Las Vegas -- An algorithmic approach to treatment that takes into account anatomic, functional and aesthetic deficits is helpful for optimizing outcomes in patients seeking surgery because of herniated lower eyelid fat pads, said Oscar M. Ramirez, M.D., at the Facial Aesthetic Surgery 2004 meeting, here.
"Given the complexity of the lower eyelid, lower lid blepharoplasty should not be approached in a simple or cookbook fashion," he says. "Successful results are best achieved using an individualized approach that is based on the unique characteristics of each case and appreciation for the features that define a beautiful lid. Those include absence of scleral show, a lateral canthus that is higher than the medial canthus, absence of ciliary tilt, tarsal fullness and a slight infratarsal depression to afford a nice blending between the lower lid and cheek."
Dr. Ramirez is clinical assistant professor of plastic surgery, Johns Hopkins University, Baltimore, and a private practitioner at Esthetique Internationale in Timonium, Md.
Based on variables
The treatment algorithm for patients undergoing surgery for a herniated lower eyelid fat pad is based on the following variables: orbital rim position (the vector), tear trough ("V") deformity, the size of the eye (small, normal, large), and severity of both skin wrinkling/excess and tarsal laxity.
Tarsal laxity is assessed using three tests--the snap test, the distraction test and vertical canthal displacement. A total score [less than or equal to] 10 is considered normal, and in that situation, no additional intervention or only a preventive orbicular suspension is indicated for suspending the lower lid. A score of 11 to 20 represents moderate laxity, which is addressed with plication canthopexy and orbicularis suspension. Patients whose score is [greater than or equal to] 21 are considered to have severe laxity that requires canthoplasty with shortening plus orbicularis suspension. Dr. Ramirez says the orbicular suspension (plication) is done without cutting the orbicularis oculi muscle.
For addressing wrinkles, a trichloroacetic acid peel is the preferred treatment if the wrinkles are minimal. Moderate wrinkling is addressed with laser resurfacing as the first choice, although skin excision can also be performed. Skin excision is the treatment of choice, followed by laser resurfacing to improve the appearance of severe wrinkling.
Dr. Ramirez notes that the portion of the algorithm that determines treatment based on the vector is more complex, as it takes into account the absence or presence of a tear trough deformity and size of the eye. If the vector is positive and there is no tear trough deformity, the treatment is determined according to eye size. For individuals with small eyes, the fat pads are repositioned inside the orbit. However, if the eyes are normal or large, the fat can be safely removed, and Dr. Ramirez's preferred approach for achieving that is through a transconjunctival incision.
If the patient has a positive vector but a tear trough deformity is present, the fat is maintained within the orbit in patients with small eyes, and the tear trough deformity is treated with fat grafting or a vertical suborbicularis oculi fat (SOOF) lift. When there is a positive vector, tear trough deformity and the eyes are normal or large, the fat pad is slid to improve the tear trough, and then the patient may or may not need a SOOF lift.
Patients with a negative vector--i.e., location of the orbital rim >3 mm behind the corneal plane--are offered an orbital rim implant to convert the vector to positive. If the patient declines the implantation procedure, then canthoplasty is performed. In either case, additional treatment is determined, as described above, according to the absence or presence of a tear trough deformity and size of the eyes.
Orbicularis oculi intact
Dr. Ramirez points out that, in contrast to a traditional blepharoplasty technique, his treatment approach avoids cutting the orbicularis oculi muscle in order to avoid denervation of the lower eyelid and associated complications.
"Although it is controversial among surgeons, I have shown through a number of published studies and presentations that transsection of the muscle denervates the pretarsal portion of the lower orbicularis," he says. "Therefore, I camouflage any tear trough deformity with a vertical SOOF lift and treat the lower eyelid itself with removal of skin and orbicularis suspension/plication only. In avoiding muscle excision, I have been successful in nearly eliminating all of the complications that are often associated with lower eyelid blepharoplasty, including scleral show, ectropion and even corneal damage that can lead to blindness."
Similarly, when performing a facelift for patients who want full-face rejuvenation in addition to treatment for bulging lower eyelids, his technique is also designed to avoid denervation of the lower eyelid. The facelift is divided into two components--the central oval of the face is approached in the subperiosteal plane, while lifting of the lower face and neck is achieved working in the subcutaneous layer.
"The mimetic muscles of the face and the facial nerves lie in the intermediate layer, and facelifts done in that tissue plane also carry a risk for denervation of the lower eyelid and other muscles of the face," Dr. Ramirez says.
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