Chemical and Laser Resurfacing of the Eyelids and Face

Chemical peels, mechanical abrasion, and more recently laser and electrosurgical devices are used to resurface eyelid and facial skin. The common feature in these techniques is the denaturation or removal of the skin surface. These techniques typically help to hide skin changes related to sun exposure and aging by evening the skin tone, decreasing dyschromia, and diminishing wrinkles. These techniques all require careful case selection and patient preparation with appropriate treatment and postoperative care. Recent interest has focused on less invasive therapy with techniques that leave the epithelium largely intact, shortening healing time and reducing the risk of complications. Aging and sun damage induce a number of changes in skin, including wrinkling, the development of muscle- or gravity-related folds, irregular pigment or dyschromia, and the growth of benign and malignant skin lesions. Scars from acne, trauma, or surgery can also be indications for skin resurfacing. Potential benefit in all of these techniques must be balanced against risks and expected healing time. A medical history must be obtained, looking for a history of immune dysfunction, prior acne, or a history of herpes simplex outbreaks. Prior treatment with radiation or isotretinoin (Accutane) may diminish the pilosebaceous units required for healing. Acne rosacea and cutaneous telangiectasia may be aggravated by skin resurfacing. Cutaneous history must focus on scarring tendencies such as keloid formation, skin type, and ancestry. In particular, one must determine the patient’s skin type, most commonly by assigning a Fitzpatrick’s skin type. Patients with skin type III require careful topical preparation for skin resurfacing treatment in most cases, and patients with skin type IV or higher are more prone to scarring and pigment issues and are not treated with medium depth to deep skin resurfacing techniques by most clinicians. Wrinkles may be graded by the Glogau classification scheme. This scale from “fine wrinkles” (type 1) to “only wrinkles” (type IV) will help to define the amount and type of treatment needed. These loose recommendations will generally hold true in determining effective therapy. The deeper and more invasive the treatment, the more important the role of skin preparation and prophylaxis.

Lower Eyelid and Midfacial Rejuvenation

Over the past two and a half decades, techniques for midfacial rejuvenation have evolved. Midfacial rejuvenation has gained significant popularity among many aesthetic surgeons, including the ophthalmic plastic surgeon. Yet rejuvenation of the midface remains a challenge for the aesthetic surgeon who seeks facial harmony. A variety of techniques and approaches are available, yet no single approach is ideal for all patients. It is clear that the age-related anatomic alterations that cause patients to seek rejuvenation vary from patient to patient, and that many patients have more than one anatomic alteration that must be addressed to rejuvenate the lower lid. The surgeon must address the individual needs of each patient for optimal results. It has also become clear that the lower eyelid and midface form a continuum that needs to be addressed in its entirety for optimal rejuvenation. To achieve this, the surgeon must understand the basic concepts important to lower eyelid and midface rejuvenation, which include an understanding of eyelid and midfacial anatomy, an understanding of aging changes of the lower eyelid and midface, and surgical approaches and nonincisional options. A full understanding of aging changes in the lower eyelid and midface is essential to successfully address midfacial rejuvenation. A harmonious facial appearance consists of a balanced relationship among all tissues of the face. With age, disturbance of this harmony among midfacial tissues occurs. The aging process of the midface encompasses the lower eyelid, malar fat pad and associated structures, melolabial fold, and lateral perioral region. Hester describes four important features of midfacial aging: (1) baring of the inferior orbital rim with creation of a hollow valley at the junction of the lower eyelid and cheek; (2) descent of the malar fat pad, with loss of malar prominence; (3) deepening of the tear trough; and (4) exaggeration of the nasolabial fold. The midface represents a crucial aesthetic unit of the face. It is bordered by structures that play major roles in the overall appearances of the face. The lower eyelid and tear trough toward the nose and the lateral canthus and crow’s feet at the superior lateral aspect frame the midface superiorly.

Upper Eyelid Blepharoplasty

The purpose of this chapter on blepharoplasty is to familiarize the reader with relevant eyelid anatomy, appropriate preoperative evaluation, and the surgical fundamentals of upper eyelid blepharoplasty. In addition, modern modifications of blepharoplasty will be presented, with special attention to aesthetic blepharoplasty and surgical considerations in the Asian eyelid. Blepharoplasty defines a group of surgical procedures by which excess skin, orbicularis muscle, and orbital fat are removed from the upper eyelids. The ideal goal of blepharoplasty is to rejuvenate the eyelid and restore a youthful eyelid position without compromising eyelid function. A postoperative taut upper eyelid resulting in lagophthalmos and ocular surface compromise equates to an unsatisfied patient and surgeon. Likewise, excessive orbital fat excision can create a sunken superior sulcus and an eyelid contour with an undesirable cosmetic appearance. Similar to many other oculoplastic procedures, many variations in surgical technique in blepharoplasty have been employed over the years. Despite the differences, all these modifications rely upon the same underlying fundamental principles. Key steps in successful blepharoplasty surgery occur before the first skin incision is made. The eyelids are not islands unto themselves; rather, they are intimately connected to other facial structures, most notably the brow and forehead for upper lid blepharoplasty and the midface complex for lower lid blepharoplasty. Failure to preoperatively address pertinent nearby structures can yield unwanted postsurgical results. In addition to the assessment of facial structure, a preoperative blepharoplasty evaluation should include a proper medical and ocular history. Patients with a bleeding diathesis or a history of anticoagulation should be counseled and anticoagulation medications withheld if medically appropriate. A history of ocular surface issues or previous anterior segment surgery should be investigated and a slit-lamp examination performed to assess for dryness and corneal pathology. Conditions that can affect eyelid position, such as myasthenia gravis and thyroid-related orbitopathy, should be stable for a minimum of 6 months prior to blepharoplasty. Assessing brow position and function is essential when considering a patient for upper eyelid blepharoplasty. Normal brow position in males is along the superior orbital rim, and in females normal brow position is about 1 cm superior to the orbital rim.

Management of Orbital Cellulitis

Orbital cellulitis is an acute infectious inflammation of the post-septal orbital tissues. This chapter outlines the medical and surgical management of bacterial orbital cellulitis. The paranasal sinus complex is the most common source of orbital bacterial infection. Over 50% of orbital cellulitis cases result from secondary extension from the paranasal sinuses. Other causes of orbital cellulitis include spread from ocular and periocular infections such as dacryoadenitis, dacryocystitis, and panophthalmitis; trauma, insect bites, or surgery; or endogenous sources in immunocompromised or septic patients. Orbital cellulitis resulting from sinusitis is believed to start with viral or allergic inflammation of the upper respiratory system. The inflammation decreases mucociliary clearance and causes obstruction of the sinus ostia. The sinus mucosa absorbs air, thereby creating negative pressure within the sinuses. Transudation occurs, creating a nutrient medium for bacteria. Aerobic and facultative organisms proliferate, and inflammatory products accumulate resulting in decreasing oxygen tension and pH. As inflammatory products are produced, sinus pressure increases, causing mucosal blood flow to decrease. A proliferation of obligate anaerobes occurs as aerobic bacteria consume the remaining oxygen. Young children are less likely to develop anaerobic conditions within their sinuses because their ratio of ostia size to sinus volume is much larger than that of adults. The sinus cavities enlarge markedly with age while the ostia remain approximately the same size. Thus, as children become adults, the decreased ratio of ostia size to total sinus volume increases the propensity for anaerobic sinus infections. The bony walls shared by the orbit and sinuses account for approximately half of the orbital surface area. Bacteria and inflammatory products from the sinuses may extend directly into the orbit through the neurovascular foramina, congenital bony dehiscences, anastomosing valveless venous channels, or compromised bony walls in cases of osteitis and necrosis secondary to sinusitis. An abscess may form in the subperiosteal area, a relatively avascular potential space. Subperiosteal abscesses most often involve the medial orbital wall, as it is the thinnest wall and is adjacent to the ethmoid sinuses.

Fractures Involving the Orbit

Orbital and periorbital injury can occur with localized trauma to the eye or in the setting of multiple trauma associated with injury to other vital organs. A reported 16% of major trauma patients have ocular or orbital injury, and 55% of patients with facial injury have associated ocular or orbital injury. In general, the amount of ocular, soft tissue, and bony damage is related to the amount, duration, and direction of force applied to the orbit and face. Nevertheless, orbital injury is common and can be a subtle finding in the context of other facial or life-threatening injuries. Geometrically, the bony orbit most closely resembles a four-sided pyramid consisting of an apex, a base, and four sides: roof, floor, medial wall, and lateral wall. The absence of the orbital floor posteriorly and the inclination of the lateral wall toward the medial wall changes the geometric shape from a four-sided pyramid to a three-sided pyramid at the orbital apex. The bony margin circumscribes the orbital entrance and provides anterior support for the thin bones of the interior walls of the orbit. Rounding of the orbital walls blends demarcation of the superior, medial, inferior, and lateral walls. The entrance measures 40 mm horizontally and 32 mm vertically. The widest portion of the orbital margin lies about 1 cm behind the anterior orbital rim. In adults, the depth from orbital rim to apex varies from 40 to 45 mm. Safe subperiosteal dissection may be accomplished along the lateral wall and orbital floor for 22 mm and along the medial wall and orbital roof for 30 mm. The volume of the orbit is approximately 30 cc. The triangular floor of the orbit serves as the roof of the maxillary sinus. Several areas of thin bone create weak points in the orbital floor that are susceptible to fracture. The thinnest portion is medial to the infraorbital groove and canal, particularly posteriorly, where the medial wall has no bony support. In the posterior aspect of the floor, the infraorbital fissure extends as the infraorbital canal.

Management of Ectropion and Floppy Eyelids

Ectropion is defined as an eversion of the upper or lower eyelid away from the globe. Classes of ectropion include involutional, cicatricial, paralytic, and mechanical. Ectropic eyelids develop from horizontal eyelid laxity, medial canthal tendon laxity, vertical skin tightness, neuromuscular dysfunction, and lower eyelid retractor disinsertion. Ocular complications associated with ectropic eyelids include corneal exposure and scarring, conjunctivitis, ocular discomfort, photophobia, epiphora, and decreased vision. The entire face and eye should be carefully examined when a patient presents with ectropion. A systemic approach enables the physician to more fully understand the underlying disease process and best therapeutic approach. Ectropion can be quantified by pulling the central portion of the lid anteriorly and measuring the number of millimeters from the anterior cornea to the apex of the eyelid. Ectropion etiology can be elucidated by evaluating for horizontal eyelid laxity, orbicularis dysfunction, vertical skin tightness, and lower eyelid retractors disinsertion. Horizontal eyelid laxity is typically a result of lateral or medial canthal tendon stretching. Laxity of the canthal tendons produces a redundancy in the eyelid tissues, resulting in ectropion, often referred to as an involutional ectropion. Lateral canthal tendon status can be determined by gently pulling the eyelid nasally. The inferior crus of the tendon can then be palpated to evaluate for dehiscence. The medial canthal tendon can be evaluated by pulling laterally and noting the displacement of the inferior punctum. The severity of canthal tendon laxity should be quantified prior to any surgical intervention. 8-2-1 Lateral Canthal Tendon Laxity and the Lateral Tarsal Strip Procedure. Although a variety of methods have been advocated for treatment of lateral canthal tendon laxity, we prefer the lateral tarsal strip, introduced by Anderson. This procedure corrects the underlying anatomic abnormality, does not require reapproximation of the eyelid margin, and is relatively easy to perform. The lateral canthal region is injected with lidocaine 2% mixed with 1:100,000 epinephrine using a 27- or 30-gauge needle. After ensuring appropriate anesthesia, Stevens scissors are used to create a lateral canthotomy and exposure of the lateral orbital rim.

Management of Entropion and Trichiasis

Entropion is a posterior rotation of the upper or lower lid margin against the globe; the causes include involutional changes within the eyelid tissues or cicatricial shortening of the posterior lamella of the eyelid. Congenital lower lid entropion is rare and results from an excess of skin and orbicularis oculi muscle being only loosely attached to the eyelid retractors. The symptoms of entropion—which include ocular irritation, lid spasm, pain, redness, and watering—are worse in the presence of a keratinized lid margin (occurring in cicatricial disease) and where the ocular surface is compromised. Discomfort may lead to secondary blepharospasm, which exacerbates the entropion by causing the preseptal part of the orbicularis muscle to override the pretarsal component. The eyelids and globe should be examined to identify underlying causative factors—in particular the degree and position of tissue laxity, the position of the eyelid margin and lashes, and the thickness of the tarsus. Any secondary effects of entropion, both within the lid and on the ocular surface, should also be noted. 7-1-1 Tissue Laxity. Aging of collagen and the force of gravity leads to eyelid laxity and an excess of tissues, particularly the anterior lamella of the lid. Stretching of the orbicularis muscle and canthal tendons results in horizontal laxity, and eyelid stability is further compromised by enophthalmos due to age-related fat atrophy. Where there is a relative dissociation between the anterior and posterior lamellae, the preseptal orbicularis muscle overrides the pretarsal muscle, leading to eyelid inversion, and this effect is exacerbated both by laxity of the lower lid retractors and age-related tarsal atrophy. Tissue laxity in the absence of orbicularis overriding tends to cause ectropion; with complete loss of retractor action, this can result in complete eversion of the tarsus (“shelf ectropion”). Horizontal laxity of the eyelid tissues is assessed by grasping the lid skin and applying gentle traction in the appropriate direction. The overall horizontal laxity is judged by the extent to which the eyelid can be parted from the globe—greater than about 6 mm is abnormal for a lower eyelid—and by the speed with which the retracted lid returns to the surface of the globe (the “spring-back” test).

Botulinum Toxin Injections for Facial Rhytides

Once feared for its deadly properties, Botulinum toxin is now revered for its effectiveness as a treatment in minimally invasive facial rejuvenation. The injection of Botulinum toxin is the most frequently performed nonsurgical cosmetic procedure, with at least 4.8 million procedures in 2009. First approved by the U.S. Food and Drug Administration (FDA) in 1979 for the treatment of strabismus, Botulinum toxin was shown to be both safe and effective for use to decrease muscle function. Botulinum toxin’s cosmetic applications were first recognized when it was noted that facial rhytides improved in the areas of treatment with the toxin when it was used for noncosmetic applications in the late 1980s and early 1990s. FDA approval for cosmetic treatment of the glabellar furrows was announced in 2002, and off-label aesthetic indications have continued to evolve. Botulinum toxin is produced by the gram-positive, anaerobic Clostridium botulinum. The neurotoxin acts on the peripheral nervous system, where it inhibits release of acetylcholine from the presynaptic terminal at the neuromuscular junction. There are seven distinct antigenic Botulinum toxins (BTX-A, B, C, D, E, F, and G) produced by different strains of C. botulinum. The human nervous system is susceptible to only five of these serotypes (BTX-A, B, E, F, G), and types A and B are currently available for human injection. In the United States, there are four commercially available Botulinum toxin preparations: three types of Botulinum toxin type A, OnabotulinumtoxinA or Botox Cosmetic® (Allergan, Inc., Irvine, CA), IncobotulinumtoxinA or Xeomin (Merz, Frankfort Germany), and abobotulinumtoxinA or Dysport (Medicis, Scottsdale, AZ). There is one preparation of Botulinum toxin type B, RimabotulinumtoxinB or Myobloc® (Elan Pharmaceuticals, San Diego, CA). Other Botulinum toxin type A products are anticipated to come to the U.S. market in the next decade as well. Different formulations of Botulinum toxin type A are biochemically unique and are not necessarily equivalent in dosing. The Botox unit is three times as potent as the Dysport unit, but this conversion ratio does not take into consideration safety or antigenic potential. Practically speaking, a range of 2.5 to 3 to one has been recommended to make Dysport dosing approximate the effects of Botox.

Rejuvenation of the Forehead and Eyebrows

The eyes and upper face impart more emotion than any other part of the human body and can communicate temperament through a variety of complex movements and expressions. The influence of the eyebrow on facial anatomy is subtle but critical in establishing mood as determined by facial expression. Upward-slanting eyebrows suggest surprise or sadness, downward-slanting eyebrows denote anger, flat eyebrows hanging over the eyes suggest fatigue, and eyebrows with a proper arch suggest happiness. Concepts of facial beauty continue to evolve over time, yet certain aesthetic principles invariably define the youthful brow and upper face. The head of the brow should begin at a point directly above the alae of the nose, and the tail of the brow should end on a line drawn from the alae of the nose through the lateral canthus. Classical aesthetic principles held that women have eyebrows with a high, graceful arch, accompanied by a deep superior sulcus and well-defined lid crease. The head of the brow began 1 to 2 mm above the supraorbital rim and the lateral third was elevated up to 1 cm above the rim, with the high point of the arch directly above the lateral aspect of the limbus. Current fashion seems to prefer flatter brows with a subtle upward slanting of the brow tail, rather than a high, accentuated arch. The tail of the brow thins as it elevates laterally. Fullness of the brow tissue and a less shallow superior sulcus has also become en vogue, reflecting the overall trend toward facial fullness as a sign of youthfulness. Men tend to have a straighter brow that lies at or slightly above the orbital rim, with a shallow superior sulcus and a more subtle lid crease. As the face ages, thinning skin and tissue laxity diminish the youthful appearance of the brow and upper eyelid. The eyebrows become ptotic, resulting in vertical redundancy of the upper lid skin. The drooping brow and inelastic skin combine to cause upper eyelid tissue to drape over the lid margin, often obstructing the superior visual field.

Surgical Exploration of the Orbit

The orbit comprises the globe and optic nerve surrounded by a complex tangle of muscles, nerves, and vessels, all cushioned in pockets of fat. While surgery in the anterior orbit is readily performed, the challenge increases significantly for deeper orbital pathology because the bony walls on four sides and the eyeball and lid structures anteriorly limit both access and visibility. The apex is a particularly difficult area because so many vital structures converge in its narrow confines. The history and physical examination help narrow the differential diagnosis so that appropriate imaging and special investigations may be arranged. The urgency of these diagnostic tests to allow appropriate medical or surgical intervention is partly determined by the speed of symptom onset and by the presence of significant pain or progressive functional impairment such as vision loss or diplopia. Computed tomography (CT) scans are usually readily available and help define the tissue characteristics and location of an orbital lesion. Reformatting allows coronal, sagittal, and 3-D views without repositioning the patient, although a true coronal CT scan may be requested if a distensible varix is suspected. Contrast CT scans may be useful for assessing the vascularity of the lesion but require an evaluation of renal function. Magnetic resonance (MR) scans may characterize certain soft tissue features better, identifying fluid levels and determining whether a lesion involves normal anatomic structures such as the optic nerve, muscle, or lacrimal gland. They are particularly useful in evaluating lesions of the optic nerve and chiasm. Ultrasounds may help to define certain superficial orbital lesions (distinguishing a lymphoma from a pleomorphic adenoma in the lacrimal gland, for example) and are very useful in assessing intraocular pathology. Positron emission tomography (PET) scans may help determine the presence of recurrent malignancy or lymphoma in a previously operated or treated site and whole body evaluation may be helpful for staging lymphomas. A trained neuroradiologist can help interpret a complex image. In general, well-circumscribed, accessible lesions are excised in toto. Poorly defined, infiltrative lesions and those causing tissue destruction (suggestive of malignancy or aggressive inflammation) usually are biopsied, either by needle or with surgery.