PERIORBITAL SURGERY AND ENDOSCOPIC FOREHEAD … · Upper Eyelid Blepharoplasty 9 Step 2 Marking the Incisions After Analyzing the Skin Excess Intraoperative Assessment of Skin Excess

Jacques VAN DER MEULEN

PERIORBITAL SURGERY ANDENDOSCOPIC FOREHEAD LIFT

®

PERIORBITAL SURGERY ANDENDOSCOPIC FOREHEAD LIFT

Jacques VAN DER MEULEN

Periorbital Surgery and Endoscopic Forehead Lift4

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Periorbital Surgery and Endoscopic Forehead LiftJacques van der MeulenDutch Craniofacial UnitDepartment of Plastic, Reconstructive and Hand SurgeryErasmus Medical Center | Rotterdam, The Netherlands Velthuis Kliniek |

Radetzky Villa | Vienna, Austria |

Corresponding address of the author: Jacques van der MeulenRadetzky VillaCobenzlgasse 46, A-1190 Vienna, AustriaPhone: +43-1-328-1200E-mail: [email protected]

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Periorbital Surgery and Endoscopic Forehead Lift 5

Table of Contents

1 Upper Eyelid Blepharoplasty

Step 1 Analyzing the Upper Eyelid . . . . . . . . . . . 8

Step 2 Marking the Incisions After Analyzingthe Skin Excess . . . . . . . . . . . . . . . . . . . . 9

Inferior Limit of Upper Eyelid Incision . . 9

Intraoperative Assessment ofSkin Excess . . . . . . . . . . . . . . . . . . . . . . . 9

Superior Limit of Upper Eyelid Incision 10

Lateral Skin Excess . . . . . . . . . . . . . . . . . 10

Medial Skin Excess . . . . . . . . . . . . . . . . . 10

Step 3 Infi ltration . . . . . . . . . . . . . . . . . . . . . . . . . 11

Local Infi ltration Anesthesia. . . . . . . . . . 11

Step 4 Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Incision of Skin . . . . . . . . . . . . . . . . . . . . 11

Step 5 Resection of Skin . . . . . . . . . . . . . . . . . . 11

Undermining of Skin . . . . . . . . . . . . . . . . 11

Step 6 Resection of Excess Orbital FatIf Indicated. . . . . . . . . . . . . . . . . . . . . . . . . 12

Upper Eyelid Fat Compartments . . . . . . 12

Excision of Fat . . . . . . . . . . . . . . . . . . . . . 12

Step 7 Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . 12

Step 8 Closure of Skin . . . . . . . . . . . . . . . . . . . . . 13

Step 9 Volume Restoration of the Upper Eyelidby Lipofi lling . . . . . . . . . . . . . . . . . . . . . . . 13

Harvesting of Fat . . . . . . . . . . . . . . . . . . . 13

Processing of Fat . . . . . . . . . . . . . . . . . . . 14

Injection of Fat . . . . . . . . . . . . . . . . . . . . . 14

2 Lower Eyelid Blepharoplasty

Step 1 Analyzing the Aging Lower Eyelid . . . . . 16Scleral Show . . . . . . . . . . . . . . . . . . . . . . 17Ectropion . . . . . . . . . . . . . . . . . . . . . . . . . 17

Step 2 Markings and Infi ltration Anesthesia. . . 18Markings . . . . . . . . . . . . . . . . . . . . . . . . . . 18Infi ltration Anesthesia . . . . . . . . . . . . . . 18

Step 3 Incision of the Lower Eyelid . . . . . . . . . . 19Step 4 Correction of Protruding Infraorbital Fat 20 Technique: Fat Redistribution . . . . . . . . . 21Step 5a Suspension of the Lower Eyelid (I). . . . . 22

Tightening of the OrbicularisOculi Muscle: Muscular Sling . . . . . . . . 22

Step 5b Suspension of the Lower Eyelid (II) . . . . 22Tightening of the Lateral CanthalLigament: Canthopexy . . . . . . . . . . . . . . 22

Step 5c Suspension of the Lower Eyelid (III). . . . 23Repositioning of the Lateral CanthalLigament: Canthopexy . . . . . . . . . . . . . . 23

Step 6 Skin Excision and Closure. . . . . . . . . . . . 24

3 Browlift

Step 1 Analyzing the Brow Position . . . . . . . . . . 26

Step 2a Methods of Browlift (I): Excision of Skin (Direct Browlift, Coronal Browlift) . . . . . 27

Step 2b Methods of Browlift (II):The Temporal Browlift . . . . . . . . . . . . . . . 28

Step 2c Methods of Browlift (III):The Endoscopic Forehead Lift . . . . . . . . 29

1 Upper Eyelid Blepharoplasty


Upper Eyelid Blepharoplasty

The eyelids have a protective function. They prevent the eye from drying out by covering (part of) the cornea and by spreading the tear fi lm across the cornea. The lower eyelid is mainly static in its function, whereas the upper eyelid plays a major role in actively spreading the tears as they are secreted by the lacrimal gland.

The upper eyelid crease is formed by the attachments of the levator muscle fi bers into the skin in front of the tarsal plate. The lateral canthus is approximately 2 mm higher than the medial one. The rim of the upper eyelid is normally positioned 1 – 2mm below the upper limbus. One should always be aware of the horizontal position of the upper eyelid and note any asymmetry present before surgery. Levator muscle weakness could dis-guise the problem of skin laxity, therefore leading to a suboptimal result.

In the medial aspect of the upper eyelid one can often fi nd a distinct bulging. This is mainly due to prolapsed intraorbital fat resulting from weakness of the medial orbital septum. Make sure to mark this, since this should be addressed separately during surgery.

The position of the eyebrow should be taken into ac-count as brow ptosis can result in an overestimation of the true amount of skin excess in the upper eyelid. When indicated, consider repositioning the eyebrow fi rst before proceeding with an upper eyelid blepharo-plasty.

The normal eye.

1

The aging eye

2

Analyzing brow ptosis. Normal (left) and low (right) position of eyebrow in relation to supraorbital rim.

3

Step 1

Analyzing the Upper Eyelid

Lateral canthus

Upper eyelid skin excess

Supratarsal crease

Medial fat protrusion

Medial canthus

Skin resting against eyelashes

Upper Eyelid Blepharoplasty 9

Step 2

Marking the Incisions After Analyzing the Skin Excess

Intraoperative Assessment of Skin Excess

Ask the patient to keep their eyes closed. Grasp the skin using a non-toothed forceps and pull it down towards the lower incision marking. Be careful not to overdo this in the medial aspect of the eyelid. If needed, use a Burrow’s triangle there (see Fig. 9, p. 10).

Typically curved lower incision skin marking.

4

Intraoperative assessment of skin excess (lateral view).

5

Intraoperative assessment of skin excess (crossectional view).

6

Markings can be made in either an upstanding or supine position, using a waterproof marker pen with a fi ne tip. Note the amount and location of skin excess, as well as the way in which the subdermal volume is dispersed.

Inferior Limit of Upper Eyelid Incision

The lower incision is slightly curved and follows the shape of the eyeball. The tarsal crease in the upper eyelid can be used as a guide. Make sure to leave at least 7 – 8 mm between this caudal incision and the rim of the upper eyelid.


Superior Limit of Upper Eyelid Incision

While the aim is to resect as much as skin as possible, in reality there is a functional limit to what should be resected. It is advised to restrict the skin reduction by leaving a margin of at least 7 mm between the cranial border of the incision and the eyebrow.

Lateral Skin Excess

Usually, the skin excess is more in the lateral section of the upper eyelid. This can be addressed by guiding the incision upwards at an angle of about 45 degrees. Preferably, try to limit its length as much as possible in order to reduce the more obvious part of the scar as much as possible. The scar should not extend beyond the lateral orbital wall.

Again, if these conditions cannot be met, then consider performing an additional (lateral) browlift.

Incision line in case of relatively limited skin.

7

Marking in case of mostly lateral skin excess.

8

Marking in case of lateral and medial skin excess.

9

Medial Skin Excess

In case of medial skin excess, a Burrow’s triangle can be added to prevent a ‘dog ear’ from forming above the medial canthus. Fishtail designs have also been described.


Step 3

Infi ltration

Step 4

Incision

Step 5

Resection of Skin

Local Infi ltration Anesthesia

A common combination is: Lidocaine 1% with Adrena-line 1:200.000. For reasons of comfort consider adding 1cc Sodium-bicarbonate to 9 cc of the above, thus reducing the acidity of the injected fl uid and making the injection less painful. Use for instance a 24-Gauge needle and infi ltrate from lateral to medial, using already infi ltrated skin to reintroduce the needle.

Local infi ltration anesthesia.

10

Marking in case of mostly lateral skin excess.

11

Skin resection.

12

Incision of Skin

Make sure to meticulously follow the lines as marked before the procedure. Putting the skin under some light traction may facilitate this.

Undermining of Skin

The skin can be undermined in a subdermal plane while resecting, using either scissors, a knife or monopolar diathermia. Most surgeons take a strip of orbicularis oculi muscle at this stage, in order to reduce the volume and create a fold in the upper eyelid.

In principle though, it is probably best to leave it un-touched as much as possible, keeping its function in mind. One could leave this decision depending on the volume of the upper eyelid, which should be noted dur-ing the preoperative examination in the upright position.


Step 6

Resection of Excess Orbital Fat If Indicated

Step 7

Hemostasis

Fat compartments of the upper eyelid.

13

Resection of fat.

14

Hemostasis.

15

Upper Eyelid Fat Compartments

The orbital septum gives access to two fat compart-ments in the upper eyelid. Typically, the fat in the lateral pocket is more yellowish than the one seen in the medial pocket.

In the laterocranial part lies the lacrimal gland (Fig. 13, colored in green) just inside the supraorbital rim. Be careful not to harm this important gland.

Excision of Fat

Even though an eyelid with a youthful appearance usually contains more subcutaneous fat then at a later age, in some cases of uneven distribution resection of fat still is indicated. A thorough preoperative evalua tion is paramount in order to determine where and how much fat should be resected. The medial (= white) fat compartment often houses the biggest bulk, but be careful not to overresect. This will inevitably lead to hollowing of the upper eyelid, which results in a very unnatural appearance and should be prevented.

Hemostasis

Meticulous hemostasis is of the utmost importance. It will improve the postoperative appearance and will keep recovery time to the bare minimum. Reducing the risk of postoperative hemorrhage will also limit the risk of a retro-bulbous hematoma. This most feared of complications could, if neglected, lead to optic nerve compression and blindness.

Lacrimal gland


Step 8

Closure of Skin

Step 9

Volume Restoration of the Upper Eyelidby Lipofi lling

Closure of Skin

The skin is preferably closed using a intradermal con-tinuous suture. A monofi lament thread like Prolene 6/0 is best suited due to its sliding characteristics, making it both easy to apply as well as to remove. A small needle (for instance a P3 cutting needle) will help in achieving a precise approximation of the skin layers.

Suturing of the wound.

16

‘A-line deformity’ in the medial aspect of the upper eyelid.

17

Harvesting of fat.

18

Volume Restoration of the Upper Eyelid by Lipofi llingManifestation of aging is basically related to changes that occur on three levels:

� Reduction of skin laxity, � Caudal migration of subdermal tissue and � Progressive atrophia of (sub)dermal tissue.

This last factor leads to loss of volume in the face. Especially when (too much) fat has been resected in the course of a previous upper eyelid surgery, over time, an indentation appears in the medial one-third of the upper eyelid, which is referred to as ‘A-line deformity’ (Fig. 17). Restoration of the natural curvature of such a depleted upper eyelid can be achieved by adding volume via fat injection, which can result in a youthful and more natural appearance.

Harvesting of FatFat harvesting is done by liposuction. Possible donor areas include the abdomen (Fig. 18), the thighs and the medial aspect of the knees. Recent evolutions in har-vesting cannulas (smaller but more holes) have resulted in fat consisting of smaller particles, which is claimed to have a higher revascularisation rate due to the in-creased surface area.


Processing of FatColeman* advocated spinning the fat in a centrifuge for 3–5 minutes (Fig. 19). Alternatively, one can leave the fat to settle for a period of 15–30 minutes, during which the separation of fat and other substances occurs as a natural process. It is claimed that due to this, stem cells collect in a separate (white) layer on top of the fat. Including this fraction rich in stem cells when transfer-ring the harvested fat into smaller injection syringes (Fig. 20), is believed to add to the regenerative effect of the method.

Injection of FatHarvesting the fat by multiple-hole cannulas makes it more liquid-like. This renders the fat easily injectable by means of smaller-gauge needles, which makes the procedure more refi ned. Defects can be corrected to a higher degree of precision. Typically, the medial as-pect of the upper eyelid is fi lled in the submuscular/preseptal space with 1 to maximum 2cc of this liquefi ed fat (Fig. 21). By injecting small drops are discharged along the course of multiple tunnels at the target area (Fig. 22).

Centrifugal separation of the fat.

19

Transfer into 1cc syringes.

20

Fat injection to correct ‘A-line deformity’.

21

Method of infi ltrating the fat.

22

* COLEMAN SR. Facial recontouring with lipostructure.Clin Plast Surg 1997: 24: 347–267.

2 Lower Eyelid Blepharoplasty


Lower Eyelid Blepharoplasty

The texture of skin around the orbit makes that the ag-ing process of the face often fi rst becomes apparent in this area. Where the changes with age in the constantly moving upper eyelid are mainly due to increased skin laxity, those in the lower eyelids are more related to the relaxing of suspension structures, as they are more static in their function. The purpose of the lower eyelids is to protect the lower half of the globe, which makes it very important to position them properly and under the correct tension.

In order to be able to translate the patients’ demands into a surgical procedure that suits them best, a thorough understanding of the anatomical key struc-tures of the lower eyelid and of their changes during the aging process is mandatory.The aging lower eyelid.

1

Lateral cross-sectional view of the anatomy of the lower eyelid.

2

Suspensory structures of the eyelids.

3

Step 1

Analyzing the Aging Lower Eyelid

The subcutaneous changes show on the outside. Loss of tension in the support structures of the lower eyelid, like in the infraorbital septum, results in protrusion of the intraorbital fat over the edge of the infraorbital rim. This is refl ected by the malar bags, which so often are the reason of discontent.

Several structures are in place to support and maintain the position of the lower eyelid:

� the tarsal plate � the canthal ligaments � the orbicularis oculi muscle

The tarsal plate is integrated into the ligamentous suspensory system of the lower eyelid. Both, the tension of this suspensory system as well as the position of the canthal attachments is essential in de-termining the position of the (lower) eyelid.

Sagging of lateral canthus

Tarsal plate

Orbicularis oculi muscle

Sagging of intraorbital septum

Lateralcanthal

ligament

Medialcanthal ligament

Tarsal plate

Scleral show

Increased skin folds

Tear trough deformity

Lower Eyelid Blepharoplasty 17

Ectropion

The outward sagging of the lower eyelid is referred to as ‘ectropion’. Commonly, this occurs in the lateral aspect of the lower eyelid, but is observed medially as well. Causes for this fi nding could lie in the lower eyelid itself (increased laxity of canthal ligaments or the orbicularis muscle), or in the surrounding tissues. Ectropion is a dreaded complication after lower eyelid blepharoplasty, usually due to an over-enthusiastic resection of skin or a misjudgment of the suspensory capacity of the lower eyelid. In this situation, the protective function of the cornea is impaired, which can lead to reduced vision.

Scleral show.

4

Ectropion.

5

Scleral Show

Typically, the lowest point of the lower eyelid margin is located at the level of the limbus. When this point is located more laterally, there is more exposure of the sclera of the eye, hence the term ‘scleral show’. This can be the result of, for instance, increased lower eyelid laxity due to aging, but may also stem from a malposition of the lateral canthal ligament or a shortage of skin in the lateral aspect of the lower eyelid.

When present, one should consider taking extra measures to restore positional and functional balance during the procedure.


Markings

The typical incision for access to the lower eyelid runs approximately 1– 2 mm below the eyelashes. It extends into the lateral canthal region at an angle following the natural skin lines, therefore providing an opportunity to correct any excess of skin without causing a ‘dog ear’ at the end of the procedure.

Infi ltration Anesthesia

Infi ltration should include not only local and regional blockage of the infraorbital nerve, but also that of the zygomatical branch of the trigeminal nerve. This nerve provides sensation to the lateral aspect of the orbital region as shown in the illustrations.

Subciliary incision line.

6

Infi ltration of zygomatical branch.

7

Sensory nerves in the periorbital region.

8

Step 2

Markings and Infi ltration Anesthesia

Supra-orbital nerve

Zygo-matical

nerve

Supra-trochlear nerve

Infra-orbital nerve


Step 3

Incision of the Lower Eyelid

9

10

11

12

13

14 15

The sequence of dissecting into the lower eyelid could be as follows:

1. Canthal incision by use of a knife. This incision should be made at an angle with the lateral orbital wall, following the wrinkles that usually fan from there into the temporal area. The precise location of this lateral component is therefore different in every case. The incision then continues a few millimeters under the cilia as far as or just beyond the level of the limbus (Fig. 9).

2. Subcutaneous dissection by use of scissors, creating a tunnel above the level of the muscle (Fig. 10).

3. Tilt the scissors and cut the skin while following the subciliary incision line (Fig. 11).

4. Submuscular, preseptal dissection (Fig. 12).

5. Transmuscular cut, providing instant access to the preseptal layer (Fig. 13).

6. Preseptal dissection towards the arcus marginalis. Make sure to use a ‘von Langenbeck’ retractor to lift the soft tissues away from the infraorbital septum, which makes it easier to dissect in the right plane (Fig. 14).


The most common methods for correcting protruding infraorbital fat are:

1. Tightening of the infraorbital septum: The caudal edge of the loosened septum is reattached to the arcus marginalis by means of a running suture, thus restoring it to its original position and tension (Fig. 16).

2. Fat resection via a subciliary incision: Good ex-posure of the infraorbital region can be obtained by using this access. Usually, resection of fat is mainly confi ned to the medial compartment. The advantage of this approach is that it provides a good way to resect any skin excess that might be present at the same time. Disadvantage of fat resection is the po-tential risk of a ‘hollow-eye appearance’ in the long term (Fig. 17).

3. Fat resection via a transconjunctival approach: The most obvious advantage of this approach is the prevention of a visible scar, thus making it an option to consider mainly in the absence of skin excess in the lower eyelid. Apart from that, another advantage is that the orbicularis oculi muscle is left alone, therefore reducing the risk of limiting its function, which is sometimes seen after using the external subciliary approach. Main disadvantage is that this procedure needs to be performed under sedation or general anesthesia in order to prevent discomfort for the patient, considering the proximity of the cornea (Figs. 18, 19).

4. Lipofi lling: Recent evolution in facial plastic surgery has added another aspect to rejuvenation, which is in direct contrast to the techniques described under point 2 and 3, namely the restoration of volume. While fat injections might not be able to completely replace other methods of periorbital rejuvenation, they can certainly act as an adjunct to them, like for instance when fi lling the tear trough.

Step 4

Correction of Protruding Infraorbital Fat

16

17

18

19


20

21

22

23 24

Technique

Fat Redistribution

Dr. Hamra presented the following technique of arcus marginalis release and subsequent fat distribution in 1995* as part of his composite face lift theory. The prin-ciple consists of preserving the fat and redistributing it over the infraorbital rim in order to camoufl age the rim.

1. Preseptal dissection towards the arcus marginalis (Fig. 20).

2. Dissect over the inferior rim of the orbit (arcus mar-ginalis) down into the cheek in a supraperiosteal plane, creating a small pocket. This also releases the subcutaneous skin adhesions to this rim, which adds to the correction of the malar bags (Fig. 21).

3. The septum is incised at the level of the arcus margi-nalis, which releases the fat from the compartments (Fig. 22).

4. The infraorbital fat is moved over the rim, down-wards into the supraperiosteal pocket. This maneuver involves that the skin adhesions are also released, facilitating mobilization of the malar bags (Fig. 23).

5. By moving the intraorbital fat down and subcutan-eous tissues of the cheek upwards on top of the fat, a double layer coverage of the infraorbital rim is obtained. The skin is then closed with an intradermal running suture, usually combined with tightening of the muscle in a sling (Fig. 24).

* HAMRA ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995; 96:354–362.

HAMRA ST. The role of orbital fat preservation in facial aesthetic surgery: A new concept. Clin Plast Surg 1996; 23:17– 28.


The orbicularis oculi muscle plays a vital role in the suspensory mechanisms of the lower eyelid. Its function and position should therefore be taken into consideration in every lower eyelid procedure. Often, suspending the lateral muscle segment at the lateral orbital rim is the fi rst step in those operations that aim to reinforce the active support mechanism in the lower eyelid (Fig. 25).

Muscular suspension.

25

Canthopexy, tightening the ligament.

26

Step 5b

Suspension of the Lower Eyelid (II)Tightening of the Lateral Canthal Ligament: Canthopexy

In case of increased laxity of the lower eyelid, a tighten-ing of the lateral canthal ligament should be considered. Make sure that the traction suture is placed through the ligament in continuation with the tarsal plate and that it is moved into the correct position and direction, since the origin of the ligaments lies on the medial aspect of the lateral orbital wall. Denying to acknowledge this detail results in reduced protection and may thus pre-cipitate damage to the cornea.

Step 5a

Suspension of the Lower Eyelid (I)Tightening of the Orbicularis Oculi Muscle: Muscular Sling


The position in which the lateral canthal attachment is placed is essential for the position and thus the outer aspect and balance of the eyelids. On average, the lateral canthus is positioned at the level of the lower limbus of the iris, which is 1 – 2 mm higher than the medial canthus. During surgery this position can be adjusted according to demand. A protruding eye might need a 1-2mm higher positioned lateral canthus to achieve a proper lower eyelid position.

It is important to make sure that the canthal ligament is fi xed to the inside of the lateral orbital wall. This means that the suture should really pass through the bone for the ligament to end up in the right position (Figs. 27, 28).

Underlying anatomy, transosseous fi xation.

27

Intraoperative view of the transosseous fi xation of the lateral canthal ligament.

28

Step 5c

Suspension of the Lower Eyelid (III)Repositioning of the Lateral Canthal Ligament: Canthopexy


Step 6

Skin Excision and Closure

The amount of skin that can or should be excised in a lower eyelid correction is often subject of debate. The minimum amount of skin that is required in the lower eyelid can be determined by asking patients to open their mouth while looking upwards at the same time. If the eyelid is properly supported, then the skin that is loosely overlapping the cranial wound edges in this position should be safe to resect. Usually, the majority of this surplus will be located in the lateral part of the lower eyelid.

Defi ning the amount of skin resection with open mouth and eyes rotated upwards.

29

Lateral skin resection only.

30

Put no tension on the skin when resecting.

31

Continuous running suture for wound closure.

32

3 Browlift


Browlift

The eyebrows (together with the eyelashes) form a pro-tective barrier for the eye by preventing, for instance, sweat, dust or other debris to drop down into the orbital area and thus possibly into the eye itself. They also play an important role in non-verbal communication, where specifi c movements of the eyebrows can vividly en-hance emotions like anger or surprise.

There is a wide range of natural as well as gender-related variation in the position of the eyebrow:

� The medial part of the eyebrow is usually located at, or slightly above the level of the supraorbital rim.

� The apex of the eyebrow is located at the level of the lateral limbus.

� In men, the lateral aspect of the eyebrow mostly sits on the supraorbital rim, while in women it is positioned (on average) 1–3 mm higher.

� The lateral part of the brow normally ends at a level 2–3 mm higher than that of the medial part.

This variation demonstrates that in each case the proper brow position should be assessed on a case-to-case basis.

Brow ptosis is confi rmed when the brow is located caudally to the supraorbital rim (Fig. 1). Ptosis is mostly found in the lateral aspect of the brow, but medial ptosis does occur. Often, this is associated with hyper-activity of the muscles in the glabella region. An intimate knowledge of the anatomy in this area is a must in order to achieve a suitable solution in each case (Fig. 2).

When dealing with the brow position, one must be aware of the site and course of the sensitive nerves located in this area in order to prevent any iatrogenic damage to motor or sensory nerves (Fig. 3).

The brow is attached to the lateral aspect of the supra-orbital rim by means of strong ligamentous attach-ments to ensure a stable position. Mobilizing the brow in a subperiosteal approach requires a release of these lateral attachments (Fig. 4).

Analyzing brow ptosis; considering position of soft tissues in relation to underlying orbit.

1

Muscles of the forehead.

2

Nerves of the forehead.

3

Ligamentous attachments of the eyebrow and the forehead.

4

Step 1

Analyzing the Brow Position

Frontalis

Supra-orbital n.

Depressor supercilii

Corrugator

Supra-trochlear n.

Temporal crest (transition zone)

Procerus

Facial n. (frontal

branch)

Periosteal attachments

Orbi cularis oculi

Browlift 27

Direct excision.

5

Classic, coronal lift.

6

Step 2a

Methods of Browlift (I): Excision of Skin (Direct Browlift, Coronal Browlift)

1. Direct excision of skin of the forehead: Main indication is the elderly patient with already marked skin creases in the forehead. Disadvantage (besides the scars) is the limited stability of the result and the inevitable concomitant damage to the supraorbital nerve (Fig. 5).

2. Classic, coronal lift: Total mobilization of the fore-head via a scar in the hair-bearing skin. Excellent exposure, although at the cost of a sizable scar. The drawbacks inherent to the method involve that the hairline is raised if the incision is made in the hair bearing skin. This can be prevented by position-ing the scar at the level of the hairline. A second disadvantage is the numbness of the hair-bearing skin posterior to the incision line (Fig. 6) that will inevitably result from cutting the supraorbital nerve.


3. Transpalpebral lift: The brow can be approached during an upper eyelid blepharoplasty, which saves an extra scar. This method, however, is limited to the lateral half of the brow due to the location of the supraorbital nerve. Stable periosteal fi xation is often diffi cult, resulting in less predictable results in the long term (Fig. 7).

4. The Fogli browlift: for a long time, temporal lifting was considered a variation of the type-1 approach (direct excision of skin), in that it offers the advan-tage of concealing the scar within the hair-bearing skin, but with the drawback that its effi cacy is lim-ited to the lateral aspect of the eyebrow. However, Dr. Fogli* developed another approach in this area when publishing a review of 270 cases of temporal lift in 2003. Employing this technique gives access to the lateral orbital region via a temporal inci-sion, just within the hairline (Fig. 8).

1. Scissors are used to undermine down to the level of 1 cm caudal to the hairline (green area, see Fig. 8) in a subgaleal plane. At the level of the temporal crest though, this dissection proceeds below the periosteal layer in order to release the attachments.

2. Halfway between the hairline and the eyebrow, the tip of the scissors is used to penetrate the galeal plane (Figs. 8, 9), after which dissection proceeds caudally in the subcutaneous plane. In this way, the frontal branch of the facial nerve is spared. Dis-section is carried all the way down to the zygoma via the supra orbital rim and the lateral orbital wall, in order to mobilise the tissues extensively.

3. Then, the galea is elevated, doubled up on it self, and sutured to the temporal fascia in order to achieve permanent fi xation at a higher position (Fig. 10).

* FOGLI AL. Temporal lift by galeapexy: A review of 270 cases. Aesthetic Plast Surg 2003;27:159–165.

Step 2b

Methods of Browlift (II): The Temporal Browlift

Temporal incision according to Fogli.

8

Galeal transsection according to Fogli.

9

Galeal fi xation according to Fogli.

10

Transpalpebral lift.

7

Browlift 29

Step 2c

Methods of Browlift (III): The Endoscopic Forehead Lift

5. Endoscopic forehead lift: The endoscope was introduced into browlifting by Ramirez in 1995**. Access to the subperiosteal plane is obtained via three longitudinal incisions just within the hairline (Fig. 11). A blunt-tipped elevator is used to raise the fi rst 3 to 4 cm of the forehead, while following this subperiosteal plane in a caudal direction (Fig. 12). It is wise to stop at this point, since it is very easy to inadvertently perforate the periosteal layer due to the curvature of the frontal bone. The endoscope is now introduced to proceed with the dissection un-der direct vision (Fig. 13). In this way, the periosteal layer is mobilized up to the level of the supraorbital rim and down to the lateral aspect of the orbit and zygoma, gradually freeing the lateral attachments of the brow (see Fig. 4).

** RAMIREZ OM. Endoscopic subperiosteal browlift and facelift. Clin Plast Surg 1995; 22: 639–660.

Endoscopic forehead lift, incisions.

11

Endoscopic forehead lift, blunt dissection.

12

Endoscopic forehead lift, introducing the endoscope.

13

Temporal crest

Temporal crest


(Continued from previous page). Once dissection arrives at the supraorbital rim, the muscles of the glabella region should come into view. When marked interglabellar frowns are present it is an option to cut the corrugator, procerus and depressor supercilii muscles at this stage, although care should be taken not to harm the nerves. Cutting and weakening these muscles reduces downward traction of the eyebrow. The adjunctive use of botox is indicated at this point in that it mainly contributes to lifting the medial as-pect of the eyebrow by blocking the muscles that pull it downward.

View of glabellar musculature during endoscopic forehead lift.

14

Procerus

Corrugator Supra-trochlear n.

Supra -orbital n.

Browlift 31

Fixation can be achieved by a variety of methods. Based on the authors experience, the use of both absorbable hooks or uni-cortical screws have been shown to work well. In case of the screws, the wounds are closed with staples, while pulling up the skin behind the screws with maximal tension. The screws are then easily removed in an outpatient setting after two weeks. In case of using the absorb-able hooks, the skin is lifted and pinned down in the desired location. Expect the hooks to disappear over the course of 6 to 12 months.

6. Botox injections: Medial browptosis is often caused by overactive depressor muscles. With the use of Botox, the caudal pull of these muscles can be reduced, usually resulting in a considerable elevation of the medial aspect of the eyebrow.

Endoscopic forehead lift, position of screws and method of fi xation.

15


Upper and Lower Blepharoplasty

208000 Surgical Handle, Fig. 3, length 12.5 cm,for Blades 208010 – 15, 208210 – 15

208215 Blade, Fig. 15, sterile, package of 100

533013 ADSON Dressing Forceps,micro-model, serrated, length 12 cm

533113 ADSON Tissue Forceps, micro-model,1 x 2 teeth, length 12 cm

513310 STEVENS Scissors, curved,length 10 cm

208000

208215

533013

533113

513310 499001

499001

505610 516113

841111 Bipolar Coagulating Forceps, insulated, straight, blunt, length 11 cm

847000 E Bipolar High Frequency Cord, for AUTOCON®

II 400 SCB systems (111, 113, 115, 122, 125),AUTOCON® II 200, AUTOCON® II 80,KARL STORZ Coagulator 26021 B/C/D, 860021 B/C/D, 27810 B/C/D, 28810 B/C/D, AUTOCON® systems (50, 200, 350),Erbe-Coagulator, T and ICC series,length 300 cm

26 5200 43 Electrode Handle, with 2 buttons for activating the unipolar generator, yellow button: unipolar cutting, blue button: unipolar coagulation (Cable 26 5200 45 required)

26 5200 40 Needle Electrode

26 5200 45 High Frequency Cord, for Electrode Handle 26 5200 43, length 400 cm

499001 KILNER-GILLIES Hook, one prong,small curve, length 17 cm

505610 SENN-MÜLLER Retractor, double-ended,one side with 3 sharp prongs,other side with blunt blade, length 16 cm

516113 RYDER Needle Holder, tungsten carbide inserts,extra delicate, length 13 cm


Endoscopic Forehead Lift

50230 BWA HOPKINS® Wide Angle Forward-Oblique Telescope 30º,enlarged view, diameter 4 mm, length 18 cm, auto clavable, fi ber optic light transmission incorporated, color code: red

50230 BWA

50200 ES Optical Dissector, with distal spatula, fenestrated, large, sharp,for use with HOPKINS® telescopes 30°

50200 ES


58212 AA

58210 BA Raspatory, straight, width 6 mm,working length 15 cm

58210 CA Raspatory, straight, spatula 12 x 12 mm,working length 15 cm


58210 AGA Raspatory, curved, width 9 mm,working length 15 cm

58210 CGA Raspatory, curved, spatula 12 x 12 mm,working length 15 cm

58210 EGA Raspatory, curved, spatula slightly curved,width 8 mm, working length 15 cm

58210 GGA Raspatory, curved, arc-shaped spatula, width 9 mm, working length 15 cm

58210 CGA



50232 GG

50232 GG CLICKLINE Dissecting and Grasping Forceps,dismantling, non-rotating, with 4 locking positions, double action jaws, robust, curved sheath,size 3 mm, length 18 cm,

including: Metal Handle, insulated Outer Sheath, with forceps insert

50245 GW CLICKLINE Scissors,dismantling, non-rotating, with 4 locking positions, double action jaws, serrated, curved,horizontal opening, curved sheath,size 5 mm, length 18 cm,

including: Metal Handle, insulated Outer Sheath, with scissors insert

9

15

505610

505610 SENN-MÜLLER Retractor, double-ended,one side with 3 sharp prongs,other side with blunt blade, length 16 cm


Imaging Systems and Light Sources

20 2120 30

20 2120 30 TELECAM One-Chip Camera Head,color system PAL, soakable,gas-sterilizable, with integratedParfocal Zoom Lens, f = 25 – 50 mm (2x),2 freely programmable camera head buttons

20 1612 01 Cold Light Fountain LED NOVA 150,highperformance LED cold light fountainwith KARL STORZ light outlet,power supply 100 – 240 VAC, 50/60 Hz

including: Mains Cord

20 1612 01

495 NA Fiber Optic Light Cable,with straight connector, diameter 3.5 mm,length 230 cm

495 NA


TP100 DE TELE PACK X LED, endoscopic video unit for use with all KARL STORZTELECAM one-chip camera heads and video endoscopes, incl. LED light source similar to Xenon technology, with integrated digital Image Processing Module, 15" LCD monitor with LED backlight, USB/SD memorymodule, color systems PAL/NTSC,power supply 100 – 240 VAC, 50/60 Hz

including: USB Silicone Keyboard, with touchpad, with US character set USB Flash Drive, 8 GB Mains Cord

Imaging Systems and Light Sources

TP100 DE

Power input 100 W

Power supply 100 – 240 VAC

Dimensionsw x h x d 450 x 350 x 150

Weight 7 kg

Interfaces - Video interface:DVI-D (in/out)

- Audio: 3.5 mm jack(rear), Line-in, Line-out

- Footswitch port: 5-pinsocket for footswitch

- LEMO socket (side)- Printer port: USB

Light source - Lamp: LED- Color temperature:

6400 K- Average life span:

approx. 30,000 hours

Image format JPEG

Video codec MPEG-4

Video format PAL/NTSC

Storage interface USB 2.0; SD memory card(SDHC-compatible)

LED backlight monitor - Screen size: 15"- Resolution: 1024 x 768- Contrast: 700:1

Loudspeaker Power: 2 W

Specifi cations:


20 5322 01 AUTOCON® II 200 ,power supply 200 – 240 VAC, 50/60 Hzincluding:Mains Cord

20 5322 01 C AUTOCON® II 200,power supply 100 – 120 VAC, 50/60 Hzincluding:Mains Cord, US version

20 5322 01-010 AUTOCON® II 200, with GASTRO-Cut, power supply 200 – 240 VAC, 50/60 Hzincluding:Mains Cord

205322 01C010 AUTOCON® II 200, with GASTRO-Cut, power supply 100 – 120 VAC, 50/60 Hzincluding:Mains Cord, US version

nAUTOCON® II 200High Frequency Electrosurgical Unit,Recommended System Confi gurations

Specifications:

HF rated power

Max. voltage

Degree of coagulation

- Cutting Power-Cut (unipolar): 220 Watt/500 Ohm GASTRO-Cut (unipolar): 200 Watt/75 Ohm- Coagulation Standard-Coag (unipolar): 120 Watt/50 Ohm Forced-Coag (unipolar): 120 Watt/500 Ohm Standard-Coag (bipolar): 120 Watt/75 Ohm

- Cutting Power-Cut (unipolar): 740Vp GASTRO-Cut (unipolar): 550Vp- Coagulation Standard-Coag (unipolar): 190Vp Forced-Coag (unipolar): 1800Vp Standard-Coag (bipolar): 190Vp

Power-Cut: 8GASTRO-Cut: 4Standard-Coag: 8Forced-Coag: 4Bipolar Standard-Coag: 8

Autostart

Autostop

Safety systems

Power supply

Dimensions w x h x d

Weight

Certified to

Coagulationbipolar

Coagulationunipolar standard

- permanent power control- maldosage- neutral electrode safety system- automatic Self-Test

100 – 120 VAC or 200 – 240 VAC, 50/60 Hz

410 x 165 x 385 mm

10 kg

IEC 60601-1, CE acc. to MDD


nAUTOCON® II 200System Components

33321 MF

26 5200 46

26005 M

Connecting Cable

27806

Neutral Electrode

27805

26 5200 45

Handle

26 5200 43

Knife Electrode

26 5200 36

U N I T S I D E

P A T I E N T S I D E

CLICKLINE Grasping Forceps

Unipolar High Frequency CordHandle with Cord, unipolar

Knife Electrode

26 5200 36

Unipolar High Frequency CordBipolar High Frequency Cord

26176 LE

TAKE-APART® Bipolar Grasping Forceps

26180 HA

20 0178 32

Two-Pedal Footswitch

20 0178 30

One-Pedal Footswitch


Innovative Design � Dashboard: Complete overview with intuitive menu guidance

� Live menu: User-friendly and customizable � Intelligent icons: Graphic representation changes when settings of connected devices or the entire system are adjusted

� Automatic light source control � Side-by-side view: Parallel display of standard image and the Visualization mode

� Multiple source control: IMAGE1 S allows the simultaneous display, processing and documentation of image information fromtwo connected image sources, e.g., for hybrid operations

Dashboard Live menu

Side-by-side view: Parallel display of standard image and Visualization mode

Intelligent icons

Economical and future-proof � Modular concept for fl exible, rigid and3D endoscopy as well as new technologies

� Forward and backward compatibility with video endoscopes and FULL HD camera heads

� Sustainable investment � Compatible with all light sources

IMAGE1 S Camera System n


Brilliant Imaging � Clear and razor-sharp endoscopic images inFULL HD

� Natural color rendition

� Refl ection is minimized � Multiple IMAGE1 S technologies for homogeneous illumination, contrast enhancement and color shifting

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image

FULL HD image CLARA

SPECTRA B **

* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.



TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to 3 link modules, resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB and digital Image Processing Module, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz

including: Mains Cord, length 300 cm DVI-D Connecting Cable, length 300 cm SCB Connecting Cable, length 100 cm USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US

* Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications:

HD video outputs

Format signal outputs

LINK video inputs

USB interface SCB interface

- 2x DVI-D - 1x 3G-SDI

1920 x 1080p, 50/60 Hz

3x

4x USB, (2x front, 2x rear) 2x 6-pin mini-DIN

100 – 120 VAC/200 – 240 VAC

50/60 Hz

I, CF-Defib

305 x 54 x 320 mm

2.1 kg

Power supply

Power frequency

Protection class


Weight

TC 300 IMAGE1 S H3-LINK, link module, for use with IMAGE1 FULL HD three-chip camera heads, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz, for use with IMAGE1 S CONNECT TC 200ENincluding:Mains Cord, length 300 cm

Link Cable, length 20 cm

For use with IMAGE1 S IMAGE1 S CONNECT Module TC 200EN


TC 300 (H3-Link)

TH 100, TH 101, TH 102, TH 103, TH 104, TH 106 (fully compatible with IMAGE1 S) 22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3, 22 2200 54-3, 22 2200 85-3 (compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*)

1x

100 – 120 VAC/200 – 240 VAC

50/60 Hz

I, CF-Defib

305 x 54 x 320 mm

1.86 kg

Camera System

Supported camera heads/video endoscopes

LINK video outputs

Power supply

Power frequency

Protection class


Weight

Specifications:

TC 200EN

TC 300

* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.


For use with IMAGE1 S Camera SystemIMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300and with all IMAGE 1 HUB™ HD Camera Control Units

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head,50/60 Hz, IMAGE1 S compatible, progressive scan,soakable, gas- and plasma-sterilizable, with integratedParfocal Zoom Lens, focal length f = 15 – 31 mm (2x),2 freely programmable camera head buttons,for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

IMAGE1 FULL HD Camera Heads

Product no.

Image sensor


Weight

Optical interface

Min. sensitivity

Grip mechanism

Cable

Cable length

IMAGE1 S H3-Z

TH 100

3x 1/3" CCD chip

39 x 49 x 114 mm

270 g

integrated Parfocal Zoom Lens,f = 15 – 31 mm (2x)

F 1.4/1.17 Lux

standard eyepiece adaptor

non-detachable

300 cm

Specifications:

TH 104

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head,50/60 Hz, IMAGE1 S compatible, autoclavable, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal lengthf = 15 – 31 mm (2x), 2 freely programmable camera headbuttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

IMAGE1 FULL HD Camera Heads

Product no.

Image sensor


Weight

Optical interface

Min. sensitivity

Grip mechanism

Cable

Cable length

IMAGE1 S H3-ZA

TH 104

3x 1/3" CCD chip

39 x 49 x 100 mm

299 g

integrated Parfocal Zoom Lens,f = 15 – 31 mm (2x)

F 1.4/1.17 Lux

standard eyepiece adaptor

non-detachable

300 cm

Specifications:

IMAGE1 S Camera Heads n

TH 100


9826 NB

9826 NB 26" FULL HD Monitor,wall-mounted with VESA 100 adaption,color systems PAL/NTSC,max. screen resolution 1920 x 1080,image format 16:9, power supply 100 – 240 VAC, 50/60 Hzincluding:External 24 VDC Power SupplyMains Cord

9619 NB

9619 NB 19" HD Monitor,color systems PAL/NTSC, max. screen resolution 1280 x 1024, image format 4:3, power supply 100 – 240 VAC, 50/60 Hz,wall-mounted with VESA 100 adaption,including:

External 24 VDC Power SupplyMains Cord

Monitors


Monitors

Optional accessories:9826 SF Pedestal, for monitor 9826 NB9626 SF Pedestal, for monitor 9619 NB

26"

9826 NB

–

–

–

19"

9619 NB

–

–

–

KARL STORZ HD and FULL HD Monitors

Wall-mounted with VESA 100 adaption

Inputs:

DVI-D

Fibre Optic

3G-SDI

RGBS (VGA)

S-Video

Composite/FBAS

Outputs:

DVI-D

S-Video

Composite/FBAS

RGBS (VGA)

3G-SDI

Signal Format Display:

4:3

5:4

16:9

Picture-in-Picture

PAL/NTSC compatible

19"

optional

9619 NB

200 cd/m2 (type)

178° vertical

0.29 mm

5 ms

700:1

100 mm VESA

7.6 kg

28 W

0 – 40°C

-20 – 60°C

max. 85%

469.5 x 416 x 75.5 mm

100 – 240 VAC

EN 60601-1, protection class IPX0

Specifications:

KARL STORZ HD and FULL HD Monitors

Desktop with pedestal

Product no.

Brightness

Max. viewing angle

Pixel distance

Reaction time

Contrast ratio

Mount

Weight

Rated power

Operating conditions

Storage

Rel. humidity


Power supply

Certified to

26"

optional

9826 NB

500 cd/m2 (type)

178° vertical

0.3 mm

8 ms

1400:1

100 mm VESA

7.7 kg

72 W

5 – 35°C

-20 – 60°C

max. 85%

643 x 396 x 87 mm

100 – 240 VAC

EN 60601-1, UL 60601-1, MDD93/42/EEC, protection class IPX2


UG 540 Monitor Swifel Arm, height and side adjustable,can be turned to the left or the right side,swivel range 180°, overhang 780 mm,overhang from centre 1170 mm,load capacity max. 15 kg, with monitor fi xation VESA 5/100,for usage with equipment carts UG xxx

Equipment Cart

UG 220

UG 220 Equipment Cart wide, high, rides on 4 antistatic dual wheelsequipped with locking brakes 3 shelves, mains switch on top cover, central beam with integrated electrical subdistribu-tors with 12 sockets, holder for power supplies, potential earth connectors and cable windingon the outside,

Dimensions:Equipment cart: 830 x 1474 x 730 mm (w x h x d), shelf: 630 x 510 mm (w x d),caster diameter: 150 mm

including: Base module equipment cart, wide Cover equipment, equipment cart wide Beam package equipment, equipment cart high 3x Shelf, wide Drawer unit with lock, wide 2x Equipment rail, long Camera holder


Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer,200 V – 240 V; 2000 VA with 3 special mains socket, expulsion fuses, 3 grounding plugs, dimensions: 330 x 90 x 495 mm (w x h x d),for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor,200 V – 240 V, for mounting at equipment cart, control panel dimensions: 44 x 80 x 29 mm (w x h x d),for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm, height adjustable, inclinable,mountable on left or right,turning radius approx. 320°, overhang 530 mm,load capacity max. 15 kg, monitor fixation VESA 75/100,for usage with equipment carts UG xxx

UG 510

with the compliments of

KARL STORZ — ENDOSKOPE

Documents

PERIORBITAL SURGERY AND ENDOSCOPIC FOREHEAD … · Upper Eyelid Blepharoplasty 9 Step 2 Marking the Incisions After Analyzing the Skin Excess Intraoperative Assessment of Skin Excess