Periorbital Rejuvenation

Tom D. Wang and Adam T. Ross

Rejuvenation of the periorbital region provides a more youthful appearance to one of the focal points of the face. As the average age of our population increases, these procedures are likely to become increasingly more common. Accurate preoperative examination, assessment, and counseling are imperative to achieve an excellent result. Also, careful selection from the spectrum of available techniques, combined with meticulous surgical precision, will assist the surgeon in rejuvenating the individual patient. Although no one ideal surgical procedure exists, many safe and effective strategies have been developed as we have learned more about the effects of aging. This chapter provides a history of techniques used in eyelid rejuvenation, as well as an overview of the evaluation process.

Rejuvenation of the periorbital region can be one of the most rewarding procedures for both patient and surgeon. Many believe that the “eyes are the window to the soul,” and as such they significantly contribute to the general appearance of the patient as perceived by an observer. As time passes, a youthful appearance fades as tissues stretch, adipose tissue settles and atrophies, and skin becomes redundant. Thus, procedures to rejuvenate the periorbital region are designed to counteract these changes related to aging.

A thorough review of the literature written on rejuvenation of the periorbital region can be somewhat perplexing for the young facial surgeon. The myriad of techniques offered for each orbital finding encountered in the aging patient illustrate that, to date, there is no perfect technique to reliably rejuvenate this area. Compounding the complexity of choosing a course of action is the common admission that different techniques work better in the hands of different surgeons.

Clearly, the search for the ideal technique continues, and to the credit of modern-day, evidence-based surgeons, more emphasis has turned to defining the etiology of the signs of aging rather than simply offering techniques used to camouflage appearance. Many techniques, even those most commonly performed, have the limitation that they further alter anatomy in a nonanatomic fashion, but often will produce excellent results. We predict that the time will eventually come that prevention of the changes related to aging will be more successful, leading to a reduced need for rejuvenation procedures. As the population ages, attention will likely be turned to procedures that more closely replace the anatomy found in youth. Until that time comes, however, we are left to use one or many of the excellent, safe, and successful techniques that are well described in the literature.

Obviously, an exhaustive discussion of orbital anatomy, its changes, and those techniques available to correct the aging eye are beyond the scope (and length) of this chapter. However, a brief overview of anatomic changes and available techniques will provide a base from which those interested can pursue further study.

♦ History of Eyelid Surgery

Although exact dates are somewhat ambiguous, the documented history of eyelid surgery finds its beginnings in the writings of Susruta, a legendary Indian surgeon who is thought to have lived more than 2000 years ago. Although the practice of surgery became less popular after early interest (and clear technological disadvantages), it experienced a rebirth in the 10th and 11th centuries. At that time, Arabian surgeons were noted to remove excess skin folds to improve vision—our first documentation of functional blepharoplasty. It was not until 1792 that Beer, an Austrian ophthalmologist, provided the first illustration of this upper eyelid deformity in his textbook, and in 1818 Von Graefe coined the term blepharoplasty to describe reconstructive procedures of acquired eyelid defects.¹ Shortly thereafter, European surgeons began to focus on upper lid reduction, and in 1844, Sichel first described the lower lid pseudoherniation of fat found with aging.

In the early 20th century, advances in anatomic description of the periorbita were reported, as were early attempts at cosmetic blepharoplasty. Bourquet, in 1929, was the first to describe the presence of two separate fat compartments of the upper eyelids and procedures to remove them. Claoue and Passot, in 1931, went on to describe the transconjunctival approach to remove these fat pads. Castañares, in 1951, was the first to provide detailed anatomy of the orbital fat compartments and popularized skin and fat resection of the aging lower lid.¹ In 1952, Fox suggested dermachalasis as a term to describe the relaxation and redundancy of eyelid skin over time. We continue even today to more accurately describe eyelid anatomy with respect to aging, facilitating new surgical techniques to reverse or obscure these changes.

♦ Eyelid Anatomy

An accurate understanding of periorbital anatomy and function is clearly a prerequisite for any surgeon performing cosmetic or reconstructive surgery in or around the orbit. Excellent texts currently exist with more detail than space permits in this chapter.

Upper Eyelid

The current discussion of upper eyelid anatomy will focus on the Western eyelid, although ethnic variation is well described in the literature and an understanding thereof is clearly important before proceeding with any surgical intervention, especially with regard to the Asian eyelid. As well, the contribution of the upper third of the face, specifically the eyebrow subunit, to the upper eyelid must be evaluated correctly, and often intervention involves modification of both regions.

The skin of the eyelid is the thinnest in the body (1 mm) and therefore heals extremely well without hypertrophy or contraction. However, the skin thickens as it extends to the brow and lateral orbital rim, where it is more susceptible to unpredictable scarring. The upper eyelid skin has very little subcutaneous tissue but is firmly connected to the underlying orbicularis oculi muscle through fine connective tissue attachments.

The orbicularis muscle is divided into pretarsal, preseptal, and orbital components, with the orbital component responsible for voluntary closure of the eye and the remaining regions responsible for involuntary and reflexive closure. The medial canthal tendon is formed as the superficial and deep heads of the pretarsal orbicularis insert onto the anterior and posterior lacrimal crest, respectively. Likewise, the lateral canthal tendon is formed from the coalescence of orbicularis laterally into the orbital tubercle of Whitnall.

Just deep to the orbicularis is the orbital septum, a thin fibrous sheet that originates at the orbital rim from the arcus marginalis and is continuous with orbital periosteum. The septum fuses with the levator aponeurosis 2 to 5 mm above the superior tarsal border. The tarsal plate and conjunctiva lie deep to the orbital septum.

A preaponeurotic fat pad lies, divided into central and medial components, posterior to the orbital septum and anterior to the levator aponeurosis. These fat pads are separated by the trochlea. The lacrimal gland occupies the lateral aspect of the orbit.

The levator palpebrae superioris muscle and Müller’s muscle are the retractors of the upper lids. The levator palpebrae superioris muscle originates at the lesser wing of the sphenoid and inserts onto the anterior, inferior one third of the tarsus and into the orbicularis muscle and skin. This insertion into the skin and muscle of the upper eyelid forms the upper eyelid crease, which falls 10 to 11 mm above the Western eyelid margin.2

Lower Eyelid

Unlike the upper eyelid, there are no significant racial differences in lower eyelid anatomy, which is similar in many ways to the upper lid, with skin, orbicularis, and septum encountered similarly.² The presence of the lid retractors differentiates the lower lid anatomically. The capsulopalpebral fascia of the inferior rectus muscle encompasses the inferior oblique muscle, and these fascial layers reunite anteriorly to contribute to the formation of Lockwood’s suspensory ligament. In addition, the capsulopalpebral fascia also fuses separately with the orbital septum ˜4 to 5 mm below the inferior tarsal border, and this structure along with the inferior tarsal muscle allows retraction of the lower lid.

The medial and lateral canthal tendons, with the overlying pretarsal orbicularis muscle, form a tarsoligamentous sling to maintain normal lower lid tone. The medial canthal tendon attaches anteriorly to the frontal process of the maxillary bone and posterior to the posterior lacrimal crest. The lateral canthal tendon attaches to the lateral orbital tubercle of Whitnall.

Between the orbital septum and lower lid retractors lies adipose tissue divided into lateral, central, and medial compartments. The inferior oblique muscle separates the medial and central fat pads. The central and lateral fat pads are separated by the arcuate expansion of the inferior oblique muscle. The medial fat pad has a characteristic lighter color than that of the central or lateral pads. The size of these fat pads is not related to body habitus and they do not appear to regenerate once removed.³

The midface plays an equally important role with respect to the lower eyelid as the brow does with respect to the upper eyelid. Inferior to the orbital rim and posterior to the orbicularis oculi muscle is a fat pad called the suborbicularis oculi fat (SOOF) pad. Along with the malar fat pad, changes in position of these midface structures contribute to lower eyelid appearance and clearly need to be addressed simultaneously.

♦ Age-Related Changes of the Eyelids

Upper Eyelid

The appearance of the upper eyelid may be affected by changes in eyebrow position that are well described. Specifically, lateral ptosis of the eyebrow may add fullness to the upper eyelid, adding to skin redundancy and functional visual field loss. Combined with the loss of frontal volume and the reabsorption of retroorbicularis oculi fat (ROOF), eyebrow changes may accentuate aging changes inherent to the eyelid.⁴ The ROOF fat pad, which rests on the lateral portion of the superior orbital rim between periosteum and eyebrow, may descend and exacerbate lateral bulging of the eyelid.5

The orbicularis may hypertrophy over time presumably due to the necessary blinking that one does throughout life. This causes the preseptal portion of the orbicularis to become redundant and may roll over the firmly attached pre-tarsal orbicularis.² The descent of the eyebrow, and therefore the orbital portion of orbicularis, compounds this redundancy. Gravity and constant repetitive motion conspire to cause the skin to lose its natural elasticity.

Although usually less significant an issue in the upper eyelid than in the lower eyelid, a weakened septum may permit pseudoherniation of the orbital fat. Fullness in the lateral aspect of the upper eyelid may also result from ptosis of the lacrimal gland. Weakening of the suspensory ligaments of the globe with aging also causes the eye to descend inferiorly into the orbit. This manifests as a superior sulcus deformity, which is accentuated by gradual age-related loss of intraorbital fat.⁶

Lower Eyelid

It is now recognized that a youthful, cherubic appearance is associated with a single convexity evident on lateral view that begins at the inferior margin of the lower eyelid tarsus and extends down to the cheek, lateral oral commissure, and angle of the mandible. Contributions to this convexity include all of the structures previously described, as well as their natural blend into a well-supported midface, and changes in position and volume of these structures are the culprits of lower eyelid and midfacial aging (Fig. 5.1).

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