Inferolateral Orbital Rim Research Articles

Topography of the Central Retinal Artery Relevant to Retrobulbar Reperfusion in Filler Complications.

Vision loss caused by retrograde occlusion of the central retinal artery is a serious complication of cosmetic filler injections. Salvage methods that involve applying hyaluronidases in the retrobulbar space to degrade filler materials have been proposed recently for rescuing the retinal circulation in an ophthalmic emergency. Sixty-six eyeballs and orbital contents were extracted from formalin-embalmed cadavers and dissected carefully to examine the topographic relationship of the central retinal artery and optic nerve. To observe the three-dimensional course of a central retinal artery that invaginates into the optic nerve, serial sections reconstructed at 100-μm intervals using software were visualized in 11 specimens. The central retinal artery ramified from the ophthalmic artery and entered the optic nerve inferiorly at 8.7 ± 1.7 mm (mean ± SD) from the posterior margin of the eyeball. The intraneural course of a central retinal artery changed acutely between the periorbital environment of the fibrous optic nerve sheath, intermediate subarachnoid spaces, and center of the optic nerve stroma. When applying a retrobulbar approach for central retinal artery reperfusion with hyaluronidases, the reliable access route is suggested to be at a depth of 3.0 to 3.5 cm from the border of the inferolateral orbital rim, based on consideration of the entry point of the central retinal artery into the optic nerve.

Floppy eyelid syndrome "plasty" procedure: Employment of a periosteal transposition flap for surgery of floppy eyelid syndrome.

Floppy eyelid syndrome "plasty" (FESplasty) is a surgical technique that addresses underlying superior tarsal plate and lateral canthal instability in floppy eyelid syndrome (FES) and aims to restore normal anatomical and physiological function to the upper eyelid. To describe the use of FESplasty in the surgical management of FES, and to report outcomes in an initial patient cohort. Retrospective study. Seven patients (nine eyelids) with FES undergoing FESplasty. A single surgeon (G.W.) performed all procedures. FESplasty utilizes a periosteal flap based at the inferolateral orbital rim, and applied to the anterior surface of the upper tarsal plate. It is combined with a titrated shortening procedure of the upper eyelid. Patient demographics, comorbidities and ocular symptoms and signs were recorded preoperatively. Pre- and postoperative upper eyelid distractibility were graded and documented. Postoperative improvement in upper eyelid distractibility and symptomatology, operative complications and FES recurrence. FES symptoms and upper eyelid laxity improved at last follow-up (average 24 weeks) in all patients, with no FES recurrences after a maximum follow-up of 36 weeks. One patient, in whom FESplasty exacerbated his pre-existing aponeurotic ptosis, required definitive ptosis surgery subsequently. There was one case of postoperative wound infection. Obstructive sleep apnoea was present in four of the seven patients. The remaining three patients were awaiting assessment. FESplasty is likely to confer long-term effective stabilization of the lateral canthal tendon, lateral commissure and superior tarsal plate. Anatomical and functional results appeared to have been successfully achieved.

Lowering Lateral Canthoplasty and Orbital Rim Shaving: An Ignored but Necessary Procedure for Maximizing the Effect of Reduction Malarplasty in Asians.

Although reduction malarplasty is a well-accepted procedure for Asians with prominent cheek bones, some patients are not fully satisfied with the outcomes and request further surgery. This is because much attention on the contouring procedure has focused on the position of the zygomatic body and arch. As a result, periorbital appearance including the axis of the lateral canthal angle and the protrusion of the inferolateral orbital rim are often overlooked or ignored. The authors introduce a new surgical technique for maximizing the effect of reduction malarplasty that allows for both the lowering of the lateral canthal angle and reduction of the orbital rim in selected Asian patients. In this retrospective study, the medical records of 41 patients who underwent lowering lateral canthoplasty in conjunction with reduction malarplasty were reviewed. Of those, orbital rim reduction was combined in 21 patients. In addition to the intraoral and preauricular approach for standard reduction malarplasty using an L-shaped osteotomy, lower eyelid and continuous canthotomy incisions were made. And then the protruding inferolateral orbital rim was shaved off, followed by inferolateral repositioning of the lateral canthus. Outcome measurements included a square millimeter of the cheek area surface using a software program (image J: IJ 1.46r) in 17 patients. A statistically significant difference can be observed between preoperative and postoperative measurements of the area. Average decreases of measurements were 4761.59mm2 (18.5%) from 23,639mm2 preoperatively to 18,878mm2 postoperatively (P < 0.05, paired t test). The up-slanting lower eyelid margin was lowered, and the protruding zygomatic body with inferolateral part of the orbital rim was reduced by the procedure in all cases. Cosmetic outcomes were encouraging and satisfying to most patients. Four complications occurred: asymmetry in two patients (4.9%) and lid malposition in two patients (4.9%). Conjunctival edema was noted in half of the patients but resolved within 1month. The simultaneous lowering lateral canthoplasty and reduction malarplasty offer Asian patients desiring a slim and soft image a novel surgical option. The procedures proved to be a reliable and consistent technique that provided satisfactory results in carefully selected patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Three‐Dimensional Infraorbital Foramen Location Relative to Facial Landmarks: Preliminary Results

Infraorbital nerve block injections are performed by either an intraoral approach per the oral vestibule or an extraoral approach through the skin near the infraorbital foramen. Many studies have assessed the location of the IOF relative to bony landmarks, teeth, as well as soft tissue landmarks with mixed results. Few studies have assessed the location of the IOF in three dimensions. This study analyzed the location of the IOF relative to a midpoint between the inferolateral nasal aperture and inferolateral orbital rim via three‐dimensional models rendered from 18 adult crania. The distance from the midpoint to the IOF averaged 4.16±1.43 mm (mean±SD) on the left and 3.93±1.43 mm on the right. Wilcoxon matched‐pairs signed rank tests revealed no significant difference among sides (p=0.325). This report also addresses differences among the x, y, and z axes. These preliminary data demonstrate the utility of three‐dimensional analysis for the assessment of IOF location. Understanding the location of the IOF in three dimensions may aid in determining the best patient‐specific approach for infraorbital nerve block.Support or Funding InformationWV Research Challenge Fund [HEPC.dsr.17.06] and [HEPC.dsr.14.13]This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Analysis of Craniofacial Remodeling in the Aging Midface Using Reconstructed Three-Dimensional Models in Paired Individuals.

Aging leads to a panoply of changes of facial morphology. The present study was conducted to analyze modifications of the facial skeleton with aging, using high-resolution imaging and comparing the same individuals at two time points. The electronic medical record system was reviewed since its inception in 2001 for patients for whom two computed tomographic scans of the midface were obtained at least 9 years apart. The computed tomographic scans were converted into three-dimensional craniofacial models for each patient, using the initial and the follow-up computed tomographic scan data. The models were used to highlight areas of bone growth and bone resorption using a color scale and to perform a cephalometric analysis. Seven patients with a mean age of 61 years and computed tomographic scans on average 10.3 years apart were included. Bone resorption was consistently present (100 percent) at the pyriform aperture and the anterior wall of the maxilla. Resorption was noted at the superocentral (71 percent), inferolateral (57 percent), and superomedial (57 percent) aspects of the orbital rim. Resorption occurred earlier at the inferolateral orbital rim followed by the superomedial orbital rim in later decades of life. Paired-analysis of change in the orbital rim height and width demonstrated a mean decrease over time but was not significant. Bone remodeling in the same individual, over a period of 10 years, was characterized by resorption at the pyriform aperture; anterior wall of the maxilla; and superocentral, superomedial, and inferolateral aspects of the orbital rims.

Lower Blepharoplasty With a Combination of Release and Lift of the Fascia Ligament of Orbicularis Oculi

The inferolateral orbicularis oculi of the lower eyelid can be divided into 2 layers. The inner layer is a true ligament and referred to as the "fascia ligament of orbicularis oculi." Releasing this ligament can improve the aesthetic result of lower blepharoplasty. The anatomy of the fascia ligament of orbicularis oculi was investigated in cadaveric and histologic studies. Additionally, thousand cases of lower blepharoplasty were performed utilizing a combination of release and lift of this ligament from 1996 to 2009. Cadaver study demonstrated the fascia ligament of orbicularis oculi is a distinct fibro-structure. Its origin is from the periosteum of the inferolateral orbital rim and extends superomedially and inserts into the deep surface of the orbicularis oculi at the junction of the muscle's middle and lateral thirds. This ligament is 13.5 ± 2.5 mm in length and 11 ± 2.0 mm in width. In the clinical study, by releasing this ligament, 3 to 6 mm more redundant lower eyelid skin can be removed compared with traditional lower blepharoplasty, which can improve the outcome of periorbital rejuvenation and achieve better long-standing aesthetic results. The fascia ligament of orbicularis oculi is a structure connecting the orbicularis oculi to the periosteum of inferolateral orbital rim. The lower blepharoplasty with combination of release and lift of this ligament can improve the outcome of lower blepharoplasty, which is a minimally traumatic procedure with long-standing results of orbital rejuvenation.

Surgical anatomy of the lower eyelid relating to lower blepharoplasty

The aim of this review is to familiarize the reader with the critical lower eyelid anatomy as is related to lower blepharoplasty or a midface lift. The contents include 1) the lacrimal canaliculus in the lower eyelid: the depth and width (diameter) of the vertical portion were 2.58±0.24 mm and 0.44±0.07 mm, respectively. A vertical portion of the canaliculus was about 1 mm (1.11±0.16 mm) deep, and the horizontal portion was about 2~3 mm (2.08±2.74 mm) long 2 mm below the mucocutaneous junction, which is where an incision may be made when performing epicanthoplasty. 2) Motor innervation to the lower orbiculis oculi muscle: the pretarsal and preseptal OOMs were innervated by five to seven terminal twigs of the zygomatic branches of the facial nerve that approached the muscle at a right angle. The mean horizontal distance between the lateral canthus and the zygomatic branch was 2.31±0.29 cm (range: 1.7~2.7 cm) and the vertical distance was 1.20±0.20 cm (range: 0.8~1.5 cm). 3) Sensory innervation of the lower eyelid skin: the majority of the terminal branches (93.8%) of the ION were distributed to the medial to the lateral canthus. Most (99.4%) of the terminal branches of the ZFN were distributed to lateral to the lateral canthus. 4) Retractor of the lower eyelid; capsulopalpebral fascia (CPF): the orbital septum blended with the CPF most closely at 3.7~5.4 mm beneath the lower tarsal border and differently at 3.7±0.7 mm on the medial limbus line, 4.3±0.8 mm on the midpupillary line and 5.4±1.0 mm on the lateral limbus line. 5) Arcuate expansion (AE): The AE was a fibrous band expanding from the inferolateral orbital rim to the medial canthal ligament. A sector (fan-shaped) of the AE originated in the angle of 5 to 80 degrees at the circumference of the inferolateral orbital rim circle, falling within the range of 3 to 5.5 o'clock, and then it tapered and attached to the inferior border of the medial canthal ligament. 6) Suborbicularis oculi fat (SOOF) in the lower eyelid: the SOOF was located in the inferolateral side of the orbit within a range between medial +15 and lateral -89 degrees to a vertical midpupillary line. Histologically, the SOOF was situated deep to the Orbicularis oculi muscle and superficial to the orbital septum and periosteum. The SOOF consisted more of fibrofatty tissue rather than being the pure fatty nature like orbital fat. I hope surgeons can achieve desirable outcomes with the knowledge reviewed in this article.

Anatomy of Arcuate Expansion of Capsulopalpebral Fascia

The aim of this study was to elucidate the detailed anatomic structure of arcuate expansion (AE) and its nearby structures. Eighteen orbits of 13 Korean adult male cadavers of a mean age of 76.5 years (range, 75-78 years) were used. Sixteen specimens were grossly dissected, and 2 were for histologic study.Arcuate expansion is a fibrous band expanding from the inferolateral orbital rim to the medial canthal ligament. A sector (fan shaped) of AE originated in the angle of 5 to 80 degrees at the circumference of the inferolateral orbital rim circle, falling within the range of 3 to 5.5 o'clock, and tapered and attached to the inferior border of the medial canthal ligament. Arcuate expansion was located deep to the orbital septum and superficial to the inferior oblique (IO) muscle. It overlapped the middle part of the IO muscle as it crossed and connected to the capsulopalpebral fascia. The tensile strength of the 5-mm width of AE at halfway was 6.7 +/- 3.8 N, and that at the orbital margin was 5.4 +/- 2.7 N.We think that AE prevents the protrusion of the eyeball and orbital fat and functions as a pulley holding overcontraction of the IO muscle.

The Concentric Malar Lift: Malar and Lower Eyelid Rejuvenation

Midface rejuvenation surgery is most challenging. The margin of error for the lower lid is on the order of 0.5 mm, and the cosmetic result can sometimes look unnatural. A minimally invasive technique for malar and lower lid lift is proposed. Two incisions are used: the standard subciliary lower eyelid incision and one on the lateral part of the upper eyelid. Through these incisions a skin flap lower eyelid dissection and a subperiosteal malar dissection are performed. The arcus marginalis itself is not transected as is the case when the malar area is entered from the lower eyelid. Rather, a subperiosteral release of the arcus marginalis is performed through a muscle-splitting incision at the lateral canthus. Eyelid malposition is avoided because the muscles, vessels, and nerves converging toward the medial canthus are not interrupted. The subperiosteal dissection of the arcus marginalis extends to the medial canthus and also releases the insertion of the orbicularis oculi superior malar part. Consequently, all the attachments of the tear trough are released. Two subperiosteal suspensions connect the central part of the nasolabial volume and, more laterally, the central part of the malar area to the inferolateral orbital rim. The elevation of the malar volume resulting from these suspensions is concentric with the orbit. A final third suspension vertically connects the orbicularis oculi muscle with the underlying periosteum to the bone of the lateral orbital rim. Significant skin excess is removed from the lower eyelid. Complete disinsertion of the tear trough attachments combined with the malar elevation treats the entire palpebromalar groove. The lifted fat volume fills the space resulting from the subperiosteal disinsertion. A safer, more natural and more reliable result is achieved because the vectors of traction with this technique are exactly opposite those of the midface aging process, and because a very stable fixation is created between the lifted malar periosteum and the malar and latero-orbital rim bones.

Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus.

Description of the surgical anatomy of the superficial fascia of the face must include its deep attachments. These attachments have been mapped out for the forehead, temple, and cheek as retaining ligaments. The deep attachments of the orbicularis oculi of the lower lid and lateral canthus have long been recognized in canthopexy surgery but have yet to be properly defined. Six fresh cadavers were dissected with histologic support, and the results were correlated with surgical observations. The fascia of the deep aspect of the orbicularis is attached to the periosteum of the orbital rim by an orbicularis retaining ligament. This attachment is weakest centrally and tightest over the inferolateral orbital rim. The retaining ligament fuses with an expanded fibrous attachment beyond the lateral canthus, the lateral orbital thickening, which extends over the lateral orbital rim onto the adjacent deep temporal fascia. Aging changes are associated with attenuation of the ligamentous support provided by the orbital thickening and the orbicularis retaining ligament, which then allows inferior displacement of the lower boundary of the lid and contributes to the typical effects of age in this region. The superficial fascia of the lateral orbital region has a continuous connective tissue structure linking the temporoparietal fascia and orbicularis fascia to the lateral canthal tendon by means of the tarsal plate connection. Release of the deep ligamentous attachments (lateral orbital thickening and orbicularis retaining ligament) of the orbicularis fascia is important in some canthopexy and in rejuvenation procedures. The release allows effective redraping and upward mobilization of the orbicularis of the lower lid and the premalar soft tissues.