Today’s concept of facial rejuvenation emphasizes harmonious natural looking without the stigma of surgery.
Several techniques have thus far affected elevation of the midface through various approaches to anatomical repositioning of tissues.
Currently, however, to achieve the signs of midface aging with a more natural result is entirely related to factors and volume.
Improved understanding of the facial aging process has led to the concept of repositioning volume as a three-dimensional tissue structure mobilized upward in a vertical direction.
Based on this concept, procedures for facial rejuvenation are in constantly evaluation.
Techniques development began with Hinderer, a pioneer in anatomical description of the periorbital region, and more specifically, the nasojugal groove.
He described open surgical techniques for repositioning tissues in this region, via lower blepharoplasty incision. Since 1991, in addition to the periorbital region, attention also turned to the midface, especially with the work of Issue and Ramirez. And also, Graf suggested the endoscopic repositioning of midfacial tissues.
New surgical principles were introduced, such as preservation and repositioning of the periorbital fat, treatment for muscles of the glabellar region, and repositioning of orbicular is muscle and suborbicular is oculi fat (SOOF).
The open approach discussed here, through lower blepharoplasty incision, allows direct fixation of tissues along inferior orbital rim periosteum, respecting vertical vectors, so the upper nasolabial fold and lid-cheek junction are directly improved In order to obtain the desired lower eyelid tonicity and to maintain a natural and youthful aesthetic of eyelid shape, a lateral canthopexy is performed.
Two common and troubling complications of blepharoplasty, scleral show, and ectropion, are greatly decreased as a result of the midface direct fixation and the lateral muscular canthopexy.
The patient underwent local Anesthesia and sedation (160 ml of 0.9% saline solution, 20 ml of lidocaine 2%, 20 ml of 0.5% Marcaine and 1 ml of 1:200.000 epinephrine).
From this solution, 20-30 ml was used in total for the upper and lower eyelids. A sub ciliary incision is made and continued laterally into a crow’s feet line. A skin flap is developed at 1.5 centimeters inferiorly.
Undermining is performed through the orbicularis oculi muscle while maintaining the pre-tarsal strip of the orbicular is muscle (3-4 mm).
Maintaining this muscle portion intact is important for lower eyelid closure and support. Care must be taken to not damage the buccal branch from the zygomatic nerve innervating the orbicular is oculi muscle to avoid postoperative hypotonicity of the lower lid.
Orbital septum is also maintained intact. Mild third elevation will hide a mild to moderate amount of infraorbital fat protuberance. If periorbital fat is grossly herniating, electro-coagulation of the septum will reduce the fat pads into the orbital cone.
In patients with moderate to severe infraorbital fat protuberance fat excision is not performed but rather perform orbital septum electrocoagulation to shrinking and is important for lower eyelid closure and support.
Care must be taken to not damage the buccal branch from the zygomatic nerve innervating the orbicular is oculi muscle to avoid postoperative hypotonicity of the lower lid.
Orbital septum is also maintained intact.
Mild third elevation will hide a mild to moderate amount of infraorbital fat protuberance.
If periorbital fat is grossly herniating, electro-coagulation of the septum will reduce the fat pads into the orbital cone.
In patients with moderate to severe infraorbital fat protuberance fat excision is not performed but rather perform orbital septum electrocoagulation to shrinking and move back the fat pad preventing the occurrence of enophthalmos.
Caudal and supraperiosteal undermining along the inferior orbital rim, toward the midface, under the orbicular is muscle and suborbicular is oculi fat pad (SOOF) is done, releasing orbital retaining ligament following the inferior orbital rim, avoiding going to medial to preserve the angular artery and the buccal branch from the zygomatic nerve.
An immediate lifting of the lateral canthus is observed.
Inferior and lateral to the infraorbital nerve, the pre-zygomatic space described by Mendelson is undermined until nasolabial fold.
Detached midface tissue is vertically suspended with prolene 4.0 and fixed to the periosteum of lower orbital rim in four points; first, medial to the infra-orbital nerve, setting the lowest portion of the orbicularis, and second, central portion of the orbital rim (pupil line), lateral to the infra-orbital nerve, then third, to the inferolateral orbital rim, thus suspending and fixing the SOOF, and finally, fourth, securing the orbicularis muscle to the lateral orbital rim at the level of the pupil.
Four stitches (prolene 4-0) are used initiating 0,5 cm from lacrimal punctum until lateral part or inferior orbital rim (from medial part to lateral part of inferior orbital rim suspending midface soft tissue taking care of with angularis artery), aiming to transpose this descended tissue, to fill up the tear trough deformity and to obtain an effective and long-term result in midface suspension.
Lateral canthus support (prophylactic canthopexy) is a routine component of the procedure, used to obtain the desired lower eyelid tonicity and to maintain an aesthetic, natural eyelid shape. The associated complication rate is acceptable.
Dissection is carried out through the upper blepharoplasty incision.
A submuscular tunnel is created toward the lateral portion of the inferior presential orbicularis muscle. Through the tunnel, the orbicularis muscle of lower lid is clamped and pulled up vertically and medially, anchored to the periosteum of the inferior border of the superior orbital rim.
Conservative resection of lower eyelid skin is performed after assessing static and dynamic tissue surplus (mouth opening). Intradermal sutures are made.
Dissected areas are taped over, to minimize tissue edema and to maintain suspension.
457 patients underwent surgery between 2004-2016, 373(81.6%) women and 84(18.4%) men, between 36 and 79 years old, mean age 51 years old. Seventy-five percent of these patients underwent primary surgery and 25% had had previous blepharoplasties.
Three hundred thirteen patients (68.4%) were reached for an interview and could be evaluated postoperatively, with an average of 42 months after surgery.
Two hundred sixty-three (84%) were women. From the survey, twenty-eight patients (9%) referred minor complications as edema, chemosis and eyelid shape change.
The other patients could not be found at the time of the interview. Retouch surgeries happened between 4 to 12 months after the first procedure (average of 8 months) and they were made in nine patients.
They were related to a unilateral new canthopexy for symmetrization (5 patients), removal of excessive skin, fat pad excess removal and removal of a thin muscular strip.
Minor complications were transitory and disappeared at least in three months, after local massage.
These patients had a closer follow-up and were found to answer the questionnaire.
Regarding the patients interviewed, 84% (264/313) thought that blepharoplasty enhanced their physical appearance and judged as an excellent result. 21 patients were happy with the results one year after the surgery.
Only 9 percent (28/313) were not completely satisfied with the result and minor complications were observed, all related to bruises on the skin 21 days after the surgery.
No ectropion was observed. Ninety-one percent (285/313) of the patients stated that relatives thought they had a much younger appearance postoperatively. The most commonly mentioned improvements were in the sub palpebral pouches and in the palpebromalar groove (85% and 71% respectively, among those reporting good results).
Ninety-three percent of patients liked their new appearance after the surgery, and their meantime of self-assessed rejuvenation was 6 years. Figures 13 and 14 show the results obtained with the technique described herein.
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By Tarek Balkacemi
For more information visit Arabist Group Medical Section.