Lateral Canthopexy Research Articles

Comprehensive and Global Approach of Soft-Tissue Deformities in Craniofacial Neurofibromatosis Type 1.

To present a single-institution experience in the comprehensive and global soft-tissue surgical approach of patients with craniofacial neurofibromatosis type 1 (NF-1). A retrospective analysis of patients with craniofacial NF-1 (n = 20) who underwent craniofacial soft-tissue reconstruction between 1993 and 2014 was conducted. Surgical treatment was individualized according to age, functional and/or aesthetic impairment, neurofibroma types, anatomical location, size, and patient/family and surgical team preferences, regardless of previously published compartmental grading systems. The surgical results were classified based on 2 previously published outcome rating scales (craniofacial symmetry improvement and need for additional surgery). All patients underwent en bloc translesional surgical excisions, 12 facial suspension, 3 eyebrow suspension, 2 ear suspension, 9 lateral canthopexy, 5 horizontal shortening of the tarsus of lower eyelid, and 1 horizontal shortening of the tarsus of upper eyelid. The degree of craniofacial symmetry improvement was considered "mostly satisfactory" (75%), and the overall rate of surgical results ranked according to the need for additional surgery was 2.4 ± 0.50, with variations according to the spectrum of soft-tissue involvement. According to the experience and surgical outcomes presented in this study, the soft-tissue surgical approach of the craniofacial NF-1 should be global, comprehensive, and individualized.

Minimally Invasive Approach in Surgical Treatment of Tumors of Maxilla

Objective: By benign and malignant tumors of the maxillary sinus and maxilla there is frequently a need to perform a total maxillectomy. In this article we describe a transconjuctival-transoral approach, which can be evaluated in terms of esthetic result, complications, integrity of the important structures of the midface that provide physiological function and reduce the rehabilitation period. Study design: We operated seven patients in the time between 2013-2014. Among them were four patients with malignant tumors with preoperative radiology treatment one patient with malignant tumor without preoperative radiology treatment and two patients with benign tumors. All these patients have no recurrence until now. Methods: The surgical technique is performed in following steps: transconjunctival incision, exposure of the zygomatic bone, low orbital rim and orbital floor through precise dissection of the structures of the low eyelid, intraoral incision, traditional osteotomies with preserving the low orbital rim, lateral canthopexy, skin suturing. Results: Reduction of the postoperative treatment period and complications, better esthetic results. Conclusion: Transconjunctival-transoral approach benefits the conventional ones in fast rehabilitation, good esthetic results without facial scars and low eyelid malposition

The Locking Y Lateral Canthopexy With Osseous Integration: Clinical Experience and Surgical Technique.

To describe a surgical technique to correct lateral canthal tendon disinsertion with a strabismus surgery-inspired locking capture of the tendon complex and osseous integration via drill holes. Retrospective interventional case series including all patients with lateral canthal tendon disinsertion who underwent locking Y lateral canthopexy with drill hole reinforcement by 1 surgeon (D.T.T.) between 2006 and 2011. Outcome measures included resolution of presenting ocular symptoms, improved blink dynamics and lid closure, correction of lagophthalmos and exposure keratopathy, and need for further surgery. A total of 53 lateral canthopexies with osseous integration were performed in 42 patients who fulfilled clinical criteria for lateral canthal tendon disinsertion. The population was biased toward treatment failures; 81% of eyes (43/53) had a history of prior lateral canthal tightening, and of these 30.2% (16/53) had undergone 3 or more procedures. Postoperatively, all eyes demonstrated improved eyelid position and blink mechanics, and 83% (44/53) had subjective resolution of epiphora and ocular irritation. Lagophthalmos was fully corrected in 95% (19/20) of cases, and corneal staining resolved in 88% (14/16). With a mean follow-up period of 24 months, 3.7% of eyes (2/53) required additional lateral canthal tightening. The locking Y lateral canthopexy is an effective and durable method for repositioning the lateral canthal tendon complex to improve blink dynamics, eyelid closure, and cosmesis. Even in a population heavily biased toward treatment failure, clinical results are excellent and the reoperation rate is low.

Orbital soft tissue surgery for patients with Treacher-Collins or Nager syndrome. A new surgical approach with early correction of soft tissue: prospective study

Orbitopalpebral anomalies in mandibulofacial dysostosis (Treacher-Collins syndrome) can be difficult to correct surgically and most authors recommend correction of the malar bone after the age of 8 years. We propose a new, early surgical approach for periorbital defects that involves initial implantation of autologous fat and subperiosteal malar lift with a pedicled upper eyelid flap. We prospectively studied 5 children, 3 of whom had previously had orbital reconstruction. Initial fat graft into the periorbital area was followed by a subperiosteal malar lift with lateral canthopexy, and a pedicled upper eyelid flap if needed. Two surgeons independently assessed the patients’ characteristics including scleral show before and after operation, antimongoloid palpebral fissures, canthal dystopia, number 6 cleft (Tessier classification), skin quality, and surgical and ophthalmic complications. Before operation 3 patients had had ophthalmic problems. Postoperative evaluation showed improvements in scleral show, canthal dystopia, and skin quality, and correction of antimongoloid palpebral fissures and subcutaneous number 6 clefts. There were no postoperative complications. The proposed protocol gave satisfactory aesthetic and functional results in children with Treacher-Collins syndrome. We recommend that it is considered for periorbital reconstruction in all patients with a mandibulofacial deformity.

Lateral canthopexy - a simple addition to lower lid blepharoplasty

Rejuvination of the lower lid is a challenging procedure. Lower lid malposition and ectropion are serious postoperative complications. Therefore presurgical assessment of the lower lid function and laxity are a must before performing a blepharoplasty. Lateral canthopexy is an effective procedure to minimise the risk of postsurgical ectropion. Its necessity increases with rising age of the patients. The canthopexy supports the lower lid postion in the case of increasing vertical tension.

Beneficial effects of turnover orbicularis oculi muscle suspension flap for treating facial fractures via subciliary incision.

In patients with moderate lower lid laxity, the lower orbicularis oculi muscle becomes atonic or ptotic. Hence, in such patient populations, with periorbital fractures, additional vertical support endorsement either by lateral canthopexy or orbicularis oculi muscle suspension flap must accompany plate and screw fixations. In this report, we shared our experience in applying prophylactic suspension to the lower lid with turnover orbicularis oculi transposition muscle flap in zygomatic fractures treated by subciliary approach in 98 patients. Our results show that turnover orbicularis oculi muscle suspension flap avoids the rounding of the lateral canthal angle more successfully and prevents ectropion better than the resuspension orbicularis oculi muscle flap does. We advocate using this flap where zygomatic fractures are approached via the subciliary incision. We foresee that it is a reliable and easily executed technique especially in middle-aged patients with moderate lower lid laxity for the prevention of ectropion.

Alternative Surgical Treatment of Paralytic Lagophthalmos Using Autogenic Cartilage Grafts and Canthopexy

This study aims to analyze the use of autogenic auricular cartilage grafts as weight for the upper eyelid in conjunction with lateral canthopexy for patients with mild paralytic lagophthalmos. This procedure was also accompanied by elevation of the lower eyelid using the cartilage graft for moderate cases. We conducted a retrospective study including case series of 30 patients with paralytic lagophthalmos from 1997 to 2010. For mild cases, cartilage from the auricular scapha was placed in pretarsal space of the upper eyelid and cartilage from the concha was inserted in preaponeurotic space and then sutured to the levator aponeurosis in conjunction with lateral canthopexy. For moderate cases, lower eyelid was also elevated by suturing cartilage graft to tarsum and resting it by the inferior orbital rim. All patients had some degree of keratopathy before the intervention. After treatment, they presented with evident clinical improvement, reduction of eye symptoms, and resolution of keratopathy. During the mean postoperative follow-up of 37.3 months, none of the patients presented with cartilage graft exposition, reabsorption, visibility, infection, or warping. Complete eye closure was achieved in 24 (80%) patients, whereas the remaining 6 (20%) patients had residual asymptomatic lagophthalmos. The intervention using autogenic auricular cartilage grafts explained in this study was only effective for the treatment of mild and moderate cases of paralytic lagophthalmos. This outpatient surgery is associated with low morbidity and achievement of functional and aesthetic improvement.

Experience With Cervicofacial Flap in Cheek Reconstruction

One of the methods for midface soft-tissue defect reconstruction has been the cervicofacial flap. Cheek skin defects of 35 patients were reconstructed with cervicofacial flaps. This study was done from 2007 to 2011. Mean follow-up was 24 months. In these patients, tumors including 19 basal cell carcinomas, 11 squamous cell carcinomas, and 5 malignant melanoma were excised, and cheek reconstructions were done by this flap in defects of 5- to 8-cm diameter in 3 zones . We did some modifications in the cervicofacial flap. In our experience, 35 patients aged 30 to 75 years (mean, 53 years), 16 women (46%) and 19 (54%) men, had a reconstruction with cervicofacial flap. Lesions included basal cell carcinoma (n = 19), malignant melanoma (n = 5), and squamous cell carcinoma (n = 11) in the cheek region. We performed periosteal malar bone anchoring suture of the flap in all cases and lateral canthopexy with this flap in 11 cases where lesions were in the suborbital or lateral periorbital region. Cervicofacial flap with malar bone periosteal anchoring with or without lateral canthopexy is a good aesthetic choice for cheek skin reconstructions.

Reconstruction After Complex Facial Trauma

Major facial trauma injuries often require complex repair. Traditionally, the reconstruction of such injuries has primarily utilized only free tissue transfer. However, the advent of newer, contemporary procedures may lead to potential reconstructive improvement through the use of complementary procedures after free flap reconstruction. An 18-year-old male patient suffered a major left facial degloving injury resulting in soft-tissue defect with exposed zygoma, and parietal bone. Multiple operations were undertaken in a staged manner for reconstruction. A state-of-the-art free anterolateral thigh (ALT) perforator flap and Medpor implant reconstruction of the midface were initially performed, followed by flap debulking, lateral canthopexy, midface lift with redo canthopexy, scalp tissue expansion for hairline reconstruction, and epidermal skin grafting for optimal skin color matching. Over a follow-up period of 2 years, a good and impressive reconstructive result was achieved through the use of multiple contemporary reconstructive procedures following an excellent free ALT flap reconstruction. Multiple staged reconstructions are essential in producing an optimal outcome in this complex facial injury that would likely not have been produced through a 1-stage traditional free flap reconstruction. Utilizing multiple, sequential contemporary surgeries may substantially improve outcome through the enhancement and refinement of results based on possibly the best initial soft-tissue reconstruction.

Soft Tissue Management of Orbitotemporal Neurofibromatosis

The aim of this study was to provide an overview of a single-institution, 30-year surgical experience with the soft tissue management of orbitotemporal neurofibromatosis. Lessons learned are highlighted in case presentations. From 1981 to 2011, all patients who presented to the Chang Gung Memorial Hospital Craniofacial Center with craniofacial neurofibromatosis and orbitotemporal involvement were retrospectively reviewed. The medical records of those patients who underwent surgical correction were reviewed for age, extent of involvement, procedures performed, histologic confirmation, and acute complications. All patients were grouped according to the Jackson Classification. The electronic photobank was queried to evaluate results. Thirty-five patients presented to our center with orbitotemporal neurofibromatosis during the study period. Thirty-one patients underwent surgical management of their disease. The average age was 25 years (range 4 to 57 years). Over half of our patients (n = 18) presented with concomitant disease of the cheek. The 2 most common procedures performed were lateral canthopexy (n = 24) and upper eyelid excision (n = 24). The only acute complication recorded was a postoperative hematoma on the fourth postoperative day following simultaneous lateral canthopexy and upper eyelid excision which required operative evacuation. In orbitotemporal neurofibromatosis, tissue hyperextensibility and tumor weight adversely affect outcomes. Treatment of concomitant disease of the cheek should be prioritized in order to provide periorbital support prior to addressing the delicate structures of the eyelids. Preservation of the lateral canthal unit and levator muscle, despite neurofibroma infiltration, is critical to maximize outcomes following debulking procedures of the eyelid and orbit.

Reconstruction of Post–Radical Parotidectomy Defects

Radical parotidectomy presents a unique combination of reconstructive challenges. The high visibility of the region and the specialized structures involved create an interdependence between aesthetics and function. This article describes the authors' surgical concepts and experience in post-radical parotidectomy reconstruction. The various components of reconstruction following radical parotidectomy, including contour restoration, skin coverage, mandible reconstruction, and facial reanimation, are reviewed. The authors discuss their methods of choice and specific technical refinements. Twenty-one post-radical parotidectomy reconstruction patients (male:female, 17:4; median age, 75 years) treated from July of 2006 through May of 2010 were identified. Information on patient demographics, etiology, reconstruction technique, surgical complications, postoperative adjuvant radiotherapy, and survival was obtained. The most common indication for radical parotidectomy was metastatic cutaneous squamous cell carcinoma, followed by carcinoma ex pleomorphic adenoma and direct extension from primary cutaneous malignancy. The authors' standard approach in reconstruction was a combination of anterolateral thigh free flap and cervicofacial rotation advancement flap, repair of the facial nerve with the nerve to the vastus lateralis segmental interpositional graft, gold weight loading of the upper eyelid, lateral canthopexy, temporalis and digastric muscle transfers, and a delayed brow lift. Surgical complications include undercorrection of facial reanimation, gold weight extrusion, wound breakdown, and infections. Seventeen patients (81 percent) received adjuvant radiotherapy (range, 50 to 66 Gy to the primary site, 40 to 60 Gy to the neck). Radical parotidectomy is a morbid procedure that is sometimes necessary for oncologic control. With sound principles and attention to detail in reconstruction, however, quality of life can be greatly improved. Therapeutic, V.

Lateral Canthoplasty With Acellular Cadaveric Dermal Matrix Graft (AlloDerm) Reinforcement

Lateral canthal dystopia can lead to lower eyelid malposition, abnormal lateral eyelid fissure appearance, and lagophthalmos. In most cases, the lateral canthus can be repaired with a standard lateral canthopexy or canthoplasty. In a fraction of cases, especially when recurrent, the surgical repair may require additional lateral canthal reinforcement.

Resultados clínicos e satisfação dos pacientes após blefaroplastia inferior

To evaluate the results of fifty patients undergoing transcutaneous lower eyelid blepharoplasty. We conducted a prospective, randomised, controlled trial between April 2005 and May 2007. Patients were randomly divided into two groups: Group 1 consisted of 25 surgical patients undergoing traditional lower blepharoplasty and routine lateral canthopexy; Group 2 consisted of 25 patients undergoing lower blepharoplasty with fat bags transposition and routine lateral canthopexy. We used the Rosenberg Self-Esteem Scale UNIFESP / EPM to assess patients' self-esteem. We also requested the participation of three independent surgeons, who examined the pre and postoperative photographs and quantified the results with the aid of a topographic scale. The mean age was 48.8 years, predominantly females (96%). The analysis of photographs showed a 96% significant improvement. Self-esteem scores improved from a preoperative average of 5.1 (SD = 4.1) to a mean of 3.6 (SD = 3.5) six months after the operation (p = 0.001). Both procedures are safe and effective with low complication rates, causing improvement of self-esteem assessed six months after the operation.

Discussion: Traditional Lower Blepharoplasty: Is Additional Support Necessary? A 30-Year Review

T authors correctly credit Dr. Thomas Rees with popularizing the skin/muscle flap approach to lower blepharoplasty. This occurred at the Manhattan Eye, Ear, and Throat Hospital over 35 years ago. I learned the technique there, as the senior author of this article probably did before me. This procedure remained a workhorse technique, with one faculty member extolling its virtues as a fast and effective procedure as late as 1998.1 Working in this environment where hundreds (if not 1000) were performed yearly, I agree with the authors that the method causes few functional problems in the hands of experienced surgeons. Practicing in this same community has allowed me to observe the long-term results of skin/muscle flap procedures in patients presenting years later for a secondary rhytidectomy or other procedure. Although many still appear quite good, there are also many that exhibit either hollowing, scleral show with rounding of the ocular aperture, or both (Fig. 1). These aesthetic issues constitute the major criticism of the technique and have led to the development of newer methods that preserve orbital fat volume, avoid middle lamellar scarring, and avoid orbicularis denervation. Although the authors prove the safety of skin/muscle flaps, they do not recognize the aesthetic morbidity associated with the technique, which is actually the larger issue. The authors’ aversion to canthopexy may be traced back to the type of canthopexies performed at the Manhattan Eye, Ear, and Throat Hospital many years ago. These were aggressive procedures that included both canthotomy and cantholysis. They were tedious to perform and sometimes resulted in late deformities caused by canthal disinsertion. Moreover, the resulting strong upward cant of the eyelid that was typical, albeit temporary, may have been acceptable for reconstructive cases but was less appealing for use in aesthetic blepharoplasty. Modern canthopexy methods are less destructive and complex than these earlier ones. Lateral retinacular suspension, described either as a cantholytic type by Jelks et al. or a noncantholytic type by Fagien, is relatively easy to perform.2,3 Therefore, the threshold for using it is much lower in borderline situations. Moreover, it can be either temporary or more permanent based on variations in technique. Positioning of the fixation point need not be as high as that taught in earlier times. Temporary tarsorrhaphy is another option that is a simple method of providing lower eyelid support during the early postoperative period. It can also be used to control developing chemosis either at the time of the procedure or later, should it first become evident after surgery. The authors defined the need for lower eyelid support in this study based solely on lower eyelid tone, not position. In fact, they state that “the aesthetic preference of the senior author is for a more ‘wide open,’ sculpted appearance of the eyes.” They consider mild lower eyelid malposition with scleral show lateral to the limbus as an aesthetic concern and not a complication. Though perhaps true by strict definition, a paradigm shift occurred some time ago where a narrower ocular aperture is recognized as one of the hallmarks of the youthful norm. Therefore, modern techniques encourage a more liberal use of lid-tightening procedures to control lid position for aesthetic reasons, an intent that lies beyond the concern for preventing functional problems. Although the authors lament that some advocate performing this on every patient, a more reasonable rate of application was seen in a recent review of 248 patients where a lateral canthopexy was performed in 18 percent.4 The authors do not mention some of the associated aesthetic benefits of canthopexy. For ex-

A Simplified Lateral Canthopexy Technique

Sir: Lateral canthopexy has become a routine part of cosmetic lower blepharoplasty to prevent lower lid malposition, especially in those patients with laxity of the lower lid and negative vector anatomy.1 All canthopexy techniques involve securing the lateral retinaculum to the periosteum of the superolateral orbital rim with a suture. However, the surgical approach to identify the lateral retinaculum varies, with some techniques requiring more surgical expertise than others. Perhaps the most challenging technique is that of Jelks et al.,2 who dissect the lateral retinaculum from above through an upper blepharoplasty incision. Dissection of the lateral retinaculum through the lateral extension of a lower blepharoplasty incision is advocated by others.3,4 In this article, we describe a technical modification of the Hamra5 transcanthal canthopexy that involves percutaneous placement of the canthopexy suture through the confluence of the superior and inferior gray lines at the lateral canthal angle. An upper blepharoplasty is completed, but the lateral extent of the incision is not closed or, in the case in which upper blepharoplasty is not performed, a small incision is made in the upper eyelid crease laterally. An 18-gauge needle (Fig. 1) is used to create a puncture wound at the confluence of the superior and inferior gray lines at the lateral commissure of the eye. One arm of a double-armed 5-0 Prolene suture (Ethicon, Inc., Somerville, N.J.) is placed through the puncture wound, capturing the lateral retinaculum, and directed into the upper blepharoplasty incision, below the orbicularis oculi muscle. The second arm is subsequently placed through the same puncture wound but on a slightly different path into the upper lid incision. These two sutures are secured to the periosteum on the undersurface of the superolateral orbital rim at a level just above the pupil or superior limbus, thus tightening the tarsoligamentous sling. The suture is tied and tension of the lower lid is checked. (SeeVideo, Supplemental Digital Content 1, which demonstrates the lateral canthopexy technique, https://links.lww.com/PRS/A164.)Fig. 1.: Needle placement.Video.: Supplemental Digital Content 1 demonstrates the lateral canthopexy technique, https://links.lww.com/PRS/A164.The lateral canthopexy described here is a modification of the Hamra transcanthal canthopexy. In our modification, a needle is used to access the lateral retinaculum and direct canthopexy suture placement. It is a minimally invasive technique that is simple to perform, especially in the hands of a novice blepharoplasty surgeon. An advantage of this technique is absolute assurance of capturing the lateral canthal tendon. Extensive dissection to identify the tendon is not required, which limits operative time and postoperative edema. Furthermore, recreation of the lateral retinaculum and canthal angle as in canthoplasty (cantholysis) techniques is obviated. With this minimally invasive technique, results have been excellent, with few complications. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Mort Rizvi, M.D. Michael Lypka, M.D., D.M.D. Mark Gaon, M.D. Bradley Eisemann, B.A. Michael Eisemann, M.D. Department of Plastic and Reconstructive Surgery Methodist Hospital and Weill Cornell Medical College Houston, Texas Michael Lypka, M.D., D.M.D. 1 Hermann Museum Circle Drive, Suite 3070 Houston, Texas 77004

Repairing the Loss of Areas of the Palpebromalar Region: A Modified Mustardé Skin Flap Technique

Sir: First described by Mustardé in 1971, the advancement-rotation temporojugal skin flap has been used largely for the loss of areas of the cheek, the temple, and the inferior eyelid.1 Reconstruction by a temporojugal flap using a deep plane sub–superficial musculoaponeurotic system (SMAS) flap, as first described by Barton and Zilmer and popularized by Kroll et al., is used when there is loss of temporojugal substances, or even the external canthus, where the SMAS is well-defined and separable.2,3 However, the role of the SMAS is weak in the palpebromalar region. In effect, the palpebromalar region is the sum of two aesthetic units: the palpebro-orbital region, where the orbicularis oculi muscle plays the role of the SMAS; and the malar region, which is essentially constituted of subcutaneous fatty tissue.4 Consequently, we propose our temporojugal skin flap associated with a malar lift adapted for use in the case of loss of the palpebromalar area. This technique is of special interest in elderly patients, where the risk of ectropion is increased because of a defective skin-SMAS system. Our technique consists of the following: Resection of the tumor according to the Mohs' technique. Lesion repair after finding the margins of healthy tissue using biopsy excisions and microscopy: make the incision starting from the inferior eyelid in line with the lacrimal point, then make one upward and outward line starting from the lateral canthus and curving toward the tip of the eyebrow, then toward the temple and descending to 2 cm below the ear lobe. Then, move 1 cm forward perpendicularly. Incision and broad dissection of the subcutaneous fat above the SMAS plane. Rotation of the skin flap upward and inward. Malar lift: separation of the subperiosteum of the malar fat pad and then fixation the periosteum of the margo orbitalis (Fig. 1).Fig. 1.: Malar lift: subperiosteum dissection.Prior placement of the inferior eyelid under tension using lateral canthopexy: remove the inferior canthal lateral tendon from its orbital attachments, totally free the inferior eyelid and create a neotendon, which is then reinserted in the orbital periosteum at the desired position. Subcutaneous fixation of the cutaneous-fat skin flap at the temporal aponeurosis to give anchorage points. Cutaneous closure by separate points. At the end of surgery, the cutaneous coverage is satisfactory and the stasis of the inferior palpebral region is conserved (Fig. 2).Fig. 2.: Conservation of the stasis of the inferior palpebral region.The aim is to achieve a deep plane with vertical traction, which is fixed firmly to the periosteum.2,3,5 Use of the sub-SMAS is feasible for the loss of substance of the temporal or the external canthus. However, the SMAS is limited to the lower palpebral and malar regions with the loss of central or paracentral substance. With the same purpose as deep dissections, we propose a subperiosteal detachment of the malar region with vertical traction. Associated with a classic lateral canthopexy, the malar lift provides major support for the inferior eyelid. This technique should be used for the reconstruction of large defects of the inferior eyelid and the malar region. DISCLOSURE The authors have no financial or commercial interests to disclose. Sophie Converset-Viethel, M.D. Philippe Kestemont, M.D. Jose Santini, M.D. Alexandre Bozec, M.D. Nicolas Guevara, M.D. Head and Neck Surgery Department University Hospital Nice, France

The “Mini Tarsal Strip” Lateral Canthopexy for Lower Eyelid Laser-Assisted Blepharoplasty—Indications, Technique and Complications in 614 Cases

The aim of this article is to describe the “mini tarsal strip procedure”, a form of lateral canthal tendon plication to tighten the lower lid and give a better apposition of the lower eyelid to the globe. We describe this procedure in the context of transconjunctival lower lid blepharoplasty.

Minimally invasive lateral canthopexy (MILC)

Many techniques have been described for lateral canthopexy. Here, we describe a technical modification of lateral canthopexy that involves percutaneous placement of a canthopexy suture through the confluence of the lateral superior and inferior grey lines or lateral canthal angle. A total of 52 canthopexies in 26 patients have been performed with excellent results and few complications. Our lateral canthopexy modification is a minimally invasive technique that is simple to perform, with absolute assurance of capturing the lateral canthal tendon.

Periorbital Skeletal Augmentation to Improve Blepharoplasty and Midfacial Results

Narrow palpebral fissures, short lower lids, and full cheeks are hallmarks of youthful periorbita. The presence of these features is predicated on a convex upper midface skeleton. Faces whose midface skeletons are flat or concave do not manifest these youthful attributes, tend to age prematurely, and are prone to lower lid malposition after blepharoplasty. Augmentation of the infraorbital rim with alloplastic implants can provide convexity to the deficient upper midface skeleton. Suspension of the cheek soft tissues (subperiosteal midface lift) on this now supportive framework narrows the palpebral fissure, shortens the lower lid, and gives fullness to the cheek. The addition of lateral canthopexy to skeletal augmentation and subperiosteal midface lift can restore lower lid position when previous blepharoplasty has resulted in lower lid malposition in patients with deficient midface skeletons. This concept has been utilized in 87 patients (65 female, 22 male) over the last 7 years. Of these 87 patients, four patients (5 percent) required revision surgery to correct implant malposition or prominence. Three patients (3 percent) required implant removal to treat infection. Implants were later replaced in two of these three patients. Augmentation of the infraorbital rim with alloplastic implants provides convexity to the upper midface skeleton. Together with lower lid and midface soft-tissue suspension, it creates or restores youthful periorbital aesthetics.

Aesthetic blepharoplasty

Blepharoplasty is one of the most demanding aesthetic procedures, and relevant anatomical knowledge of the eyelid and surrounding area is essential. The pathophysiology of ageing in these sites results in varied clinical features. In upper blepharoplasty, lateral brow lift is a necessary adjunctive procedure. Access through the upper blepharoplasty incision is used to adjust retro-orbicularis oculi fat, for glabellar myotomy, and lateral canthopexy. In lower blepharoplasty, the traditional approach is to use a skin and muscle flap, but skin-only flaps are being reported increasingly. Septal reset and plication of the orbicularis oculi is recommended instead of excision of fat. The aim is improvement of cosmesis with no signs of the procedure.