Oculoplastic surgery largely consists of traditional approaches to many of the encountered diseases. Our specialty has well-established methods for most surgeries and we use our good old fashioned surgical instruments, but advances are continuously being made to improve patient outcomes while at the same time abiding by sound surgical and medical principles according to anatomy. These advances are made in both surgical and non-surgical approaches to functional and aesthetic oculoplastic surgery. This article discusses some of these trends as they relate to surgery.
Brow Lift Surgery
Various approaches to brow lifting surgery have existed for years and most surgeons follow some version of these techniques. Options include a direct brow lift with incisions just above the brow hairs, a pretrichial brow lift with the incision just anterior to the hairline, a coronal brow lift with an ear-to-ear incision behind the hairline, and an endoscopic brow lift with small incisions hidden behind the hairline.
New techniques related to these established surgeries have been published. For instance, the minimal incisions vertical endoscopic lifting (MIVEL) combined with fat grafting to optimize rejuvenation of the periocular aesthetic unit as described by Bernardini, Gennai, Izzo and Devoto in JAMA Facial Plastic Surgery.
In this technique, a Gennai stitch is used by making stab incisions in the forehead just below the paramedian incisions. A Reverdin needle is passed from the forehead incision under the scalp to exit at the paramedian incision. The needle is loaded with the suture and brought back out of the forehead incision. The tip of the Reverdin needle is then passed beneath the skin from the forehead incision back out through the paramedian incision. The suture lassos the deep tissues and repositions them to a more posterior location.
Another novel technique was described recently by JD Perry in Ophthalmic Plastic & Reconstructive Surgery. His technique uses a small-incision frontalis muscle transposition flap for lateral eyebrow ptosis repair. A 1.5cm incision is made in a lateral forehead rhytid. Dissection is carried down to expose the frontalis-orbicularis angle, the frontalis-orbicularis insertion and the lateral extent of the frontalis muscle. A pedicle of frontalis muscle is then created and transposed laterally to lift the brow.
Blepharoplasty
Blepharoplasty surgery has remained fairly traditional, especially upper eyelid blepharoplasty. That being said, supplemental surgeries have been written about.
Recently, Kotlus, Schwarcz and Nakra published in Ophthalmic Plastic & Reconstructive Surgery on their experience using a CO₂ laser applied to the sub-brow skin, the upper medial canthal skin and the pretarsal skin in 30 patients in conjunction with incisional upper blepharoplasty. All of their patients demonstrated a reduction in rhytidosis with a mean improvement of 42 percent. Only one patient experienced wound dehiscence. The authors conclude that the results reduce the need for medial incisions to address medial canthal, upper eyelid/infra-brow skin redundancy and rhytides of the medial canthus and upper eyelid.
Many over the years have developed nuances to lower eyelid blepharoplasty, especially techniques to redrape the fat, add fat or shape the tear trough area. Asian blepharoplasty approaches are constantly being updated. One of the latest descriptions was published by Zhao et. al in Aesthetic Plastic Surgery. The group described a modified method combining Z-epicanthoplasty and blepharoplasty to develop out-fold type double eyelids. The upper eyelid blepharoplasty incision is extended toward the crossing point of the epicanthal vertical axis and the lower eyelid skin. An additional line is drawn from the upper skin incision to the new intended point of the medial canthus. Two flaps are made and transposed to reform the medial canthus, obliterating the epicanthal fold and exposing the caruncle.
Lateral Canthoplasty
Often our patients have eyelid laxity and it is extremely important to identify this anomaly prior to eyelid surgery so that the lateral canthus can be supported during the procedure. Traditional management of eyelid laxity includes the lateral tarsal strip, which is an effective way to horizontally tighten the lid via a lateral canthotomy and inferior cantholysis.
For less aggressive lid laxity, a lateral canthopexy can be performed, avoiding a canthotomy/cantholysis and just involving a small incision through the skin lateral to the canthus with plication of the tendon to the lateral orbital rim.
Other novel techniques have been described to address lid laxity and lateral canthal tendon dehiscence. Dan Georgescu wrote in Current Opinion in Ophthalmology about surgical preferences for lateral canthoplasty and canthopexy, including an inferior retinacular lateral canthoplasty in which a skin-muscle flap is raised at the lateral canthus through an upper lid blepharoplasty incision. The inferior crus of the lateral canthal tendon is dissinserted and the tendon is reanchored in a more superior position at the lateral orbital rim. The inferior retinacular suspension is performed by passing a double-armed suture through a small lower eyelid incision, looping it around the lateral canthal tendon, and attaching it at a more superior location on the lateral orbital rim through an upper lid blepharoplasty incision.
The lateral canthal resuspension sine canthotomy technique was described by Georgescu and colleagues in Ophthalmic Plastic & Reconstructive Surgery. This canthopexy technique is performed through an upper eyelid incision. Dissection is carried out toward the lateral orbital rim around the lateral canthal tendon. A 4-0 PDS suture on a P-3 needle is passed through the upper eyelid incision beneath the orbicularis muscle but anterior to the lateral canthal tendon and externalized at the apex of the lateral canthal angle at the mucocutaneous junction. The suture is then passed back through the same hole in the angle but passed deep and inferior to the tendon and then externalized through the blepharoplasty incision. The suture is then passed through the periosteum just superior to Whitnall’s tubercle.
Next month’s article will continue the discussion on oculoplastic trends as they relate to surgery, as many of the commonly performed surgeries are constantly undergoing revisions.