Midface Lift Research Articles

The Transconjunctival Deep-Plane Midface Lift: A 9-Year Experience Working Under the Muscle

Rejuvenation of the midface with a natural-looking, safe, and long-lasting result is a challenge in aesthetic surgery. The ideal approach should be easy to perform, with minimal risk and significant benefit. The combination of transconjunctival exposure and preservation of the periosteum may result in lower morbidity than traditional midface rejuvenation. The authors present their 9-year experience with the transconjunctival deep-plane midface lift (TDML) and discuss the benefits and limitations of this procedure relative to traditional approaches. A retrospective review (2000-2009) was conducted of 124 consecutive patients treated by the same surgeon (JWF) with the TDML approach. The technique combines transconjunctival and preperiosteal dissection under direct vision. Collected data included patient demographics, operative technique, concomitant procedures, and postoperative results. Complications and revisions were reviewed to assess safety and long-term efficacy. Patients included 97 women and 27 men, with a minimum of 13 months of postoperative follow-up (median, 56 months). The mean operating time for upper blepharoplasty with TDML was less than 150 minutes. No significant complications occurred. One patient required reexcision of redundant lower eyelid skin, and another patient underwent secondary excision via traditional midface lift. The TDML procedure is safe and effective. The technique is readily applicable and more "forgiving" than the traditional midface lift. With proper patient selection, the limited soft-tissue dissection reduces surgical morbidity. Patients with excessive skin redundancy or festoons should be treated with more traditional techniques.

A Three-Dimensional Computed Tomographic Measurement of the Location of Infraorbital Foramen in East Asians

The aim of the study was to examine the different anatomic variations of the infraorbital foramen (IOF) in relation to sex, side, and age using three-dimensional computer tomography in East Asians. Three-dimensional computer tomography scans of patients who were admitted to our institution without any facial abnormality or fracture were included. Two hundred forty patients (480 eyes; 120 male and 120 female patients) were evaluated for the location of the IOF according to sex and age group. For evaluation of the location, the distance of the foramen from the dacryon and that from the inferior orbital margin were measured. The location of the IOF differed statistically between sexes, and the foramen of males was located more inferotemporally, compared with the foramen of females. The location of the foramen changed rapidly during the first 3 years of life and at ages 10 to 12 years. The location change leveled off at after 20 years of age, and the location changed inferotemporally along with growth. This anatomic knowledge of the location of the IOF may suggest that age and sex be considered for infraorbital nerve block, midface lift, and incision of periosteum in inferior orbital wall fracture, especially in children.

Three-dimensional assessment of zygomatic malunion using computed tomography in patients with cheek ptosis caused by reduction malarplasty

Reduction malarplasty is one of the most popular aesthetic surgical procedures for reshaping facial contour in oriental people. Especially for those who have a wide midface and a prominent zygoma. Although malunion and cheek ptosis are known as major complications in reduction malarplasty, but there have been few reports about their causes and patterns. The authors experienced many revision reduction malarplasty using the coronal approach to correct cheek ptosis with malunion and were able to categorize the types of malunion by analyzing 3-dimensional CT imaging prior to revision surgery. A total of 24 patients underwent revision reduction malarplasty with the coronal approach to correct the unfavorable result after primary malarplasty. Most patients complained of various degrees of cheek ptosis associated with malunion. In all cases, the status of zygomatic malunion was evaluated through 3D CT imaging. The operative procedures during revision surgery including repositioning of the inferolaterally displaced malar complex to the appropriate position and obtaining bone-to-bone contact with rigid fixation. If bony absorption at non-union margin was found during the operation, bihalved calvarial bone was grafted into the bony gap. Midface and forehead lifts were also performed when indicated. The types of zygomatic malunion could be categorized into four patterns according to the shape of displacement. The degree of displacement was relevant to the condition of the fixation in all cases. The higher the grade of malunion was evaluated in 3D CT imaging, the more difficult procedures it required during revision surgery. The postoperative results in all cases were satisfactory without any complications. In reduction malarplasty, inappropriate fixation and the ignorance of repositioning vector can lead to cheek ptosis and malunion by the action of masseter muscle. The malunion types apprehended by the preoperative 3D CT scanning enabled precise operative planning before revision surgery. In all grades of zygomatic malunion with cheek ptosis, revision reduction malarplasty with coronal approach was a very useful solution because it offers a wide surgical field, enables accurate repositioning along with firm fixation and easily allows simultaneous midface lift.

Endoscopic assisted surgery: excision of frontal and temporo-zygomatic lesions

Introduction: Endoscopic assisted surgery has become increasingly accepted in the field of oral and maxillofacial surgery over the past decade. The literature describes its use in brow and mid face lifts, excision of cheek lipomas and benign tumours and cysts of the frontal region.

Lateral Canthal Resuspension Sine Canthotomy

The purpose of this study is to describe a novel canthopexy technique-the lateral canthal resuspension sine canthotomy (LCR-SC)-performed via an upper-eyelid incision and to compare it with the lateral tarsal strip procedure (LTS). This is a retrospective study in which the pre- and postoperative photographs of 20 patients per group who had LCR-SC, LCR-SC + midface lift (LCR-SC+ML), or LTS were analyzed by using the Image-J 1.40 software. Parameters measured were as follows: the horizontal palpebral aperture margin-reflex distance 2 (MRD-2) and the height of lateral canthus. LCR-SC was performed through an upper-eyelid incision, by using a 4.0 Prolene suture. For the LCR-SC+ML, a large myocutaneous flap was created first and anchored to the orbital-rim periosteum. The surgical technique is described. Two-way ANOVA was used for analysis. The horizontal palpebral aperture was significantly increased by LCR-SC and LCR-SC+ML when compared with LTS (1.61 ± 0.22 mm and 1.56 ± 0.14 vs. 0.04 ± 0.12 mm; p < 0.01). LCR-SC and LCR-SC+ML decreased the MRD-2 more than the LTS (1.06 ± 0.26 and 1.50 ± 0.23 mm vs. 0.86 ± 0.1 mm; p < 0.01). All 3 procedures increased the lateral canthal height by less than 0.5 mm. LCR-SC is a safe and effective procedure for tightening the lower eyelids. It tightens both the upper and the lower cruri of the lateral canthal tendon, avoiding imbrication of the eyelids. LCR-SC obviates the need for a lateral canthal incision and widens the horizontal palpebral aperture. LCR-SC is more effective than LTS at decreasing the MRD-2. Concomitant midface elevation (LCR-SC+ML) further decreases MRD-2.

Periocular Cosmesis &amp; Facial Dynamic Procedures

AbstractPurpose To present Periocular Cosmesis &amp; Facial Dynamic Procedures, that can be performed in severe and refractory facial nerve palsy cases.Methods Didactic course lectureResults Facial reanimation using dynamic procedures is a multidisciplinary rehabilitative type of management which may be undertaken in longstanding and severe facial nerve palsy. This management includes facial nerve repair, facial nerve substitution and temporalis muscle transfers. Peri‐ocular aesthetic issues need to be addressed in severe and refractory facial nerve palsy cases. Brow lift, midface lift and facial lift can be performed to improve functionality and cosmesis.Conclusion These procedures can provide a moderate to significant degree of improvement in facial nerve functionality and periocular cosmesis

Facial Plastic and Reconstructive Surgery

Program Description: Patients with facial nerve paralysis suffer significant cosmetic and functional morbidity due to lack of eye protection, ectropion, and lack of muscular control of the lower face. These effects can not only socially isolate the patient but may cause devastating complications to the affected organ including corneal ulceration and poor oral intake requiring nutritional supplementation. While the etiology of facial paralysis can be multifactorial, most of these patients eventually require the attention of the facial plastic reconstructive surgeon. Management of the eye involves not only loading the upper eyelid but tightening the lower eyelid. Many procedures are available for this rehabilitation, and these will be discussed. Gold weight versus platinum weight for the upper lid, shortening, tarsal strip, or wedge excision of the lower lid will be compared and contrasted. Mid-face reconstruction can be addressed by mid-face lifting or by nasal valve repair. The high incidence of nasal obstruction following facial nerve paralysis often is not recognized and should not be neglected. Rehabilitation of the nasal valve is straight forward and well received by patients. The lower face functions to allow for proper articulation and deglutition. Without oral competence, drooling and social isolation will occur. The reconstructive options for the lower face can be considered as either dynamic using a temporalis muscle sling or as dynamic with just some form of acellular suspension. The advantages and risks associated with the procedures and the operative results of these techniques will be discussed by the panel. Each panelist in this multidisciplinary presentation will present their preferred method of rehabilitation and then case scenarios will be used to explore subtleties of each surgical approach. This miniseminar will consist of a short presentation by each panelist with a focus on individual case management presentations. Audience participation will be encouraged. Educational Objectives: 1) Be able to manage the acute and chronic effects of paralysis of the upper eye. 2) Add tarsal strip to their management paradigm of the lower lid. 3) Discuss the benefits and disadvantages of lower face reanimation with dynamic vs adynamic reconstruction.

The Anatomy of the Palpebral Branch of the Infraorbital Artery Relating to Midface Lift

The aim of this study was to elucidate a branch of the infraorbital artery (IOA) crossing the arcus marginalis into the orbit that might be vulnerable during a procedure of midface lift or fat sliding or a transposition in lower blepharoplasty.Eleven orbits of 6 Korean cadavers were dissected after injecting red latex into the external carotid artery. The IOA and nerve were identified. A branch of the IOA running upward was traced. In 28 cases of blow-out fracture, a branch of the IOA crossing the arcus marginalis into the orbit was identified, and the location was measured from each medial and lateral canthus.The palpebral branch of the IOA (PIOA) emerged from the infraorbital foramen and ran superior and lateral to the orbital septum. After passing through the orbital septum near the arcus marginalis, PIOA was distributed to the orbital fat. The palpebral branch of the IOA was identified in 21 (75.0%) of 28 fractured orbits. Twenty orbits had 1 PIOA, and 1 orbit had 2 PIOAs. The location of PIOA from the medial canthus (49.0%) was approximately half of the eye width in average. Most of the PIOAs (91%, 20 of 22 arteries found) were included in the range of 40% to 80% of the eye width from the medial canthus.Knowledge of the anatomic course of the PIOA crossing the arcus marginalis is conducive to cauterizing the vessels, as needed, in the subciliary or transconjunctival approach for lower blepharoplasty.

Endoscopic assisted surgery: excision of frontal and temporo-zygomatic lesions

Introduction: Endoscopic assisted surgery has become increasingly accepted in the field of oral and maxillofacial surgery over the past decade. The literature describes its use in brow and mid face lifts, excision of cheek lipomas and benign tumours and cysts of the frontal region.

Subperiosteal Midface Lift: Its Role in Static Lower Eyelid Reconstruction after Chronic Facial Nerve Palsy

Purpose: To describe the effect of subperiosteal midface lift on lower eyelid position of patients with chronic facial nerve palsy.Methods: In an observational prospective study nine patients underwent subperiosteal midface lift. Indications for surgery were lower eyelid paralytic retraction, lagophthalmos, ocular surface disruption, reactive tearing, midface ptosis, and facial asymmetry. Exclusion criteria were previous rehabilitative oculofacial surgery, and facial nerve palsy onset less than a year. Preoperative and postoperative assessment included evaluation of lower eyelid position, lagophthalmos, midfacial ptosis and facial asymmetry. Follow-up was at 1 week, 1 month, 3, and 12 months, postoperatively. Results: All patients referred improvement in their symptoms at 3 and 12 months, postoperatively: lower eyelid position (P=. 004), lagophthalmos (P=. 004), ocular surface symptoms, reactive tearing, and facial symmetry at rest.Conclusions: Subperiosteal midface lift has an effective role in the static lower eyelid malposition correction after chronic facial nerve palsy.

Vertical Subperiosteal Mid-face-lift for Treatment of Malar Festoons

BackgroundMalar mounds may be accentuated by chronic lid edema, with the development from malar edema to malar mounds and finally to malar festoons. Because standard techniques do not seem effective and not specifically proposed for the treatment of malar festoons, subperiosteal vertical upper-midface lift associated with lower blepharoplasty overcomes these shortcomings.MethodsTwelve patients (3 males and 9 females, age = 47 ± 6 years) underwent video-assisted endoscopic subperiosteal vertical upper-midface lift (SUM-lift) in conjunction with a lower blepharoplasty between 2006 and 2007 for treatment of malar festoons. This includes simultaneous lower blepharoplasties and video-assisted transtemporal subperiosteal and sub-SMAS tissue release.ResultsAll patients healed uneventfully without any major postoperative problems. The surgical outcome was evaluated according to the analysis of photographs obtained before and after surgery and the analysis of pre- and postoperative measurements. The technique we used (SUM-lift) achieved a significant rejuvenation of the midface and the malar festoons.ConclusionSubperiosteal vertical midface lift resuspends and redrapes the facial network that originates at the level of the orbital rim. It seems to improve the permeability characteristics of the malar septum in the treatment of malar festoons and malar mounds by freeing the cheek tissue from underlying bone and redraping the malar septum. It is a reliable technique to improve malar mounds, palpebral bags, or festoons.

Endoscopically Assisted Triple-Suture Midface Lift: A Refined Cable-Suture Technique

Superior repositioning of ptotic malar fat pads in an aging face is considered a key element in midface rejuvenation [2, 4, 5]. Several surgical techniques have been developed to achieve this goal, but many remain technically challenging or are associated with increased patient morbidity [6, 7]. The unique anatomy of the malar fat pad, loosely attached to the superficial musculoaponeurotic system (SMAS), makes elevation of the malar fat pads via traditional methods of SMAS rhytidectomy less than optimal [1, 2]. The principle of transcutaneous suspension of malar fat pads with cable sutures was introduced in 2002 [7]. The cable-suture technique can provide both restoration of volume and optimal repositioning of fat pads. Based on this, we developed the endoscopically assisted triple-suture midface lift (‘‘3S’’ midface lift) technique to enhance the midface lift through three sets of suspension sutures, all anchored to the deep temporal fascia: (set 1) transcutaneous suspension cable suture around the nasolabial fold, (set 2) suspension suture on the apex of the malar fat pad, and (set 3) temporal scalp dermal suspension suture. Preoperative markings are drawn with the patient sitting. The nasolabial crease is marked, and a point is marked on the midpoint along a line 5 mm lateral and parallel to the nasolabial crease. This is where a stab incision will be made for the insertion of a cable suture. The vector along which the cable suture will be pulled is perpendicular to the nasolabial crease. Another point 20 mm below the lateral canthus is marked, indicating where the suspension suture on the apex of malar fat pad will be placed. This point is similar to Tonnard’s point [8, 9] The temporal scalp incision is about 20 mm behind the hairline. This procedure can be performed with the patient under local or general anesthesia depending on what other accompanying procedures are being performed simultaneously. The temporal incision can be extended caudally to join the preauricular incision of open rhytidectomy or be a standard temporal working port for an endoscopic forehead lift. The dissection is performed with the help of a 3-mm 30 endoscope on the plane between the superficial and deep temporal fascia. The dissection is carried gradually into the midface between the suborbicularis oculi fat and the orbicularis oculi muscle [3]. After the midface is entered, further dissection is performed bluntly into the cheek region. Figure 1 shows the extent of the dissection. The cable suture is inserted through the stab wound lateral to the nasolabial crease using the method described by Sasaki and Cohen [7]. The thread of the cable suture is passed through to the temporal incision. Under direct vision by the endoscope, a hemostat is inserted to grasp the apex of the malar fat pad at the previously marked point below the lateral canthus. After confirmation of adequate malar fat pad movement, a 4-0 Prolene suture is passed through and also brought out through the temporal incision. Both the cable suture and the malar fat pad suture are anchored to the deep temporal fascia and tied with maximal tension. The medial edge of the temporal scalp wound then is deepithelialized to a width of about 3 mm. The deepithelialized portion is anchored to the deep temporal C.-C. Yu R. Tsai T.-C. Tung (&) Celebrity Cosmetic Center, 3F-1, 243, Sec. 1, Fu-Hsing S. Rd, Taipei City 10666, Taiwan e-mail: tung@celebritycosmetic.com

A Novel Technique for Repositioning Lower Eyelid Fat via the Transoral Approach in Association with Midface Lift

BackgroundOrbital fat repositioning in association with subperiosteal midface elevation has been variably described via both the transconjunctival and skin muscle flap approaches. Poor visualization, middle and posterior lamellar cicatricial fibrosis, technical difficulty, and incomplete release are disadvantages commonly ascribed to the transconjunctival approach. Lower eyelid malposition and retraction also are commonly seen in association with skin muscle flap approaches. A simple technique using the intraoral approach to release the orbital septum and postseptal fat is described in this report. This procedure avoids complications associated with the violation of key lower eyelid anatomic structures and markedly improves visualization through an incision allowing a much larger access.MethodsA retrospective review of six patients who underwent endoscopically assisted midface elevation in combination with lower eyelid fat repositioning via a transoral approach since 2009 and were followed up for at least 1 year is presented. A pre- and postoperative assessment of tear trough depth, lower eyelid fat herniation, and midface descent is made. Four of the six patients presented also underwent concurrent additional facial rejuvenation procedures including endoscopically assisted brow-lift, genioplasty, structural fat grafting to the nasolabial folds, and lower eyelid “pinch” blepharoplasty. Standard upper buccal sulcus access incisions were used for subperiosteal midface elevation and exposure of the lower orbital septum. Fat redraped over the orbital rim was not secured with fixation sutures as is commonly performed using lower eyelid approaches. Human cadaveric dissection with endoscopic visualization also was performed to demonstrate the reported technique.ResultsDuring this study, one complication developed for a single patient who experienced a temporary dense right zygomatic and frontal branch nerve palsy lasting 8 weeks. No evidence of lower eyelid malposition, ectropion, entropion, incomplete release, or asymmetry was otherwise encountered. Improvement in tear trough appearance, lower eyelid herniation, and midface descent was noted in all six patients.ConclusionA novel approach for lower eyelid fat transposition in combination with midface lift using the intraoral approach is presented. Excellent visualization, decreased operative times, technical ease, and improved outcomes all are potential advantages of this technique over standard approaches in which access to lower eyelid fat is achieved through the conjunctiva or a skin muscle flap.

Extended Lower Eyelid Skin Muscle Blepharoplasty

A patient presenting to a facial plastic surgeon with lower eyelid aging often has accompanying midface descent. Many surgical options exist to address these deformities. Blepharoplasty techniques include both the transcutaneous skin-muscle flap as well as the transconjunctival approach. The midface can be addressed via a multitude of techniques, including percutaneous suspension of the malar fat pad, deep plane dissections, subperiosteal and endoscopic midface lifts, and transorbital approaches. Patients who have some midface ptosis but do not meet the standard criteria for formal midface lifting, or who want to avoid the extended recovery associated with such techniques, could benefit from less invasive procedures. We propose the extended skin muscle blepharoplasty to address midface descent and lower lid aging to patients as an alternative to formal midface lifting. The extended skin muscle blepharoplasty is an excellent technique for patients with orbicularis hypertrophy, skin redundancy, a tear trough deformity, and premalar ptosis, as it addresses each of these deformities with minimal downtime. Results for patients with mild but visible midface descent are gratifying.

Midface Lifting: Current Standards

The most significant factor contributing to the overall change in the appearance of an individual's facial features over time is age. This process of gradual structural weakening of the face begins during the third decade and continues to worsen during the remainder of an individual's lifetime. Here, we discuss how the approach to midface rejuvenation has evolved over time owing to our increased understanding of the aging process. In addition, we discuss specific techniques that we use that have helped us achieve more natural and lasting results.

Analysis of Flap Tension in Surgical Rejuvenation of the Midface

To determine the flap tension present for 2 different surgical approaches for midface lifts and whether a gingivobuccal incision for release of the midface periosteum will diminish the resultant load on the midface flap. Cadaver study. Anatomy laboratory at the University of Florida. Twelve fresh-frozen cadaver heads are subjected to a transblepharoplasty (TB) approach on one side of the cadaver head while a transtemporal (TT) approach is performed on the contralateral side. The tension (grams) generated by moving the midface flap a distance of 1.03 cm is recorded by a digital load cell. A gingivobuccal incision is made on each side to allow transoral periosteal release (TOPR) of the midface flap, and the experiment is repeated. Three trials are performed for each operation, and the average load is calculated. A paired t test is applied. The tension resulting from the TT approach (172 g) was not found to be significantly different from that of the TB approach (179 g; P = .75). Significant differences in the resultant tension were not appreciated when comparing standard techniques to TT with TOPR (141.5 g; P = .27) or for TB with TOPR (164.1 g; P = .45). An experimental method is described for determining flap tension in facial rejuvenation surgery. No significant difference is found between flap tensions generated in the TB and TT approaches to the midface.

Minimally Traumatic Midface Lift Approach for Patients in Their Early 30s and 40s

To evaluate the effectiveness of the minimally traumatic midface lift approach in combination with the Wrinkle Severity Rating Scale (WSRS) criteria. From July 2007 to September 2009, 21 female patients underwent the minimal incision midface lift procedure. The procedure was mainly composed of a small arrow-like incision just superior to the top of the auricle, a fanlike subcutaneous dissection, and 3 suspension sutures. After 6 months, objective and subjective criteria were recorded, photos were taken for documentation and the WSRS scale system was used. Postoperative adverse effects were also recorded. All 21 patients completed more than a 6-month postoperative follow-up, and all the patients gained complete recovery. In the doctor's evaluation for using the WSRS system, 3 patients (14.3%) felt fair, the remaining 18 patients (85.7%) felt good, and no patients (0%) had poor results 6 months after the operation. In patient self-evaluation, 5 patients (23.8%) felt fair, the remaining 16 (76.2%) felt good, and no patient (0%) had poor results after 6 months. No serious operative complications including facial nerve palsy and skin slough were found. The minimally traumatic midface lift is a simple, reliable, and effective approach for the aging face of women in their 30s and 40s.

Periocular cosmesis

Abstract Purpose Facial nerve paralysis is one of the most devastating peripheral nerve injuries which implies severe functional, cosmetic and psychological consequences to the patients. The periocular area can be improved cosmetically by raising the tissues that have been drooped. These techniques are brow lift for the forehead‐ brow area, midface lift for the mid part of the face and face lift for restoring the contour of the tissues of the lower face. These are static techniques and support the tissues that are not any more innervated and are atrophied and drooped by the force of gravity. Methods In particular brow lift can be achieved by direct incision over the brow, by endoscopic forehead‐brow lift using anchoring systems or alternatively by small incision non endoscopic forehead brow lift through an eyelid incision. Midface lift can be achieved by subperiosteal or pre‐periosteal lift of the tissues or by using a suspension system. Face lift can be achieved with a deep planar rhytidectomy which can lift the tissues of the mid and lower face. Combination of forehead, midface and face lift can be necessary for the maximal possible symmetry of the face in a static position. There is a limitation of these techniques in regards to the dynamic reanimation of the face. There are several dynamic procedures helping at this direction. Results In particular, in case of a transected facial nerve, the disrupted facial nerve can be restored by α) direct end–to‐end coaptation or by β) cable nerve graft interposition Other techniques include: • Temporalis muscle transfer • Free nerve‐muscle grafts • Ipsilateral nerve transposition • Facial nerve‐cross face anastomosis. Conclusion The above available dynamic procedures may provide some degree of facial tone or voluntary facial movement.

Small Incision Preperiosteal Midface Lift for Correction of Lower Eyelid Retraction

Postblepharoplasty lower eyelid retraction is often due to scarring of the middle lamellae and/or vertical shortening of the anterior lamellae. Traditional reconstructive techniques involve a transconjunctival incision combined with a spacer graft. Other techniques involve a subperiosteal midface dissection or limited preperiosteal dissection. Elevation of the midface reduces the gravitational effect of the cheek on the eyelid and recruits skin for the anterior lamella. This study evaluates a technique for correction of lower eyelid retraction using a preperiosteal midface lift via a lateral canthal incision in a series of patients. Twenty-eight patients (56 eyes) with postblepharoplasty lower eyelid retraction were evaluated. Preoperative evaluations for inferior scleral show, corneal staining, and epiphora were documented. The patients underwent bilateral preperiosteal midface lift and canthoplasty via a lateral canthal incision. Follow-up ranged from 12 to 18 months. Average preoperative inferior scleral show was 1.96 mm (range, 1-3 mm). Seventy-eight percent of patients had epiphora, and 54% had corneal staining. Average postoperative lower eyelid position was +0.07 mm (range, 0 to +1 mm) above the inferior limbus. Average change in lower eyelid position relative to the inferior limbus was 2.04 mm. In all eyes, the final lower eyelid position was either at the inferior limbus or above it. All eyes had resolution of epiphora and corneal staining. Two patients required revision of lateral canthus on one side to improve symmetry. Mobilizing the midface in the preperiosteal plane through a lateral canthal incision provides excellent elevation and support of the eyelid. The small incision allows easy access to adhesions along the inferior orbital rim and to the preperiosteal plane beneath the entire midface. Preperiosteal midface lift combined with canthoplasty provides significant improvement of postblepharoplasty lower eyelid retraction.

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.