124

Hair follicles nrc found itra whkh of the foiJm\~ng l:tyers oftl Stalp? (A) Epidcnnis (B) Pnpilbty dermis (C) Reticular dennis (D) Subcutaneous layer

The correct response is Option 0.

l11c hair follicles are located " ithin the:: subcutaneous Jaycr of the scalp. Human hair is primarily composed of th~.: kcmtn protcin: the hair shaft is produced by the ma~ which is in tum produced by ihc follicle. Hair follicles are indentations of th.e epidermis locnted 'vithin 1he subcutaneous layer of the scalp. l t is important to know the 8.Il3tomy of the llnir foUiclc in order to successfully harvest and transpl~m sc-alp hair~ wloich can be reta:irned w.ith son1e degree of peflll~ncn; follow-inc rrnrupl ntation. Bee me rucce&!:fuJ punch wafting epend:> uu ut~:liculous tectmiquei the grafts should be h .. m cslcd at the appropri3te depth while a\'oiding trauma to lhe ha:ir follicles.

Rtfiw~s 1. Uebel CO. Micro~fb Olnd mini~rafu: a ne\v appi'Mich for b:JldnC$$ surgery. Ann Plast Srug. 199 t :27:1~6. 2. Votlli.sCr. ll"!rrcplntccn.en smgery. Jn: M.:CamthyJG,e-d. Pia ll.cStl~rJ'. Philaddphht!, P

Hoir Growth Cycle

Anaoen

ACTIVE GROWTH PHASE

2-6 Yart

Stages

TRANSITION PHASE

1 2 Weeks

- Anagen = growth - Catagen =involution , l;el99~p ~ ~rest

Telooen

tive

/

Return to Anaoen

HalrMtn fotmtng new hair

RESTING PHASE

S-4 W.ks

EAR Y AAJIJ"

Regressive = TRANSITION Catagen 2- Jweeks

Skin-------.... ~~~~~~~~~ Connective tissue---.~~~ r;JitJa~=?AC~~

Aponeurosis~ Loose areo~l~~~

tissue

r I \

I Fog 7 18 Granls Alias of Anatomy 12th Ed LW&W 2009

Anagon 2-6 years

llS

A 1-year-old child with Picm: Robin~ has nonnal mandibular omu1JL IS r- His jaw dcformuy is bcsJ deto:ribc-d

(A) brnchygm!hia (B) hypcpbsia (C) m~erop:nia (D) micraQn3lhb (E) n:tl\linath~1

The I:Oiftet rcspoasc is Option E.

R

126

Whkh oflllc followil1g is lbc: mosllikdy result rotlowinc lbc: intralcsioculln~ or corticosteroids for c=tment of keloid~!

(A) Ah-.'lltc of od\'ti'S

E p i c a n t h u s i n v e r s u s : S m a l l s k i n f o l d w h i c h a r i s e s f r o m t h e l o w e r l i d a n d r u n s i n w a r d s a n d u p w a r d s .

A s s o c i a t e d w i t h t h i s i s a n i n c r e a s e d l e n g t h o f t h e m e d i a l c a n t h a l l i g a m e n t a n d a l a c k o f t h e n o r m a l .

d e p r e s s i o n s e e n a t t h e i n t e r n a l c a n t h u s

I n s i m p l e E n g l i s h : a v e r t i c a l f o l d o f s k i n f r o m t h e l o w e r e y e l i d u p e i t h e r s i d e o f t h e n o s e .

. B l e p h a r o p h i m o s i s : T h e p a l p e b r a l f i s s u r e i s r e d u c e d i n h o r i z o n t a l d i m e n s i o n

T h e n o r m a l h o r i z o n t a l t i s s u e l e n g t h i n a d u l t s i s 2 5 t o 3 0 m m w h e r e a s i n t h i s s y n d r o m e i t i s u s u a l l y 2 0 t o

. 2 2 m m

. I n s i m p l e E n g l i s h : e y e l i d s t h a t a r e a b n o r m a l l y n a r r o w h o r i z o n t a l l y

E p i b l e p h a r o n i s c h a r a c t e r i s e d b y a c o n g e n i t a l h o r i z o n t a l f o l d o f s k i n n e a r t h e m a r g i n o f t h e u p p e r o r l o w e r

e y e l i d c a u s e d b y t h e a b n o r m a l i n s e r t i o n o f m u s c l e f i b r e s . T h i s e x t r a f o l d o f s k i n r e d i r e c t s t h e l a s h e s i n t o a

v e r t i c a l p o s i t i o n , w h e r e t h e y m a y c o n t a c t t h e g l o b e . T h i s i s f o u n d m o s t c o m m o n l y i n A s i a n

i n d i v i d u a l s , . e s p e c i a l l y c h i l d r e n . E p i b l e p h a r o n i s a c o n g e n i t a l l i d a n o m a l y i n w h i c h a f o l d o f s k i n a n d

u n d e r l y i n g o r b i c u l a r i s m u s c l e p u s h t h e l a s h e s a g a i n s t t h e e y e b a l l

.li t t.al Journ.il el Oplill!.Linmugp www lfjlllla"at:ff'du

FOXL2 mutations in Chinese patients \!Vith blepharophimosis-

pto s i s-e pi canth.u s i nve rs us syndrome

Ptosis and inverted epicanthal folds in blepharophimosis

( a) Preoperative view of a 5- month- old boy (patient 6) with blepharophimosis syndrome; the IPFH measures 1 mm. (b) The same patient's appearance 1 day after frontalis suspension with supramid ( 5 Jackso.n Inc., Alexandria, VA, USA) . (c ) Same patient's appearance 8 months after frontalis suspension; 4 months before one- stage correction. (d} Poor elevation of the left interpalpebral fissure occurred after one-stage correction. Then, he underwent levator resection of the left eye 1-year after the one-stage procedures. Same patient's appearance months after leV

Operative procedure. (a) Skin markings. (b) Lateral canthotomy and suturing the conjunctiva to the eyelid cutting edge with polyglactin 6-0 (Vicryl) to prevent adhesion. (c) Skin hooks gently retract the flaps to expose the medial canthal structures. Fibrous tissues are exposed and excised. An anchorage hole for the wire is located superior to the level of medial canthal tendon. (d) The surgical wire is secured to two sides of the medial canthal tendon so as to adjust the distance between two sides. (e) Dissection of the levator aponeurosis from the septum and conjunctiva to show Whitnall's ligament. Placement of a double-armed, 4-0 Vicryl suture at the tarsus through the aponeurosis above Whitnall's ligament. (f) Removing the redundant levator aponeurosis .

Surgical correction for lower lid epiblepharon in Asians

rotating .-;uture technique hns several djscinctions: (1 ) the skin incision is mude just below the lash line IDStcad of the lower margin of wrsus in order not tO form a low~r ey.:lid crc11SI.! and \'isiblc s ar. (2) The vcrrically oriemed e~elashes are rorared by making an adhesion between the subcutaneous tissue of (he upper skin flap and the tarsal plate with 3-6 buried ro[ating sutures. (3) The amount of rutaLilln i~ adjus11.0d by Lh..: plnccmt!nt of sururcs onto the tarsus. \Vhen we need more mtat!l-tion, 'IVe place the smures on the more inferior part of th!! tarsus. As a suture material, we pr!!-fer 8-0 nylon m absorbable surures m lessen the recurrence rate. (4) M.irurnaJ amounts of the r~:dundant skin and orbicularis muscle are removed to moid ectropion or lmwr eyelid retraction.

procedures such as full thickness eyelid su-t:uresJ11 ~ buried sutures.' V-Y plascy/ ,., and excision of the skin and orbicularis muscle8 1 .... 19 have been used as trcaunent for epiblephuon.

Full thickness sutures are simple and fast, as irr correcrs Ihe basic pathophysiological defecrs b)t creating a scar between the s~in, orbicularis, and eyelid rctracwr, producing a cosmetically accep[able eyelid crease, and avoiding sacrific-ing the normal eyelid tissue. u l -1 This proce-dure, however, showed ll high recurrence rate, up (0 29%, J and is recommended only for mild cases.

Excision of the skin and orbicularis muscle V\lith tarsal fixation (modi:ft.ed Hotz procedure, Horz-Celsus procedure) has been the most commonly performed procedure. 1' ,. This procedure is simple and has been successful in correcting epiblepharon. However, lower eyelid retraction or ectropion could result from tlris procedure if too much skin or orbicularis is removed (Fig 3). In addition, recurrence of epiblepharon could also be a problem if roo small an amount of skin is removed.

Figure 1 This patie7lt required removal the lower eyelid crease which occurred as a result of epiblepharon surgery. H e was displeased wirh his cosmetic result even though no cilia touched his cornea. Congenital entropion epiblepharon. A. Creation of an

infralash ellipse, consisting of skin and pretarsal orbicularis muscle. B. Closure incorporating tarsal tissue enhances everting effects.

Figure 2 Surgicalrcclmiqucs. (A) Note the vertical direction of the eyelashes. (B, C) Buried 8-0 nylon su111rcs are placed ro alluw adhesious 10 form between the tarsal plateaud the subcutaneous tissue of rho: upper skiu flap. (D) Cross sccricu demonstrates swurc iu irs proper position. (E) Minimal amowtts of redundant skiuuud orbicularis muscle arc remlroJcd to avoid ectropion or lower eyelid retraction. / u both cuds of the iucisiou, rite dogcars arc remuvcd with rria11gttfar skiu cxcisiou. (F) After mcticui{)IIS haemosrasis, the slu'u is closed with a rwmiug 6-0 fast absorbing gut suture.

128

A 41-year.old woman who recently losr 45.5 kg (100 lb) hns severe skin laxity of 1J1c . 1 deposition Th J'k 1 am1s wu 1 modcrnl' f 1 e most 1 c y ~usc of her cuJTCnt findmgs IS loosening of which uflhc following f~i:.? ~: 3

(A) Clavipectoral (B) Co11es' (C) Deltoid (0) Pectoralis major (E) Scarpa's

The com-ct rcspon.'~ is Option A.

Th.!.s p.l:lcrtt"s skin bxity is most likely c:tu~~-d by :1 loosening oft he clnvipectoralliascia. Anatomic ~>ludic" have shown thJt in , Nth the rott rissue:s of the poslcromcdint ann arc finnly su~pcncfcd to a Iough yet dynamic fit-;ciu1 11yMcrn sl' ,

. I' I I . mg thJt ultinu:dy gains its strength from the cl3viculnr pcnostcum by mc:tns o ltc c avpcctoral and nxillary fasciae. 1'lk= clJ'iJX".-tO:al r3sci3 lies d~t> to the JX'1:lornlis major muscle nmJ extends liom the clavicle to the dome of the

~'il~ f.1s.:i3. Loosening of these connections. combined w~lh ':lnxntion of the ~1scia itself with ngc, weight fluciUlrions. and g.r.l'iutionnl pull. results in signilic:mt ptOSIS of the poslcromedtal nrm. Other mechanisms ctxlmburi.ng to arm p~l'Sis include rclaxnlion and stretching or the skin and superficial liascial system of the ann, as weU as fhccidity oi the posterior am1 muscles resulting from ngc and lnck of exercise. Fuscinl anchoring

br:!chiopbs~ is u..~ to COfTC'Ct this dcfonnity. F~i:slJndlcring ;md SU-'PCDsion of the superficial fascial system can be used in body contouring of other sites in the trunk md c\nemiries. including CoUcs' fascia in the medial thigh liO nnt.l Scnrpa 's fascia in ab

Figure 9.3 Brnchial excess extending doMl from lhe postenor axJII!I)' l1ne. A dot.ble-Jnt~ailrg paif of lines drawn frcm the reg1on of the olecrnnon to the regton of the excess. Th1s IS SIJT1iar to dMsion ot syndactyllzed dig1ts.

Medial Olecmnon

Rgure 9.2 (a) ~ed treatmen' and exaSKJnvillh Z plasty in lhe axJIIa lb} After closure with bmsposed Z pl::my. tl\fter Strnuch et aL 2004.,8 v.rth permisSIOn.)

Fig. 3. Beginning o f the markings with two lines. The firs t horizontal line is lo-e

Fig. (4): Type 81 : Skin redundancy of proxima l one third of upper ann (a), Markings of semilunar axillary resection (b).

Fig. 8. Very s uperficia l undermi ning immcdia1cly u nder 1he skin layer.

Fig. 10. Compressive su1ure closure wi th many dimples and a Zplasty.

Fig. 12. (A) Patient after 50-kg weight Joss with excessive fat and skin. (B) Half a kilogram resection on each side. Currently, it is preferred to locate the scar line a little more posteriorly.

(a)

Fig. (5): Type B l : Preoperative frontal view of the left arm (a), Postoperative frontal view of the left arm (b), Preoperative frontal view of the right arm (c), Postoperative frontal view of the right arm (d), Preoperative posterior view of the left am1 (e), Postoperative posterior view of the left arm (t), Preoperative posterior view of the right am1 (g), Postoperati ve posterior view of the right arm (h).

Fig. (8): Type 82: Preoperative fronta l view of the left arm (a), Postoperative fronta l view of the left arm (b), Preoperative fronta l view of the right am1 (c), Postoperative fronta l view of the right arm (d), Preoperative posterior view of the left am1 (e), Postoperative posterior view of the left am1 (f), Preoperative posterior view of the right am1 (g), Postoperative posterior view of the right arm (h).

(a)

(e)

Fig. (9): Type 83: Skin rcdWldaney of more than proxinlal one third of the upper arm and reaching the elbow (a), Markings of curvilinear incision and vector of pull (b).

(b)

(f )

(a)

(c)

(g) Fig. (10) : Type 83: Preoperative frontal view of the left arm ( a), Postoperative frontal view of the left arm (b), Preoperative frontal view of

the right arm (c), Postoperative frontal view of the right arm (d), Preoperative posterior view of the left ann (c), Postoperative posterior view of the left arm (f), Preoperative posterior view of the right arm (g), Postoperative posterior view of the right arm (h).

F ig. ( 11 ): Type 4: Skin redundancy at lateral chest wall (a), Markings ofcircumlinear incision at lateral chest wall, arrows show the vector of pull (b).

Fig. (12): Secondary zone of adherence at the mid-arm (a), arm contour is restored after severance of the adherent zone and lipoinjection.

Preoperative v iew of secondary zone of adherence (a), postoperative v iew shows elimination oftbe ad11erent zone.

Non Excisional Brachioplasty

(a)

:): Depithel inlizntion technique in non excisional bra-chioplasl)l.

(2): Curvil inear incision and oblique vector o f pull. : Skin redundancy of more than two third of the upper arm.

Technique: 2 curvl.. tn plannL'tlto be clinun done in the rL'~octoon beneath the depothchali/cd rcgoonto make ot a~ p.lpcr thm layer "hich can be "" aginatcd ca>oly. Neither e>.c~>ion nor undermining i' done. \'ector of pull can be dorcctcd on an obhquc fa>luon to allo" elomma11on of both tr:on" er-e and 'cnical e:~.ct-"'' (Fig. 2). Thi' help to 3\oid 3n) inciMon diMal to the clbO\\ in the fo rc.mn. E\ci,ion ;., done at the u~illa "ith repair of Sf'S. Dcrrni> to dcnni> 'utunng "done u'ing 2..() :\1onocryl Comt>re>'"e ganncnt i> u.cd for t\\0 \\CFig. (S): Prcopcmtivc postcri or view of the right arm (A). Pre~ operat ive posterior view of the left arm (B). Postopcrntivc post~ r ior \'iew of the right arm (C), Postoperative posterior view of the left ann (D).

Fig. (6): Type 82: Skin redW>dancy of more than pro~imal one third of upper arm and not reacbong tbe elbow (a). Markings of Ted Lockwood (b).

Non Excisional Brachioplasty

f'ig. (4): Prcopcralivc from al view of the right aml (A), Prco~ erativc fro ntal view of the left arm (B). PostDperative frontal view of the right ann (C). Post-operative frontal view o f the left arm (D).

Fig (7): DepithclialiLation is done in Modified Ted Lock"ood tecbruque.

L-Brachioplasty

------ Point 35 ------ Polnlo 5-e ~uato:

points 1-6

Figure 1. (A) The color-coded preoperative markings for the L-brachioplasty are shown. The ink dots placed at points 1 to 6 are marked sequentially in freehand. as described in the text. The dots are connected to create upper arm hemielliptical and lateral chest elliptical excisions. After the lines are drawn, the linear distances are measured and adjusted so that the distance from points 1 to 3 equals the distance from points 3 to 5 , and the distance from points 5 to 6 equals the distance from points 1 to 6. (B) The patient's outstretched arm demonstrates these relationships even more effectively. If the patient's arm deformities are symmetrical, then these measured distances, as well as the width from points 2 to 4, will be the same or otherwise adjusted. (C) The advancement point 5 is dotted with a surgical marker, as it is found along the posterior incision line by pinch approximation to point 1, the deltopectoral groove. (D) Connecting point 4 to point 5 completes the descending limb of the hemiellipse.

L-Brachioplasty

Figure 2. Wilh the markings completetl, the effects of graviry when the arms are fu lly extendetl help to demonstrate that the appro:dmation point 5 drops horizontal to point I. This view bener reveals the equal lengths of the anterior and posterior mcisions on the arms and each lateral chest.

Figure 3. The patient's arm lies on an arm board, extended at about 80 degrees, throughout the procedure. Cutting the sleeve exposes the arm, the markings, and their crosshatched alignment.

--

Figu re 7. (A) This illustration demonstrates the planned chest and arm excision, which is removed from proximal to distal with an avulsion-like technique over the arm after the perimeter incision is complete. (B) Proximal to distal avulsion of arm skin is shown intraoperatively, aided by a scalpel. The lymphatics are probably best spared by this direction of the skin avulsion. Lillie adipose remains on the undersurface of the skin resection, while the bed is mostly defalled neurovasculalure.

L-Brachioplasty

ng11N' 4 . Exdlkln Slle' ttposumon 1:1 dw rathc.al mnov.rl ol f.n under 1M skin 101M'~. Th~itep uluJ.sonk-.JSWwd bpopl.ttty b prdemd by rbe JUrgton (WIO. 'f1Mo dlust:ro~lk)n tfUf'l shows oideqwlt' dliMI~ n dfcermfned by pinch tftl.

A

/ )\ ~

::.::...-=- .:_!.....j.oo --- -- J

Figure S. The exdsion site is depressed by radical far removal following three-step excision site 1iposuccion. The perime1er Incision Is made first along the posterior ann and chest and then along the anterior ann and chesr.

L-Brachioplasty

E

Figure 8. The first step in the closure is the advancement or the subcul aneous fascia or point 5 (now the lip or the posterior triangular flap) to point I in the deltoid muscular fascia with interrupted 2-0 gauge absorbable sulures.

figure 6. S1aning from 1he lower chest, the skin and fat excision proceeds across the clavi pectoral fascia. Full thickness chest wall adipose is anached to the skJn resection.

Figure 9. (A) The two-layer skin closure commences with the barbed Quill SRS suture. Precise alignment and crosshatch markings should be placed and followed prior to suturing. The subcutaneous fascia is closed with horizontal running 0 barbed PDO Quill suture. Shorter interval vertical passes are employed in the thicker subcutaneous tissues of the chest. (B) Unlike illustration A, which shows for clarity a completed run of barbed sutures without synching, the intraoperative photograph demonstrates that after the first four th rows, the suture is synched to approximate the skin edges and then precisely synched after every other pass of the needle. (C) The anchor advancement of the posterior flap to the deltopectoral fascia with 2-0 Vicryl has been completed. The first four horizontal bites of the double-armed 0 PDO barbed suture are being placed. (D) The two ends of the PDO Quill suture have been pulled and synched to securely approximate the fragile subcutaneous fascia. (E) An illustration of the final closure, with the widely spaced 0 PDO and the shorter intradermal 3-0 Monoderm suture at the completion of the procedure. The PDO closure is secured with a J-shaped return and bury of the end in the suture line. (F) The periodic dimpling of the dermis near the suture line is indicative of a secure closure and will fade over time. The topical adhesive is applied at th is point, followed by a lightly pressured dressing.

L-Brachioplasty

Figu re I I. (A, C, E) This 53-year-old woman presented at 165 pounds, having previously lost 135 pounds. (B, D, F) Eighteen months after a total body lift , including an L-brachioplasty. Her results approach the aesthetic ideal described in the text, with minimal visibility of the scars.

L-Brachioplasty

Figure 10. (A, C, E) This 58-year-old woman presented at 145 pounds, having lost 150 pounds e ight years prior. Her preoperative markings are shown in the frontal and posterior views. In addition to the excision lines, there was limited cosmetic liposuction of the posterior arm. (B, D, F) Five weeks after L-brachioplasty seen in Figures 1-3, S-7, and 9. The patient's heal ing was uncomplicated, leaving symmetrical curvilinear scars from the height of the axilla to the posterior border of the arm. At this point in early follow-up, the smaller axillary hollow is maturing as the overall swelling reduces.

L BRACHIOPLASTY Preoperative Markings Meticulous preoperative surgical markings permit expedi-tious intraoperative excision of the patient's excess skin and fat, which will result in more symmetrical closures. Freehand markings should be made by the surgeon, fol-lowed by linear distance measurements to establish equal lengths for the anterior and posterior incision lines. With both sets of markings in place, there should be little need fo r intraoperative skin adjustments, such as those required for dog-car corrC'CtJons. Although "pinch-and-gather tech-niques are reliable for determining the width of resection, heavy arms arc difficult to estimate, so the author suggests planning an undcrrescction. At the time of closure, if the resection proves 10 be madequate, another perimeter cen-timeter excision can be performed along either resection line. A complete video presentation of the authors' tech-nique is available at www.acsthcticsurgeryjoumal.com.

The L-brachioplasty connects a hemielliptical skin exci-sion of the medial ann to an elliptical excision of the lat eral chest through the axilla. Dr located with the pxccss skin of the axilla and la teral chest.

When the arms arc fully raised. the equal lengths of the anterior and posterior incision lines of the upper arm and chest are confirmed as they are connected by a gentle zig-zag across the axilla (Figure I B and Figure 2). An mferi-orly-based triangular Oap of the proximal posterior upper arm, with point 5 at the apex, will be advanced across the axilla to point 1. Cross-hatching alignment lines are drawn and followed to align the closure after the skin resection (Figure 1 B).

L-Brachioplasty massive weight loss (MWL) excision site liposuction (ES L) If brachloplasty Is the only procedure being performed, the arms are prepped clrcumferentlally while the patient is awake, and he or she is then dressed In a paper gown. The patient Is placed In a s upine position, and the arms are abducted about 80 degrees on arm boards. After the induc-tion of deep sedation a nesthesia, consisting of Propofol, Fentanyl, and Medazolam. the s leeves are split to expose the operative site and draping Is completed (Figure 3). Arm intravenous Infusio n Is avoided whenever possible. to prevent extravasallons of fluid within the wound.

The width of resection Is rechecked after the operative site has been exposed. Between 100 and 200 mL of saline with l mg of epinephrine a nd 30 mL of l % xylocalne per liter are Infused through a thin, multlhole, blunt-tipped needle inserted Into stab wound Incisions within the resecuon pattern near points I and 3. If only ESL Is being

performed , infusion should be limited to the planned exci-sion, so that the closure Is not restricted by swoUen Ussue. The subcutaneous fat within the arm excision site is removed as completely as possible through liposuction (Figure 4). The authors prefer the preliminary application of uJuasonic energy. as It appears to better preserve neu-rovasculature than liposuction alone. After the uJuasound, the fatty emulsion Is suctioned. leaving the skin thin, with a profound depression. More limited liposuction may then be performed as needed to reduce girth elsewhere.

The final check for the approp11ateness of the width of resection Is easily performed following ESL. If overresection was inadvertenlly planned, a nanow band on defatted arm skin can be reta ined. With anterior traction on the arm skin, the poster1or arm Incision is made through the skin, down to the superficial fascia. Once it has progressed through the fascia, the Incision pops open and then is

undermined to about I em. The posterior incision is then conunued across the axilla and along the lateral chest to the tapered end at point 6. The anterior straight line Is similarly Incised, undermined, and continued across the axilla, descending as the anterior Incision of the lateral chest to the depth or the senatus fascia (Figure 5). If breast augmentation or spiral nap breast reshaping Is scheduled, the posterior limb of the ellipse is not incised until the mastopexy/augmentation Is complete because the advancement of skin In a breast augmentation reduces the need for lateral chest skJn resection.

The skin resection begins with thick full-thickness skin and subcutaneous tissue resection from the chest and continues through the thin axillary tissues over the clavlpectoral fascia {Figure 6). Distal traction of the arm skin proceeds like an avulsion removal, assisted by scal-pel cuts to the dermis (Figure 7 A,B). Little bleeding Is encountered, as the arm skin Is removed like a full-thickness skin graft. Superficial veins, lymphatics, and sensory nerves can be seen within a latticework bed of connective tissue nearly empty of adipose. Bleeding should be minimal. The proximal posterior triangular flap is advanced to

the deltoid fascia at the groove with several 2-0 braided absorbable sutures (Figure 8). This is the anchoring stitch that keeps the scar from drifting distally. Care should be taken to avoid thinning the advancement flap, as the tip vascularity Is already marginal and the temporary fullness will recontour to a natural axillary hollow. With the preoperative hatch marks as a guide, the Incisions are then aligned with towel clamps. Additional skin can be resected along the wound edge if the closure Is too loose. New hatch marks are drawn, and the towel clamps are removed.

Although any continuous horizontal running, 2-0 gauge. long-lasting absorbable suture could approxi-mate the subcutaneous fascia, the author prefers 0 or

P o l y d i o x a n o n e P D O h t t p : / / s u r g i k . c o m / p d o . h t m

S u r g i k ' s P o l y d i o x a n o n e s u t u r e b e t t e r k n o w a s P D O i s a m o n o f i l a m e n t a b s o r b a b l e , s y n t h e t i c s u r g i c a l s u t u r e

c o m p o s e d o f t h e p o l y e s t e r p o l y ( p - d i o x a n o n e ) , a n o n a n t i g e n i c a n d n o n p y r o g e n i c p o l i m e r . P D O i s i n d i c a t e d

f o r u s e i n s o f t t i s s u e a p p r o x i m a t i o n , i n c l u d i n g u s e i n p e d i a t r i c c a r d i o v a s c u l a r a n d o p h t h a l m i c p r o c e d u r e s .

P o l y d i o x a n o n e s u t u r e i s n o t i n d i c a t e d i n a d u l t c a r d i o v a s c u l a r t i s s u e , m i c r o s u r g e r y , a n d n e u r a l t i s s u e . T h i s

s u t u r e i s p a r t i c u l a r l y u s e f u l w h e n t h e c o m b i n a t i o n o f a n a b s o r b a b l e s u t u r e a n d e x t e n d e d w o u n d s u p p o r t ( u p

t o s i x w e e k s ) i s d e s i r a b l e

C h a r a c t e r i s t i c s o f s u r g i k ' s P D O s u t u r e

D r i l l E n d n e e d l e s f o r m a x i m u m s t r e n g t h b e t w e e n t h r e a d a n d n e e d l e s

E x t e n d e d h o l d i n g s t r e n g t h , m a i n t a i n s t e n s i l e s t r e n g t h f o r u p t o s i x w e e k s

L o w e r t i s s u e r e a c t i o n t h a n c h r o m i c g u t s u t u r e

E x c e p t i o n a l g o o d k n o t s e c u r i t y

E l i m i n a t e s b a c t e r i a l m i g r a t i o n a l o n g s u t u r e l i n e

E a s y t i s s u e p a s s a g e

S t r e n g t h d u r a t i o n : 5 5 - 6 5 d a y s

A b s o r b d u r a t i o n : 1 8 0 - 2 0 0 d a y s

129

. I . ' taiiOll n.:ntoval. - tl ~ bl -on.--en uttoo shown in the above photograph wtshes to un< c go . ..,~ ,er-cld m3D who h3S lc ue ~ '>

:\ -'.. . . m~ most appropriate management. Whi~ of me fcllowmg lS c (:\) C:ubon dioxide h . .;..'! ablation (B) Sm31 e.~cision . .

E.: ; .. 3lld full-thickness skm grafung (C) ~~.on ts with the Q-switdt.:d Nd:Y J\G laser (D) Mulupk U\!'.3ffil :..n (E) De:nnabr:1..

130

Which of the following structmes pro, ides sens:~tio::1 to the upper cranial surface of the ear? (A) Anterior branch of the great awicub.r nerve (B) Arnold's branch of the '"a:.OUS nerve (C) Auriculotemporal nene (D) Lesser occipital oer\e (E) Posterior branch of ihe great :1uricuhr ncf\e

The correct response is Option D.

Branches of the lesser occipital nerve supply scllS!tion to the upper cr::mial surface oflhe ear and skin of the anterior and superior surfaces of the external auditory c:mal. The anterior br:mch of the great auricular nef\e (which fonns from branches of cervical nef\e roots C2-3 \\ithin the cef\iC31 plexus) supplies sensation to the lower half of the lateral surface of the ear, while the posterior branch innervates the lower ponion of the cranial surface of the ear. The auriculotemporal ner\e provides sen53tion to the anterosuperior surface of the external ear. Arnold's ncf\e, which is a bmnch of the vagus nme. supplies sc~tion to the skin of the concha :1nd posterior car canaL

Rtferenas 1. Allison GR. Arullomy of !he auriclr. Clm Plast Surg. 1990: li~09-1l1. 2. McKinney P, Katrnna OJ. Pre\rotion of injury to tht ~~~ Jurirol!ll"ntr.-e during rh~ tid~tomy. Pla.Jt R~ron.Jtr Surg. 1980:66:675-679. 3. n.7,_,_ ,,. .. , __ Lt ,. '"-r --- I ' --~-1 ,.., ... .,....,K ...... ~ihilirv oftht fJce. Pla.J/ RtCOIISir Surg. 1990:86:-(!9-BJ.

Sensory Innervation

Auneulo-temporal [V3)

Greoter Auncular (

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T h e c o r r e c t r e s p o n s e i s O p t i o n D .

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t h e e n t i r e s k i n o f t h e n a s a l d o r s u m a n d t h e g l a b e l l a . I t a l s o c a n b e a c c o m p l i s h e d

1 1 1

a s m g l e - s t a g e p r o c e d u r e w h i l e

t h e p a t i e n t i s r e c e i v i n g l o c a l a n e s t h e s i a . S i n c e i t s i n t r o d u c t i o n , t h e d o r s a l n a s a l f l a p h a s b e e n m o d i f i e d b y m a n y

s u r g e o n s . F o r e x a m p l e , t h e p e d i c l e c a n b e b a c k - c u t t o t h e a n g u l a r a r t e r y , a n d t h e g l a b e l l a r p o r t i o n o f t h e f l a p n e e d

n o t b e u s e d .

1 l 1 e d o r s a l n a s a l f l a p p r o v i d e s a n e x c e l l e n t c o l o r , t e x t u r e , a n d t h i c k n e s s m a t c h , w h i c h i s i t s g r e a t e s t a d v a n t a g e . I t i s

p r e d o m i n a n t l y u s e d t o c o v e r d e f e c t s t h a t o c c u r f o l l o w i n g e x c i s i o n o f l e s i o n s o f t h e n a s a l t i p . D e f e c t s a s l a r g e a s 2

e m m a y b e c o v e r e d w i t h t h i s f l a p . A p o t e n t i a l d i s a d v a n t a g e a s s o c i a t e d w i t h u s e o f t h i s f l a p i s t h e v i o l a t i o n o f o t h e r

a e s t h e t i c s u b u n i t s o f t h e n o s e .

A d o r s a l n a s a l f l a p w i l l n o t r e a c h a c o l u m e l l a r d e f e c t . A m e d i a l c a n t h a l d e f e c t i s e a s i l y r e c o n s t r u c t e d u s i n g a s k i n

g r a f t o r s m a l l l o c a l f l a p . A n a s o l a b i a l f l a p i s b e s t u s e d f o r c o v e r a g e o f a d e f e c t o f t h e a l a r b a s e . A 3 - c m d e f e c t i s

b e y o n d t h e l i m i t s o f a d o r s a l n a s a l f l a p ; a f l a p t h a t p r o v i d e s a d d i t i o n a l t i s s u e ( s u c h a s a f o r e h e a d f l a p ) w o u l d l i k e l y b e

n e e d e d t o c l o s e t h i s d e f e c t .

R e f e r e n c e s

I . G r e e n R K , A n g e l a t s J . A f u l l n a s a l s k i n r o t a t i o n f l a p f o r c l o s u r e o f s o f t - t i s s u e d e f e c t s i n t h e l o w e r o n e - t h i r d o f t h e n o s e . P l a s t R e c o n s t r

S u r g . 1 9 9 6 ; 9 8 : 1 6 3 .

2 . M _ a r c h a c D , T o t h B . T h e a x i a l f r o n t o n a s a l f l a p r e v i s i t e d . P l a s t R e c o n s t r S u r g . 1 9 8 5 ; 7 6 : 6 8 6 .

3 . R 1 e g e r R A . A l o c a l f l a p f o r r e p a i r o f t h e n a s a l t i p . P l a s t R e c o n s t r S u r g . 1 9 6 7 ; 4 0 : 1 4 7 - 1 4 9 .

1 3 2

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h d . f . . ~ . y s 1 c a e x a m m a t 1 0 n s 1 o w s

e x c e s s i v e o o m g o t h e u p p e r e y e h d s k m ; V I s u a l f i e l d t e s t i n g c o n f i r m s b t t h

1 4

b ' l . o s r u c t t o n m e u p p e r f i e l d s L e v a t o r

e x c u r s i O n I S m m 1 a t e r a l l y . T h e r e I s 2 m m o f p t o s i s o f t h e l e f t e r d t h h

_ y e 1 , e n g t e y e I S u n a f f e c t e d .

I n a d d i t i o n t o b l e p h a r o p l a s t y , w h i c h o f t h e f o l l o w i n g i s t h e m o s t

a p p r o p n a t e m a n a g e m e n t ?

( A ) D i v i s i o n o f M u l l e r ' s m u s c l e

( B ) F a s a n e l l a - S e r v a t p r o c e d u r e

( C ) F a s c i a l s l i n g

( D ) L e v a t o r a d v a n c e m e n t

( E ) R e s e c t i o n o f t h e l e v a t o r m u s c l e

T h e c o r r e c t r e s p o n s e i s O p t i o n D .

B i l a t e r a l b l e p h a r o p l a s t y w i t h f a t p a d r e m o v a l a n d p t o s i s r e -

v i s u a l f i e l d d e f e c t a n d m i l d p t o s i s T l l e s e d p a i r u s m g l e v a t o r a d v a n c e m e n t \ v i i i a d d r e s s t h i s w o m a n ' s

p r o c c u r c s a r c u s e d f o f -

g r e a t e r t h a n 1 0 m m ) . B i l a t e r a l u p p e r e y e ) J' d b l

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r p a I c n t s W i t h n o r m a l l e v a t o r f u n c t i o n ( d e f i n e d a s

e p 1 a r o p a s t y a l o n e o r . .

c o r r e c t t h e p t o s i s , w h i l e r e p a i r o f t h e p t o s i s

0

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, l d

1 1 1

c o n J u n c t i o n ' ' 1 t h f a t p a d r e m o v a l \ o v o u l d n o t

n y ~ o u n o t a d d r e s s t h e v i s u a l f i e l d o b s u u c t i o n .

This patient has. a common problem that th . evaluated clinically and verified usin . requ!res orou~ preoperative evaluation. Visual ~e(d obstru~~n. IS h b d . th g standard VISUal field testmg. Examination ofJevator function mvo]Yes srabdmng ~ e d row a; mea~nng . e excursion of the upper eyelid margin from downward gaze to upward gaze with the eyes

1 ~x~ 00 ~ ~~~t ~mt. ~~ nonnal distance benveen the upper and lower Jimbi across the pupil is 11 mm. The upper trn us

5 ou rest mm ow the superior edge of the iris and 2 mm above the superior edge of the pupil

Division of Miiller~s muscJe would not correct the t . p OSlS.

The FasaneiJa-Servat procedure is used to c t 1 li _... -~~..,.~ .:1..~-. . . . . . . . orrec m1mma ptos1s but IS a more ddftcuJr, comp catc;u pn:.u:uwc utdu

levator pt1cat1on. AccessJbdlty to mvol\'ed sn:uch-s 1 red th .a.: ed ' I w~ IS Jffil Wl uuS proc ure.

Bilateral bleph:U:opl~ combined \\~th fat pad removal and ptosis. repair using a fascial sling is recommended to correct congemtal ptosts, defined as ptosis of more than 4 mm and le\'ator functjon oflcss than 5 mm_

Resection of the levator muscle is excessive and unnecessary in patients wjth minimal acquired ptosis.

References I. Jelks G W, Smith BC. Reconstruction oftbe eyelids .and associated structures. Jn: McCarthy JG, ed. Plastic Slll'glry: Pr.il.:!~!tiJlEa. Pa:

WB Saunders Co; 1990-,.2:1765-1772. 2. Klatsk:y SA. Blepharoplassy. In: Cob en M, ed .. . \lastery of Plastic and ReconsJroctire Srtrgery. Boston. ~fa.ss: Lim::. Bro'l.ll & Co:

1994;3:1920.1940.

Levator function can be assessed through the measurement of upper eyelid excursion. That combined with a measurement of the degree or extent of ptosis allows the surgeon to choose the best procedure for each patient The degree of ptosis is best noted using a clear ruler held in front of the eyelid to be assessed The measurement in millimeters while in primary gaze will give the aperture

of the affected eye, and this may be compared with the unaffected side. The difference is the amount of ptosis, and this may be classified as mild, moderate, or severe. Grossly, one may assess the degree of ptosis by noting the position of the upper eyelid in relation to the iris and pupil The upper lid margin is normally at the level of a line that bisects the distance between the upper aspect of the pupillary aperture and the iris. One can assess the number of millimeters the ptotic eyelid lies below that line, with mild being 1 to 2 mm, moderate 3 to 5 mm, and severe greater than 5 mm. Levator function, as measured by eyelid excursion, is then recorded by having the patient look up and then down. The difference between the apertures in extreme up gaze and down gaze indicates the extent of levator function. A significant aperture in down gaze (lagophthalmos) may be an indication of infiltrative disease (i.e., Graves' disease) or a fibrotic process (i.e. , congenital). In all measurements of aperture and levator function, the eyebrow should be immobilized by the examiner to eliminate compensatory brow contribution to upper eyelid elevation (note the examiner's finger over brow in drawing

Clear

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ASSESSING lVA'TOR FUNCTION

PdmaryG""'

Lew!or aperture

Oeg1lll Ol pi"""' mla'mOderalBI&e\'ere

Up Gaze

L~orapenure

9. Levator function is the distance the eyelid travel from downgaze to upgaze while the frontalis muscle is held inactive at the brow.

Berke's Method (lid excursion): Lid excursion is a measure of the levator function. The frontalis action is blocked by keeping the thumb tightly over the upper brow and asking the patient to look up from down gaze and measuring the amount of upper lid excursion at the center of the lid. (Fig. 4a,b)

Putterman's method

www.eophtha.co ~Author

www.eophtha.com ~Author

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Fig.4a Fig. 4b

Grading of levator action < 4mm - poor levator function 5-7 mm -fair levator function

8-1 2 mm - good levtor function The normal levator function IS bei'Neen 13-17mm

This is carried out by the measurement of distance between the middle of upper lid margin to the 6'o clock limbus in extreme up gaze. This is also known as the Margin limbal distance (MLD). Normal is about 9.0 mm

The difference in MLD of ~No sides In unilateral cases or the difference with normal in bilateral cases multiplied by three would give the amount of levetor resection required.

Assessment in Children

Measurement of levator function in small children is a difficult task, as the child allows no formal evaluation. The presence of lid fold and increase or decrease on its size on movement of the eyelid gives us a clue to the levator action. Presence of anomalous head posture like the child throwing his head back suggests a poor levator action.

Iliff Test

This is another indicator of levator action. It is applicable in first year of life. The upper eyelid of the child is everted as the child looks down. If the levator action is good lid reverts on its own.

- - -The palpebral li$$ure the dislance between the upper and lower eyelid in vertical alignmenl with t he cenl er olthe pupil.

Normal - 9-1 Omm in primaJY gaze

Should bo soon in up gaze, down gaze and primary gazo

Amount of ptos is = difference in palpebral aponuros in unilaleral ptosis or Difference from normal in bilateral ptosis

6. The marginal reflex distance-1 (MRD-1) - the distance between the center of the pupillary light reflex and the upper eyelid margin with the eye in primary gaze. A measurement of 4 - 5 mm is considered normal. It is important to crosscheck the am ount of measured ptosis lest the palpebral aperture may be giving false value due to abnormal positioning of the lower lid.

Fig2

Amount of ptosis The difference in MRD 1 of the ~No sides in unilateral cases or the difference from normal in bilateral cases

gives the amount of ptosis.

Hold the light source directly in front of the patient looking straight ahead. The distance between the center of the lid margin of the upper lid and the light reflex on the cornea would give the MRD 1. If the margin is above the light reflex the M RD 1 is a +Ve value. If the lid margin is below the corneal reflex in cases of very severe ptosis the MRD 1 would be a - ve value. The latter would be calculated by keeping the scale at the middle of upper lid margin and elevating the lid till the corneal light reflex is visible. The distance between the reflex and the marked original upper lid margin in - ve sign would be th e MRD 1.

Grading of severity of ptosis < or = 2mm : mild p tosis = 3 mm : moderate ptosis

= or > 4 mm : severe ptosis

It must be rem embered that ptotic lid in unilateral ptosis is usually higher in down gaze due to failure of levator to relax.

The ptotic lid in acquired ptosis is invariably low er than normal lid in down gaze.

7. The marginal reflex distance-2 (MRD-2) - the distance be~.veen the center of the pupillary light reflex and the lower eyelid margin with the eye in primary gaze. A measurement greater than 5 mm is considered normal.

8. The margin crease distance (MCD) is the distance from the upper eyelid margin to the lid crease measured in down gaze. In women, a central measurement of 8 - 10 mm is considered normal, and in men, 5- 7 mm is considered normal.

It helps in planning the surgical incision. In some cases where more than one lid creases are present, the most prominent one should be considered. (Fig. 3)

Visual Fields

Sit directly facing the patient, approximately 1 metre away

Visua l inatten t ion 1. Ask patient to focus on your face & not move their head or eyes during the assessment 2. Hold both arms out with your fingers in the periphery of both yours & the patients field of v i sian 3. Remind the patient to keep their h ead st ill & their eyes fixed on your face 4. Ask patient to point at which fingers are moving 5. Move the fingers of left & right han d in whichever order you choose 6. Then move the fingers of both han ds simultaneously 7. If patient only notes one side moving. this suggests the presence of v isual neglect

Det a iled visual fields 1. Ask patient to cover one eye with their hand 2.. If the patient covers their right eye, you should cover your left eye (mirror the patient) 3. Ask patient to focus on your face & not move their head or eyes during the assessment 4. Ask the pat ient to tell you when they can see your fingertip wiggling 5. Outstretch your arms, ensuring they are situated at equal distance between yourself & the patient 6. Posit ion your fingertip at the outer border of one of the quadrants of your visual field 7. Slowly bring your fingertip inwards, towards the centre of your visual field until the patient sees it &. Repeat this process for each quadrant at 10 o'clock 12 oclock 14 o'clock 18 o'clock 9. If you are able to see your fingertip. but the pat ient cannot this would suggest a reduced visual field 10. Repeat this assessment process on the other eye

Confrontation visual field exam Humph,.ey automated perimetry

B e n i g n j u v e n i l e m e l a n o m a = S P I T Z N E V U S

1 3~

1 1 s months .n,-r . . . . ted with the acsthcltc rcsu I . )J --old wom:m who IS di.S.1ppom sal c.ID.,tmclif'ln '''llh Tite above phmogrnJ>h~ arc of a Slycar .... thot her lower nose looks pointy and that she l~'lS na . . rhlllOJ>Iasty. IC s:~,.. .

undcll;utllg pnmary . . I I lar collapse with msptral!on. deep brc;athin:;. On cxmnm:mon. ~ IC l.'b a

ro ri31C opcrnti\'C management? Which of the following is the most app p

, 0' 10 incrclSC lip SUpjl< - . s pinched and l:tcks support. '

up' ppon and alae to increase su .

Although the alae appear flllrcd bttause of the obscocc of tip suppon, the lower Jmrnl canilaget havo aU...dy bceu trimmcdcxccssh-cly, D.l>d their Qppc.,ranco 1\'JI.J only worsen with funbcr rrirrunmg. In the 5:lme way, the upper nose appcan wide because of the np deficiency, but is instead an oPJ)IOJlri.,tt "'dth, :>s detnonstr.otal by the smooth curve from !he rim or lhc hi'0\\' 10 the nose, ond WOUld not benefit from OSIC:Otomies. Weir restttions would only acc:cnlllatc the pinched naul tip. B=usc this J13ricnt's probl

Pinched Nose Rhinoplasty - Revision Rhinoplasty for Pinched Tip

Pinched nose tip could anse as a complication of rhinoplasty. Pinched nose anses from aggressive removal of nasal t ip alar rim cart ilage, or by over-suturing the alar c artilages together. Pinched nose is not only displeasing but c an also result in the obstruction of nasal airilow at t he internal nasal valve.

Spreader ~Graft

Fig. 17.1. A-E. A Unilateral pinched nose with loss of lower lat eral cartilage in the lateral crus area, corrected with apposi tion of a discoid cartilage graft from the septum, slightly cut to shape on one side and fixed with transalar sutures. B Young girl with analogous unilateral pinched nostril Insertion of a

Fig. 17 .2A, B. Pinched nose in a 31 -year-old lady after resection of almost the whole lateral crus of the lower lateral carti lages.

septal cartilage graft into the nostril through the intercartilag inous incision. F End of the secondary operation, with equili bra ted nostrils and transalar mattress suture in place tied over a plastic sheet. At the same time the fioor of the vestibule has been narrowed

Carved cartilage grafts from the septum had to be inserted ir to both nostrils. A Preoperative, B postoperative views

c

Fig. 17.3A-c. Bilateral use of composite graft from the inner side of the crus helicis with skin and cartilage for expansion of the lateral vestibular wall

Fig. 17.4A J. In a severe case of pinched nose with cicatrical retraction of the nostril, a simple cartilage 9raft is not suffi-cient. A composite graft from the inner side of the crus heli cis is needed, with skin and cartilage for lining the scarred vestibular wall. Such a Q!raft is used in this case on the right side after removal of scar tissue in the tip and al'ar area and opening of the intracartilaginous inCISion. The is then su tured into the gap of this incision with transalar mattress su tures tied over a plastic sheet. A. B Preoperative views. C Com posite graft is taken from the crus helicis,leaving the external sk1n intact. 0 A cartilage graft from the septum is used as a columellcu batten. E End of the secondary procedure with transalar mattress sutures in place. F Mattress sutures are tak-en out 2 weeks later

Fig.17.4. G- J Late result of the revision

Fibrous Prominent Tip

In rare cases, we encounter hard, rigid tips in noses al-ready operated several times. The tip-lobule complex and the anterior part of the alae are full of fibrous tis-sue. The tip may be too narrow or too wide and asym-metric and the fibrous tissue needs to be removed be-fore the cartilaginous structures are remodelled (Figs.q.5-17-11).

Fig. 17.S. A Middle-aged female patient with secondary pinched nose,a tip full of fibrous tissue and a flat upper dor-sum. B-H seep. 136

Fig. 17.S. B Beginning of the operation: pinched zones with loss of cartilage to be made good and supratip area where a mass or scar tissue had to be removed are ouclined. The bilat-eral areas outlined had to receive a composite cutaneo-carti-laginous ear concha graft (C) through the intercartilaginous incision. The columellar and alar bases had to be reinserted more distantly. The bony pyramid had to be placed in a more prominent position wi th che osteotomies.D End or the opera-tion, with d isplaced columellar and alar bases and transnasal sutures to keep the composite graft in place and the bony part in the new. more prominent position. E- H Early and late results

D

c

Fig. 17.6. A Ugly aspe

Fig. 17 .9. A Young female patient with distorted tip of the nose, the left dome protruding more than the right one and slant-ing laterally because a short strip of cartilage has been re-moved. B- 0 Situation in axial view at the beginning of the in tervention and at the end in drawing and photo. The dimple on the left side shows the lack of continuity of the lower later-

Fig. 17.7. A Similar case to that in Fig. 17.6, operated several times and now with fibrous tissue in the tip- lobu-le area. 8, C Beginning and end of the operat1on w ith tip revision, as shown n :Fig. 17.6, including a small scar revision at the dorsum. O- F Result

al cartilage graft from the septum, which had to be placed at the site of the dimple. On the right side, a marginal resection with over-and-over suturing has been carried out. On both sides, the new position of the alar cartilage after remodeling and the cartilage graft on the left have been fixed with trans-alar manress sutures. E The identical sites in profile. F- H Result

Fig. 17 .8. B- E Beginning and end ,of t he operation in drawings and photo-

graphs~ including remova~ of fibrous tissue, reduction of the lower latera l cart ilages and alar marginal resectron in profi le. F Same correct ion in axial view. G- 1 Result

Fig. 17.1 0. A Distortion of the tip, with slight bifldity of the lob-ule and collapse of the left ala. The left dome s more distal than the right. 8, C ruual view in drawing and photo at the be-ginning and at the end of the operation, showing the align-

ment of the domes and correction of the left anterior valve collapse with septal cartilage graft and transalar mattress su-tures. 0-Ci seep. 142

D

Fig.17.1D. D Profile at the end of the intervention . E Early result in axial view. F Half-profile pre- and postop-er,atively, showing the alignment of the distal carti lage border in the tip- lobule area and flattening of the biftdity. G Result in profile

Fig.17.11 . A Too-short nose and too-narrow asymmetric tip. 8 After remodeling of the alar cartilages and insertion of an onlay graft and a carti-laginous strut of the columella, mem-branous septum mattress suturing is performed to fix the pillar at the trans-fixion incision. C, 0 End of the opera-tion with the remodeled tip-columella-alar complex in drawing and photo. E-H seep. 144

PINCHED T IP

Fig. 17.11. E, F Pre- and postoperative profile and half-profile views for com-parison. G, H Result in other views

The pinched nasal rip is an eyecatching deformity because it is so up front. It is usually caused by the enthusiastic excision of alar cartilage along with too much vestibular lining. Often there has been interruption of rhe integrity of the alar carti-lage arch. The combination of all of these excesses destroys the natural flow of the tip into the ala and columella, often leaving the tip too full or too isolated from the ala by carti-lage notching. The alar creases extend too far forward into the tip, and the alae often show asymmetric retraction due to lack of lining and insufficient alar cart ilage support . The multiple and varied deficiencies create a mirage that makes specific di-agnosis difficult. Yet even partial replacement of lost tissue with similar tissue can be beneficial.

This 34-year-old male bad a red uc tion rhinoplasty that ev-idenrly removed tOO much alar cart ilage and inrerrupted the integrity of the alar arch. The pinched tip caused moderate alar collapse with reduction in the airway. Septal cart ilage

This pacient had suffered inrerruption of her alar caHilages, resulcing in collapse of rhe alar arch. Her br[clge had been lowered wo much. Thus, replacemem of whar is missing re-qui red a cwo-ciered septal cartilage g raft co rhe bridge. Re-duction of the remaining excess alar cartilage, plus splincing of the collapsed sides with septal cartilage srrucs, brough t back some of the naturalness to her nose.

strurs taken during a submucous septal resection were shaped to fill om the depressions on either s ide of the rip. A rwo-riered graft was used on the lefr. These carti lage srrurs were inserted through marginal inc isions to bridge the hol lows. A bilateral osteotomy with infracw res improved the width of the nasal base, and alar base wedges reduced the flare.

Here is an asymmetric pinching of the t ip that required septal cartilage scnming of the columella into the t ip and splinting of the collapsed alae with onlay cartilage struts.

This unusual pinching beneath a bulbous tip was improved by reduction of the alar cartilage bulge and defining the tip with a cartilage strut up the columella and into the tip.

135

Wloichorlhcfollowmsisd~emostcomn>on~ 1 r -J fi 11 . '-vuP tc:auon o p~wnomnng u nbdommoplasty m combmauon with sucuon hj>eetomy?

(A) Infection (B) Nerve injury (C) Scroma fonnation (D) Skin necrosis (E) WouuJ Jchiscencc

The correct response is Oplion C. The most common complication of a full abdomlnopi!Uty pcrronn~-d in conjml(lion with t~uction lipccrumy is thr fonn:uion of 1.cromas. Ah.housh this rcnu.iM .1 ~iuw. ~ublcm.. SltpS thai an be ukcn to n:Uuc:c rhe (IOtenMJ risk for the dc\'dopment of serorna:s incluck 3\"0idin& ckct:I'OCtgul3tion for djsscction, limiting the quaruity of Joc.'ll o.ncsthctic used, sccuring the flap with quilting sumrcs. 3nd mnint3ining tHh:qu.atc wound dmilln,Gc.

Infection. ncrvt injury, skin ncaosis.. 1nd wound dchisccncc: a.rt all kss common compligtions. The prophyl

136

A 50-yeor-old woman hos righc eyelid ptosis of 2 mm. tw~ dnys a~cr undergoing uncomplicated four-eyelid blcpha.roplasty under loco! anesthesia. On physic-al.exammataon, .'.here tS t~odc~tc ct.lema of the upper and lower eyelids. Which of the following is the most appropna[e next step m management.

(A) R~surance and continued follow-up examinations (B) Eyelid massage and stretching exercises (C) Administration of phenylephrine eyedrops (D) Immediate op~rativc exploration of lhe eyelid (E) Levator plication seven days after the initial procedure

The correct response is. Option A.

Ptosis of a miJd to moderal.e degree is a common fmding. foJiowing blepbaroplascy; conunon causes include postoperative edema of the eyelids and hemorrhage into ~\tOller's muscle. Because 1hese complications generally resolve spontaneously over time, reassurance and observation with frequent follow-up examinations are most appropriate.

Eyelid massage and stretching exercises are effective for management of early ectropion of the lower lids. Phenylephrine cycdrops are only indicated if the ptosis is caused by Horner's syndrome. Although operative exploration is warrante.d in patienlS who have eyelid discrepancies following blcpharoplasty, it would not be useful in this patient who did not initially undergo repair of the levator mechanism. Instead, surgical treatment in this patient should be delayed for two to six months to allow for sponrancous recovery.

Rffer~nces l . Flow-en RS. Optim:~l procedure in secondary blcpbaroplasty. Cli'f Pfeut Surg. 1993 ;2 0:22S-2l7. 2. Kulwin DR. Kersten RC. Ulcpharoplasty and brow eft:\'lilion. In: Dortzb3ch RIK , ed . Opfrthafnrlc PlasJJc Sllrgery': Prermlirm ami

Manag~rtteltl oJCompl#cotl01u. New York, NY: Ravc.on Press.; 1(}94.91 112.

B ooepset (leVator de~)

0 Asian

Figure 41 Tht anatomic vtlfiOtrons in the upper eyelid displayed by dijferrot tthmc groups and tht chon/ItS OSS(I(iottd with senescence within each group of/ow foro co11w~nct of onotomy. Atony of thtse ethnic dijfertnus art trostd by ogmg ond/or ottt'lluotron of strudur~ of/owing for whotllrAt to coli o unified upper lid ronapt. A, The normal youthful ()((identol upper eyelid has ltvOtor txttnSions rnsertrng onto the skin suifoct to dtfitlt o lid fold that ovetO/ItS 6 to 8 mm above the tid margin, Note the orbrtol septum cootescmg wtth the ltvOtor aponeurosis creating tht fot

A B

Figure 43 The keypoints in planning and exewting the upper lid blepharoplasty are as follows: A, Determination of lite endogenous lid crease or heiglll at which to create a new lid crease (if different than the existing crease). The latter would require supratarsal fixation. The level of this crease will serve as the lower limb of the blepharoplasty incision and the height of supratarsal fixation. should that be necessary. The width or extelll of skin excision is determined by pinching the lid skin between forceps using slight lash line eversion as the end point. This superior point will determine the location for the superior limb of the skin incision (lefl). 8, Determination of the extelll of lateral eyebrow ptosis and, hence, the amount of lateral upper eyelid hooding. Tile degree of lateral hoodi11g will dictate the paint of the lateral extension needed to treat the hooding. The greater the hooding the more lateral the extent of the incision (lop. dark 10 lighler shades of color). In general, itlcisions that extend beyond the orbital rim are not well tolerated (middle). The unequal lengths of l11e upper and lower limbs are effectively Burow~ triangles to eliminate dog-ears and must be exaggerated as one widens the lateral skin excision. Also a brow that lacks stability may be pulled down by tension induced by a wide lateral excision. Here a balance must be made between the extent of lateral hooding and the drive to maintain incision lines within the confines of the orbital rim. Once the lateral extent of the incision becomes excessive then a lateral brow suspension should be entertained.

Figure 4-4 In practice the upper lid blepharop/asty can be efficiently performed using a few technical manipulations consistent with the anatomy. Digital traction and light pressure by the surgeon and/or assistant allow smooth quick skin incisions. A, Slightly more pressure must be exerted on the scalpel laterally as the skin thickens around and lateral to the orbital rim. BJ The skin may be elevated with the orbicularis muscle in one maneuver using an instrument on the skin-muscle section to be resected and pulling this superonasally while providing digital traction laterally. I find a needle-tipped insulated cautery to be most advantageous in this and other succeeding steps, especially in avoiding any delaying hemostasis problems. The orbital septum is then widely opened, exposing the preaponeurotic space.

UPPEA LID Bl.EPHAROPLASTY

CJ The underlying levator aponeurosis is protected by opening the septum as cephalad as possible, because the levator and septum diverge as one moves superiorly.

Whrtnall's ligament

Figure 4-4 Continued D, The medial f at .evator aponeurosis pad may require some digital pressure to expose and grasp; however, care should be taken not to overly resect fat when using digital pressure techniques. Excessive traction and manipulation of fat could cause a deep orbital hemorrhage and should, therefore, be avoided. E, Closure may then be performed and I pref er 6-0 nylon interrupted sutures laterally and 5-0 nylon intracuticular sutures medially. Interrupted sutures

Pli!S&Jrl! on gkltll! eauii!!S meciM rat pac1 10 IM9!

D Medial fat pac! removed

...-....- ~ ?\,~,~' E Closure

running stuture

B

0

Figure 4-5 A, An upper lid blepharop/asty is delineated with marking ink. Slight upper lid lash line eversion delineates the extent of the skin excision. This can be ascertained by pinching the upper and lower limbs of the centro/ aspect of the incision lines together with an instrument. B, An upper lid skin excision leaving the orbicularis muscle behind. The muscle is thin, and the underlying orbital seplllm is visualized in the vertical traction line lying between the upper and lower hooks. c, An incision line is mode with a scalpel, and the skin flop is elevated with a cautery. 1 prefer to remove central orbiwloris muscle beneath the skin and avoid a second step as well as hemostasis problems, leaving the orbital septum intact. D, The orbital septum is then incised at its more superior extent. The septum may be stabbed or widely incised with a needle-tip cautery. Fat will prolapse spontaneously or with light digital pressure. The medial fat (held 10 forceps) is whiter and lies medial to the superior oblique muscle, whiCh can be visualized if desired. The central or preaponeurotic jot (pulled laterally by suction cannula) is darJ..er, less fibrous, and loosely but definitively adherent to the levator aponeurosis. Continued

Figure 4-5 Continued E, Contralateral upper eyelid shows preoponeurotic fat lymg lateral to the superior oblique muS/e and visualiZed more anatomically as a thin yellowish fan-shaped Ioyer attached to the levator aponeurosis. The med10/ fat is ~parole, isolated betv.een the medtal orbit and the superior oblique muS/e After fat resection, closure may be performed as shown m Figure 4-4 F, Close-up photograph of an upper lid b/epharoplasty demonstrating some important anatomic and clmica/ features. Here the lower forceps is indenting the levator aponeurosis and the upper forceps is retracting part of U1e preaponeurotic jot just lateral to the visualized preoponeurotic fat , the orbital septum remams intad. Note that the orbital septum must be violated to gain access to the superior orbit, tile levator. and the preoponeurot1c jot Also note that tile whiter medial orbital fat IS spontaneously prolopsmg anteriorly and the more central preoponeurot1c jot is loosely attached to tile underlymg levator mechanism G, The upper lid is placed on moderate trad1on. and the preaponeurot1c fat is partially divided wtth a cautery and retraded nasolly witil forceps. just above the skm trad10n hook one can see the tarsal plate wllh overlying orb1cu/ans muS1e (wh1te), above that, a blue bond corresponds to a levator dehJSence from the tarsal plate, and supenor to that the levator aponeurosis is wnved as a white flat jan Whitnall's ligament is ~en as a v.hite thin band lateral to the cut end of the preaponeurotic jaL just above Whitnall's l1gament is the blackened (cauterized) cut end of the orb1tal septum, and just below \Vhitnall's ligament is the levator palpebrae supenoris muS1e, which is pale yellow and vaSularized compared with the wlute aponeurosis distally. Modifications m the levator or at the levator tarsal jundion can be easily performed with th1s exposure

E

LEVATOR MODIFICATIONS

A

Figure 4-6 A, Once the upper lid skin is incised or excised, the levator may be modified (shortened/lengthened) without mobilization in a number of ways. The skin edges may also be incorporated in these modifications so as to accentuate or move a lid crease. These changes may be performed alone or in combination and may be utilized freely with the standard upper lid blepharaplasty as already depicted (see Figs. 4-4 and 4-5). The orbital septum in the lower two drawings is shown to be intact to render a clear distinction in anatomic structures. Clinically, the septum may be left intact when the septum fuses with the aponeurosis above the level at which a modification will be performed; however, the septum may be liberally opened and Whit nail's ligament visualized in all cases. Continued

n

Figure 4-6 Continued 8, In the upper lid the skin and orbtCulam muscle have been removed from the underlying orbital septum. Forceps provide traction on the septum, demonstrating its rigidity and its insertion onto the bony orbit The preaponeurotic fat is visible superiorly beneath the septum. c, Once the septum is incised, free access is gained to the superior orbit. The upper lid is on traction, and the levator aponeurosis and more supertor levator muscle is seen. D, The levator may be modified in a number of ways wtthout complete disinsertion from the torso/ plate. Several vaoations include p/icating the levator muscle alone, removing a strip and apposing the cut ends, or pltCatmg and removing the excess levator above the suture line. Here a strip of levator is removed. The underlying cornea is visible through conjunctiva and Mallets muscle Tile suture is placed througll the two cut ends and left loose for demonstration purposes before being tied down. E, Supratarsol fixation is a powerful tool for creating, preserving, or altering the height of the upper lid fold. 1 prefer to use a small absorbable suture Here the suture is passed from the lower skin margin, through the levator aponeurosis, and then through the upper skin margin. Once tied down, the two skin edges are apposed at the desired level onto tile levator aponeurosis, thereby simulating the normal mechanism for eyelid crease formation

Figure 52 As with the upper lid, the successful completion of the lower lid blepharoplasty requires a few technical steps that will simplify and speed its execution. The anatomy of the lower eyelid can be advantageous to the surgeon in properly performing these steps. A, The primary incision should be in a desired fold or potential fold at and lateral to the lateral canthus. The incision should be limited but be able to admit a small curved scissor. The scissor should be passed through the incision into the suborbicularis preseptal space. 8, This plane is developed from lateral to medial while gently pushing and spreading the scissor. Once this plane is developed, the myocutaneous flap can be mobilized with ease. The scissors are withdrawn and only one limb is inserted into the preseptal postorbicularis plane, with the other over the skin surface. The scissors may be beveled toward the eyeball (less skin, more muscle}. C, The second incision is completed lateral to medial with the assistance of inferior digital traction, ending just lateral to the lower lid punctum. The flap should be mobilized to the orbital rim without violating the septum. This is best achieved with a combination of digital cheek traction inferiorly and instrument elevation of the myocutaneous f lap.

0 lnased orbdal septum

E RemoYO me

H a-n '""*'

Figurt 63 The uonscon)ltnCTivol approach to the retrosep I 7iou may be mont of two ways prtstptol or reuoseptol (top). By jar the most controlled and anatomically consistent IS the prtseptol route tl ~II her case on msu/ottd retractor (e g., Dtsmorrts) 1S txtreme/y useful The ret1oseptol route entails simply inc,smg the conjunctiva and cutting through the lower hd tetroctors mto the postseptol space (dolled hn~t The preseptol route ttqwrts entry into the postorbiculons preseptol space above the juSIOil of the 10\>er lid retroCIOIS and the orbital septum. Tlus w1ll allow drrtavisuolizotion of the septum, ond eoch Jot pod con be oddrtssed SftJOrolt/y m o com rolled fashion. To apediently oc/11eve this, o fnv simple steps ore nect!.lllry. A prottaive lens may be used. A, A conJunctNol stay suture is placed dup in the fornix and Ifact ion is applied superiorly ll-h1/e the lid mOf71tn is evened. TiltS couSts the infmor tdge of the torSIII plate to use toward the surgeon 8, The CllnJitnctrvo and lower ltd rmoaots ore mcrsed JUSt below the torso/ plate entermg the post orbiCularis prtstpto/ spou. This plane is dtveloped to the orbital rim w1th the OSSIStonce oft he tract lOll suture ond o nonconductwe mSirument Cootmurd

Nasal

I 01 Ren'lo'e tal paas \ 02 Repo6!Uonw paiS tnerDIJge " --

figure 6-3 Continued C, The orbital septum may then be wide~ incised or pundured and the inferior oblique muscle identified and preserved. 01 and 02, The jot pads may be addressed individual~ in teeping with preoperative plans with either resection, repositioning, conservation, or any combination of these techniques. In repositioning, I prefer a supra periosteal tunnel with a temporary transcutaneous stay suture to maintain the proper location. ,A ~"Sie absorbable closure suture is useful in avoiding Tenon inclu~on cysts. It should be placed laterally to avoid postoperative complaints of comeal irritation.

A B

Figure 6-4 The surgical sequence for transconjunctival access to the retroseptal space requires appropriate traction and exposure and can be applied for fat resection, repositioning, and in medial midface exposure. The technique is also useful for bone exposure in trauma and/or elective osteotomies. When the procedure is properly executed, the preseptal postorbicularis plane may be rapidly exposed to the orbital rim and the surgeon may then perform whatever procedure is deemed necessary. A, Lid eversion with wand traction using a small hook (I prefer double to avoid traction injury to the lid margin) allows exposure of the conjunctival fornix. A traction suture is placed here {plain gut). 8, Needle-tip cautery is used to dissect the preseptal postorbicularis plane down to the orbital rim. Note: the orbital septum is left intact with fat pads visualized. Continued

c D

E

Figure 6-4 Continued C, The orbital septum may then be selectively incised and fat addressed, or the orbital rim may serve as a juncture point for midface adjustments. Here the medial fat pad is delineated by a curved hemostat. The fat pad is seen lying on the insulated retractor as it is teased anteriorly. This may be used for redraping in a fat preservation procedure. D, The inferior oblique muscle should be identified and preserved as it divides the medial from the central fat pads. E, Conjunctiva is closed with a single interrupted plain gut suture placed lateral to the cornea. Skin may be addressed with a rhytidectomy or other procedure (see Fig. 6-1).

SOA DOA

\ ~

D Orbicularis Oculi Muscle 0 Tarsal Plate

Fig. 2-20 Thera are 1011 artenal arcades n the upper eyelid the margnal arcade (MA),the ~ arcade (PA,. the ~I orbital arcade (SOA), and the deep ortlltal arcade (DOA). Each provides sman vertical brarlChes runnmg oo both sides ol the orbJClllaris ocul1 muscle or on both Sides of the tarsal ptate. From these small vertical b~. 'ine wssels branch of' to the skin, muscle, and tarsal plate. F8, frontal branch of the supa1icaal temporal artery; ZOA, zygomatiCCHlltlitaJ arte!}'; LPA, lateral palpebral art!ll)'; STA, supratrochlear art!ll)'. (Reproduced w th permiSSIOn from Kawai et aP'. JolJ'nal of Plastic and Reconstructive SUrgery. Uppncott. Williams and Willoos.)

Eyelid retraction. This results from fixation of pretarsal skin to a shortened levator aponeurosis, or to prominence of one or both eye globes. In both of these situations diagonal fingers can prove corrective. Resort to fascial graft, only if necessary

a c

A-C, Diagonal fingers. Cutting the free edge of the levator aponeurosis and rotating down in order to lengthen the previously shortened or transected aponeurosis.

Figurt 11 oblique wm.'llf:Uon of 1M nghl orblr and adnaa /)(ginning onlerillf/y t>!th slin and ending pm/erJor/y ~lh con]untdDI form from onretior lo posltnor to superJOr to in{eriot, lhos ltfWng os o pulley. rht pti!OpofltfJrolic and pti!CDpsulopo/pdxal Jot islooldy bul dtfimtrw/y linltrl to lht rt>ptf11vt rtlfiKIDn; htnct, dthispalpe1>1ral fascia

Figurt 1-3 Tht uppa and lower C)'(flds orr suspended in spou, tet.ht-rt d mnilolly and loterolly by tht conthol ttnd~ ond th~ in tum ore lintai to Whrtnofl'l ond Lockwood's ligaments. Tht orbittll otld palptbrollobt-s of W Jocrimol gland ort dividN by Whitnall'l ligomfflt Tht orlntal septum mserts ol

~~orbital nm, exctpl in~rolaterofly Vthtrt it in~rts beyond tht rim /Ofming ill"'s reuss.

B F;ztt 1 CrllfllfJUftl B. On lartrol Ktw. iht anG/ofy ~trn UPPtJ and lotwr tydidi iS cltlu. lhl upptt ar.d hwlf !itfllo 1M1Jt Wllh 1M ptnoslt.'Vm t.Xltffttlfly and tht ptnotb110 ltll.trftOIIy rht ltvotDf o~ mtttttS Wrth lht stPtllm llfld 1M prtopontUroiJC /41 ~ fin~ to UJt Jnut ond onty otuwblt by ~lml lht JtPlllm. &IOfltn nJISllt ts J)m,:.olhonumcfiCQJJy mBt'fWlltd and lS tbr fhghllfnght t'ltw!Of of lbt Upptf litl, trspomi~ /01 I to 1 mm C/ Ol'UMIII. 1M UJpsokJpolpt/JIDl /IN/I 01 kJwtt eydd tltiOci/JI J,)'51t'm Ufivs 0/J fht injlnOt obhqut and tluJm&MJn. JMft!/Ml' lflllowtJqdd "JmOUio{ lhtMUy" w1rtJ1 !MJk>bri!tkpmW 0 Whm ftfldinJifltiJI!WlPfJ(JD lhUotljUnctiwi tt!lbon rbd/. cownri,J 0t undmm}flu~ thttydit15 and thm OtJto tMeydJo/1 lho D Stmtlm to l'nuraltmd pcmtllll Gym/wnd tlslwfJtrtm lhtbody r1JtJotmlhtlowttotbrt IS 1/lthmd lltt~ptum but ffl/fO(jt 1'4 IMttiRKkll.s)'SUm HmaJI lf'lll'fbtlllmttl l'ilPSlllopotptbtol Jot All bnol Jot olml.td br ~ID .so I bot trOCVOtl pkJutJ on onltn l:'.ltiiConal /01 JX(K/JI(e o dnturbafJ(t' m lht dp CUOMitJtld JfllmCMOI/iJI. NO~ thtc.oo#mcto{ tMfnfmot MJrfOJ lqtUtn WU.Ir llltcopwlopolpdmli /(Mawtfl bt"" l/lt Jn/mot I.Q1'5Q(

plo~ rhs lOIIt of coo/eanu JS a /fi'IOmi oam routr ID 1M lmpotfDfll polmriol spou. 1 wn th11 rht pmtomKulark pmops.ufopa/pttlml }IJJJO( spou, wfJKh IS lfflpoffDnllfl dtfr!y mwllng both tfOrucoti)UndiKII Qnd tfQfiSCI"Qnt'O(.ft bltphotoplaShtl.

Figure 14 The upper lid incision with the orbital septum incised exposes the tarsal plate just above the traction hook. The whiter levator aponeurosis above the taool plate merges into the redder levator muscle. The dense white condensatron of fibers known as Whitnoll's ligament is easily wsuolized lying at the junaion of the preaponeurotic fat pod and the levator. The preaponeurotic fat is retroaed superiorly by the forceps. Note the loose but definitive altachments the fat has to the levator. A/sa note the latera/third of Whitnall's ligament as it courses to insert on the internal orbital rim. Here the laaimol gland is biseaed into orbital and po/pebrallobes. The /rght yellow orbrtallobe is visualized here, sandwiched between the orbital nm p05teriorly and olxM with Whitnall's ligament below. A small segment of the palpebra/lobe is visible medially and mferior to the ligament.

Figure 1-9 The medial canthal tendon envelops the lacrimal we. It is tripartite, with anterior, posterior, and wperior limbs. Like the lateral canthal tendon, ill limbs are continuous with the taf50f plates. The components of this tendon along with its/otero/ counterpart are enveloped by deep and superficial aspects of the orbicularis muscle. This arrangement is important in maintaining a functional and active lacrimal drainage system.

T~ UPPfr, lower, and common canaliculi closely oppralimote this tendon system: and core should bt takl!n to preserve their mtegrity when altering any o!ipt'(t of the medial canthal tendon. This tendon may require on elt1ve tightening pr()(edure, especially in coSt'S in which a lateral canthal pr()(tdure alone would produce puncta/ and low mol dystopia

Posterior limb, medial canthal tendon

Lacrimal fossa

Anterior and posterior lacrimal crests

The extraocular muscles form a cone whose apex lies near the optic foramen (A). All muscles insert at the annulus of linn except the levator and the superior oblique. The most anterolateral red us check ligament inserts on Whitnal/'s tubercle. On anterior view {8}, the most anterior muscle in the orbit, the inferior oblique, can be seen dividing medial and central fat pads. The lateral fat pod can be seen draping over the orbital rim into the recess of Eisler. This may be one fador contributing to its reputation as the most frequently missed fat.

Upper puncta

Tarsal plates

Ort>lculalls muscle (supedlclal portion) and orbital septum contrtlxitlng to the lateral retinaculum

Figure 1-15 The anatomy of the lateral canthal region shows the integration of muscular, tendinous, and other components of the /otero/ retinaculum. The prd orsal orbicularis muscle follows the d p portion of the lateral canthal tendon behind the septum instrting on whitnoll's tubercle The preseptol orbicularis muscle moves superficially with tM superficial ospts of the lateral canthal tendon, just ont~rior to the orbitol v ptum. Not~ the orbital septum dividing into anterior and posterior /eajl~ts in continuity with the periosteum and periorbito. Whitnoll's ligom~nt, seen through the stptum (Insert) stnds o small component sufXriorly ond a main component to split the lacrimal gland and inJDt on Whitna/l's tubercle.

Lacrimal

orbital portion

Lacrimal duct

Papilla

Inferior meatus

Figure 1-11 Much of the soft tissue of the medial canthal region is comp05ed of the lacrimal drainage system. The vertical, horizontal, and common components of the canaliroli along with the lacrimal sac are enveloped by superficial and deep heads of the orbicularis muscle (pretarsal orbicularis posterior ond preseptal anterior). The tarsal plates ore perforated by the upper and lower canaliculi. The lower is more /otero/, and both vertical components are 2 mm in height. The horizontal components are 6 to 8 mm long and converge into a common system before the lacrimal soc (90% of the time). The lacrimal sac has an investing fascia tl10t allows the orbicularis muscle to exert farce5 on it as well as the canaliculi. The lower third of the lacrimal drainage system is intraasseous (lacrimal duct). The entire system drains into the inferior nasol meatus and can be affected by turbinate loteralizotion or hypertrophy.

Lacrimal gland,

orbital and palpebral

lobes

Conjunctival, tarsal and

limbal goblet cells ---t~~~...:;i~~

,.'!!!~~-Glands of Zeis and Moll

figurt 116 Claseup view olthe upper lateral adnexa and Whitnai/S ligament with the septum dtvided. This region of the fornix is rich in conjundival cells specializing in the produdian of tear components.. The upper and lower lids ore perforated by tarsal meibomian glands, and each follicle has associated glandular elements (leis and Moll). Whitnol/'5 ligament con be seen extending over o medial-to-lateral course dividing the laaimol gland into orbital and palpebra/lobes and inserting at Whitnol/'s tubercle. More centrally, it con be seen in its primary role as a veaor conversion pulley for the levator muscle.

Figure 1-20 Normal/ower eyelid position is shown with the lid at or above the lower limbus (corneosc/eral junction). This is not only cosmetically pleasing but serves to maintain adequate corneal wetting by minimizing ambient evaporative loss. Note the cephalic inclination of the lateral commissure compared with the medial commissure.

f igure 1-7 Theeighl bones of the orbitbosicollyaeatetwosignijicont fodalbuttresses, thejrontal-zygomotic-moxillory and the jrontal-nosol-maxillary. The sphenoid articulates with lhezygomaundis the major delineator between the middleaania/fo

Fig. 22 Double eyelid. Parallel crease configuration

Fig. 24 A typical Caucasian eyelid vJith anaturaluppereyelidcrease Aponeurotic fibers form interdigitations tothepretarsalorbicularisocu1imuscle Pr~fat and a subdermal attachment along the

superior tarsal border.

Strategic placement of intramuscular v-~~ suturescreates

/ -~nfoldirgolcrease

. .... - ....

... .

1\ 2 1 E!ltry for bcKh needles of double-armed sutures F;g,~ _3_T__...,....,...-""""'!llOomco"ipzaogolhaoghms0n.

F'IJ-~ v....wa-.5.{i>!>IT-..d --,...~achnquo . ..,.,l:nrt.Jzn:laJ ... ~

""""u-~Rcol""""'fibL

A

II

J

=:s PrBCasal Oll:!aJar1; t .. ator apooelro!is Tarsus

' Coojunc:r.a

c T~~ Fi~J-6-7 -1> T~ntnoa:noolondinl.-.d""'"'"'!!lodn.,..,_

Levator

Skin

Upper tarsus

Suture passage from " ., "'"'.,_,.,.. . . Skin~ Levator - Skin closure, which tends t [T}-sktn (SfT/S) crease. 0 produce a static

Suture passage from: Skin ~Tarsus- Skin

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Levator 1 inferior subcutaneous knot

Fig. 6-2 Skin (S)-1 closure, which r~vator (L)-skin (S/US) superficial crea~. uces a dynamic and

Fig. 6-4 Place between the in~ent of ligature buried tissues and the f 'ortsubcutaneous According to Fer=~ez;neurosis. resu~s in a deeper and m thts procedure dynamic crease. ore permanent

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fle. t .. 2 L.ne0-e.Aitlorth ~\ooomectpoi"IIB,IN ~cMthlil~-..... ll'le~..,Rl..Tlw~t*l ll~tDnJwponO_~.._ 0-Bilo....,.,.,.~b--~nc.oro..-..:iadto poi'IIA.hhontr~ ~ ...... ~

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Figrm 11.14 (A) l'ul: Z-cpkanthoplastydesign. lin~ BOis ex~ by retr.octing the epicanthal fold. (B) The skin paddle of triangle EAC is excisN.An incision is made Figurr 11.15 (A) l'ilrk Z-rpkanthoplasty marking. (B) Point D and line BD are shown by pulling the epicanthal fold ml"dia!ly. from poinuA to point Band from point B to pint O,c..,atinga flp EABO. (C)Th .. flapis rotatM.A 511\Urt' ispa~d from point A to point D.

Figure !2.16 (A) The epicanthal (old is held in place quite nicdyafterbeing rotate

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8

0 A C

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Fig. 19-12 Long.tsrm rest1ls. vlllh lh9 cisapporaniiCO olll'los DA-8 and DA-C.

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v ()iginal Z-epk:anthoplas~ 8 l.lodif.ed Z ~nflloplasty B Flg. 19-13 ThQ OfiQin;ll Z--epicanthoplasly and lho mociliOO Z~thoplasty

Anesthetic mixture and Injections Two rmxtures of loeal ane.sthet.es are then ptepafed

1. 10mL of 2% lidocaine (Xylocaine) conta1n1ng 1 100 000 ddu110n of epinephrine 10. mixed With 150 units of hyaluronidase. if ava1lable. and labeled 'regula( (This mixture is still acidic in nature.)

2. 1ml of tha above mixture is further diluted with 9ml of injecta~e normal saline. This mixture now has a pH closer to neutrality s1nce it has been dtlu\ed with the buffering aciiOn of 1nJ9clablo normal saline The opinophnno concentration is now 11 000 000 (labeled "diluted")

A drop of topical anesthetic. 0.5% proparacaine hydrochlonde (Ophthaine. Ophthe11c) IS apphed CMJr each come a for comfort pnor to surgical preparation and draping Using a 30-gauge half-inch needle. 0 25-0 5ml of the diluted mixture is infiltrated subcutaneously ~r the superior tarsal border of the mid-portJOn of I he hd During the next 2 minutes anesthesia takes effect and one can observe blanching of the eyelid skin from the powerful vasoconstrictive effect of the diluted epinephnne (Fig 7 7).

The regular m1xture s then lnJee-ted in the subor-blcularie plane Mong the rmdMectlon or Che upper ltd, usually applytng less than 1 OmL per eyehd

The purpose or this two4 s t aged inject ion of loca l anesthetic is to allow for a relatiVely painles s pre-infiltration to anesthetize the aurg.c.l field before the full strength or acdc 2% Xylocina gtven {1) (One may add sodium bicarbonate to the 2% mix to achieve the same effecL for a 10% wlume mucture, 1ml or 8 4% 9odtum bicarbonate. contain.ng 100mEq or 8 4g per 1 OOmL. ta mixed With 9ml of the 2% Xytoca1ne ) The hyaluronidase promotes dtsperston of t he anesthetic and greatly reduces any t1ssue d tstOJ1ton, facthtatmg the ldenttficatton of ny creaea hne that the p.ehent may have

When confronted With a patient with a low threshold for pain , one may supplement the local fiel d tnfihration w.th a frontal ne rve block a 30-gauge hillf-inch needle may be used to appfy 1mL of the anesthe tic imo the supraorbital space JUSt lateral to t he s upraorbital notch

The eyehds ond rac.e are then prepared tn tht usual fashion for ophthalmec ptastic su rgety The eyes again receN"& a drop of topical anesthetic, th1s time usmg tatracane hydro. mu(ld& fot longor-tastng cornoal anesthtla To eliminate the poasible sensation of cl ausuophobia that may occur with draping over the nose and midface. a s1ngle layer or s t enia mvst ened, porous gauze may btl placed ov..r tha patient' oxpoaad no and mouth Black opaque corneal proteclors are then appHed under the eyelids.

The he1ght of the tarsus deternvnes the overall central posrt1on of the surgical crease; the shape is determined by how you design the medial one-third and lateraJ one-third of this lower line of mcsion, accord1ng to the patient's preference.

The shaved-cff lip of a wooden coHen-tipped applicator dipped with methylene blue is used to indicate the proposed c rease. The upper lid is everted and the vertical height of the tarsus ts measured 0\'er the central portion of the lid with a caliper (Ftg. 7.8). This measurement - which is usually between 6.5 and 8.0mrn - is careflllly transcribed onto the external skin surface, again over the central part of the eyelid skin This point directly overlies the superior tarsal border and will serve as a reference point for the overall crease hetghl along the central one-third of the eyelid, whether the crease shape is to be nasally tapered, parallel. or, in rare cases, laterally flared. For those patients who have a crease. one should also measure the tarsus to confirm that the apparent crease is indeed the correct crease line to use, whether one is planning to preserve or enhance rt

Ftgure 7.8 Thrs nght upper fyelid S evertCKI and a caliper uled to menure the centralhet of the ta.rs.~.os.lhapoi'rtiS lranscrtJed onto me external surface of the sm. and serves as a central reference pont for tile lower ltle of 1r1ca10n

If the crease is to be nasally tapered, the medJal one-third of the incision line is marked such that it tapers towards the medial canthal angle or merges with the medial upper lid fold (Fig. 7.9) The laletal one-third is usually marked in a leveled configuration, although occasionally a patient may request a slight upward widening over the lateral segment of the crease.

Figure 7.9 Markllg alld design of a nasally tapered aease The medllf ooe-thl'd of tne IJ1CI5on lne.s taper towards the medial eanthal engle The \atefal ()(I~ ny beecher 'eveled or rtare-d slght1y upwerd

For the parallel crease, the measured height of the superior tarsal border is drawn across the width of the eyelid skin (Fig. 7 10)

Flqure 7.10 Mal\>llg 1111d destgn of a paralel crease

To create adequate adhesions, some subdermal tissue must be removed. A strip of skin measuring about 2- 3mm is then marked above and parallel to this lower line of incision. In patients who want a nasally tapered configuration, this upper line of incision is tapered towards the medial canthal angle. or to merge wit h any medial upper lid fold that may be present. The segment of skin to be excised is frequently less than 2mm over the medial portion of the crease

The inc1s1on is then earned out using a No. 15 surg1cal blade (Bard-Parker) along the upper and lower lines. incising just through the dermis and within the superficial orbicularis oculi muscles. Fine capillary bleeding is controlled us1ng bipolar wetfield cautery (Fig. 7 11)

Ftgure 7,11 Upper and \ower Inca of 11CIIion have~, opened with. a 'o 1 ~surgical blade wih wetfleld ~lar cautery appied to vascular oo~ that may arise trom orbiculans rmsde

The excision of a strip of skin is not required in every case: however, I believe that it facilitates the removal of subsequent layers of the lid tissues, thereby permitting adequate crease formation. At this point, the superior tarsal border is