forward pushing the orbital septum, orbicularis oculi muscle and skin anteriorly (top). The capsulopalpebral fascia and inferior retractors muscle are incised through the conjunctiva and the herniated fat pad is reduced (center). The fat pad is then contained by suturing the lower (ocular) flap of the capsulopalpebral fascia to the orbital rim and raising and moving the eyeball forward (bottom) |
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Infraorbital Sulcus
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A final observation of the aging eye is the appearance of the infraorbital sulcus. With aging, the soft tissues of the cheeks (including the premalar fat pads) gravitate downward, resulting in infraorbital sulci, nasolabial folds and jowls. The sulcus is opposite the inferior orbital rim and it is deepened by the herniated fat pads of the lower eyelids. Raoul Loeb (16) of Brazil grafted or filled in the nasojugal furrow with the herniated fat pads, then Sam Hamra (17) from Texas mobilized the herniated fat pads to fill in this defect. Robert Flowers (18) of Hawaii created and successfully used the tear trough implant to fill in the deformity. We prefer to manage this condition by relocating the premalar fat pads with the SMAS during a face lift (19) . Not only do we improve the infraorbital sulci, but this greatly improves the herniated fat pads, the cheekbones, the nasolabial folds and the jowls. This is one of the reasons why I rarely, if ever, see an indication for liposuction of the nasolabial folds or the jowls and even less for the premalar fat pads because relocating this displaced fat is more physiological and gives a better and more natural-looking result.
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TABLE 6. Methods to Improve Crow's Feet
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| Static crow's feet |
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Brow ptosis |
Rx: Brow lift |
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Actinic or Senile |
Rx: Retin A, Peelings, Dermabrasion, Laser resurfacing |
| Dynamic crow's feet |
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Incise, excise or cauterize the vertical fibers of the orbicularis oculi muscle Surgical approaches: |
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- Canthopexy |
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- Brow lift |
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- Blepharoplasty (upper or lower) |
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- Face lift |
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Cover with the SMAS (Fogli) (11) |
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In some cases, to give further improvement, a face lift can be combined with either a reduction (not excision) of the herniated fat pads of the eyes using the capsulopalpebral fascia through a transconjunctival approach, or a lateral canthopexy. If a patient refuses a face lift the latter two techniques are less invasive and can be used to improve the defect.
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Alain Fogli (20) of Marseilles described a beautiful technique of improving the sulcus by buttressing the herniated fat pads with the SMAS and he uses it to cover the vertical fibers of the orbital orbicularis muscle, thereby improving dynamic crow's feet. I have used this technique for a few years and it gives great satisfaction to my patients and to myself.
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Fig.8.Postoperative decubitus position (A) . Pressing the eyeball creates an enophthalmia and a herniated fat pad. Removing the herniated fat pad will only serve to maintain the enophthalmia. Postoperative decuvitus position (B) . After reducing the herniated fat pad and maintaining the reduction with the capsulopalpebral fascia, pressure on the eyeball to the point of blanching the skin created neither a herniated fat pad nor an enophthalmia
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| Fig. 9. A patient with herniated fat pads (left) managed by reducing the herniated fat pads and maintaining the reduction with a transconjunctival approach using the capsulopalpebral fascia (right) |
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Conclusion
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With these approaches, skin is rarely removed from the upper or lower eyelids and fat pads are never removed. The results are spectacular and remarkably natural because the pathophysiology of the aging eye is attacked specifically. Of course we eliminate the terrible complications arising from conventional upper and lower blepharoplasty such as scleral show, ectropion, lagophthalmia, enophthalmia and retrobulbar hematoma.
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Table 7. Management of Scleral Show
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Lateral canthopexy |
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Transconjunctival incision of the capsulopalpebral fascia + hard palate mucosa as a "spacer" |
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Proper SMAS face lift (to reduce the downward pull of the cheek) Avoid: - tarsorrhaphy - skin graft - wedge resection |
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References
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- Camirand A. A comparison between parallel hairline incisions & perpendicular incisions when performing a face lift.
Plast Reconstr Surg Vol. 99, No. 1, January 1997
- Camirand A. Improvement to the scars of temporal and frontal face lifts. In: McKinney P (ed): Yearbook of Plastic Surgery. In press.
- Camirand A. Amélioration des cicatrices de lifting temporal et frontal. Ann Chir Plast Esthé, 1991;35(3)
- Camirand A. Amélioration des cicatrices de lifting temporal et frontal. Presented at the Premier Congrès Franco-Américain de Chirurgie Esthétique, Paris, June 1989
- Camirand A. How to improve face lift scars. Presented at the Xth Congress of the International Society of Aesthetic Plastic Surgeons, Zurich, Switzerland, 1989, p. 35.
- Camirand A. Canthopexy and transconjunctival blepharoplasty are preferable to lower blepharoplasty.
Can J Plast Surg 1993/94;1(4):184-187
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Aesth Plast Surg 1996;20:15-22
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- Henderson JW. Relief of eyelid retraction. Arch Ophthalmol. 1965;74:205-216
- Harvey JT, Anderson RL. The aponeurotic approach to eyelid retraction. Ophthalmology. 1981;88:513-524
- Siegel R. Palatal grafts for eyelid reconstruction. 1985;76:411-414
- Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a hard palate mucosal graft. 1989;107:609-612
- Kersten RC, Kulwin DR, Levartovsky S, Tiradellis H, Tse DT. Management of lower-lid retraction with hard palate mucosa grafting.
Arch Ophthalmol 1990;108:1339-1343
- Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast Surg 1993;20(2):393- 400
- Hamra ST. The role of orbital fat preservation in facial aesthetic surgery: a new concept. Clin Plast Surg 1996;23(1):17-28
- Flowers R. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993, 20(2):403-415
- Camirand A, Doucet J, Harris J. Managing the infraorbital sulcus of aging. Can J Plast Surg 1996;4(1):
- Fogli A. Orbicularis muscleplasty and face lift: a better orbital contour. Plast Reconstr Surg 1995;96(7):1560-1570
- Smith BC, Della RC, Nesi FA, et al. Ophthalmic Plastic and Reconstructive Surgery. Vol. 1. St.-Louis: Mosby Co, 1987
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