124

Hair follicles nrc found itra whkh of the foiJm\~ng l:tyers oftl Stalp?
(A)
(B)
(C)
(D)

Epidcnnis
Pnpilbty dermis
Reticular dennis
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. lt 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.

2.

Uebel CO. Micro~fb Olnd mini~rafu: a ne\v appi'Mich for b:JldnC$$ surgery. Ann Plast Srug. 199 t :27:1~6.
Votlli.s Cr. ll"!rrcplntccn.en smgery. Jn: M.:CamthyJG,e-d. Pia ll.cStl~rJ'. Philaddphht!, P<~: WBS:~undc:rsCo; l990;l:E5'1-' 1337.
OvL. ........ t-"P~
with IB-MEA & o

'OJ

~e
r l p ds

..;

at the surfo

Cross secton
f
a

matrix

KE RATIN

f i larn

nt

lnterrneda e

FaloMent protein

Hair Growth
~-b;~-- Pore

Epidermis [
Sebaceous
gland
Bulge region
Dermis

Outer root
sheath

...fa9.1r>~r-- Basement
rJ~~~~~r
membrane
~.JA--H-- Sebaceous

gland
l~rlf--++--*1-- Keratinized

Dermis
Hair - - - 1 --r--HII'I'\
follicle

cells
.N:i'>;,.--Eccri ne
sweat gland

~~~....,.Jtr-!J-- Hair

papilla

~===-~~~-Dermal blood
..,.;
vessels

Inner root
sheath
Hair fiber

Subcutaneous [

tat

Dermal
papilla

Hoir Growth Cycle

Anaoen

Telooen

Return to Anaoen

HalrMtn
fotmtng new hair

ACTIVE
GROWTH PHASE

2-6 Yart

TRANSITION
PHASE
1 2 Weeks

Anagon
2-6 years

RESTING
PHASE

S-4 W.ks

EAR Y

AAJIJ"

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

tive
Regressive = TRANSITION

Catagen
2- Jweeks

S k i n - - - - - - -.... ~~~~~~~~~
Connective tissue---. ~~~
r;JitJa~=?AC~~
Aponeurosis~

Loose areo~l~~~
tissue

I \
I

Fog 7 18 Granls Alias of A natomy 12th Ed LW&W 2009

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<lm1!Nthia, "hich is defined os ~lerior di5j>IOmcnl of UIC chin with normal mandibular dimensions, is best used
10 dc<mbe the findings seen in this patient with Pierre Rob~ scquc:nce. Other terms such 3S bracnnnathia,
microgn.1thoo. congenitll mandibular o!rdio. mandibular h)-poplasm. ond tn:lndibular hypotrophy 113,.., beet used in the
description of this condition. ~~owcvcr, bccnu~c all ~fth.csc terms _denote a~nonn~litics i~ mandibu.lar ili'OWth,thcy
arc frequently usc.J incorrectly: mstcad. nom~nl mandobulnr growth os n clnsstc find on& of l'oerrc Rob on sequence. In
oddition.lloc wrgcon should be aware tlut diC growth potential in patieniJ with I'Clrognnthia and posto:riordispl~mcnt
of the chon on external m3IIipulalion is excellent Pie-m: Robin sequence is also cbar.~ctcrizcd by respiratory
obstruction and glossoptosis.
Mia~oa IS defined as X>oonnaJ dc\1:lopmcn1 on lliC region of the mentll symphysis. Hov.'e\-er, this tmn can be
do fTerenti.red from lflicrosnathia bcc3use all of the m;mdibular cornponcniJ do nOIIu\'C to be invoh'Cd: insteac~.aome

patients luve an isolated small chin deformity with norm.allysizcd jaw componenl5. Microgenia can also occur in
conjunction ,.;th mandibular hypoplasiA or mandibular prognathism.
Rqtmotrs

I.
l.

McCnnhy JO. K:~wamoto fl. Gnyson 811. 1:1 tl. Sura~:ry urthe jaws. In: McCauthy JO, t'tl. PltJStic Swg~I'J'. Phil~del11hl11,
Slllllld C... t990:2 IIU- 1474.
McCtlfhyiG,KoyrP, Itwi.IIP.dll. C,...iof>C101.,..,..,...._ In: McCriyiG. cd. Pbti<SW,.I): Phlbddpbit.Pt:
Co. 19'10,4 JIOIJI60.

ra WD

wos.-..

Bird Facies

Pierre-Robin Sequence

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<' effects on the 'urroundins tissues

(IJ) 1),-crc~M:d risk for mlignont degeneration
(C' ) l> c~r~n ;cd ri~k for recurrence
OJ) l,nck of clloctivcncss on the eonncctlve tissue composition of the k:cloid
(I!) Symj>lottutic n:ticf of iu:hing nd burninG
l'k <On"CCt tnponsc is Option E.

tnualcdonal eonicosiCtOid injcxlions"" :unona IC\erallhaapies usod for uotmcnt ofl:cloids. OtJ>cr thenjlCIIIIC
ltiOOblit.c< tncludc application of ocei~W\'C Stlicone dnessinss, usc or compressive pressure camnJ;S or drusinss.
intc1fcron ll~enlp)', r:uliation ther:tpy, cryosurJery, and laser or surgical cxcis ion. Nnnc of these tn:atmcnlt have been
shown to be totally effective; howc\'er, oonieostcroids have been shown to relieve the itching und bun11ng symt>toms
assoc:int~d with the kcloids, as wcll3s to decrease the collagen content of the kclnids nnd subsequently dccrcnse thci
sit e. t:.xtision perfonncd eoncomiU>utly with injection of conicostcroids will reduce the rate of recurrence to 30%
to SO'%. Low-dose rodiotion lhcrupy administered postoperntively is :usociated with a similarly l'l.'<luccd rnl~ of
recurrence.

""",_.
1.

l.

. _ B 1'\orcs F. n.. .......... otlo)............... ICanltrloicb.. lorJ~. t"""'"IS95.

Sct.adal AP. GordoD L (]gdba M. d., Pmmt ol ~. . b:bd IKWIOI ...... ~"Qtrt~ ~"' tftJC""-' \YMI
tadalttOa t.hmrp)- a u1od cd. PfCI'9C'(.tn W,. tnd ~,of the: ltk'r111Wc ~ol Sw;: 1'996:.22.:569-.Si.a

Epicanthus inversus: Small skin fold which arises from the lower lid and runs inwards and upwards.
Associated with this is an increased length of the medial canthal ligament and a lack of the normal .
depression seen at the internal canthus
In simple English: a vertical fold of skin from the lower eyelid up either side of the nose .
. Blepharophimosis: The palpebral fissure is reduced in horizontal dimension
The normal horizontal tissue length in adults is 25 to 30mm whereas in this syndrome it is usually 20 to
. 22mm
. In simple English: eyelids that are abnormally narrow horizontally
Epiblepharon is characterised by a congenital horizontal fold of skin near the margin of the upper or lower
eyelid caused by the abnormal insertion of muscle fibres. This extra fold of skin redirects the lashes into a
vertical position, where they may contact the globe. This is found most commonly in Asian
individuals, .especially children .Epiblepharon is a congenital lid anomaly in which a fold of skin and
underlying orbicularis muscle push the lashes against the eyeball

.lit t.al Journ.il el Oplill!.Linmugp

www lfjlllla"at:ff'du

FOXL2 mutations in Chinese

patients \!Vith blepharophimosispto 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) T he 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 mon ths be fore one- stage correction. (d} Poor elevation of the left interpalpebral fissure occurred after onestage correction. Then, he underwent levator resection of the left eye 1-year after the one-stage procedures. Same patient's appearance
months after leV<! tor resection of left eye.

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!ltion, '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

....

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 procedure, 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.e d 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.

F igure 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 1J c

1
deposition Th
J'k 1

am1s wu 11 modcrnl' f3 1

e most 1 c y ~usc of her cuJTCnt findmgs IS loosening of which uflhc following f~i:.?
~:

(A) Clavipectoral

(B)
(C)
(0)
(E)

Co11es'
Deltoid
Pectoralis major
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<.lominoplasty. Tile
d.:ltoid :1."1<1 sx~:oralis nujor fasci l M\'C no effect on upper ann laxity.
-~'lrM:'a

I.
3.

L~l~-a..~

T. B~t'j't.uty uith rupertici:~l f3..~ci:tl suspension. Pins/ Rt:t'OIISir Surg. 1995;96:912920.

Llw~.'\'1 TE. &:j'Crii.,-.:1 f.1..<ci.ll S)"Stem (SFS) of the tnJnL: :md e.xtn:mitics: n new concept. Pln.rr Recrm.rlr Sm'J:. 1991 :H7: 1009-1018.
TC..::k"'C."lm B. \We~ S Rcjuvm.:~tion of the upper :mn: concept. !'ItiSI Rtcotufr Surg. 199H: I02:515-55 I.

CLAVIPECTORAL FASCIA

~- Suspensory ligament --\-f:~W~~!f

of the axilla

Pierced by:
Acromiothoraclc trunk
Cephalic vein
Lateral pectoral nerve
Lymphatics

0 El5e'Aer.

Dr.llte al: GraYs Anatomy IO< Students - www.studentconsult.com

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 loe<ltcd w here t he future sutu re line will

be. The length of this first horizontal line

exceeds the lesions by 2 em. The end is
located at the union of the upper twothirds and the lower o ne-third. T he n the

vertical line in the axilla is drawn.

Fi g. 6. The i nferior incision line is olr

ta incd by join ing A and B. Poi nt B is the

red uction of the axillary diameter, a lso

determined by pinching. We then add
the t riangle of axillary resection a nd the
Z.plasty.

Fig. 5. Point A is the maximu m width

of resectio n drawn a fter pinching of the
excess area.

1-l g. 7. Liposuctio n under the area of

resectio n . No fat should be left between
the skin a nd the a poneurosis. All that
remains is a thin fibrous network wit h
all the importa nt ele ments, s uch a s the
lymphatics.

Fig. 10. Compressive su1ure closure

wi th many di mples and a Zplasty.

Fig. 8. Very s uperficia l under mi ning

immcdia1cly u nder 1he skin layer.

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.

Fig. (4): Type 81 : Skin redundancy of proxima l one

third of upper ann (a), Markings of semilunar
axillary resection (b).

(a)

Fig. (5): Type B l : Preoperative frontal view of the left arm (a), Postoperative frontal view of the left arm (b), Preoperative fro ntal
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 righ t 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).

Fig. (9): Type 83: Skin rcdWldaney of more than proxinlal

one third of the upper arm and reaching the
elbow (a), Markings of curvili near incision and
vector of pull (b).

(a)

(a)

(b)

(c)

(e)

(f )

(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.

(a)

Preoperative v iew of seco ndary zone of

adherence (a), postoperative v iew shows
elimination oft be ad11erent zone.

Non Excisional Brachioplasty

:): Depithel inlizntion technique i n non excisional brachioplasl)l.

Technique:
2 curv<.'d S ~upcrficial onci~i1ln' arc done. The
upper one '' marl..ed one em po"cnor to the bt
ccpllal groo' e (Fig. 2). The lo"cr one i~ n~;arl..ed
later accordmg. to the antictpated redundant !>l.. tn
plannL'tlto be clinun<lled. Ctrcumfcfl.1tllal hpthucllon ''done fin.t. Dcp11hchahn11on t> done in the
rL'<Iund.tnt km "luch i' planned to be .:~ci;~;,d m
the original technique' (Fig. 3). Thi' i' folio" cd
by deep and uperfictal hpo>~octoon beneath the
depothchali/cd rcgoonto make ot a~ p.lpcr thm layer
"hich can be "" aginatcd ca>oly. Neithe r 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 \\C<!b.

(2): Curvil inear incision and oblique vector o f pull.

arm.

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

Fig. (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).

: Skin redundancy of more than two third of the upper

f'ig. (4): Prcopcralivc from al

view of the right aml (A), Prco~
e rativc fro nta l view of the left
a rm ( B ). PostDperative frontal
view of the right ann (C). Postoperative 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 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.
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 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.

Fig u 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

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.

ng11N' 4 . Exdlkln Slle' ttposumon 1:1 dw rathc.al mnov.rl ol f.n under 1M skin

101M'~ . Th~itep

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.

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.

L-Brachioplasty
A

/
)\ ~
::.::...-=- .:_!.....j.oo

---

-- J

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 subcu taneous 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-a rmed 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

Fig u 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

Figu re 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
o f the posterior arm. (B, D, F) Five weeks after L-brachioplasty seen in Figures 1-3, S-7, and 9. The patient's healing was
uncomplicated, leaving symmetrical curvilinear scars from the height o f the axilla to the posterior border of the arm. At this point
in early follow-up, the smaller axillary hollow is maturi ng as the overall swelling reduces.

L BRACHIOPLASTY
Preoperative Markings
Meticulous preoperative surgical markings permit expeditious 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, followed 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 techniques 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 centimeter excision can be performed along either resection
line. A complete video presentation of the authors' technique is available at www.acsthcticsurgeryjoumal.com.
The L-brachioplasty connects a hemielliptical skin excision of the medial ann to an elliptical excision of the lat
eral chest through the axilla. Dr<1wing the ant<.>rior straight
lin<.> of the h crniellipsc at or sligh tly above the bicipital
groove, and the curved line of the herni-ellipsc along the
posterior arm leaves a swooping scar from axilla to elbow.
The greatest fullness is thereb} placed along the mid-posterior arm where it belongs.
There are six critical points for th e preoperative marking
(Figure I A,B}. which should bt> located with the p<1tient's
ann abducted and the forearm Oexed 90 degrees. The surgeon should initially p lace ink dots in the following locations: at the deltopcctoral groove (pomt I); at the widest
portion of the midann, slightly anterior to the bicipital
groove (point 2); and at the termination of the brachioplasty, around the e lbow or beyond (point 3). The straight

or slightl y bowed line connecting these points is the anterior incision line (Figure 1). The width of midarm excision
is dctennined next by gathering and pinching the excess
skin and fat posterior to point .2, then marking point 4 along
the posterior margin of the arm. With the patient's arm
raised and the skin stretched, a straight line is drawn from
the widest area on the posterior arm (point 4) to meet the
antenor !me termmation at point 3. The adequacy of the
width of thts distal resecllon is adjusted by pinching and
gathering. The proximal portion of the posterior incision
line is then drawn b} finding the critical point 5 that can be
advanced to point I. Pinch approximation o f point 5 to
point 1 advances the posterior axillary fold and tightens the
posterior ann (Figure IC). At this point in the marking, ~n
moomplete hemiellipse is evident (Figure I D). The antenor
incision from point I lo point 3 is equal in length to the
curved posterior incision from elbow point 3 to the advancement point s. Wilh the arm extended, the posterior line
continues across the axilla. remaining several centimeters
away from the posterior axillary fold, to descend toward a
tapcroJ latera l chest m.1rk (point 6) as the posterior incision
line of the lateral chest. T he length of this line (point 5 to
point 6) will vary directly with the skin laxity and rolls of
the lateral chest. A parallel line descends from point I
through the axilla and poslerior to the lateral pectoral fold
to taper to point 6. The skin excision between these last two
Jines (point 5 to point 6 and point 1 to point 6) removes the
t>xccss 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 zigzag across the axilla (Figure I B and Figure 2). An mferiorly-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 1B).

L-Brachioplasty

massive weig ht loss (MWL )

If brachloplasty Is the only procedure being performed, the

arms are prepped clrcumferentlally while the patient is

awake, and he or s he 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 induction of deep sedation a nesth esia, 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 excision, 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 neurovasculature 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

excision site liposuction (ES L )

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 scalpel cuts to the dermis (Figure 7 A,B). Little bleeding Is
encountered, as the arm skin Is removed like a fullthickness 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 approximate the subcutaneous fascia, the author prefers 0 or

Polydioxanone PDO

http://surgik.com/pdo.htm

Surgik's Polydioxanone suture better know as PDO is a monofilament absorbable, synthetic surgical suture
composed of the polyester poly (p-dioxanone), a nonantigenic and nonpyrogenic polimer. PDO is indicated
for use in soft tissue approximation, including use in pediatric cardiovascular and ophthalmic procedures.
Polydioxanone suture is not indicated in adult cardiovascular tissue, microsurgery, and neural tissue. This
suture is particularly useful when the combination of an absorbable suture and extended wound support (up
to six weeks) is desirable
Characteristics of surgik's PDO suture
Drill End needles for maximum strength between thread and needles
Extended holding strength, maintains tensile strength for up to six weeks
Lower tissue reaction than chromic gut suture
Exceptional good knot security
Eliminates bacterial migration along suture line
Easy tissue passage
Strength duration: 55-65 days
Absorb duration: 180-200 days

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 ~
'>
:\Whi~
-'.. of mefcllowmg
. lS. m~c most appropriate management.
(:\) 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..<:ion

Th.: corr-.x~ ropon.::c is Option D.

The QS\\itched ~d: YAG aod ale.'(andri:i! hse:s a:~ b.!st used for remo\':tl ofblue-I!J'Cen tattoo pigments. In contrast,
the Nd: YAG laser works best for red. b;;m11.. :nd, oZJ.ge p:gmentS. while the Q-switched ruby laser is used to remove
tattoos with "violet and purple pigme:ns.. Bec::!-.:se p70fessional onoos often extend deep within the dermis, multiple
treatments are required.

Because it causes minimal damage to adjacot tissues. the c:ubon dioxide laser is effective for ablation (skin
resurfacing), cutting, and coagulation. Ahbougb serial excision can be used in the treatment of traumatic tattoos,
scarring is a common sequel3.. Drnrobras:o:1 is I'\X'Ommended for small traumatic tattoos.
ReferDKn
1. Kilmer SL, Lee ~IS. GmeEO:

2.

n-1. n :d. 1b: ~~:.e.! ~t:YAG 1:1.= efT~ctiwly trots 13ttoos:

3 controlled. doseresponsc study.

Arch lNrmatol. ~~~: 1.:9:9_'il.

.
.
.
.
Kurokawa M. lsshtki ~. T
T. n :1. ~ c:s.e cf:::a=-gc:il p!.mm~ 10 ttc':ll tr:!Urn:lllC unoos. Plasl Reconslr Surg.

19 ~:94: 1 069.

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.
2.
3.

Allison GR. Arullomy of !he auriclr. Clm Plast Surg. 1990: li~09-1l1.
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.
n.7,_,_,,. ..,__ Lt , . '"-r --- I ' --~-1 .,....,K ......~ihilirv oftht fJce. Pla.J/ RtCOIISir Surg. 1990:86:-(!9-BJ.

,. ,. .

Auneulotemporal
[V3)

Sensory
Innervation
Greoter Auncular (<:2, C3]

Auditory
branch of the
vagus nerve
Auriculotemporal

Lesser
occ~ital

nerve

r:3 Lesser occipital

Ll::J nerve
~Auriculote mporal

~nerve

roQ Auditory branch of

tQg the vagus nerve

r.:::J Great auricular

nerve

~nerve

Fig uno 2. (A) Flap O..ign. inciolon wilhin ~., frown

linH wieh lmfc.d Ct<V~.i;lt txttnsion. Lao11 i'lcdion ~t n.1.sot.ciM
junction. 0~ m.nttd
ipsA- 10 llop ptdic'-.

Figu<t 3. (A) Six monfl folow-up. (B) O.,.;qu view with sidtwal
...,

cono 6tfcnnity txoisiOft

(B) Aft clos.wt ol dol..._

.,..,c~rog

Figure I. Defect after twnor excsion preoperative mark-

Figure 2. [nunediate postoperative view.

ings of nasal flap.

131

TI1e dorsal nasal flap is most appropriate for coverage of which of the following defects of the nose'!

(A) A 1-cm defect of the alar base

(B)
(C)
(D)
(E)

A 1-cm defect of the columella

A 2-cm defect of the medial canthus
A 2-cm defect of the nasal tip
A 3-cm defect of the lateral wall

Generated by CamScanner from intsig.com

The correct response is Option D.
Tile dorsal nasal flap was first described in 1967. Flap transfer usually invol~es ro~tion.and caudal advancement of
the entire skin ofthe nasal dorsum and the glabella. It also can be accomplished 111 a smgle-stage procedure while
the patient is receiving local anesthesia. Since its introduction, the dorsal nasal flap has been modified by many
surgeons. For example, the pedicle can be back-cut to the angular artery, and the glabellar portion of the flap need
not be used.
1l1e dorsal nasal flap provides an excellent color, texture, and thickness match, which is its greatest advantage. It is
predominantly used to cover defects that occur following excision of lesions of the nasal tip. Defects as large as 2
em may be covered with this flap. A potential disadvantage associated with use of this flap is the violation of other
aesthetic subunits of the nose.
A dorsal nasal flap will not reach a columellar defect. A medial canthal defect is easily reconstructed using a skin
graft or small local flap. A nasolabial flap is best used for coverage of a defect of the alar base. A 3-cm defect is
beyond the limits of a dorsal nasal flap; a flap that provides additional tissue (such as a forehead flap) would likely be
needed to close this defect.

References
I.

Green RK, Angelats J. A full nasal skin rotation flap for closure of soft-tissue defects in the lower one-third of the nose. Plast Reconstr

Surg. 1996;98:163.
2.
3.

M_archac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr Surg. 1985;76:686.
R1eger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg. 1967;40: 147-149.

132

A 68-year-old
womanf seeks correction
eyelids and impaired upward ~aaze . Ph ys1ca
1exammat10n
s11ows
h d.
of .drooping
.
excessive
m
th e upper fields Levator
oo mg ob'lthe upper eyehd. skm; VIsual field testing confirms obstructton
excursiOn IS 14 mm _1aterally. There Is 2 mm of ptosis of the left eye rd
th

h
unaffected.

1 , eng t eye IS
In addition to blepharoplasty, which of the following is the most appropnate
management?
(A) Division of Muller's muscle
(B) Fasanella-Servat procedure
(C) Fascial sling
(D) Levator advancement
(E) Resection of the levator muscle

The correct response is Option D.

Bilateral blepharoplasty with fat pad removal and ptosis re -
visual field defect and mild ptosis Tllese
d
pair usmg levator advancement \viii address this woman's

procc urcs arc used fo

f
greater than 10 mm). Bilateral upper eye)J'd bl 1
r pa Icnts With normal levator function (defined as
ep 1arop1asty alone or 111

.
.
correct the ptosis, while repair of the ptosis 0 1 , ld
conJunction '' 1th fat pad removal \ovould not
n y ~ ou not address the visual field obsuuction.

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 drow
mea~nng .e excursion of the upper eyelid margin from downward gaze to upward gaze with the eyes
~x~ 00 ~ ~~~t ~mt. ~~ nonnal distance benveen the upper and lower Jimbi across the pupil is 11 mm. The upper
1trn us 5 ou rest mm ow the superior edge of the iris and 2 mm above the superior edge of the pupil

a;

Division of Miiller~s muscJe would not correct the. ptOSlS.

The FasaneiJa-Servat
procedure
1
but IS
a more ddftcuJr,

_... pn:.u:uwc
-~~..,.~ .:1..~. . ..
. ..
is. used to correct m1mma
ptos1s
complicatc;u
utdu
levator pt1cat1on. AccessJbdlty to mvol\'ed sn:uch-s

1
r

ed
th
.a.:
ed
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.
2.

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.
Klatsk:y SA. Blepharoplassy. In: Coben M, ed .. .\lasteryofPlastic 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 ofptosis 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 ofptosis, and this may be classified as mild,
moderate, or severe.
Grossly, one may assess the degree ofptosis by noting the position ofthe
upper eyelid in relation to the iris and pupil The upper lid margin is normally
at the level ofa line that bisects the distance between the upper aspect of
the pupillary aperture and the iris. One can assess the number ofmillimeters
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 oflevator
function. A significant aperture in down gaze (lagophthalmos) may be an
indication ofinfiltrative disease (i.e., Graves' disease) or a fibrotic process
(i.e., congenital). In all measurements ofaperture 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

ASSESSING lVA'TOR FUNCTION

PdmaryG""'
Lew!or aperture
Oeg1lll Ol pi"""'
mla'mOderalBI&e\'ere

Clear

""''

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)

www.eophtha.com
~Author

www.eophtha.co
~Author

uP

Fig.4a

~ A ZE

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'N een 13 - 17mm

Putterman's method
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 Childre n
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 p alpebral li$$ure the dislance between the upper and lower eyelid in vertical alignmenl with t he cenl er olth e pupil.
Normal - 9-1Omm in primaJY gaze

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

Amount of ptos is

difference in pal pebral 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 pu pillary 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 a bnormal positioning of the low er 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
w ould 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
w ould be a - ve value. The latter w ould 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 w ould be th e MRD 1.

Grading of severity of ptos is

< 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 margi nal refl ex distance-2 (MRD-2) - the distance be ~.vee n 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 margi n 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

Vis ua l inatten t ion

1. Ask patient t o focus on your face & not move their head or eyes during the assessment
2. Hold both arms out w ith your fingers in the periphery of both yours & the patient s field of vi sian
3. Remind the patient t o keep their h ead still & their ey es fixed on your face
4. Ask patient t o point at w hich finger s are moving
5. Move the fingers of left & right han d in w hichev er order y ou choose
6. Then move the fingers of both han ds simult aneously
7. If patient only not es one side moving. this suggest s the presence of visual neglect

De t a iled v isual 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 focu s on you r face & not move their head or eyes during the assessment
4. Ask the patie nt to tell you when they can see your fingertip wiggling
5. Outstretch you r arms, e nsuring they are situated at equal distance between yourse lf & the patient
6. Position you r fingertip at the outer border of one of the quadrants of you r visual field
7. Slowly bring your fingertip inwa rds, towards the centre of your visual field until the patient sees it
&. Repeat th is process for each quad rant at 10 o'clock 12 oclock 14 o'clock 18 o'clock
9. If yo u are able to see you r fingertip. but the patient cannot th is would suggest a reduced visual field
10. Repeat th is assessment process o n the other eye

Confrontation visual field exam

Humph,.ey automated perimetry

Benign juvenile melanoma = SPITZ NEVUS

1 3~

rcsu1I 1s months .n,-r

. ..
. ted with the acsthcltc
.
--old
whonose
IS di.S.1ppom
'''llh
Tite above phmogrnJ>h~ arc of a )J
Slycar....
thotwom:m
her lower
looks pointy and that she l~'lS nasal c.ID.,tmclif'ln
.

rhlllOJ>Iasty. IC s:~,..
.
.
undcll;utllg
pnmary
. .
I
I
lar
collapse
with
msptral!on.
deep brc;athin:;. On cxmnm:mon. ~ IC l.'b a
Which of the following is the most approp ri31C opcrnti\'Cmanagement?
(A) Cantlagc
,
0'mg 10 incrclSC lip SUpjl<)l1
.'Ctinn
1caniloncs
gra
to .mcrcasc. nasa 1JlrtlJc
1

.
.
"
of
the
lower
a
tern
'
"
(B) Cephalic mmu11n,

(C) Osteotomies to narrow th~ u~>lpcrrnn~r~

.
1o d crc3.ic a
r, .
(D) Weir rcsccuons
c
correct
lhe
polybcak
de
OnHIIY
(E) Trimming of lite dorsal scplum 10
,

pnn~,try

is Option i\.

""~'

.
. , rhinoplnst), I roe<tlun:.
.. I
1
t
,
excessive rcduclion dunng the
. I rcoll;tlr.: th<
This pruicnl has 3 polybcnk
obstntction with inspimlion.is
oflhc """'"Ill'
combined with poor proJCCtwn o ~~c most nppropri:llc next step Ill managcmclll >< -
. s pinched and l:tcks support. '
up'
and alae to increase suppon .
Tl c corrccl response

dc~o,nn,:':s.,~~~;cc~l~:

s.us;~~:;~~;':;:,;;ing

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 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<lllS
from tll<-=<ive reduction ol the dorsal scprum,
any filrlbtt rcducttoa 1\'0Ukl only worsen the defonnity.

or

h.w~ ~uJ~

P4<~,_,.

~STD,at ~" f'rolll..,stWIC,,.otnlts. Saioii.GwJ,Mo:

PI'Oloku,. in W<oed&ly lbuort..,). Ia: .labt>e Rli1~ litd ed. S.int Louit, Mo: CV Moby Co;

I.

Pat:~Iooby
G. Jo:.,.lt.;.povjcnioo:
aoalsllldmo..,.__ Ia:
CV
Co; 19U;IO

2.

Sbea.IH.
Silffa AP
1917:2: IIJS-1401.

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-sut uring the alar c artilages t ogether. Pinched nose is not
only displeasing but c an also result in the obstruction of nasal airilow at t he intern al nasal valve.

Spreader ~Graft

<
Correction of a pinched nos-e by revision rh inoplasty re quires reinforcing t he alar cart ilage support
struct ure of t he nasal tip by addinQI nasal cartilage grafts, harvested eit her from t he septu m or the ear
cartil age. Alar spreader cartila-ge grafts and/ or sept al spreader grafts are used to fix a pinched nose.
A :spreader graft is a pair of straight pieces of cart ilage w hich are sut ured on each side of t he

septum to reinforce and to keep straight t he nasal septum and the nas al bridge. A spreader graft will not
only straighten the nose but 'MVill also open a narrow intern al nasal valve, which will in effect open up the
nas al airway . A spreader graft rhi noplasty is performed eit her via an open rhinoplasty or closed

rhinoplasty approach.
Pinched Nose
A pinched nose means a permanent sinking of the vestibular wall, obstructing the nostril and creating an unaesthetic alar groove on one or both sides. This nasal deformity is always secondary to an excessive lower lateral
cartilage resection and must be differentiated from the
collapsing ala, which is only seen on inspiration, owing
to its particular slackness. The pinched nostril results
from the loss of a wide part of the lower lateral cartilage
and often also from a concomitant vestibular scar retraction.

Iaginous incision and, if necessary, maintained in posiIf the alar cartilage needs to be reduced during a prition with trans-alar mattress sutures tied over a plastic
mary rhinoplasty by resection of a segment, this should
sheet (Figs. 17.3, 17-4).
not be performed in the lateral part of the lateral crus,
von Szalay (1991) referred to a case of secondary
but in a more median or paramedian section, as otherpinched nose operated on by our method using a comwise the postoperative loss of continuity of the cartilagposite graft placed at the proximal border of the lateral
inous vault leads.to the emergence of a pinched nose in
crus.
the next few months. This precaution must be absolutePrimary cases of pinched nose are rare. They present
ly observed in any method of tip and ala sculpturing, an omega shape of the cartilaginous dome, with visible
but especially when using the procedure of Ponti ( 1969), ~.., external depression near to the very tip or a weak laterwhere the "butterfly" structure used in this technique al crus with undulated shape. In those cases, there is
should be cut as narrow as possible in the dome.
continuity of the whole lower lateral cartilage. The exWhen the vestibular lining is intact, it is merely nec- ternal depression encountered in primary pinched nosessary to reconstruct the alar cartilage framework. To es cannot be compared with the external depression of
this end, I insert a meticulously shaped discoid cartilage cases with anterior valve collapse because in the first
graft harvested from the septum. This graft is cut into a there is no loss of cartilage continuity.
slightly convex form and fixed, like a bridge, over thereThus, in primary cases, there is a good indication for
maining parts of the lateral crus with trans-alar mat- a spreading device, as advocated by Gunter and Rohrich
tress sutures (Figs. J7.I, 17.2). For this purpose Nicolle (1992). They described a bar-shaped alar spreader graft
(1986a, b) inserts a bevelled elliptical septal cartilage and a triangular spreader graft sutured between the alar
graft of the whole length of a lateral crus and dome cartilages like the septal cartilage bar used by Ochi and
through an alar rim incision. In the case of severely de Werd (1988), who, in cases of valve collapse, placed
pinched nostrils with cicatricial retraction a simple car- ,.. their bar transversally, spanning the dorsal septal ridge
tilage graft is not sufficient. For patients thus affected I at the level of the junction of the upper and lower laterhave recourse to a composite graft, which is best haral cartilages. We think such transverse bars are useful in
vested from the inner side of the crus helicis, to rebuild
cases with no loss of continuity of the lateral crus. Oththe vestibular lining and the missing cartilaginous erwise, there is an absolute need to fill the gap left by
framework at the same time, after the removal of scar loss of cartilage by means of cartilage grafts or compostissue. This graft is sutured into the gap at the level of ite grafts.
the intracartilaginous, intercartilaginous, or infracarti-

Fig. 17.1. A-E. AUnilateral 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.BYoung
girl with analogous unilateral pinched nostril Insertion of a

septal cartilage graft into the nostril through the intercartilag

inous incision. FEnd of the secondary operation, with equili
brated nostrils and transalar mattress suture in place tied over
aplastic sheet. At the same time the fioor of the vestibule has
been narrowed

Fig. 17 .2A, B. Pinched nose in a 31 -year-old lady after resection

of almost the whole lateral crus of the lower lateral cartilages.

Carved cartilage grafts from the septum had to be inserted ir

to both nostrils. A Preoperative, B postoperative views

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

c
Fig. 17.4A J. In a severe case of pinched nose with cicatrical
retraction of the nostril, a simple cartilage 9raft is not sufficient. 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'a r area and
opening of the intracartilaginous inCISion. The is then su
tured into the gap of this incision with transalar mattress su
t ures tied over a plastic sheet. A. BPreoperative views. CCom
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. FMattress sutures are taken 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 already operated several times. The tip-lobule complex
and the anterior part of the alae are full of fibrous tissue. The tip may be too narrow or too wide and asymmetric and the fibrous tissue needs to be removed before 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 dorsum. 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 bilateral areas outlined had to receive a composite cutaneo-cartilaginous 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 operation, with d isplaced columellar and alar bases and transnasal
sutures to keep t he composite graft in place and the bony
part in the new. more prominent position. E- H Early and late
results

Fig. 17.6. A Ugly aspe<t of the tip in a

middleaged woman operated several
tomes. The protrusion of the tip is
caused by a mass of fibrous tissue pulling forward the domes of the lower lat
eral cartilages. 8. C Axial v rew in drawing
and photo at the begrnnong and at the
end of the operation, showing reductoon of the domes, removal of fibrous
trssue, insertron of a trp on lay graft, and
alar marginal resections sutured in the
overand over manner. D. EProfile view
of the same procedure. f . H Result

Fig. 17.8. A A further similar case of a

postoperative increase of the tip volume, with fibrous tissue spreading thE
domes

Fig. 17.7. A Similar case to that in

Fig. 17.6, operated several times and
now with fibrous tissue in the tip- lobule area. 8, CBeginning 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

Fig. 17.9. A Young female patient with distorted tip of the nose,
the left dome protruding more than the right one and slanting laterally because a short strip of cartilage has been removed. 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-

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 transalar manress sutures. EThe identical sites in profile. F- H Result

Fig. 17 .8. B- EBeg inning and end ,o f t he

operation in drawi ngs and phot ographs~ including remova ~

of fib rous
tissue, reduction of the lower latera l
cartilages and alar marginal resectron
in profi le. F Same correct ion in axial
view. G- 1Resu lt

Fig. 17.10. A Distortion of the tip, with slight bifldity of the lobule 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 beginning 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 sutures. 0-Ci seep. 142

Fig.17.1D. D Profile at the end of the intervention . E Early result in axial view. F Half-profile pre- and postoper,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 cartilaginous strut of the columella, membranous septum mattress suturing is
performed to fix the pillar at the transfixion incision. C, 0 End of the operation with the remodeled tip-columella alar complex in drawing and photo.
E-H seep. 144

Fig. 17.11. E, F Pre- and postoperative

profile and half-profile views for comparison. G, H Result in other views

PINCHED T IP

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 t he alar cartilage 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 t he ala by cartilage notch ing. The alar creases extend too far forward into t he
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 diagnosis difficult. Yet even partial replacement of lost tissue
with si milar tissue can be beneficial.

This 34-year-old male bad a red uc tion rhinoplasty that evidenrly 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 . Th us, replacem em of whar is missing requi red a cwo-ciered septal cartilage g raft co rhe bridge. Reduction of the remaining excess alar cartilage, plus splincing
of the collapsed sides with septal cartilage srrucs, brough t
back some of t he naturalness to her nose.

strurs taken during a submucous septal resection were shaped

to fill om the depressions on either s ide of t he rip. A rworiered graft was used on the lefr. These carti lage srrurs were
inserted through ma rginal inc isions to b ridge the hol lows. A
bilateral osteotomy with infracw res improved t he width of
t he nasal base, and alar base wedges reduced the flare.

Here is an asymmetric pinching of the tip that required

septal cartilage scnming of the columella into the tip 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~
orp~wnomnng
-J

fiu11 nbdommoplasty

mcombmauon
with
sucuon

.
'-vuP1tc:auon
hj>eetomy?

Infection
Nerve injury
Scroma fonnation
Skin necrosis
(E) WouuJ Jchiscencc

(A)
(B)
(C)
(D)

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<Ktic usc
uf ;mtibiotics and antibiotic inig:uioo will hdp to mini111izc 1he potential for wound infoction. l11c ris.k for skin necrosis
and skin slough is inci'C3SCd when abdominoplasty procedures arc combined with suction lipcclomy; a hi.slory of
sn'!Okins or diabetes meUi1~ ISS \\'CII as 1he pr<Sentt of abdominal scan. QO also incrQSC: the p:.ticn1's risk (or
necrosis. Wound dehiscence e:tn result from infcriM swg.ic:al technqucs, cx~ss wocmd tension, and insufficicn(
plilcemcnt of dei!p dcm:u~l sul'urcs.

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 t S 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)
(B)
(C)
(D)
(E)

R~surance and continued follow-up examinations

Eyelid massage and stretching exercises

Administration of phenylephrine eyedrops
Immediate op~rativc exploration of lhe eyelid
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.
2.

Optim:~l

procedure in secondary blcpbaroplasty. Cli'f Pfeut Surg. 1993 ;2 0:22S-2l7.

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.
Flow-en RS.

ooepset
(leVator de~)

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<ontommg preopo11eurotic space. The position of the levotorskin /into~ and tht ollltroposterror rekltronship of the preoponeurotic Jot
determrne lid fold htrght ond degu~ of sutws conaJVity or com-o:ity (as sho-.n on the nght half of each anatomiC dep1e1ron~ 8, In the deep-ser
eytlrd or m the cose of fel'Otor dehisance from the torso/ plait, tilt upper lid crtose is displaced superiorly The orbrtol septum and
preoponeutotrc fotlmktd to tilt ltvotor ore displaced superiorly and postenorly. Thtst onotomrc chon/ItS crtott o high lid aeose, o deep superior
sulcus. ond, m lht cose of ltvotor dehisunu, eyelid ptosis. C, In tht aging or boggy eyelid, the septum btromtS otttnuottd and strndlts. Tht
prtoponeutotrc Jot ottochmrots loosen, ondthis allows orbitolfotto prolapse fomord and sJrdt o>rr tht /No tor mto on anterior ond inferior
poSitiOn Tilt net rtsu/1 is on mfetiot disptoument oftht levotor sl.Jn ottochmrots ond o low and ontmor fJOSIIIOn oft/It prtoponeurotrc Jot pod.
Clrmcolly. thiS rtsults m o low lid atose that is only of~ millimnm from tht lid morgm ond may not bt viSible 01t1ng to the m~rhonging lid.
0, Tht youthful ldlon eytlld OIIOtomiCOI/y rtsembles lht boggy or SttltSUnt upper lid tuth o low IMitOt st.m liHit of odfltsion and mftnOt and
ontmorly locoted prtoponeurotic Jot Tht dtoroeuristic, but vorioblt, low eyelid atose and coma upper eytfrd ond sulcus ort ciOSSK.

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.

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 skinmuscle 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.
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.
Figure 4-4

UPPEA LID Bl.EPHAROPLASTY

Pli!S&Jrl! on gkltll!
eauii!!S meciM

rat pac1 10 IM9!

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

Medial fat pac! removed

...-....-

?\,~,~'

running stuture

Closure

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. 1prefer 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

LEVATOR MODIFICATIONS

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

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. 1prefer 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.
Lov.-&r hd. re1nteted ~riolty (CCI'IjUnCirvai iUtfaoeJ

lnased orbdal septum

RemoYO me<N~IIld
cen1ral fat pads

Central tat pad

PrwsMn on upp4H' lid

a~u54nl ~l&ral orbilat 1at pad
lo bulge anlenorty

L&ral tal pad

Figure 5-2 Continued D, The septum may then be opened either widely or with stab incisions. E, In
either case the inferior oblique muscle should be visualized and protected. I usually identify the oblique
muscle before resection or repositioning fat. The muscle is most anterior medially, adjacent to the medial
fat pod, and this is the best place to identify it using on instrument to spread or probe while
concomitantly applying light digirol pressure. F. Remember overresection of fat. especially the lateral
compartment. can lead to less than acceptable cosmetic results. Skin resection should be conservative
and invoke lateral and ceohaUc vectors.
Continued

a-n '""*'<ling onto<rupood w1Ur-.

laleBiy
.,._.1

-I\IVW'Ig -

rnodill

Figure 52 Continued G, This will render the most tension under the canthus and the least distraction
force in the mid lower lid. I find it helpful to have the patient look up and open his or her mouth to add
conservation to the skin excision step (inset). Before closure, it is sometimes helpful to resect a few
millimeters of orbicularis muscle at the superior aspect of the flap. This does not affect function and
avoids the annoying post-blepharoplasty bulge or roll. H, Closure is completed after hemostasis is
controlled. I prefer running 60 silk medially and interrupted nylon laterally.
Rm" OEC10MY -lOWS! uo

Figure 6-1 Rhytidectomy of the lower lid may be achieved without raising a cutaneous or
myocutaneous flap. A, An incision is first placed in a lateral fold or potential fold. B, The incision is
completed lateral to medial, and I prefer to develop the inferior aspect of the pretarsal postorbicularis
in continuity with the superior aspect of the preseptal space. C, Lateral and cephalic traction is applied
to the orbicularis muscle near its raphe, and a wedge resection is performed. D, The cut edges of the
muscle are approximated with sutures. E, Skin is separately addressed, again invoking the lateral and
superior vectors as shown previously.

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 ~IIher case on msu/ottd retractor (eg., 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 retroCIOISand the orbital septum. Tlus
w1ll allow drrtavisuolizotion of the septum, ond eoch Jot pod con be oddrtssed SftJOrolt/y m o comrolled 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 Ifaction 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 postorbiCularis prtstpto/ spou. This plane is dtveloped to the orbital rim
w1th the OSSIStonce ofthe tractlOll suture ond o nonconductwe mSirument
Cootmurd

tl

Nasal

01 Ren'lo'e tal paas

tnerDIJge

02 Repo6!Uonw paiS

"

--

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, Iprefer asupraperiosteal tunnel with atemporary 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.

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

Figure 6-4 Continued C, The orbital septum may then be selectively incised and fat addressed, or the orbital rim may serve as ajuncture point
for midface adjustments. Here the medial fat pad is delineated by acurved hemostat. The fat pad is seen lying on the insulated retractor as it is
teased anteriorly. This may be used for redraping in afat 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 asingle 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
0

Orbicularis Oculi Muscle

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 ocul1muscle 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, Diagonal fingers. Cutting the free edge of the

levator aponeurosis and rotating down in order to lengthen the
previously shortened or transected aponeurosis.

B
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]un<tiw lOVii'Jng lht on IDiot 'Lkto Tht orlJiaJ/aris mwlt Bonligu0Ul
oeapiro6s. ond wperfiool muwloopoflt!JroU<S)'Itm jWA!illaytr rht otbiiDI
1tp1Um" conflueru mlh 1M fJtfJIJ5ltvm of lht sJ.u/1 and otbiC. os e las lht penorbriD. 1111! llfbJIDI
st{Jium " abofused ro lht ~'OIDT palpebrae and, lhettfott, """' "'a complete boundary brill...., lht
an!Bwr and dttp orbit 001! mnnotarrt~~ lht prmpontvrolic {at wilhout vro/oting lht wperor septum.
AnaioROus/)1. lht mfetror otbllill st{Jium IS mtimatdy lmbJJ to lhe pmoslLJJm and 1M mpsu/opo/ptbtol
faJiJDily>!Lm. rht main rrlractoo of 1M upper and /owtr Nth are lht lriDIDT and mpsu/opolptbtol
foJiJO, ltS{It!U>r/y. lht holor IS SU>(Jtnded from lht W{Jtflot Orbrl by ll'hllnol/~ lillOmtnL This
slrucJutt allows lht mu!lle lo cho~~gt >tdDI 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, dthis<Lnu oflht hotClf from rM tllflOI p/o~ INIII ltJJd IO a W(J<!f/01
wkJJs dtfotmity. rht lof'lOI platLsore rht end pomt/ot relractot mseroon and pr(M/k lid stability and
ll!lh lhefroolok~

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 tbrfhghllfnght 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 Ibot 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. 1wn th11 rht pmtomKulark pmops.ufopa/pttlml
}IJJJO( spou, wfJKh IS lfflpoffDnllfl dtfr!y mwllng both tfOrucoti)UndiKII Qnd tfQfiSCI"Qnt'O(.ft bltphotoplaShtl.

oritntollon.

Orbital sejXum
(par11ally removed)

Recess of

'CapotJ<>palpe1>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.

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.

Posterior limb,
medial canthal tendon

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

The extraocular muscles form acone 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 redus 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.

Lacrimal fossa

Anterior and posterior

lacrimal crests

Upper puncta

Tarsal plates

Lacrimal duct

Papilla

Inferior meatus

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.

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

,.'!!!~~-Glands of
Conjunctival,

Zeis and Moll

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

Lacrimal

orbital p ortion

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.

Figurt 121 The two basic mechanisms for lower eyelid malposition due to an imbalance in the norma/forces, with distraction overcoming
support, are demonstrated clinically. In A, a 61yeor-old man demonstra tes sc/eml s/ww and slight ectropion on lateral view. In this case, the
intrinsic support mechanisms of the lower eyelid (canthal, torso/, museu/or, etc.) lwve weakened sa as to allow the lower eyelid to be displaced
down and away from the globe by normal extrinsic forces (gravity, etc.). In B, a 64yearold woman become symptomatic after having hod
eyelid and facial procedures in which excessive distraction forces were created. These forces exceeded her own intrinsic support mechanism,
which was likely weak to begin with. This potienr would hove benefitted by lmving her own intrinsic support mechanism strengthened during
her cosmetic procedure sa as to resist bot/! physiologic and iatrogenically induced extrinsic distraction forces. Note the scleral show, left lower lid
t!dropion, lateral tonthal dystopia, and injection of the ronjunctivo especially on the left, indicating nn eyeball that is inadequately wetted nnd
covered. The yelfowgreen color along the lower lid scleral junction is fluorescein dye

f igure 1-7 Theeighl bones of the

orbitbosicollyaeatetwosignijicont
fodalbuttresses, thejrontalzygomotic-moxillory and the jrontalnosol-maxillary. The sphenoid

articulates with lhezygomaundis

the major delineator between the
middleaania/fo<,soandtheorbit.
The optic foramen is in the body at
the sphenoid. Medially, the loaimal
/OiSII is viwaliZI!d between the
onteriorondposteriorloaimalaests.
Theseae-;tsserveasinsertionsjor
respective elements of the medial
canthal tendon. Theloaimalsoclie5
within the fOSSil, betwnntheanterior
and posterior crests. Whitnoll's
tubercle is seen lying 2 to 3 mm
within the orbir and 6 to 8 mm
below the loaimal /0550. The position
of thisimportonttuberdeissolient
in performing on onotomKolly
fundionolandoestheticconthovlosty
procedure

Orbital septum
Lid/cheek junction

Infraorbital n.

Orbitomalar ligament

alar fat pad

Fig. 22 Double eyelid . Parallel crease

configuration
Pr~fat

Fig. 24 A typical Caucasian eyelid vJith

anaturaluppereyelidcrease
Aponeurotic fibers form interdigitations
tothepretarsalorbicularisocu1imuscle
and a subdermal attachment along the
superior tarsal border.

Strategic placement
of intramuscular
v-~
~ suturescreates

-~nfoldirgolcrease

.... .... - .....

1\1

E!ltry for bcKh needles

of double-armed sutures
F;g,~

_3_T__...,....,...-""""'!ll<dnq.e--U>O<o!>omco"ipzaogolhaoghms0n.

F'IJ-~ v....wa-.5.{i>!>IT-..d

- -,...~ achnquo

...,.,l:nrt.Jzn:laJ...

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

=:s
J
'

PrBCasal Oll:!aJar1;
t ..ator apooelro!is
Tarsus
Coojunc:r.a

II

-1>
c

Fi~J-6-7

T~~
T~ntnoa:noolondinl.-.d""'"'"'!!lodn.,..,_

Fig. 6-2 Skin (S)-1

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

Levator
Skin
Upper tarsus

"., "'"'.,_,.,..

Suture passage from

.

Skin ~ Levator -

Skin

closure, which tends t0 [T}-sktn (SfT/S)

crease.
produce a static

Suture passage from: Skin

~ Ta rs u s-

Skin

Fig. 6-4 Place

between the in~ent of ligature buried
tissues and the f 'ortsubcutaneous
According to
resu~s in a deeper and m thts procedure
dynamic crease.
ore permanent

Fer=~ez;neurosis.

------

Levator 1inferior
subcutaneous knot

Ag. 19-3
Thu socc;n:thbctatm
,~'iif"--~--!1111!1:~----~
_.
p;nii;Jj
IOthebn::tltnMgn
Pont

'"-10-1 Mirt.rlglcrZ~

~Pot'liA~---
~cMporl:OIIIIh,..W

Er:o'fohilrottvtwohlsc:Jo.wggbomtho

.ndolttte..,....W..n.~

lhe~~-*'

~~.AW.Is0"a'Ml

....

nm pon. A l"l"'P cross pool

bliltwu&nlhrilr38rwoh:lsiSpoRC. A
~--crcded TNs~wl

""""""""-

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~
~

Ag. l t-4

~
-----

.... ...-

~--R:elon nm P~Hia~IO Ill tara

margns. n. EAC trw1g1g Is ltviJn
~...,

'"'""""

c
B

,--- - - - - - - - - - - -- ,. - - - --

- - --, F1g.. 19-5 Pon.O.Ihernecial:ondofhl

laamallai<G, ls~ Aoo.15

~l:lleilIS~v-.W'IIho

tacnJ tflQ ~- lho ap

bb tcaJc:h9s th9 nwdal ant\31

l;ajQ ~ ln1

of h

------~,.......-------"""!

Tho.._. ...........

--""-"*"""'""'
Flg.1U

D-8

c
B

~oft:nllrVeEAC

WlGn lhD oy"*d llkn ts tunowd n

....,..._

( )

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
from poinuA to point Band from point B to p<:>int 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<!. There is no suture holding the Oap in place.(B) Virwwith lhre)-eopen

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.

Frgt<rt 11. 17 (A ) l'n'and {B) 1\t l'ilrk Z-<'J'icanthoplruty viC'~<o-s.

...............

-----------~,-..,.. .

n.. ......... ...

-~ .......... ~pt,

- - - --

- -- - - - - - , ,..ft.1t !"- ............ . .

e.-.............. ~

Fig. 19-12 Long.tsrm rest1ls. vlllh lh9

cisapporaniiCO olll'los DA-8 and

~
E

v
0

()iginal Z-epk:anthoplas~

l.lodif.ed Z~nflloplasty

Flg. 19-13 ThQ OfiQin;ll Z--epicanthoplasly and lho mociliOO Z~thoplasty

DA-C.

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 "dilut ed")

A drop of topical anesthetic. 0.5% proparacaine hydrochlonde (Ophthaine. Ophthe11c) IS apphed CMJr each comea for comfort pnor to surgical preparation and draping Using a 30gauge 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 two 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 1OOmL. ta mixed With 9ml of the 2% Xytoca1ne ) The hyaluronidase promotes dtsperston of t he anesthetic a nd greatly reduces any t1ssue d tstOJ1ton, facthtatmg the
ldenttficatton of ny creaea hne that the p.ehent may have
4

When confronted With a patient with a low threshold for pain , one may s upplement 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 ex cision 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 t arsal border is still covered by pretarsal and supratarsall'l (favored over the term ' presept al") orbicularis oculi muscle, with possibly some
terminal portions of the orbital septum. and the terminal fibers of the levator aponeurosis beneath the septum.

One may use the Jell fingers to slightly retract the upper 1nc1sion wound edge, then aim a B<Me cautery tip (or radiofrequency unit's Empire tip needle) superiorly to transect through
the preseptal orbicularis oculi muscle there. knowing that ahhough the upper incision line is only 2-Jmm above the superior tarsal border, with the upward bewling, the B<Me tip is
aiming at a point above where the septum fuses wrth the aponeurosis (In Asians the orbital septum may join the aponeurosis as low as 2- 3mm above the superior tarsal border.)
The use of the cutting cautery t ip IS in a feather-loght fash1on so as to gently reach the orbital septum. Along the way one may see some preseptal fat in front of the septum. When
the septum over the central one-thord is opened one can see the slightly bulg1ng preaponeurotic fat pad prolapsing through the opening of the orbital septum (Fig. 7. 12)_ Blunt-tipped
Westcott's spnng sc1ssors are then used to open the orbital septum

figure 7.1 Z Aner traversing through the supretarsal orbicularis In a beveled fashiOn, the orbhl septum 15 reechod and opened hortzontoJly, exposing the underlying preaponeurotic fat pads.

The orbital septum is opened along the superior line of incision and the skin-orbicularis-orbital septum flap turned inferiorly along the superior tarsal border (Fig 7 13)

F1gure 7.13 The sb\-orbculere-septal tlap may b& re-tracted Inferiorly to facilitate exp!nure 1oltle preapooeurobc fat pads and tne underlyn!l evator aponeurosiS (upside-down view of right upper lid).

Westcott sc1ssors are used to open the potential space that is present between t he preaponeurotic fat and the overlying orbicularis muscle within the redundant myocutaneous strip.
retrac~ng it with a Blai(s tossue retractor. The central preaponeurotic fat pad is dissected and separated from its fascial attachment to its underly ing levator muscle fibers (t he latter
1S salmon-colored woth wrt1cally oriented muscle striations).
The fat should be reposn1oned. allowing it to fill in the space between the levator and anterior aspect of the superior orbital rim (the supratarsal sulcus).

Occasionally, in patients with very full upper lids. significant fat is seen centrally and in an inferiorly placed position Th1s may significantly abort/interfere woth any attempt to form a
crease. In these patients. instead of mild reduction with bipolar cautery, one may opt to excise 25-50% of the preaponeurotoc fat seen within the surgocal field (Fig 7.14). Wetfield
cautery is used to treat the intra-fat vessels first; then cutting monopolar cautery is used to cut t he fat pad 2-3mm at a time These maneuvers are then repeated It may t ake two to
three repetitions before this st age is completed_ (The fat excision often necessitates a small supplement of lidocaine in the space underneath the preaponeurot ic fat pad )

Figure 7.14 OptiOnal reduction Df some preaponeutoti: fat

~ a patient with dermatochalasis and obrneration of crease should manifest awn a very minimal concawy 1n the supratarsal sulcus, one should not remove any fat, as th1s will

worsen the hollowness and cause multiple redundant folds superior to wtoere one want s t he crease to be. Instead of excision of the lat. one should reposition it supenorty.

Figure 7.15 shows excision of the myocutaneous flap (skrn, orbiculari s, and inferior remnants of septum) along the superior tarsal border. This is carried out by grasping the lateral
end of the myocutaneous Rap of the nght upper hd (or medial end of the left upper lid myocutaneous flap) with the instrument in y our left hand, then using the radiofrequency unit or
monopolar needle tip on cuU1ng mode to cut along a plane between the orbicularis within the flap and the superior tarsal border/ aponeurotic junction_

Figure 7.15 The myocutaneou.s flap is then trimmed horiZoni:Biy abngthe supemr tarsal border

Figure 7.16 Cross-sectiGnaldrawllg of trapezoidal debulklng of the preaponeurotiC platform'" ASIWl blepharoplasty

FLOWER EPICANTHOPLASTY CREATION

OF EYELID CREASE

FLOWER EPI CANTHO PLASTY CREAT ION

OF EYEL ID CREASE

FLOWER EPI CANTHOPLASTY CREATION

OF' EYEL ID CREASE

FLOWER EPICANTHOPLASTY CREATION

OF EYELID CREASE

FLOWER EP I CANTHOPLASTY CREATION

OF EYELID CREASE

FLOWER EPICANTHOPLASTY CREATION

OF EYELID CREASE

~:: Orbiculari s

oculi transition brow to upper

eyelid
Orbital, palpebral, di vided pretarsal, preseptal
~:: Orbital

septum anterior/posterior lame lla

lamella-skin, orbicularis
~:: Pos t eri or lamella-conjunctiva, upper/lower
elevators/retractor
~:: Midd l e lamella septum/tarsus
~:: Anterior

Orbital Fat

Arcus marginalis-confluence of periosteum and periorbita

origin of orbital septum
Tarsus
8-10 mrn upper, 4-5 mrn lower

Mid-face/SOOF Anatomy

-----------__. __ ------------ -------Lower eyelid to

~

" Preaponeurotic fat , deep to septum

Landmark for depressors, elevators

horizontal line through

oral commisure

Upper lid two compartments

MediaLmiddle(largest)
Lateral occupied by lacrimal gland

Lower lid three

Medial , central , lateral

lnf. Oblique separates medial/central

Mimetic musculature
00, LLSAN, LLS,

LAO, ZMa, ZMi

~

Location and quantity of

fat

Lateral canthal angle,

rounding of lids, scleral
show
Horizontal laxity/tone of
lid

Originate from
periosteal insertions
over maxilla/zygoma

+ Best upward gaze

+ Distraction test
7 nun positive for
horizontal laxity

+ Snap test
o spontaneous retum
prior to 1" blink positive
for diminished tone

Lower Eyelid and Midface

- -.----.----.---+ ---------------------- -.---------~ Youth

o sign of tmderlying
bone
Contour eyelid cheek
complex single convex
line
Skin, 00, orbital fat
one unit
o underlying bony
landmarks evident

VOUTH

Underlying landmarks
separate and obvious
Orbital fat
pseudohemiation bulge
above fixed orbital rim
Ptotic midfacial fat
Double convexity
deformity-tear
trough/nasal-jugal line
deformity

Conventional
blepharoplasty
Superior convexity
softened
Nothing to correct 00
or malar fat pad
Time leads to
hollowing/skeletonized
appearance

:XCESS FAT
~EMOVED

AGE

--~-- --~------

Nasal-jugal Line Management

-----~--~----~----- ---~-------~---~---~
~ Two

concept

Fat sparing lower lid

SOOF repo~ itioning

Fat Rep os1 t1 on1ng

--+----

blepharopla~ty

Camou11age mfenor orbual nm

Improve nasolabaal angle and cheek fut pad

Fat Sparing Blepharoplasty

R entrn orbital rat and repair septum
= Fat rcpo>. itio ning filling periorbital
d epress io n

Moc p o putur

T ransconju ncli\ o l/ tron ... c uta11co u s

Pre-,cpwt ptn nc di~<.ccti on
Inc ise a r eu b n1nrg innli..,
t rans po~c to t ovc o rbuot nn1

Fat Repositioning

SOOF Repositioning "

ubpenosteal
p.no,t<>um platfonu h>
malar soft rmue
Z) !IOm:IIICU> m~~>Cie>
advaDCed upward. 1ncrea~
ml<nU."I!ar <hstan<e
., Canthotomy and
<tunboplasl)
~levcue

,. Supraperiosteal suborbtcul
an'
Sevend sh~l modificatiOns
dependul!l on atnhor

bone

SUBPERIOSTEAL DISSECTION
I tt.. '' \ 'tthprul,tt".tl p lant' <'1~"\t<', all o f t he t.i~Mtc vi

the- mirlf.H < n1c luetin~ the pl't; o" l 'utll

SUBORBICULARIS D ISSECTION

SOOF Repositioning

figu Nl 141
fk;t:C

"'r~u:.'it-"oQC1.1bf, ot 't-q '~"~'~euhle.bJige ~

V'<et O'b~ ti"l f~ OS !he- SOOt.

tho ::ieO~I~ Qt.OI

Mltt1"~1

M\5'-1

_.,,rqty ~)) Thl!

JYO;g'\ 1 'J'ii"\SCO"''r; net l'i, oreseJral .ctP~C'l. me
i1t tta rM-er tSPE:t ot tr.u In'S' or aor.- rm cS rr..

~0\bdtTftld-C-J Ol WllllJ~lC J.;,a;,~~

~'"1171

t~~ ~n1 ~ 'l.thtll~'o!i:QI f'l9ta:.,Y' ~ YM nhwwtml

,. .,., tt ()Gfiormo<t 'r~.., *"'~fQ~C!"tl ~ot~H n ~~~

~~~-~ !Jo:..cK'l~ oor~

'~1 ~\ lh.h<tt 4nd

tlt

" ~ 9"o'(t;,.CU~t :) ,,~..... ~

r,. c: ,.,.,"'*tt&,~
us~~~ $4'' ~ tO

mJTtS:~ed M'i~-

rnu ~a lS&JS rw.-o ootn eo

var-ceo J!ID9'rorv ar.d lhe Ot01Nt

~

bt-/b"'

ncrcaoo. cart.eb""

tntlQ, t-h1-" tt".;t, l'lHU'tit't~ n.tu:;\1 I:S

!"''W( f.lJio DO~:o-vttfO~ 'O.l~(ld~l~l"o taf'l'\0 I " ' -

~~

;~

SOOF-lo'"rer orbital
rim itnmediately deep
to 00, surrounds
bodies ofLLSAN,
LLS, ZMa, Zmi
Nasolabial crease
mttscles pierce SOOF
to insert on dermis
SOOF in continuity
'"'ith SMAS

13'1

ronsplantation.
1 cars wishes to undergo l""r t
h
ho has had stable hair loss for the past scvcra y
ti I On examin:uion. he 35
A 55-year:.Old man "
t with administration of finastcridc has n~t bc~n. succc: u . n "X He has dl!nse. curly
Conservauvc m:magcrncn
cia that extends from the antcnor hatrhnc to c ~7 c..
Hafllilton's clasS 6 ma.lc.p~ttc~ alo~the scalp and excellent scalp vascularity and ctasucaty.
hair in the paricto.occapata regaon o
Which of the

. the most appropriate initial management?

ronowmg 1S

(A) Psychological profit~ 3Il~ ~rccning

(B) Trial thernpy with mlll~JOdil. .
.
(C) Establishing the antcnor rnurhnc w~th punch grafts
(D) Establishing the ante~or hairline wath scalp flaps
(E) Sagittal scalp rcducnon
TI1e correct response is Option E.

Scalp reducti~n is currently.thc.most appropriate management of male panem alopecia. 11tis technique is simple and
associated \\1th few comphcatJons. Surgical removal of the hairless scalp will diminish the total area that requires
grafting and ,,;u assist \\ith conservation of donor sites. Although vnrious excision patterns can be used based on
baldness pattern, sagittal excision patterns are preferred because they will remove the greatest amount of bald skin
due to the excess of scalp laxity seen in the sagittal plane. The surgeon should perform scalp reduction before
surgically re-establishing the anterior hairline.

Minoxidil is an antihypcncnsivc drug that has been shown to increase hair growth when applied to the scalp of men
who have thinning hair. Howc\'er, this drug does not work in patients who have extensive hair loss, such as those with
llamihons class 6 or class 7 male pattern alopecia. Although the exact mechanism of action resulting in hair growth
is not completely knovm, local \'asodilation may be cau53tive.
Psychological screening is not routinely performed in patients who request treatment of male pancm alopecia.

~~fer;;':C:atn JC. Tre:~tmcnt of male plttem baldness and postOP--~tive temper.~I b.'lldllcss in men. C/in Plast Surg.

1991: IS:?7 j 790

PiMki JB. llllir transpbnl~tlon and batd-sc:~1p reduction. Dermatol Clin. t 99 1;9: IS 1-168.

2.

The Norwood-Hamilton scale of

e-

cia> male-pattern baldness

. .
. the Hatnilton systeJD of male alo e .
f hair loss at the anterior hrurhne and
What lS
al
. . based on th a~pearance o
of male opecla IS
h . I
.
Hamilton dassificanon syst~ .
din the ten rial for further rur oss. _ __
th
It has seven dasslficanons regar g

el~e:::air loss

2: mild temporal

recessi~n

2A: frontal recession-lruld

3: moderate temporal recession
3A: frontal recession-moderate

'- \;_)

v - _lA
\;,_,)

Class 4

Class 2

Class 3
T"e

~ Soo>e

3V moderate vertex loss

d
ral areas
.
. . ~lvement of the venex an tempo
4-6: progress1ve 111 ~

of frontal and vertex reg~ons

SS
I
I
7: compete
o

Class 5 Class 6
- --

a\~

Norwood Classification of Male Pattern Baldness

~e
m c~o
II
~e
m ~0
II
t~e
II
~e
m ~0
II
~~
II
~0
m ~e
II

CLASS 2: Recedi ng Hairline

CLASS 3 :Generali zed Frontal Thinning

CLASS 4: Frontal Area & Crown Balding

CLASS 5 : Top of Scalp & Crown Balding

IJ

~0

CLASS 6: Extensive Hair Loss

II

~0

CLASS 7: Severe Hair Loss

Classification based on density of hair over vertex of scalp

The Ludwig Scale for IFemale Pattern Hair Loss

(Androgenetic Alopecia)

Grade 1: Mild

Grade II: Moderate

Grade Ill: Severe

Figure 1. The Ludwig scale for Female Pattern Hair Loss (Androgenetic Alopecia)

Ludwig Classification of Female Pattern Baldness

Generalized thinning with discrete areas of

alopecia in the frontal and crown vertex area.

Type 2

Global diffuse thinning without discrete areas

of alopecia .

Type 3

Frontal temporal recession typically seen in

male pattern alopecia.

Type 4

Scarring alopecia

Typ,e 5

Medical and hormonal causes (usually not

surgically treated)

ateral

1 cmporopanctal

Occlpllal ( 11'0) A
Jun
' KA
Prcauncular

I rcc flap

 Okura, 1939
Orentretch, 1959
Punch graft
Stnp graft
Fo1hcu1ar-umt graft
8

Setl8Ceoas 1. nd

SuboJ

Folllcu r unt1 m crogral

(1 nr :> Nlirll)

Fo itular Ltlil
(~O

gmf
B i~

eous

138

A 56-yc~-old man has the findings shown in the above panoramic radiograph. lie has a history of malignant skin
tumors since childhood. These findings are most consistent with
(A) Bazex syndrome

(B) dermatofibroma protubcrans

(C) multiple seborrheic keratoses
(D) nevoid basal cell carcinoma syndrome
(E) xeroderma pigmentosum

The correct response is Option D.

This patient has findings consistent with nevoid basal_ cell c_arcinoma syn~ome, also kno~n a.~ Gorlin's syndrome.
This autosomal dominant disorder initially presents dunng clnldhood as mull1ple b~s.al cell c~1thehomas; other finding.s
include odontogenic mandibular cysts, palmar pits, bifid ribs, vertebral abnonnn.hues, a?d mtraeranial calcifications.
The scalp, face, neck, and back are affected most frequently. Management cons1sts of sunplc excision of the lesions
and frequent follow-up examinations to monitor for recurrence.
Manifestations ofBazex syndrome, an X-linked disorder, include kinky hair, hypohidrosis, hypotrichosis, and multiple
basal cell carcinomas. Dermatofibroma protubcrans involves the development of a hard, raised, fibrous tumor in
patients ages 20 to 40 years. Although local recurrence is frequent, metastasis is rare. Seborrheic keratoses arc
sharply circumscribed, benign, waxy papillomatous lesions that have a ''stuck on" appearance. Xerodenna
pigmcntosum is an extremely rare autosomal recessive disorder first seen in childhood; it is characterized by epithelial
neoplasms, photophobia, premature aging, and freckling. 111is condition is caused by a defect in the DNA repair
mechanism of ultraviolet photodamage.
Rtifutns
I.
2.

Gorlin RJ. Goltz RW. Multiple nevoid basal cdl epithelioma. j3w c:ysts, and bifid ribs: a syndrome. N Eng/ J Med. I960;262:908.
Rayner CR. Towers JF, Wilson JS. What is Gorlin'ssyndrome7 The diagnosis and management of the basal cell naevus syndrome, based
on a study ofthinyseven patients. Br J Plast Surg. 1977;30:62.

Multifocal dermatofibrosarcoma protu

139

A 45-ycar-old woman who underwent bilateral augmentation mammaplasty with silicone gel implants 20 years ago
has developed capsularcontraeturc involving one of her implants. She is concerned about the integrity of the implants.
Ultrasonography suggests introcapsular rupture of the implant.
Which of the following is the most appropriate next step in management?
(A) Observation
(B) Level-two ultroson<>gr.~phy
(C) MammogrJphy
(0) MRI

(E) Surgery

The correct response is Option E.

Tilis patient who has probable introeapsular rupture of one of her 20-ycnr-old silicone gel implants requires surgery
to remove the ruptured implant and periprosthcticcapsule. Test characteristics (sensitivity and specificity) nnd implant
rupture prevalence have been used to calculate the probability of rupture for various patient scenarios. In
asymptomatic patients, the pretest rupture prevalence is estimated at 6.5%. Ultrasonography should be used~ .an
initial diagnostic test because of its relatively low cost. If screening ultrasonography ~hows no rupture, the probablht)'
of rupture drops to 2.2%. No funher work-up is necessary. If ultrasonography suggest.s rupture, the rclati\'el)' low
probability (37.8%) of true rupture requires a confirmatory test using MRI.

Breast ultrasound
Ultrasound may demonstrate a snowstorm appearance of an extra-capsular rupture, or the stepladder sign
of an intra-capsular rupture (a normal implant should usually be anechoic). At the time of writing (2010), the
overall sensitivity and specificity rates on ultrasound are thought to range between ~ 59 - 85 % and ~ 55 . 79 % respectively 7
Breast MRI
Considered most sensitive for detection of implant rupture. Often does not required contrast if the indication
is solely for this purpose
Non-contrast MRI may also be able to distinguish between silicone and / or saline implants by using silicone
or water only sequences. With the use of multi-planar imaging, MR may also be able to distinguish between
radial folds or true ruptures. A 'linguine sign' may be seen which is specific for an intra-capsular rupture is
due to the free floating shell within the implant. A gross extra-capsular rupture is evident as free silicone,
separate from the implant, which has extended beyond the implant capsule into the breast or axilla. Free
silicone has an increased signal in T2-stir weighted sequence without any enhancement in T1 weighted fat. suppressed sequence
The "salad oil sign" has also been described in a double lumen implant rupture, where there is mixing of the
.saline and silicone, although this on its own is non-specific

sreast MRI stlowing the linguine sign indicating intracapsular implant rupture.
li ngui n~ sign Jtle: linguine: sign is one: of th!: imaging signs of intracapsular
rupture: of a bre:ast implant.Afte:r implantation of a silicone or salin..:

MRI demonstrating a ruptured silicone gel implant

Images from a breast MRI demonstrate both intra- and extracapsular

rupture

lntracapsular breast implant rupture - "Water droplets

within the silicone phase leading to chemical shift artifacts
are indicative of a silicone implant rupture. "A breast
implant rupture is a recognised complication of a breast
implant. It can be intra or extra

lmagos from a breast MRJ demonstrate intracapsular rupture

Extracapsular breast implant rupture - "Silicone granulomas mending beyond the

fibrous capsule."

Breast MRI "Breast MRI is a rapidly growing fielc, especially in the assessment of
high risk women.

Short tau inversion recovery (STIR ) also called

short T1 inversion recovery is a fat suppression
technique with an inversion time Tl = T1 ln2
where the signal of fat is zero. This equates to
approximately 140 ms at 1.5 T.
To d ist inguish two t issue components with t his
technique, the T1 values must be d ifferent. FLAIR
is a sim ilar technique to suppress water.
Inversion-recovery imaging allows
homogeneous and global fat suppression and
can be used with low-field -strength magnets.
However, this technique is not specific for fat,
and the signal intensity of tissue with a long T1
and tissue with a short T1 may be ambig uous.

Collapsed breast implant shell - "Sagittal T2-weighted images showed a

collapsed right implant shell with silicone extravasation into the fibrous capsule
Transverse STIR images also show the intact left implant fo r comparison.

140

A 25-ycar-old man has complete loss of the upper two-thirds of the right ear nvo years after sustaininn a bum injt
to the car. On cxaminat.ion, the car lobe an~ lower part of the concha! cartilage arc viable and have ~dequatc s~i~
coverage; the car canal IS open. Scarred skm surrounds the car remnant.
Which of the following is the most appropriate operative procedure for correction of this patient's dcfom1ity?
(A) Creation of the upper car with a rib cartilage framework and coverage with a local skin flap
(B) Creat~on of thc upper ear wi_th a ri.b carti!agc framework and coverage wi~h a pre-expanded local skin flap
(C) Creat1on of the upper ear w1th a n b cartilage framework and coverage w1th a temporoparietal fnscial flap
and a split-thickness skin graft
(D) Creation of the upper ear with a Silastic framework and coverage with a local skin flap
(E) Creation of the upper ear with a Silast:ic framework and coverage with n temporoparietal fascial flnp and
a split-thickness skin graft
The correct response is Option C.
Titc most appropriate surgical procedure for correction of this patient's deformity is creation of the upper car using
a rib cartilage graft and coverage with a temporoparietal fascia flap and a sp.lit-thickness skin graft These procedures
will most likely result in a satisfactory outcome for this difficult reconstructive problem. The rib cartibgc can be
carved into an appropriate framework and covered with a thin temporoparietal fasci~ flap~ a thin ~plit-th ickncss skin
graft can be used to create the intricate detail of the external ear. When successful, thts reconstruction will be durable
and long-lasting.

..~constn 1 cli o n. howc vl.!r,

when lhc

<;M

rcmu;mt j

I
I
r I . . classic nncrolm
.
it wHi no\ stre tch m'Lctlu~tlc y In C<Wcr t 1e h mm;wtJl~
1 k.10 1~ tllc C0\1$l~C m~rcria~ o c 1~l lcc ~ '
. L:

11

I_oea !>
"'

~ 1 nJticnl w1th n bum lllJ Ury.

u.rrouJKlod by sca_rrcd 'kn. as. 10 1 l~s ,. .
,
cam.'tl !ikin expands poorly.
:Jntl shO'-'' dc~ail. Skin,c~p;tnsJon \\,dl fml b~:.msc s

i n~ Uc-causc even the mo:-.t mmnr lwuma or

g lusl
.
.~~
1 rerults but aN nor 1on,_

.a h
.
SiJ"'"ic frnmcworks c;Jn gm: gvvu c-:lr. Y ~
Silll.'ili,c fmr.~ncwork.~; m:: nul a uoo(J c oJcc ffr
wound problem can lcad to Cotnl l"'ss or lhC n;cOUSlnJCllOU,
reconstruction.
F.)'

formitv. Bunrs. 199";:!4:(1'6I ~Ci 70

8t.Jnd;;;n J'S Tout a r r~o:n-..trucnoo m ~1 bum ck
l
Cj
n l'hiladi:l tJhi11, Pa: WU S<t~tndWI Ct; 1 9?0t3:2rtJ4.2.J~2.
flll't'flt R. ReMt"ru;tnm ofthe .~tiJndt. In' MrCanh>J(1,c-d. P ,U1!C. IIJR'L'
- '

Rt/rf'VK:''J
1.

l.

skin
Deep temporal muscle fascia
(TEMPORALIS FASCIA

subcutaneous tissue
SMAS

(SUPERFICALTEMPORAL

(TemproparietafAta~c ia
...,,.._
Superficial-~~

fat pad
(Temporal fat

:zygomatic arch
Deep
fat pad

--.. . .f!o
- --l-la t

(Buccal fat pad)

...,.+--

loose areolar tissue

Superficial tempor~l
vessels
Frontal division of
Temporal Br of VII N
(Temporal branch of facial nerve )
Feclel Nerve

FIGURE 30.13. Fa bricati on of ear

framework from rib carti lage. Brent
technique, stage 1. A: The base block
is obrained from the synchondrosis of
two rib cartilages. The helica l rim is
obtained from a "floating rib cartil age.
B: Carving t he dera ils into rhe base using
a gouge. C: Thinning of rhe rib carti lage
ro produce rhe helical rim. D: Anaching
rhe rim ro rhe base block using nylon
sutures. E: Completed framework.

Figure 59-2. Rrst stage reconstruction. A, Tlle costal cartilage graft Is harvested from either contralateral or Ipsilateral 6th-8th cartilages
depending on the surgeon's preference. B- E, The framework Is constructed from a base block of the 6th and 7th cartilages, which can be
carved to show as much of the highlights of the lower helical rim, antihelix, and crura as the graft thickness will allow. F-H, Tlle helical
rim is carved from the 8th costal cartilage and Is mounted on the base block, which is further elevated in height with a segment of graft
mounted under the base block mimicking the posterior conchal wall, and addl1lonal highlights are created with grafts su1ured onto the
antihelix. I, The graft Is completed with addition of the tragal portion of the framework.

141
1l1c fitzpatrick s.k in classification stratifies patients according to
(A) actinic ~kin damage :rnd fine \\Tinkle formacjon
(U) lht po1cnlial for pigmr:ntuy changes following chemical peeling
(C) 1heir ri&lc fnr C3rdi~e toxicity associated with phcnoi peeling
(.D) 1heir riM< for h}'f'Cnropl1ic scarring following skin rcsurfhcing
(EI lhickll4.~ and laxily off:lcial skin

TIc conccl response- is Opli on B.

r:ittrlaliic:k'J<i li.Y~>1cm h~ thC' nwo,t ,,idely 11!i.4.~ method for cllossifying palicnlS according to skin type in order to :;trJtify
rhdr ri. k for the dc\'dflllllllCflt of postinfulmm:~tory hypctpigmcntation following chcmi<:11l peding and lasc.-r ~kin
rcJurfal:int~
method nf da!oos.iflcalion iF> based on the pal icnt~~ skin pigrncnlation Clnd ~-uhliicqucnl rC1ipon~c
fo11nwing c;.;posmc to uhru\'io'lcl light A t=t'blc rcprc~cnLing this clnssification system i; ~hown bcJow.

-n.h.

' kit\ T)pc

Skh\ Color

Charuterlslic~

\Vhitc:

Always hums, ne\'cr mns

ll

Whit~

White
Whj1.:

Usunlly bums, t:tns tess than r~~vcmgc:

Sometimes mildly bums, tans ~bou1 (lvcragc
JUrcly bums, tans more lhan avcmgc

JV
V
VI

l~rown

Black

Rarely bums. tans profu~dy

Never bums, deep pigmentation

Palic-nl~ who ~ta\'C Fit~:urick ~e I, type 11. or type HI skjn have the lowe~ risk for dcvcloprncnl of
~ypt:rpt,gm~ntal~.ou :~oUown1g chl!mu:al peel mg. ln COiltr.t-.;t, palicnts with type IV, type v. or type VI c;l:in arc at
mcrcascd nsk tor pigmentary ch:mgi!s.
llt'/~~nc~s

:!.

Rubin fi.'IG. cd. Mamml ojClr~mlrol P~tiJ; Sr!fx-rjlt:ml and Mc:dm;1r fJrptJ PI 1 cl 1 h~

Snujn JM. Phenol pe~l i"~ and lhe histQI)' of phenol "'' elmo {I PI . ~ 1141 c Jl Ia. l'a: JH Lappmcolt CtJ; 19'9S:J.
t'"

O>'

/It

fi.Tl J lff~,

1 9%~:!5, l-l'J,

OLIVE
UGHT

FAIR

i l l MEOIU
I

.,...,

..,

A 42-y
1-42
. car-()1d woman who d .
Wluch of the followin g responses
esrres_co~TCC;tion
.
IS most likeof periornl and pcnorbital
m id .
(A) H
.
.
ly 10 b<""' ;, oh potion/ ' ypcnnchosts

"""py w;11o 0.025% """";n.

(B)
l"""'
Ill co11 agen
C) Increased
p .
JY(
am a!-thickness b
(D) Subcutaneous atro
(E) Thinning ofthe d~

u:

The correct response is 0 pllon

. B.
Histologically, long-tcml a r .
process is believed to be ca pp ~calion of trctinoin resultS in the f,
'
resultS in obliteration of a
by activation of fibroblasts This
of new type Ill embryonic collagen; this
0 oso~
l)'JM and microsc .
.
.
nv:uwe
t o. Improvement of m ids .
.
actmic keratoses when a liofvitamin A.' also known as rctinoic acid,
becomes markedly
aO:
occurring instead
12
at a
of0.025% to
levels of as much as 80o/c Ad
e elastu,.,ty of the skin gTCllt!y increa
h I on . Dunng thiS time, de dennis
the onset of a sunburn
verse effects arc frequent and may
to :m
in
on.
ema,ispcchng,
xerosiS, prurirus,
3Dd

:~t,~n

o~tc
tlliekc~ ~ot unm~mte,

overs~o o~ce :ly strc~glh

sc~ati

inch~:;~;.h:mer du~

incr~ase coll:~gen

"
WIUJ
therapy.
..... trctlDOm
. .
Use of rctinoic acid docs nor affect Itm
. growth or loss. A p3rtial~dlickness bum is never associ"tcd

llifums
, .
ed. ~t.as1trry ofP'
orrd Rtrronstructfl't S
.
.
l. Cohtn
M1\M,
2.
KhSif\an
Grme GL, ll"'''lc
irO$' R
.t Co: ~
199-1:31?97
l9S6;
1 ' fmBni'An
clal r,....
.,.ttJII Lrt1 .mom ror Boston.
plt01oa~:cd .~in Uute.
ti((Ad ..,.,rmat<N.
"
lS:&l6.

~try.

!113..~:

"""
ff"'''
tdi~nces.~tal
ould

Isotretinoin
'1>0
T"rinom Is a rcHnold. It i> the add fom of vu.,nln A. tWi'rcrinoln ;, given by moulh fn< lhe tn,.tmenl
acne, tftnl hn< not mpond<d to olh" "'""re<; It Is not indl"'"' for uucompH"t<d adolescent""'

lsoTrednoin has also been tried in a uun1ber neoj>la~tic disease.

Sldc
,,;mn" to ,;o. A; dryn<>' of sk;OW;th s<aHng, rragilil), ehemns, P'",;'"' epi>lox;.;conjuncliv;ds, dry"'" monlh, and patmo-planlar edoUatinn. Co"' npa<lri<S, dry eyes, visual
hyperostosis,. Elevation of serum triglycerides, bepntic
__
t C/1' dor;ng Pr..,"ney & who " ' plain to be pregnant " II is Mghly Ocral...,;,, fls use wllh v\lam;u A
be '""ided ""'""of add;livc toxic cffocls. -,Tct<acycllnO> w;oh ISoTrCrinnln .,,.,cinl<d wllh bcn;gn

enzy~s~etc

ntracranial
ose: For thehypertension
topical treatlili!irtofacnc a geicontaining o-:-oso/o3PP\icd sp:wingly once or twice daily. A

therapeutic response my.y not be c~t for 6~ ,~ks

_ ~ _ ~__
\l>i>i"
0.5 mg./kg. d;,;dod ;non 2 Dn>" doUy for 2-4 months - ;r no hnprovomcnl '"" 1 month the Dose
~eased
:L.---~
lsotm _to 1mg'-=Jk.;;.:.o~..,
_11,~%
30 ----ogm gcl -_:r 14.0~ '1-. _
St;fcl_ P,~TroHnoin Ill_
-~
oTrotlnoin tO
I~ cap
33.00 TcchnoPh.rm 11'"1 lsoTrotino;n 10
oTretinoin 20 _
10
ctLool
20

Nctl~ook

~ok

...,.

~ ~~~ccutene
10
Roaccutene 20

I f"~PI~,,.mmct l l'i<~

= 1 caps:_.. 50.00
20 caps
_ 60.00
20 caps
100.00
_
l ts4.00

~P.!.

20
lsoTretinoin lOmg.
AI-Andalii'US lso'l'retinoin 20mg.
M-Aiodoiou, - - rsoTrCHnoin40.... _ __
Al-andalous

=
I

ho

_ 38.00
~Caps._
Ro~gydrug tho"f'rc~ ~mg"--~ _
30Caps.
240.00_L Rochc/Egyd~- lsoTrctinoin 20mg.
1

E-R~tiu

pnducer

Misr

Form
Cream

Composttton
8

_ _

_____._

Tretinoic acid
---~~~
-

(Topical & Oral} ~~~ ~ J.!Y..J fo - &~ ~

-~~~~-~-~~~-

-~~~~~~~~~~~~~~~

A~plied at night & washed norning- for the treatment of acne vulgaris.
lA erse effe<t>: Tretinoin is a skin hritant. may cause transitory stinging and in normal use it produces som-:l erytbema and peeling similar to that of mild suobur. Excessive application can cause severe erythema,
~ peeling, and discomfort with no increase in cffkacy. Photosen~itivity may occur
PrecaurWis: Tretinoin \s contra-indicated in pregnancyancfliibreast-feeding motners.
--rAcne-Free 0.25% 130gm. Ge\ I 3.90 ~,~
,t..~n - \ Tretinoin ().~

I~60

- --

Amoun
fTre~noin 0.5% - - - - - - - Amoun
_
Treb~~-l% _. ..,.------30 gm. Gel
7.00
Sigma Tretinom 0.025%
Acnetin-A 0.05% 30 gro. CreamL 7.00
Sigma _ __ Tretinnin 0.05%
1
0.5cYo
lSgm. ~- 7.00
Jamjom/Saudi Arabia
Trdinoin 0.5%
Acretin
~cretin 0.25%
Cf!_am I 8.00
Jamjom/Saudi Arahia ! Tretinoin 0.25% Effederm 0.05% 50ml. lotion
85.00---l- C.B. Dermatology-t>aris Tretinoin 0.05%
E-Retin
20m!. lotion I 8.00 I
M1sr
Tretinoin +Erythromycin
-oJ>5% 2Qgm. CreaDll TretinoinO])S%- dyna
0.05% 20gm. Gel ~ _l 3.20
_L_ AlexJ:Nordmark
+Tretinoin 0.05%,
~cid - 1 20 gm cre3 m 12.95
"l:CC
Retinoic +Chamomile+ Lemon+
Salicylic + Do):ycyc_li_n_e_ _ __ _

I Acne-Free 0.5%_ j JOgm. Cream

~Acne-Free 0.1 '\-!.

Acnetin-A 0.25%

~oluHou

j-00

rm-

~dyna

H~--A~!Nordmark

--~
------

Rettil-A 0.05%__ JDwm- Creim \ 19.30 !

LRetin-A 0.025%~ 30gm. Gel
f!-35 I
l Vivi~
= l SOgm. Cream___!9.00 l --

ITretinoin 0.05 o/.~..,._

Janssen!Sofcco
Janssen/Sofcco
_ _ Spectra

_ _ _ ___

Trctinoin 0.025%
Tretinoin 0.05 %

Ac'ncr ......

Free

APPLICATION : App lied at night & w ashed moming . for th e treatment of acne v ulgaris .

Acu e-FI'ee
producer

AJttoun

Form

Composition

Tretinoin OD25%

30gm. Gel

I[ Price

3 .9

Acn~Fl'e..

producer

AmolDl

Form
Soluti on

Cmnposition
Tre1inoin 0.1%

Price

4.6

Acnetin-A

Acuo-Free
producer

Amawt

pruducer

Sigma

Composition

Form

Form

Trefuwi.n0.5%

JOgm. Cream

C omposition

30 gm. Cream

Tretinoill OJJS%

Aweliu-A
producer

Acl'etin

Sicnu

Form

Composition

30 gm. Gel

producer

Jam.joom.

Tretinobt 0.025%

Form

Composition
Tretinoill 0.25%

15gm. Crea m

EITedenn

CB . Dennatolo;:y-Paris

producer

Form

Eutly:na

Composition
Tnti.Ju:li.JIO.OS%

50ml. lotion

85

pruducer

Nordmark/Alex.

Composition

Form
20gm. Gel

APPLICATION : Arlplled a! ni!Jhl & washed III0111h19 . fo1 !h e Tr eatment of acn e vui!JlUis .

Tretinoill OJJS%

3.2

Euclyn:.

FoTm

17ril

Composition
TretinliaOD!~

20 gm. Cre am

APPliCATION : Atltllied at night & washetl rnoming - fo tthe n e atme nt of a cne v ulg<uis .

3 .2

ltis a nisom e ofT e tinoin. ns e dinth e lr eaTrne nt of a enevulgarls .

pred111Cer

Stie&.l

~----~F~o~r~m~-----L----------~C~~n~p~o~si~ti~o=n----------~~
30 g m. Gel

14

DOSE : 0.5 mg./kg. divided into 2 doses daily for 24 months - if no improvement after 1 month the
dose increased to 1mg.!kg.

C/1 : d1uing PH! gnancy & fo1 lallies wh o ;u e plain to be

p.e gn<~ nt

Roaccu tene

be cause il is h ighly IIHatoge n ic: .

pl'Oducer
DOSE : 0.5 mg./kg. divide d into 2 lloses daily fo1 2-4 months - if no
dose inue asedto 1mg.lk!J.

illlfii DVe m e lll

RDe helgyDrug

afre 1 1 momh the

C omposition

Form
30 Cap.

pt'Oducer

Al-AJula.lous

lsotreti.noin. 40mg.

20 caps

Bor; Phanttaceutical btdustries

Form

Composition

Form

154

Composition
Retinoid as AdapaleM 0.1%

30 gm. Ge l

producer

Pierre Fabre/GNP

l\<bre)Tl

Form
Form
15 mi. lotion

Composition

30 gm . Cre.1m

Tretinoill 0.1%

7.5

APPLICATION : AI'Pii ed at night & washed morning . fol' the tr eatment of acne vulgaris .

producer

Ja.nssen!Sofeco

Form
JOgm. Gel

10

MaiJialene

Loc:thet
produce.r

::!-10

.Ad a(! alene

NetLook
producer

Isotretinoill20mg.

Composition
Tretinoin OD25%

18.35

Composition
Retinoid as AdapaJene 0.1%

n cases of horizontal laxity of the eyelid, surgically shortening and tightening the
eyelid in its horizontal dimension, usually via a lateral tarsal strip procedure

Hyefresh eye drops

Table 3 Preoperative Identification of High-Risk Patients

1. Dry eye syndrome
2. Thyroid disease
3. Lower lid laxity
4. Negative vector
5. Scleral show
6. Previous facia l trauma
7. Previous facia l surgery
8. Psychological issues
9. Unrealistic expectations

Figu r e 1 No rmal almond-shaped eyelid, including normal margin

reflex d ist ance, lateral commissu re 1 to 2 mm h igher than medial
commissure (arrow), t he upper eyelid highest point just nasal to the
pupil( *), and the brow position higher temporally ( d iamond) .

BC

Fig ure 3 (A) The d inrac tion test is performed by grasping the eyelid and pulling ant eriorly, Lower lid la;~~.it y Is present if the distracted di_stanc~ is
g reat er than 6 t o8 mm. {S) The snap-back test , which is used to assessorbicularisoculi f unction and lower eyelid tone, Is performed by d1sp~ac1ng

the lower eyelid inferiorly toward the orbital rim and releasing the lid. A slow re tum o f the lid is indicative o f decrease d lid tone. (C) Pat1e nt
present ing for revlsionallid surgery with evidence of severe lagophthalmos secondary to upper and lower eyelid retraction after an overaggressive
upper and lower lid blepharoplastv.

Figure 5 Following topical anesthetic, the Schirmer's strip is inserted

at the lateral limbus and removed after 5 minutes with the normal
range being between 10 to 15 mm.lfthe test is significantly less than
10 mm, then the patient has evidence of dry eye syndrome secon dary
to tear hyposecretion .

B
Figure 4 Lower lid retraction is d efined as in ferior malposition of the
lower eyelid margin without eyelid eversion and is diagnosed by
placing upward traction on the lower eyelid. (A) Normally the lower lid
can be displaced to the midpupil or above. (B) The vertical d isplacement of the lower lid is restricted in this pa tient with evidence of lid
retraction, scleral show, and lateral canthal dystopia.

Figure 2 (A) Patients wit h underlying brow ptosis may have evidence
of f ronta lis muscle contraction to raise t he brows se<:ondary t o
underlying uppe r eyelid ptosis o r sign ific.ant de rmatochalasis. (B) To
d iagnose and unmas k brow ptosis, manual p ressure is applied to t he
brow region wit h t he patie nt looking in p ri mary gaze.

Horizontal Eye Lid Shortening

Synonyms
Lateral Tarsal Strip
Lateral Canthoplasty
Definition
In cases of horizontal laxity of the eyelid, surgically shortening and tightening the eyelid in its
. horizontal dimension, usually via a lateral tarsal strip procedure
Indication
Horizontal eyelid shortening and tightening is indicated when horizontal eyelid laxity is present, often
in combination with involutional ectropion, involutional entropion, and/or floppy eyelid syndrome.
. Horizontal laxity can be diagnosed clinically by utilizing the snap and distraction tests
Contraindication
Any shortening of the eyelid should be conservatively performed. Aggressive resection of tissue can
. cause problems with secondary rounding and phimosis of the lateral canthal angle
Techniques and Principles
After the degree of horizontal eyelid laxity is determined with the snap and distraction tests, surgery to
horizontally shorten and tighten the eyelid is undertaken.

HYFRESH - JP OPHTHALMICS
Jamjoom Pharma
(Sodium Hya.rumnate 0_.2%)
ste e Ophltla1J'Iic Solutiorl
COMPOSITliON
EactJ m1 oootains::
Ac1bJe: Sodium Hva1LUOna: e.: 2.00 mg
Preservative: Sodium Ch1orite (s.tabi~d)
Excipients: Hydrogen PeroxiE, Sodium Dfhydrogen
Phosphate. Sodium Chloride and Wata for ~ njecmn_

DOSAGE AND AmiiNlSTRAllON

lnsiiii 1-2 drops mto ltle 0011juncthtal sac of 1he
eya(s) as otten as needed or as directed by 1he physiciarl
STORAGE
store at 15~-25'\C_ Should not be used more than
ooe month after opening oi the bottle.

mESENTAlilON
Hytrestl Sterfle Ophthalmic so1u1ion] 10ml in LOPE
PHARMACOLOGY:
Hytresh contains a hi;hly ~ s~c trarnon of bottle_
SIJ(jum hyaluronate. Sodium hyaluro:nste is a natura1
pllvroor. which is a'lso present in ttJe structures of ttle
IJirulln eye_Its main physica1 chaladenstic is 'risroelasticity.. This means lhat 1-tyfrestl has a rug~ \lis<Dsity between tllirlks and low viscosity during binmg
ensuring efficient ooa~ng of lhe surfare oi ftte eye_
lt1is protective coaq ot the SlJJfare of the eye helps
prevent dryness aoo irrnaoon.
Sodium hyalUJOC'late also possesses mtJCOadhesive
properties and lhe abDmy to enticf water, filus resemtf g tear mlDJS glycoprotein. lllis, together !Mth 1tle
mating properties of sodium hyaluronate resl.llfs in an
maeased pm-comeal residefloe and tear f[]m breakup ~me iYid lheretore longer lubl'i:afion of the corneal surface. Hyfresh has been uniquely form1Jia1ed to
maintain its vistoelasfic properties.
INIJICAlitONS
- De;'' Eye Syndrome
Sensation of dryrJess and other rli.nor comp1aints of
n.o pafttological signi'ficartce. Sllld'l as blJming and
OCllllar fatigue induced, tor example. by dust smoke.
mya1mosphere. air-conditioning extended computer soreen use_
ICONTRNNiliCATION
H~nsmwy to any i~enf

WARNING
Not tor injection irlto the eye

ot this p.rodUct

1.44

Slx month~ aftf't' lmdergoing h~a:tc:ml otoplasty for correction of promrne11t tars. a 27-ycar.otd m:m lias rtct1rre11t
!Prominen~ of the upper hlilfor th.c left ~ar. At tbllow-up ,cxmni.n11tion (ll'lt month a.flei surgery. the em II()]J~red
symnu!bie. Which of the foUowiog is tbe mostl.ikely cause ofthis patimt' s rOCllNent cfeForrnity7
(.A) Di~ruption oftbc tOtH.:ll:1.1l-f'll~l~id sutures

(B) Disr11prion ofllE rurures wed to create the anta1el1cal f&ld

(C) fn~dcqonte excision o{ cartil.:tgc: :hom tiE fX!locha
(D) Inadequate excision of skill 1Kun llle po,sticr ear
(E)

MCOITect pl:~ee~Ctll of tb~ J'4lSl'O~ive

dressii"'Jl;

The m(J5t lik~ly c~u:!ic oftMs .P~tien1's Ne\liroli1t pf'Qmincoo( ofthe upper tulf of tile left ~::~r is iua.d~uare plactm~11t
of su~ ~LR4 in the creatiOJl. of the ~ntihel)Cil tOld. Lru::k (]f fonmtiou of the- antml1e lie:sl fold is: one of the rnosm
common causes oi' pruninent ean. SPrrgica1 CM~tion ofthe (o1d cnn br;: accomplislu:d \'lt'htl p!l'mUJJ.Cill ~11t11.res [Ill one,
carlilagc :L1c[slon or J'C!C(m\on combined with SUtl.Jrcs.. or ab11smn of the la'"e111l ear cnrdla~ with or ,,ithout sutures.
\Vbcn l!.lsed alnnl!, ~urures. are usually vayeffo:twe in 1be cromion ofth~ :untibencnl fo~d ;,1 cbildrm l)ecaLMe Lhi!irear
camlagc:: is .soft and plii!i'b1c. In adults, who I:R!ivc: I~ ()liable cartillllge, sutures can ~ u.std ::Jio11c co cTcni'e a fuld. btl
frft1Uet1d)' oH.er leehn;qts must be performed to allow rhc carti I18J! to be-nd \Vhct'll sutrne~ are u~d al:lne. lht~ nm~
be pC!!mMictll nnd prcci:sdy pi~ or re1npsC' c:~n occur.

or con chal co.rti Iage. ski 11 resect10 0 1-- . ,

.

ORflll'!l~ti\'O
~$W~
"
'h
~
.
II
.
I
'
(JCC'Illc:nt o1 concJla~fllaJimt.l su!un::s. !ml p)acelllfnt tlf 1hP.
P --r
_, .Itc o VI IJ nspccts ol otnnJast ~ . .
.
I
l"t.. I
L_
l d .
rooummte oflhe detbmlityt'htln lhe.1 :ld -
~~ - ~ or prorn1nuu a~n, oro ~:'1 111'C y to V'-' tJJvo Yc Jn
w[~t reclln'ert:e of the ddonnil)'.
n aq~t6 ~l"Clltl.on tJu anli he Ileal rokJ, wh i~1 ~s t1to:H eom monly nssccl3t,od
Kciion

or

Figure 27-9 Mustarde's suture otoplasty technique. Posterior view of the auricle demonstrating suture placement in
the mattress suture technique of Mustarde. The sutures must
be placed through cartilage and anterior perichondrium but
not through the anterior skin. They should be placed close
enough together that the ear does not buckle when they are
secured. Dimensions cited are from Bull and Mustarde 14

Mustarde (scapha-concha) sutures produce or increase the antihelix fold

produce or increase lhe antihelix fold when the fold is absent or underdeveloped.
Sutures bowstring from lhe scaphoid fossa or triangular fossa to the posterior ~ 111aD. In Kaye's modification, sutures
are placed from the anterior approach lhroug'h liny incisions.

~~concha ) sutures

FIGURE 30.5. Otoplasty techn ique. The combination of a Mustarde scapha-concha) surure, concha )
resection w ith primary closure, and a Furnas conchal-mastoid sut ure. Note that the concha) closure is
at t he junction of t he floor and posterior wall of the concha. A: Surures placed. B: Sutures tigh tened to
create the desired conrour. C: Same sutures as seen through t he ret roauricular incision. (Reproduced with
perm ission of Charles H. Thorne, MD. Copyright Cha rles H. Thorne, MD .)

Fig. ( 1): Diagrammatic illustration of the post auricular

fascial flap: Axial cut view (left) and posterior view (right).
The skin is dissected in a strict subcutaneous plane. The fascial
flap is then dissected off the medial aspect of the cartilage.
The suture knots are then covered by the flap before skin
closure.

Fig. (2): The post auricular fascial

flap. T he flap is dissected (above left).
Sutures placed to create the antihclical
fo ld (above right). The flap is reflected
to cover the sut ures (below left). Note
the excess tissue in the flap that can
be trinuncd. The flap is secured in place
w ith complete coverage of the sutures
(below right).

St e n st ro rn 18 5 su ggest e d marg inal exc1s1o n o f a

portio n o f the h o ri zon tal h e li ' a s a solutio n t o the
pro b le m o f con t inu ed p ro t r u sio n o f t h e uppe r p o le
o f t h e ear . Fo r p e r sist e n t pro mine n ce o f th e lo bule
h e recomm e nds c r osswise scratc hing o f th e a nter ior surface of the h e li ca l tail.

Figure 19. Stenstrom otoplasty technique.

FIGURE 30.6. Stenstrom tec hnique. The antihelical fold is scored. The
cartilage bends away fro m the scoring, moving the helic.al ri m closer
to the head and increasing the prominence of the antihelix.

FIGURE 30.5. Otoplasty technique. T he combination of a M ustarde scapha-concha! suture, co ncha!

resection with primary closure, and a Furnas conchal-mastoid sum re. Note that the concha! closure is
at the junction of the floor and posterior wall of t he concha. A: Sutures placed. B: Sutures tightened to
create the desired conto ur. C: Same sutures as seen through the retroaur icular incision . (Reprod uced wi th
permission of Charles H. T horne, MD. Copyright Charles H. T horne, M D.)

'1583A

Technique of
Furnas

~-'
',

'

'

'

11. 5. 7

Furn as t echnique.

Fig 19 . Luckett's technique for the correctio n of pro minent ears.

(Reprinted with permission from Luckett WH: A new operation
for prominent ears based on tile anatomy of tile deformity. Surg
Gyneco/ Obstet 10:635, 1910. Reprinted in Plast Reconstr Surg
-/-3:83, 1969.)

Converse technique
This is a fairly compli~cated but excellent aesthetic techniqt1e
i[lVolving in(ising, tilobilizing an~d deforn1ir1g cartilage \Vitl1
sutures to ~develop an ant:it1elical rirn vvith p romin~ent
superior and inferior crura.

(b)

(a)

11.5.6 (a and b) Converse technique.

A. IMPROPER SUTURE
PLACEMENT

.,
I

__ _A

Figure 27-8 Concha} setback techniques. (A) The concha! suture technique as described by Furnas. 11 This demonstrates improper suture technique, where the mastoid periosteal suture is placed
too far anteriorly and the external auditory canal is compromised. (B) Correct suture placement in
the Furnas technique. The mastoid periosteal suture is placed far enough posteriorly to provide
adequate correction without compromise of the external canal. (C) The lateral flap technique as
described by Spira and Stal. 12 In this technique, a laterally based conchal cartilage flap is developed
and sutured to the posterior mastoid periosteum.

FIG. 4. Conchal-mas toid suuucs to correct conc ha] excess.

Auditory canal

Concha

\--~'-"-A

'/

~<(If

~J,~~!

Well placed
suture

Fig 21. Technique of suture placement to prevent excessive

forward rotation of the concha and reduction in the diameter

of the external auditory canal. (Reprinted w ith permission from
Furnas OW: Correction of prominent ears by concha-mastoid
sutures. Pfast Reconstr Swg 42:189, 1968.)

before

splint taped ear

Fie. 5. Modified fishta il tec hn ique to correct a prominent

lo bule .
Loss of
antihelical fold

Concho scaphal angle

greater than 90

Ftc . 2. Main causes of the prominent ear.

Increased cranioauricular angle

A. Normal Ear

B. Prominent Ear greater than 40 degree

concha! valgus

efudex=ezadex=5fu

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152
t" hinoplasty is scheduled to undergo rasping ofthe nasal hump and

A 26-year-old woman who d esrres cosme tc r

.
r. ll
r.
r
.
.
.
r. ll d by Weir excisions. Whtch of the 10 owmg 1actors, 1 present, w1ll
1
reshapmg and grafting of the nasa tip 10 owe
(Weir incision (or alar wedge excision
decrease the likelihood of an optimal result in this patient?
(A)
(B)
(C)
(D)
(E)

Mediterranean heritage
Presence of a bony rather than cartilaginous hump
Smoking history of one-half pack of cigarettes daily
Thickened skin with prominent sebaceous glands
Use of an open technique

The correct response is Option D.

Careful preoperative planning is an essential part of cosmetic rhinoplasty and will vary from patient to patient,
depending on each patient's anatomy and desired result following surgery. A patient who primarily desires a smaller
or defined nasal tip but has thick skin and prominent sebaceous glands will not experience the postoperative shrinkage
necessary to fit the altered nasal cartilage framework; consequently, the nasal tip may still be larger than is desired
by the patient. Consequently, the skin thickness should be assessed during preoperative evaluation and discussed with
this patient in order to ensure that her expectations are appropriate.
Although people of different heritages have different anatomic traits and possibly different desires for aesthetic
outcomes, a successful rhinoplasty can generally be accomplished with adequate plmming and input from the patient,
whatever his or her ethnicity.
The congenital dorsal hump is often comprised of 50% bone and 50% cartilage. Although the variation from patient
to patient can be significant, either type of hump may be successfully reduced; however, different methods of
reduction may be required. A small bony hump may be rasped, while larger hwnps may require the use of a saw or
chisel.
A mild-to-moderate smoking history has not been shown to affect rhinoplasty, most likely because of the excellent
blooct t1tlw within the nasal plexus.

?e

successfully used in cosmetic rhinoplasty. Open rhinoplasty

Both open and. clo~ed ~hinoplasty .techni~es can
offers better vtsuahzanon of the ttp cartilage but ts associated with greater postoperative edema and the potential
development of an external scar. However, the type of exposure should not affect the outcome of the rhinoplasty.

References
1.

2.

Daniel RK. Rhinoplasty planning. In: Aesthetic Plastic SurgeI)'. Boston, Mass: Little, Brown & Co; l993:79-1 23.
Sheen JH. Closed vs. open rhinoplasty. Plast Reconstr Surg. 1997;85:99.

Generated by CamScanner from intsig.com

153

A 25-year-old man has ectropion and excesst've

sc1era1show one

a c11emtca
I burn o f t he Iower
year aft er sustammg
n'ght eyelid' which was allo\vcd to 11ea1wit. 1tout surg 1

.
.
.
of the following is the most a

tea mterventlon. He currently uses ocular omtmcnts datly. Winch

ppropnate management?
(A)
(B)
(C)
(D)
(E)

Scar m.assage an~ intralesional injection of a corticosteroid

Full-tluckness skin grafting
Insertion of a gold eyelid weight
Lateral canthoplasty
Lateral tarsal wedge excision

The correct response is Option B.

Ectr~pion involves eversion of the eyelid margin; it frequently occurs in the lower eyelid as a result of the pull of
gravtty on the unsupported eyelid tissue. It is usually the result of mechanical (involutional or senile), cicatricial, or
neurogenic causes.

TI1is patient has classic cicatricial ectropion, which has resulted from abnom1ally healing bum wounds. The ectropion
has occurred as a result of scar contracture of the anterior lamella of the lower eyelid, leading to excessive scleral
show and exposure keratopathy. Full-tl1ickness skin grafting is recommended to replace lost tissue and prevent
secondary contracture. In addition, complete release of contracted soft tissues and use of added suppmting materials
such as cartilage should be considered.
Scar massage and intr.:tlesional injection of a corticosteroid would not improve a fixed, foreshmtcned lower eyelid.
Neurogenic ectropion is best treated by correction of the associated upper eyelid lagophthalmos using inserted
prostltetic devices (eg, gold eyelid weights).
Jn paticnto; with involutional ectropion, there is progressive laxity of the lower eyelid; the lower eyelid retractors or
capsulopalpebral fascia becomes disinsertcd from the inferior border of' the tarsal plate. Conective surgical
procedures include lateral canthoplasty, lateral wedge excision, and the Kuhn.t~Szym:mow~k! tec!mique, ':hich involves
excision of a full-thickness wedge from the region of the lateral canthus. I he skm cxc1S1on 1s then h1ddcn under a
subciliary incision.

RefuenO!.s
.
1
.
, h S
ski procedure for ectrop1on and lateral cant 10plasty. Am J Oplttha/mo/. 1966;62:533.
I. Fox SA. A mod11ied Ku nt- zymanO\\ .
.
.
, .
..
.
.

fthe C)'Ciids and assoc1ated structures. ln. McCarthy JG, cd. liastic Surge!)'. Philadelphia Pn
2. Jellcs GW, Smith BC. Reconstruction o

WB Saunders Co 1990:2:1737-1752.
.
.
"
'

I'd surgcry and the problem cyelld. C/111 Plast .>urg. 1992; 19:357.
3. McLeish WM, Anderson RL. Cosmetic eye I