Periorbital Region and Blepharoplasty

INTRODUCTION

What are the goals of modern blepharoplasty?

Identifying and treating lower eyelid laxity and upper eyelid laxity and ptosis. Preservation of upper orbital fullness and a defined upper lid crease. In the lower lid, preserving the smooth transition between the cheek and lid junction while restoring youthful eye shape.

DEFINITIONS

What is blepharochalasis?

A rare inherited disorder characterized by repetitive episodes of eyelid edema and subsequent levator dehiscence and ptosis.

What is dermatochalasis?

Loosening of the eyelid skin with fat protrusion.

Describe senile ptosis.

Involutional or senile ptosis is the most common type of ptosis seen in the elderly. Its cause is due to the dehiscence of the levator aponeurosis. These patients upon examination will have an elevated tarsal crease (>7 mm), thinned upper eyelid, and lid droop with downward gaze. Levator advancement or plication is the treatment. When evaluating a patient for blepharoplasty, one must also examine for blepharoptosis. If the ptosis is not concurrently addressed during the blepharoplasty, the patient will have continued ptosis and potentially could be unhappy with the results. The best test for evaluating ptosis is the marginal reflex distance 1 (MRD1) test.

What is an entropion?

Inward rotation of the eyelid margin.

What findings make up Horner’s syndrome?

Blepharoptosis, pupil miosis, and facial anhidrosis.

EYELID ANATOMY

Where is the apex of the brow?

The lateral limbus of the eye in forward gaze.

How many bones make up the orbit?

Seven.

What is the distance from the orbit rim to the apex?

40 to 45 mm.

Where does the nasolacrimal duct drain?

Beneath the inferior turbinate.

What is analogous to the levator palpebrae superioris aponeurotica in the lower eyelid?

Capsulopalpebral fascia.

In the setting of normal facial proportions, what distance best approximates intercanthal distance?

Orbital fissure width.

What anatomical event happens during eyelid closure?

The lacrimal puncta closes. On the other hand, during eyelid opening, the lacrimal puncta are open and in contact with the lacrimal lake at the medial aspect of the lower eyelid. The lacrimal sac is collapsed and empty at this stage, and the canaliculi are patent.

What are the layers of the eyelid?

The layers of the eyelid are the skin, orbicularis oculi muscle, retro-orbicularis oculi fat, orbital septum, orbital fat, levator muscle, Mueller’s muscle, and conjunctiva.

What muscles are responsible for medial brow retraction?

Corrugator, depressor supercilii, and, to lesser extent, orbicularis oculi.

Discuss the anatomy of the eyelid in terms of lamellar structure.

The eyelid is a bilamellar structure consisting of an anterior lamella and a posterior lamella. The anterior lamella consists of skin and orbicularis oculi muscle, the posterior lamella includes the tarsoligamentous sling consisting of the tarsal plate, medial, and lateral canthal tendons along with the capsulopalpebral fascia and conjunctiva.

What separates the anterior and posterior lamella?

The orbital septum, which originates at the arcus marginalis along the orbital rim.

Discuss the tarsoligamentous structure of the eyelid.

1. The tarsoligamentous sling creates the support structure for the posterior lamella.

2. The tarsal plates constitute the connective tissue framework of the upper and lower eyelids.

3. The upper lid tarsal plate is approximately 30 mm horizontal and 10 mm vertical at its widest dimension. The lower lid tarsal plate is approximately 24 mm horizontal and 4 mm vertical in dimension. The tarsal plates of the upper and lower eyelid are attached to the orbital rim by the medial and lateral canthal tendons and retinacular support structures.

Discuss the anatomy of the lateral canthus.

The lateral canthus consists of a complex connective tissue framework that functions as an integral fixation point for the lower lid. The lateral canthal tendon, 5 mm in length, is formed by the fibrous crura that connect the tarsal plate to Whitnall’s lateral orbital tubercle within the lateral orbital rim.

What forms the lateral retinaculum?

The lateral retinaculum is formed by ligamentous structures from the lateral horn of the levator aponeurosis, lateral rectus check ligaments, Whitnall’s suspensory ligament, and Lockwood’s inferior suspensory ligament that converge at the lateral canthal tendon.

Discuss the anatomy of the lower lid ligamentous system.

The capsulopalpebral fascia and the inferior tarsal muscle make up the lower lid retractor system. The capsulopalpebral fascia is analogous to the levator aponeurosis in the upper eyelid. The capsulopalpebral fascia originates from the inferior rectus fascia and encircles the inferior oblique muscle. The two portions of the capsulopalpebral fascia fuse anterior to the inferior oblique muscle to form Lockwood’s ligament, which then inserts on the inferior tarsal border. The arcuate expansion of Lockwood’s ligament, Clifford’s ligament, inserts into the inferolateral orbital rim and fuses with the interpad septum between the central and lateral fat compartments of the lower eyelid. The function of Lockwood’s ligament is to stabilize the lower lid on downward gaze while the lower lid retractors cause lid depression of the eyelid to increase the inferior visual field during down gaze.

Discuss the fat compartments of the eyelid.

There are two main fat pads in the upper eyelid: the central and nasal fat pads. The fat pads are posterior to the septum and anterior to the levator aponeurosis. The interpad septum divides the two fat pads and is continuous with a septal fascial connection to the trochlea. The nasal fat pad is usually more pale and fibrous in comparison to the central fat pad. There are three fat pockets in the lower eyelid: nasal/medial, central, and lateral. The nasal compartment in the lower eyelid is similar in makeup to the nasal compartment of the upper eyelid with more fibrous, pale fat. The central and lateral fat compartments are also separated by an interpad septum and a fascial extension from Lockwood’s ligament, the arcuate expansion.

What branches of the external carotid artery supply the lid?

Facial, internal maxillary, and superficial temporal.

What is the vascular supply to the eyelid, from the internal carotid system?

Dorsal nasal, supratrochlear, supraorbital, lacrimal, and terminal branch of the ophthalmic artery.

What separates the medial and central fat pads of the lower eyelid?

Inferior oblique muscle. When performing an excision or manipulation between these fat pads, the inferior oblique muscle is at risk for injury.

What is SOOF?

Suborbicularis oculi fat pad.

What is ROOF?

Retro-orbicularis oculi fat pad.

What is the anterior lamellae?

The skin and orbicularis.

What is the posterior lamellae?

Conjunctiva and Mueller’s muscle in the upper eyelid. Conjunctiva and capsulopalpebral fascia in the lower eyelid.

What autologous structure is useful in reconstruction of the posterior lamellae?

Hard palate mucosal graft.

Discuss the innervation of the eyelid.

Branches of the trigeminal nerve provide sensation to the face. The infraorbital nerve, V2, travels in the orbital floor and supplies innervation to the lower eyelid, cheek, and upper lip. The lateral palpebral branch of the lacrimal nerve, a branch of the infraorbital nerve, supplies sensory innervation to the superior lateral portion of the upper eyelid. The lacrimal nerve, a branch of the ophthalmic division of the trigeminal nerve, V1, provides sensation to the upper eyelid. The infratrochlear nerve provides sensory innervation to the medial aspect of the upper and lower eyelid. The zygomaticofacial nerve provides sensory innervation to the lateral fat pad of the lower eyelid.

What nerve can be found adjacent to the sentinel vein?