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SURVEY OF OPHTHALMOLOGY VOLUME 53 NUMBER 5 SEPTEMBER–OCTOBER 2008 DIAGNOSTIC AND SURGICAL TECHNIQUES MARCO ZARBIN AND DAVID CHU, EDITORS Cosmetic Eyelid and Facial Surgery Guy J. Ben Simon, MD,1 and John D. McCann, MD, PhD2 1 Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; and 2The Center for Facial Appearances, Salt Lake City, Utah, USA Abstract. The goal of cosmetic surgery is to reverse anatomical changes that occur in the face with aging. It is a rapidly growing subdiscipline of ophthalmic plastic surgery and includes forehead, eyelid, mid-face, lower face, and neck surgery, most performed by ophthalmic plastic surgeons. The current article reviews updates in cosmetic eyelid and facial surgery, including minimally invasive techniques such as cable suspensions, injections, and fillers. (Surv Ophthalmol 53:426--442, 2008. Ó 2008 Elsevier Inc. All rights reserved.) Key words. botulinum toxin injections cosmetic surgery forehead lower face / neck life mid-face life Ophthalmic plastic surgery has traditionally been divided into four sub-disciplines: eyelid, lacrimal, orbit, and cosmetic. Twenty years ago the average specialist focused on the first three disciplines with few surgeons having any interest in cosmetic surgery and even fewer with an emphasis on cosmetic surgery. This trend has reversed in the last decade. Today most specialists perform some cosmetic surgeries and many emphasize this area of their practice. A good metric of the growth of the subdiscipline of cosmetic surgery is the annual two-day national meeting of the American Society of Ophthalmic Plastic and Reconstructive Surgery, which devotes half of the meeting to cosmetic surgery. Cosmetic surgery is no doubt the most rapidly changing subdiscipline of ophthalmic plastic surgery. The recent trend toward greater interest in this subdiscipline has generated much recent endoscopic browlift fillers advancement. It is exciting to see the ophthalmologist bring the traditions of precision and finesse that characterize ocular microsurgery to the field of cosmetic facial surgery. This review should serve as an update of recent major changes in the field. Upper Face UPPER LID BLEPHAROPLASTY The eyes are an important component of facial aesthetics. Cosmetic surgery of the eyelids can have a dramatic effect on facial harmony and the perception of aging. Upper and lower blepharoplasties are commonly performed together. Occasionally other facial and skin rejuvenation procedures such as brow/midface lift and laser or chemical skin resurfacing are also performed at the same time.54 426 Ó 2008 by Elsevier Inc. All rights reserved. 0039-6257/08/$--see front matter doi:10.1016/j.survophthal.2008.06.011 427 COSMETIC EYELID AND FACIAL SURGERY Upper eyelid blepharoplasty (Fig. 1) is one of the most common cosmetic procedures performed by general and ophthalmic plastic surgeons. Both men and women complain about tired-looking eyes, excess skin, droopy eyelids, or circles around the eyes. Several distinct anatomic features may contribute to patients’ perception of the need for upper eyelid blepharoplasty.19 Excess and laxity of upper eyelid skin can cause superior visual field defects that are usually temporal rather than nasal, reflecting the tendency of the eyelid skin to be more extensive temporally. This may even confound diagnostic automated field testing in patients with glaucoma or ocular hypertension.71 PREOPERATIVE EVALUATION Preoperative evaluation includes a thorough and complete eye and facial clinical examination. The patient must undergo a complete medical work-up, with the emphasis on ocular surface disease and dry eyes, as well as establishment of rapport and realistic patient expectations. Patients should discontinue use of acetylsalicylic acid and other anticoagulants such as plavix, nonsteroiodal anti-inflammatory drugs (NSAIDs), vitamin E, and herbals two weeks before surgery. Coumadin should be stopped after general practitioner/cardiologist approval. Smokers should also be advised to stop smoking two weeks before the procedure, as smoking can delay wound healing.54 The relationship of concomitant eyelid and eyebrow malposition should be evaluated and documented. Evaluation of pre-septal and eyebrow fat pads is important in redefining the superior sulcus. In recent years there has been an increasingly popular belief that fullness of the eyelids is a sign of youth; this has led most cosmetic surgeons to preserve as much pre-septal fat as possible. Standard pre- and postoperative photography, on a blue background with diffused overhead lighting, are of utmost importance in aesthetic surgery and Fig. 1. can provide a useful method of evaluating improvement and anatomical changes in the eyelid position in relation to the globe, orbit, and eyebrow.117 Standard preoperative and postoperative photographs are as important to cosmetic surgery as preand postoperative visual acuities are to cataract surgery. Photographs should be taken without flash in order to see wrinkles and bags. SURGICAL TECHNIQUE Surgery is designed primarily to enhance aesthetic appearance and improve visual field deficits. Improvement in visual field is a function of excision of redundant eyelid tissue and is most dramatic in patients with a margin reflex distance equal to or smaller than 3.5 mm.40 Knowledge of the eyelid anatomy is an absolute prerequisite for performing blepharoplasty. There are two fat compartments in the upper eyelid: a pale yellow medial compartment, which derives from the adipose body of the orbit; and a deep yellow lateral compartment, derived from the preaponeurotic fat. Accessory or ectopic fat compartments have also been described in 20% of cases and may represent an extension of the lateral preaponeurotic fat pad.98 The superolateral aspect of the adipose part of the orbit does not reach the upper eyelid and therefore is not resected in blepharoplasty. The superomedial part, which is located between the superior oblique and medial rectus muscles and reaches the orbital septum, represents the medial compartment of the upper eyelid and is usually removed in upper blepharoplasty when fat sculpturing is performed. The preaponeurotic fat pad is located under the orbital roof and lies on the aponeurosis of the levator palpebrae muscle, in contact with the orbital septum. Laterally it extends behind the lacrimal gland, and medially a fibrous structure containing the reflected tendon of the superior oblique muscle separates it from the nasal fat pad. This preaponeurotic fat is the Before (left) and after upper lids blepharoplasty. 428 Surv Ophthalmol 53 (5) September--October 2008 lateral fat compartment that is resected in upper blepharoplasty. Skin margins are outlined with the patient in sitting position, these marks should be checked with the patient lying supine. The lower margin of the incision is made along the eyelid crease, beginning medially above and lateral to the medial canthus. Care must be taken not to include the naso-orbital depression, as this can cause webbing. Laterally, the line is extended to the sulcus between the orbital rim and the eyelid, and may be directed slightly upward.96 It is important to lift the eyebrow manually, elevating the excess of skin. The amount of skin to be excised is checked with toothed forceps to ensure that overcorrection of the skin is avoided. In our experience, it is important to leave 22 24 mm of anterior lamella to prevent postoperative shortening and lagophthalmos. These numbers should be adjusted upward for proptotic patients, patients with deep superior sulcus, and for the novice surgeon. Usually, a crescent-shaped incision is made in the upper eyelid. However, in advanced age lateral hooding with greater excess of eyelid skin laterally is commonly seen, so it might be preferable to use a scalpel-shaped incision that is widest laterally and tapers medially. That incision can provide indirect upward support of the lateral eyebrow.45 The eyelid is then injected with 1% lidocaine with 1:100,000 epinephrine. The initial skin incision is usually made with a sharp no. 15 scalpel, monopolar cautery, radiofrequency (Ellman) or laser. Before the skin muscle flap is excised with sharp scissors, laser, or Colorado needle-tip electrocautery (Colorado Biomedical, Evergreen, CO), bleeding vessels should be cauterized; this can be done by electrocautery or by defocusing the laser 6 8 inches (15-20 cm) away from the tissue.115 A survey conducted among plastic surgeons determined that 70 90% of all surgeons use laser as the only tool for cutting and hemostasis in blepharoplasty, and that carbon dioxide (CO2) lasers are the most common. The laser has a hemostatic effect of up to 0.1 mm on blood vessels, creating a nearly blood-free surgical site while the skin and orbicularis are being dissected and the retro-septal fat is being excised.90 Advantages of CO2 laser blepharoplasty are reduced bleeding; shorter intraoperative time and postoperative recovery period; improved anatomic dissection; and less pain, edema, bruising, and scarring.72,90 It is imperative to protect the patient by using stainless steel corneal shields when performing laser blepharoplasty because of the risk of globe perforation.115 Many general plastic surgeons in public academic centers, however, do not BEN SIMON AND MCCANN use laser and would rather use sharp blade or radiosurgery (Ellman unit). After skin and orbicularis removal, if fat sculpting is desired, the orbital septum is gradually opened, using sharp and blunt dissection, thermal cautery, or laser. One or more passes of the laser are made through the septum, permitting orbital fat to bulge. Fat is resected to the desired amount. Of the medial and central fat, only fat that comes easily into the wound is excised. It is important not to actively pull fat from the orbit. Medially the fat is whiter than in the central compartment and its anatomic position may vary. Because blood vessels present in the medial fat compartment are larger, they cannot be coagulated with the CO2 laser and must be cauterized.90 Gentle pressure on the globe causes herniation of the medial fat compartment and may help in identification. If lower eyelid blepharoplasty is planned, the skin incision is left unsutured until lower blepharoplasty is completed. This is especially important in cases where incision in the upper eyelid crease is planned for lateral canthopexy. The skin incision can be closed using running or interrupted sutures with various absorbable or permanent materials, with no apparent effects on aesthetic outcome. The use of tissue-adhesive cyanocrylate glue in skin closure has also been reported.129 The sub-brow fat pad can be repositioned during wound closure with use of eyelid suspension sutures. This can be done with 2 3 absorbable sutures that incorporate the orbicularis from the lower and upper sides of the incision along with the superolateral arcus marginalis. Placing of the sutures in this way might result in early over-correction of the upper eyelid, which, however, softens within days after the surgery. The transconjunctival approach to upper eyelid blepharoplasty is of limited usefulness in primary or secondary cases with pseudo-herniation of the medial fat pad.54,55,61 POSTOPERATIVE CARE Postoperatively, patients should be advised to use ice packs on the surgical site for 3 days to minimize postoperative swelling, and erythromycin ophthalmic ointment on the incision sites for 2 weeks. Nonabsorbable sutures, if used, can be removed 7 10 days after the procedure. COMPLICATIONS The most common complication of cosmetic surgery is failure to meet the patient’s expectations. This can be avoided by preoperative counseling of what reasonably can be achieved with surgery. In such a way patients with unreasonable expectations 429 COSMETIC EYELID AND FACIAL SURGERY can be identified. From a medico-legal standpoint, it is probably best for the surgeon to define reasonable expectations as a statement that is read and signed by the patient.66 Possible complications include upper eyelid retraction with scleral show from anterior lamellar inadequacy, lagophthalmos, and corneal exposure. Patients might present with various degrees of scleral show, tearing, ocular discomfort, and dry eyes. Acquired strabismus accompanied by persistent diplopia can occur, and superior oblique palsy and acquired Brown syndrome have been described.123,133 Blurred vision from induced corneal astigmatism usually lasts for up to 3 months after surgery, and subjective visual disturbances might last for 1 year.116 ENDOSCOPIC BROW LIFT The endoscopic approach to forehead and midface lift has become a popular method of facial rejuvenation, requiring minimal incision (Figs. 2 and 3).13,20,22,60 The use of endoscopy has led to improved aesthetics with respect to postoperative scarring, as well as to decreased healing time and greater patient satisfaction. In the past, most browlifts involved bicoronal dissection with a large incision;108 the endoscopic browlift is less invasive, better tolerated, and less prone to intra- and postoperative complications.70 The goal of forehead rejuvenation is to elevate the brows and midface, depending on the extent of dissection, and to address glabellar frown lines by weakening the corrugator and procerus muscles. It is best suited for brows with mild to moderate ptosis of up to 1.5 cm.70,108,134 A thorough understanding of the temporal anatomy, location of the retaining ligaments of the cheek, and relationship of the facial nerve to the temporal planes is of utmost importance in order to achieve aesthetic improvement and prevent complications. In younger patients it allows repositioning of the orbital portion of the orbicularis oculi muscle; in midface rejuvenation it lifts the malar pads, allowing a smooth transition onto the upper face that blends nicely into the lower face. In older patients endoscopic brow lift serves as a useful adjunct to eyelid and midface surgery. It corrects orbital festoons and lower eyelid bags and smoothens the upper third of the nasolabial fold.12 SURGICAL TECHNIQUE Preoperative marking is done with the patient in an upright position for placement of temporal and paramedian incisions, the desired brow elevation (5 8 mm medially and 8 10 mm laterally), and the anticipated course of the temporal branch of the facial nerve.108 The surgery can be performed under intravenous sedation or general anesthesia. Lidocaine 1% and epinephrine 1:100,000 are locally injected at the incision sites and to block the supraorbital and supratrochlear neurovascular bundles. The forehead and upper midface are injected with 0.01% lidocaine and 1:10,000,000,000 epinephrine solution (tumescent solution) to facilitate dissection and reduce bleeding. Incisions are made behind the hairline and include one central or paracentral and two temporal incisions, which are placed on a line connecting the ala nasi and the lateral canthus. Some surgeons make two additional paracentral incisions. Incisions are made to the depth of the periost centrally and to the depth of the deep temporalis fascia laterally. The central pocket is dissected in the sub-galeal or subperiosteal planes using a curved semi-sharp dissector. The lateral pockets are dissected toward the central pocket, while taking care to detach the conjoint fascia. Endoscope-assisted dissection is done from 1 cm above the orbital margin while working towards the Fig. 2. A 55-year-old man, before (left) 2 months after (right) forehead lift (endoscopic brow lift), and four-eyelid blepharoplasty. Note marked improvement in eyebrow position, forehead rhytids, and lower eyelid bags. 430 Surv Ophthalmol 53 (5) September--October 2008 Fig. 3. BEN SIMON AND MCCANN Before (left) and after (right) forehead lift, and upper and lower eyelid blepharoplasty. supraorbital and supratrochlear neuromuscular bundles. It is important to lyse periosteal attachments at the superior and lateral orbital rims until the sub-brow fat pad is visualized. If midface lift is desired, dissection is extended to the zygomatic arch and the lateral canthus. Medially, the corrugator muscles located adjacent to the neurovascular bundles can be lysed or sharply dissected. The procerus muscle can be dissected in a similar fashion. Prior to fixation the amount of dissection, residual adhesions, and desired lift are examined by a finger test (passing index finger in the superior orbital margin to evaluate residual adhesions that hold the eyebrow and may prevent it from adequate elevation postoperatively). There are several methods of suture fixation. The temporal pockets are fixated to the deep temporalis fascia. It is important to grasp a robust part of the superficial temporalis fascia distally and adjust the tension to the desired amount by fixating it to the deep fascia precisely at the location needed, usually in a mattress suture. Centrally, the forehead can be sutured to absorbable75 or titanium screws that are drilled in the frontal bone, or to a cortical tunnel on the outer table of the calvarium.87 Some surgeons use 2/0 monofilament nylon sutures to secure the forehead to the subgaleal tissue posteriorly. These can create bolsters, which disappear when the sutures are removed 2 weeks postoperatively. Additional fixation techniques include the use of fibrin glue, K-wire fixation, and temporary titanium screws.65,70,85,93 Skin incisions are sutured using absorbable sutures or surgical staples. Some surgeons advocate the use of dressing and elastic band for 1 week; sutures or staplers are removed 14 days postoperatively. A described limitation of endoscopic browlift is the inability to predict the long-term results of forehead elevation.108 Minimally invasive brow suspension has been described using subcutaneous suspension sutures with no open dissection, but its long-term outcome in comparison to endoscopic brow lift is not known.26 COMPLICATIONS Possible complications, which may vary with different dissection planes, include frontal branch weakness, temporary numbness, hematoma, seroma, incisional alopecia, temporal fat atrophy, wound dehiscence, suture abscess, unbalanced eyebrows, and in cases of lower blepharoplasty incision endoscopic midface lift lower eyelid retraction with lagophthalmos.24,64 Leakage of cerebrospinal fluid after endoscopic browlift was reported in a patient with a previous history of head trauma.51 Lower Face LOWER EYELID BLEPHAROPLASTY Aging in the lower eyelid can cause a number of aesthetic changes, including skin laxity or excess, orbital septum laxity, orbicularis laxity or hypertrophy, herniation of the orbital fat, canthal laxity, malar festoons, crow’s feet, and periocular wrinkles (Fig. 4).25,115 Common complaints include eyelid bags, circles under the eye, wrinkles around the eye, or a tired look. In the past a simplified approach was taken for patients seeking surgical treatment for eyelid bags. Only patients whose problem was amenable to removal of skin and fat were considered suitable candidates for classic blepharoplasty.36,106 Anatomically, relaxation of the orbital septum, orbicularis muscle, and skin can cause protrusion and shifting of intraorbital fat and eyelid bags. The traditional procedure in lower eyelid blepharoplasty was to remove the pseudo-herniated fat via skin incision. A recent, more conservative approach includes repositioning of the herniated fat in cases of tear trough deformity into the subperiosteal space. Both of these approaches may be accompanied by strengthening procedures for the attenuated septum or septorhaphy and tightening of the orbicularis muscle and skin.52,89 Defocused CO2 laser irradiation of the undersurface of the orbicularis results in persistent shortening and tightening of the muscle tissue.115 COSMETIC EYELID AND FACIAL SURGERY 431 Fig. 4. A 40-year-old woman, before (left) and 2 years after (right) four-eyelid blepharoplasty, upper eyelid skin muscle removal and fat sculpting, and lower eyelid transconjunctival fat removal. Most cosmetic surgeons today have developed a customized approach to eyelid surgery in which the specific anatomic problems are identified and the operation is individualized to address these problems. Additional anatomic changes that contribute to eyelid bags include pseudoherniation of fat pads, damaged skin, orbicularis muscle hypertrophy, eyelid fluid, tear trough deformity, and triangular malar mound.36,106 SURGICAL TECHNIQUE In cases of fat removal or repositioning or pseudoherniation of orbital fat, enhancement of the deficient suborbital portion of the malar complex is the principal component of modern lower eyelid blepharoplasty. Skin removal is usually unnecessary because there is typically inelasticity rather than actual excess of skin. The widely preferred approach is transconjunctival incision, which results in less eyelid retraction, less scleral show, and less postoperative ectropion than other methods.106,138,139 Some surgeons prefer a transcutaneous approach in patients who have hypertrophy of the orbicularis oculi muscle and therefore require muscle excision.1 The inferior fornix, eyelid skin, and lateral canthus are anesthetized with 1% lidocaine containing 1:100,000 epinephrine. The lower eyelid is retracted with a lacrimal or Desmarre retractor. A tarsoconjunctival incision is made 4 6 mm below the lid margin through the conjunctiva and lower eyelid retractors; this can be done using sharp dissection, monopolar cautery, or laser. In laser blepharoplasty, protective shields for the patient’s eyes must be used. The eyelid can be retracted using forceps with a 0.5-mm tip or by placement of a 6 0 silk suture. Gentle retropulsion on the globe helps to identify the fat compartments. The medial, central, and lateral fat pads are identified and conservative, individualized fat removal is accomplished. Hemostasis is achieved using monopolar or bipolar cautery or by defocused laser applications. Care must be taken not to damage the inferior oblique muscle that separates the medial from the central fat pocket. The endpoint for excision is reached when gentle retropulsion on the globe results in the anterior aspect of the orbital fat being flush with the orbital rim. The tarsoconjunctival incision is left unclosed, but the inferior and superior edges of the tarsoconjunctival incision are properly apposed and the lower eyelid is pulled up to make sure there is no overlap between the cut edges of the conjunctiva.15 Some surgeons routinely perform canthopexy in lower eyelid blepharoplasty. This can be done through a lower or upper eyelid; it eliminates unnecessary skin resection and is believed to restore tone and youthful contour.29,48,115 Through an incision in the upper eyelid crease,57 dissection is extended inferiorly to the level of the lateral orbital rim, leaving the periosteum intact. This stage of dissection can facilitate lateral fad pad resection if this was not fully addressed during lower blepharoplasty. The inferior limb of the lateral canthal tendon can be cut with scissors under visual inspection. A double-armed suture on a semicircular needle is placed 2 mm above Whitnall’s tubercle inside the orbital rim. The suture then travels through the orbital rim periosteum and emerges in half-buried horizontal mattress fashion through the inferior canthal tendon. Additional sutures can be used to tighten the orbicularis muscle to the superficial orbital rim. Alternatively, lateral canthal resuspension can be performed using the lateral canthal strip procedure described by Anderson and Gordy.5 Wrinkles and excess of vertical skin can be dealt with by skin resurfacing techniques, such as chemical peeling and CO2 or erbium YAG laser resurfacing. These techniques are applicable in patients with Fitzpatrick skin types I--III. Patients with darker skin are at risk of pigmentary changes; these can be managed by the pinch technique. Excess skin is crushed using a straight hemostat 1 2 mm subciliary and excised. Care must be taken to excise as little as possible of the orbicularis muscle. The skin is closed with a running suture.95 Regardless of the timing of laser treatment, transconjunctival 432 Surv Ophthalmol 53 (5) September--October 2008 blepharoplasty with adjunctive CO2 laser resurfacing results in improvement of lower eyelid bulging and skin wrinkling.18 Another modification of lower blepharoplasty involves transcutaneous plication of the orbital septum.50 An interesting report describes nonsurgical treatment for pseudoherniation of orbital fat pads by phosphatidylcholine injection, with marked improvement over a 2-year period.105 COMPLICATIONS Severe complications, such as visual loss from orbital hemorrhage, orbital injection, or posterior optic nerve infarction have been described.38,127 Other possible complications are lower eyelid retraction with scleral show, lagophthalmos, and corneal exposure. As with upper lid blepharoplasty, patients might have various amounts of scleral show, tearing, ocular discomfort, and dry eyes. Various surgical techniques have been described to address scleral show, eyelid retraction, and ectropion after lower eyelid blepharoplasty, including free tarsoconjunctival graft,27 grafting of autogenous hard palate mucosa,130 and cheek suspension using transosseous fixation and titanium screws.135 Temporary tarsorrhaphy can be used to prevent and treat scleral show and ectropion secondary to laser resurfacing or blepharoplasty.109 Acquired strabismus that includes incomitant vertical deviation consistent with an inferior rectus paresis has been described.123 In some patients, upward rotation of the globe was found to be mechanically restricted. FAT REPOSITIONING In young people the eyelid--cheek complex is a single smooth convex profile. Aging causes descent of the globe and pseudoherniation of intraorbital fat, producing a double convex or tear trough deformity on the eyelid profile and a nasojugal groove at the medial aspect of the lower eyelid.43 With advancing age this depression appears more prominent because of attenuation and descent of the orbicularis oculi and cheek fat, resulting in skeletonization of the orbital area and revealing the topographical contour of the inferior orbital rim.6 Simple removal of orbital fat can result in a hollow appearance of the lower eyelid. Preservation of the lower orbital fat is a new concept in facial rejuvenation, designed to prevent the hollow appearance that may follow the removal of excess fat in lower eyelid blepharoplasty. Such preservation creates a smooth transition to the malar eminence, blending nicely into the upper face.42,43 Aging causes progressive exposure of the BEN SIMON AND MCCANN underlying skeletal anatomy in the periorbital area, unlike in the lower facial area, where thicker soft tissue continues to cover bony landmarks. SURGICAL TECHNIQUE The basic surgical technique includes release of the arcus marginalis and advancing of the subseptal fat beyond the infraorbital rim and underneath the orbicularis muscle. The fat pedicles are temporarily externalized to the midface by suturing. They can be placed in the sub- or supra-periosteal planes, with no apparent effect on aesthetic results. This technique camouflages the lower orbital rim anatomy and provides more youthful rejuvenation of the midface.35,43,81 Other methods suggested to correct tear trough deformity include orbital fat removal, fat injections or grafts, and alloplastic cheek implants. In general, trans-conjunctival fat repositioning results in leveling of the tear trough deformity, a smooth contour of the lower eyelid, and high patient satisfaction.63 COMPLICATIONS Possible complications are incomplete resolution of pigmentary changes (dark circles), temporary skin irregularities from fat and edema, hardening of repositioned fat, granuloma formation, restricted ocular movements, or new-onset diplopia.37 SUBORBICULARIS OCULI FAT / MIDFACE LIFT The midface lies between the lateral canthal angle and the top of the nasolabial fold. It includes the medial and lateral canthal tendon, lower eyelids, suborbicularis oculi fat pad (SOOF), malar fat pad, orbitomalar ligament, orbital septum, and origins of the zygomaticus major and minor muscles and levator labii superioris. 88,99 Volumetric distribution of the midface soft tissues is an important factor in the youthful appearance of the human face (Fig. 5). If these tissues are full relative to the lower face, the individual appears healthy and young.80 A fuller midface can be achieved by an open surgical or endoscopic technique.101,103,122 Indications for midface lift include lower eyelid retraction secondary to lower blepharoplasty, cicatricial ectropion, and paralytic ectropion due to palsy of the 7th cranial nerve.49,92,122 Aesthetically, the goal of midface lift is to achieve facial rejuvenation by increasing malar fullness, decreasing skeletonization of the lower eyelid at the inferior orbital rim, and reducing prominence of the nasolabial and nasojugal (tear trough) folds. 433 COSMETIC EYELID AND FACIAL SURGERY Fig. 5. A 65-year-old woman, before (left) and 8 months post (right) transconjunctival lower eyelid retraction as a result of lower blepharoplasty. Note marked improvement in lower eyelids position. SURGICAL TECHNIQUE In patients with tear trough deformity, transconjuctival SOOF lift is adequate and yields good aesthetic results. Dissection is carried out in the preperiosteal plane, extending beyond the inferior margin of the tear trough deformity until the SOOF is identified. An anchoring suture from the SOOF pad to the periosteum of the infraorbital rim is placed along the width of the deformity. After adequate suspension, a single buried absorbable suture is used to close the conjunctival incision lateral to the cornea.32 When a more robust midface suspension is required, effective reshaping of the soft tissue of the aging midface necessitates freeing of the cheek soft tissue, both superficially and deeply, from its attachment to skin and bone. Incisions are made at the temporal scalp, inferior conjunctiva, and alveolar oral mucosa. Dissection is aimed at creating a temporal pocket, mobilizing the midface by subperiosteal dissection, and lifting the mobilized face to the deep temporalis fascia while securing the SOOF pad to the inferior orbital rim.122 Dissection is performed as far as the oral commissure inferiorly and toward the zygoma and lateral buttress of the maxilla, along the infraorbital rim, and around the infraorbital nerve in the subperiosteal plane. Care must be taken to identify and preserve the infraorbital nerve. In the lateral orbit, a small area of deep temporalis fascia is cleared near the lateral canthus. No dissection is carried out at the masseteric tendon or the zygomatic arch.80 Techniques used to re-shape the midface, once the subperiosteal tissue has been freed, include malar imbrication, insertion of suspension sutures into the deep temporalis fascia, and mechanical anchoring. If the neck is to be treated, this is done before the cheek is lifted. To avoid traction of the midface, lateral plication of the superficial muscularaponeurotic system (SMAS) is performed only after the midface has been adequately lifted.137 To avoid postoperative complications the following steps are suggested: Reattach the lateral canthus to its proper anatomic position; address the orbital fat via a trans-conjunctival approach to prevent middle lamellar scarring and orbital septum retraction; and place a suture at the inferior lateral orbital rim that stimulating the orbitomalar ligament that elevates the midface and suturing of the orbicularis oculi muscle.97 COMPLICATIONS Possible complications include temporary facial nerve trauma (in up to 5% of cases), significant orbital edema, and chemosis especially when combined with lower blepharoplasty, prolonged swelling, and skin dimpling along the suspension sutures.102 LOWER FACE AND NECK REJUVENATION Deep plane facelift techniques developed as surgeons became more aware that elevation of the deeper tissue layers of the aging face could achieve longer lasting and more natural results.3,58 SURGICAL TECHNIQUE The procedure is best carried out under general anesthesia. The face and neck are infiltrated with tumescent solution.59 Incisions are marked and made through the temple hairline, above the ear and down a natural skin crease in the pre-tragal area, and continued post-auricularly to the level of the superior conchal bowl. Pre- and post-auricular skin flaps are elevated and over the sternocleidomastoid region and over a distance of 5 6 cm (2 inches) in the face, while taking care to dissect superficial to the greater auricular nerve. In the neck the platysma muscle is identified below the angle of the mandible, and dissection is extended to the submental region anteriorly and to the lowest neck rhytid. To prevent damage to the facial nerve, the deep plane is kept above the level of the 434 Surv Ophthalmol 53 (5) September--October 2008 masseteric fascia. Care is taken to limit dissection to the undersurface of the platysma musculature in the SMAS flap. At the level of the malar eminence dissection is carried out toward the bone to identify the zygomaticus major muscle, and the SMAS flap is elevated anteriorly. Throughout the procedure this flap is kept above the anterior border of the parotid gland. Buccal fat can be resected as needed. If needed, submental platysmoplasty with direct fat excision is performed (Fig. 6).39,53,56 An incision is made 2 cm posterior to the mandibular protuberance, the subdermal fat is lifter off the underlying muscle, and the skin flap is connected bilaterally to the pre-platysmal flaps. Fat and redundant muscle are removed, and buried sutures are used to reattach the muscle edges. Finally, the SMAS flaps are repositioned and sutured along a postero-superior vector. Prolene sutures are used to attach the deep plane flap by tucking it into the preauricular area and back to the mastoid fascia. The skin is slightly lifted to prevent puckering and the excess skin is trimmed. A drainage device is used in the early postoperative period. A light pressure dressing with fluffed cotton and Kerlex is applied.3,4,9,41 COMPLICATIONS Possible complications include hematoma, paresthesia, and facial nerve paresis. These can be avoided by careful and meticulous dissection and by operating only at the level of tissue planes known to be safe.3 BEN SIMON AND MCCANN SURGICAL TECHNIQUE The procedure is performed on an outpatient basis and under local anesthesia. As in most facial rejuvenation procedures the operative area is infiltrated with tumescent solution to facilitate dissection and minimize bleeding. Incision sites are anesthetized with 1 2% lidocaine containing 1:100,000 epinephrine. Following the S-shaped incision, a limited skin flap is undermined in an oval area extending from 1 cm above the zygomatic arch to the mandibular angle caudally and 5 cm anteriorly. Dissection is in the subcutaneous plane. Superiorly the deep temporalis fascia is exposed, while care is taken not to damage the superficial temporal vessels. For the first purse-string suture a 2 0 nylon or prolene suture is inserted in a Ushaped fashion, descending to the mandibular angle and engaging the parotid fascia. The suture allows the anterior neck region to be lifted. The second purse-string suture, directed at a 30 angle, is extended to the edge of the undermined area, allowing the jowls to be lifted. The periocular region is sutured under minimal tension.110,126 A number of alternative approaches have been introduced for face and neck rejuvenation, and there is controversy over the relative advantages of the more extensive and the minimal techniques with respect to longevity and postoperative complications.3,9 Skin Rejuvenation PHOTODAMAGE S LIFT A recently developed technique requiring minimal incision for mid-lower face rejuvenation is performed via an S-shaped pre-auricular incision, followed by elevation of the facial skin and SMAS with the aid of two purse-string sutures. Exposure to the sun induces skin damage referred to as photoaging, which may be manifested clinically as wrinkles, dryness, irregular pigmentation, telangectasias, brown spots, and seborrheic keratosis. Premalignant sun-induced lesions include actinic keratosis;118 malignant lesions include basal Fig. 6. A 68-year-old woman, before (left) and after (right) lower face and neck lift including neck liposuction and platysmoplasty. Note marked improvement in platysmal bands. COSMETIC EYELID AND FACIAL SURGERY 435 and squamous cell carcinomas. Patients with photoinduced skin damage should be examined periodically for premalignant lesions. Sun protection during childhood and throughout life has been shown to reduce the risk of malignant skin cancers.69,120 Ultraviolet A and B (UVA and UVB) contribute to pigmentary changes, as well as to wrinkles, telangectasias, and lentigines.68 Actinic keratosis, which is premalignant to squamous cell carcinoma, can be treated with cryosurgery, topical 5% fluorouracil cream, and photodynamic therapy with aminolevulinic acid.73 The effects of photoaging can be reduced to a limited extent by the use of topical lotions containing alpha- and beta-hydroxyl acids that are exfoliants and moisturizers. Some of these materials contain 5% glycolic acid and 8% lactic acid, both shown to add to the improvement in roughness and mottled pigmentation.121 Topical vitamin A derivatives (retinoids) can be used to improve fine wrinkles and irregular pigmentation.62 Peeling makes the skin more vulnerable to UV radiation, and therefore sun protection is of utmost importance after this procedure. Deep chemical peeling can be achieved by trichloroacetic acid 35%, higher concentration than 50%, and phenol (Fig. 7). Possible complications of chemical peeling include keloids, hypertrophic scars, and hypopigmentation. Other modalities used to treat photoaging damage include cryosurgery, microderm abrasions, chemical and laser peeling, tissue augmentation by injectable fillers, and botulinum injection to treat dynamic rhytides.46,119 LASER Photodamaged skin and acne scarring can be improved by treatment with different types of lasers: ablative (high energy pulsed or scanned) CO2 lasers, single or variable pulse or dual ablative/coagulative mode erbium:yttrium aluminum garnet (Er:YAG) lasers, non-ablative Q-switched neodymium:yttrium aluminum garnet (Nd:YAG), diode lasers, and combined wavelength systems. The pulsed Er:YAG laser has poor penetration and is therefore used to treat superficial rhytides; the CO2 laser is better for deep rhytides and scars.94 Pulsed CO2 laser resurfacing causes ablation of normal tissue with subsequent collagen regeneration, and remodeling occurs by heat-induced collagen contraction. A similar degree of skin tightening can be achieved with the erbium laser. Laser-induced skin contraction is usually not longlasting; the postoperative decrease with the CO2 laser ranges from an average of 42% 1 month postoperatively to 36% on average at 6 months. With erbium laser treatment the skin contraction is less Fig. 7. A 42-year-old woman before (top), 5 days (middle) and 3 months after (bottom) trichloroacetic acid 25% peel for skin rejuvenation. but is more stable.28 With the advent of newgeneration ultra-pulse CO2 lasers, the skin can be successfully resurfaced with minimal risk or side effects.131 Laser resurfacing of the lower eyelid skin and periocular skin is done with the ultra-pulse CO2 laser. After each pass with the laser, debris should be removed using saline-soaked gauze, and the area dried with dry gauze. One pass usually suffices for the pre-tarsal skin, whereas 2 3 passes should be applied for the pre-zygomatic skin and lateral crow’s feet area. After laser application the treatment area should be covered with a moist dressing. 115 436 Surv Ophthalmol 53 (5) September--October 2008 The Er:YAG laser is also used to treat periocular skin deformities. In many cases, skin resurfacing by CO2 or Er:YAG yields good results even without lower eyelid surgery. Combined use of Er:YAG and CO2 lasers was recently described (Derma-K).90 Because the eyelid skin is only 0.25 mm thick, two passes with decreasing power of the CO2 laser are adequate for its removal. To avoid ectropion, the triangle below the lateral corner of the eye must be approached with restraint. An occlusive dressing with polyurethane film is applied. Epithelialization occurs after 6 to 7 days. Erythema lasts for several weeks after resurfacing with the CO2 laser and for only 2 weeks with the Er:YAG laser. This is because the Er:YAG laser does not cause thermal damage; on the other hand, it does not induce collagen shrinkage, and deep wrinkles are therefore more successfully treated with the CO2 laser. Promising results have been obtained with the CO2/Er:YAG combination laser, with post-treatment erythema of 3 weeks. Sun protection of the treated area is mandatory for 6 months.90 Possible complications include persistent erythema, allergic dermatitis, mild post-inflammatory skin hyperpigmentation, hypopigmentation, and lid retraction.18 INTENSE PULSED LIGHT Intense pulsed light, a non-coherent light produced by a flash lamp, has been used in recent years to treat photodamaged skin. By using filters with different cutoff values, it is possible to select the desired wavelength; long waves that reach the deep dermal collagen tighten the skin, improving its texture. Vascular and pigmented lesions are treated by photodermal damage either through hemoglobin absorption or melanin-pigmented lesions. Thermal damage is avoided by controlling the duration of light pulses and the interval between them, the latter must be shorter than the thermal relaxation time in the target lesion in order to ensure its destruction.31 Intense pulsed light was recently shown to be effective and safe for treating senile pigmentation, telangectasias, and rosacea, as well as for improving skin texture in facial and non-facial rejuvenation. Complications can include redness, blisters, swelling, scar formation, and hyperpigmentation.34,124,132 LASER HAIR REMOVAL (PHOTOEPILATION) Selective laser thermolysis is currently the treatment of choice for hair removal. By using a laser beam with a defined wavelength and pulse duration to specifically target the melanin, it is possible to selectively destroy the chromophore while protecting the surrounding tissue. Patients require a minimum BEN SIMON AND MCCANN of three treatments at 1.5- to 2-month intervals for body hair and five or six treatments for facial hair. The reported success rate at 6 months is 60 95%.74 Lasers used for hair removal include long-pulsed alexandrite, long-pulsed diode, and long-pulsed Nd:YAG; the first two appear to be more effective than the last.8 In addition, larger spot size appears to be more effective for hair removal, probably because it delivers more total energy per pulse and results in increased penetration.91 Possible side effects include pain, hyperpigmentation, blister or erosion, folliculitis, and hypopigmentation.8 Other methods of hair removal include shaving, waxing, electrolysis, and chemical epilation. BOTULINUM TOXIN Botulinum toxin is one of the most powerful toxins known in toxicology. It acts via parasympathetic acetylcholine inhibition (chemodenervation), which prevents fusion of the acetylcholine-filled vesicle with the plasma membrane, thereby also preventing the release of acetylcholine into the synaptic cleft. The exotoxin produced from Clostridium botulinum temporarily paralyzes the mimic facial musculature.7 Botulinum toxin was first used in 1973 and 1979 for the treatment of strabismus, and in 1985 the indication was extended to blepharospasm and dystonia.7,112--114 Aesthetic indications were added after patients noticed that treatment in the brow area produced a relaxed, unworried appearance (Figs. 8--10 ).15,113,128 Three commercial botulinum toxin preparations are currently available: Botox (botulinum toxin type A [C. botulinum type A toxin]; Allergan, Irvine, CA), Dysport (type A toxin haemagglutinin complex; Ipsen, Maidenhead, Berkshire, UK), and botolinum toxin type B, available as Myobloc (injectable solution; Elan Pharmaceuticals, South San Francisco, CA).44,47 Botulinum toxin, used alone or in combination with other modalities of facial rejuvenation, such as chemical peel, laser resurfacing, dermabrasion, or soft tissue augmentation, offers safe and effective treatment of upper face wrinkles. It has also been used in surgery for facial rejuvenation.47 Dynamic changes are caused by muscle hypertonicity and are manifested as lines or rhytids of the forehead and glabellar areas. Improvement after intramuscular injection of botulinum (type A or B) first appears after 24 72 hours, reaches a peak by 1 month after injection, and lasts usually for 3 4 months, but might persist for 6 8 months or longer.17,86 Previous botulinum toxin treatment might extend the efficacy of additional BTX injections because of attendant muscle atrophy; it was 437 COSMETIC EYELID AND FACIAL SURGERY Fig. 8. A 26-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to corrugators and procerus muscles. Note marked improvement in frowning appearance. also noted that repeated injections prolong the clinical effect.33,76 Among the many cosmetic indications are lateral canthal lines (crow’s feet), horizontal forehead lines, brow ptosis, orbicularis oculi hypertrophy and periocular skin wrinkling,30 facial asymmetry, masseteric hypertrophy to reduce a prominent mandibular angle,2 neck rejuvenation10 (platysmal bands), and decollete folds.7 Because of asymmetric results, cosmetic indications that include nasolabial folds and platysma and mouth frown are still a subject of controversy. As our understanding of the anatomy and combined mentalis and depressor anguli improves, the results of treatment are likely to be increasingly satisfactory.16 Systemic complications are rare because clinical dosages of botulinium toxin are measured in nanograms, and as it is injected locally into the muscle, very little enters the systemic circulation. Complications can be classified as local, regional, or systemic.124 Possible systemic complications are thirst, flu-like illness, and mild urticarial rash, as well as potentiation of neurological diseases such as myasthenia gravis and amyotrophic lateral sclerosis. Rare reports include anaphylaxis and respiratory arrest.21,79 Patients with human albumin allergy should avoid treatment with botulinum toxin. Possible regional complications are unwanted weakness or paralysis adjacent to the point of injection, such as droopy eyelid, brow ptosis or elevation, diplopia in the periocular area from inadvertent orbital injection, lip drooling and asymmetry in the perioral area, dysphagia (after deep neck muscle injection), reduction in facial expressiveness, and a mask-like appearance.11,15,16 Local effects can include erythema, rash, ecchymosis, and hematoma.124 Contraindications for botulinum toxin injection include pregnancy and lactation, neuromuscular diseases, peripheral neuropathy, and use of medications such as quinine, calcium channel blockers, penicillamine, or aminoglycoside antibiotics.47 FILLERS Attempts have been made over the years to augment facial soft tissue for aesthetic and reconstructive purposes. Fillers are used for the treatment of deep wrinkles and non-dynamic furrows.67,77,107 They are also useful for correction of facial, bony, and soft tissue defects of congenital or traumatic origin, and in patients suffering from scleroderma, Romberg disease, facial wasting, or AIDS-associated lipodystrophy.14,77,78 Many materials have been used, including organic particles such as autologous fat, sea coral, and injectable bovine collagen. The latter, along with inorganic liquid silicone gel, have been used increasingly in recent years. None of the proposed materials has proved entirely satisfactory because of migration, host immune response, or transitory cosmetic improvement.104 Autologous fat is not permanent Fig. 9. A 30-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to orbicularis muscle for lower eyelid orbicularis hypertrophy and crows feet. Note marked improvement in lower eyelid and lateral canthal area. 438 Surv Ophthalmol 53 (5) September--October 2008 BEN SIMON AND MCCANN Fig. 10. A 48-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to orbicularis muscle for crows feet. and its fate is unpredictable. The effect of soft tissue augmentation using fillers typically lasts 6 months. The search for newer and better materials led to the introduction of polyacrylamide, which was considered biologically inert; however, recently reported severe granulomatous reaction to polyacrylamide casts doubt on this assumption.23 A filler commonly used in the United States is an injectable bovine collagen preparation. Other common fillers include PMMA (polymethylacrylate), microspheres, silicone oil, polylactic acid microspheres, and dextran microspheres. Recently, hyaluronic acid filler (Restylane; non-animal stabilized hyaluronic acid; Medicis Aesthetics, Scottsdale, AZ) was approved by the FDA. Long-term retention of its effect has been demonstrated in a mouse model using Restylane mixed with cultured human dermal fibroblasts (Fig. 11).136 In a recent investigation of human host response to intradermal injection of various soft tissue fillers, all of the examined substances appeared to be clinically and histologically safe, but all showed host inflammatory reaction from encapsulated fibrous tissue, granulomatous reaction with giant cells, and chronic foreign body reaction.77 A less severe inflammatory response was obtained with polymethylacrylate particles, polyacrylamide, polyvinylhydroxide microspheres, and calcium hydroxylapetite. Other fillers have also had destructive inflammatory effects on soft tissues.82--84 Other possible complications of soft tissue augmentation include blindness and cutaneous necrosis from treatment in the glabellar area30,125 and arterial embolization following hyaluronic acid injection (Restylane).100,111 ophthalmic procedures is to improve or preserve vision. The success of the surgery can be readily measured with visual acuity. The goals of cosmetic surgery are more varied and success must be defined on a patient-by-patient basis. The most common goal of cosmetic surgery is to reverse anatomical changes that occur in the face with aging. Just as a successful ophthalmologist must understand the anatomy and physiology of vision a successful cosmetic surgeon must understand the anatomy and physiology of facial aging. The successful cosmetic surgeon must be able to listen to Summary Fig. 11. A 56-year-old man, before (upper image) and 6 months after Restylane injection for lower eyelid tear trough deformity, note marked improvement achieved with no incisional surgery. In many ways cosmetic surgery is very different from the rest of ophthalmology. The goal of most COSMETIC EYELID AND FACIAL SURGERY a patient’s concerns about how their appearance has been altered by age, understand the underlying anatomical and physiological changes that cause these changes, describe to the patient what sort of success they might expect in reversing these changes, and then master and stay current on a number of rapidly evolving techniques. It is a truly fascinating and challenging area of ophthalmology. For those who embrace the discipline it can be very rewarding. Method of Literature Search Medline and Medical Subject Headings search (1966--2007) was conducted using the following terms: eyelid, ptosis, blepharoplasty, eyelid bags, forehead, face-lift, midface-lift, neck-lift, rhytidectomy, browlift, chemical peel, blepharoplasty, facial implants, fat transfer, liposuction, botulinum toxin, fillers, Restylane, chemical peel, cosmetic surgery, aesthetic surgery. The search was limited to English language publications. All manuscripts’ abstracts were examined. Publications were included if they studied any aspects of cosmetic eyelid and facial surgery with emphasis on new surgical techniques and new cosmetic procedures. Comparative prospective studies were preferred; case-series were also included if they studied an important aspect of a specific cosmetic procedure. Abstracts identified were assessed for eligibility. If the abstract was unclear the full-text of the article was obtained and assessed. References 1. Adamson PA, Strecker HD: Transcutaneous lower blepharoplasty. Facial Plast Surg 12:171--83, 1996 2. Ahn J, Horn C, Blitzer A: Botulinum toxin for masseter reduction in Asian patients. Arch Facial Plast Surg 6:188-91, 2004 3. Alsarraf R, To WC, Johnson CM: The deep plane facelift. Facial Plast Surg 19:95--106, 2003 4. Anderson KW, Baker SR: Advances in facial rejuvenation surgery. Curr Opin Otolaryngol Head Neck Surg 11:256-60, 2003 5. Anderson RL, Gordy DD: The tarsal strip procedure. Arch Ophthalmol 97:2192--6, 1979 6. Baker SR: Orbital fat preservation in lower-lid blepharoplasty. Arch Facial Plast Surg 1:33--7, 1999 7. Becker-Wegerich P, Rauch L, Ruzicka T: Botulinum toxin A in the therapy of mimic facial lines. Clin Exp Dermatol 26: 619--30, 2001 8. Bouzari N, Tabatabai H, Abbasi Z, et al: Laser hair removal: comparison of long-pulsed Nd:YAG, long-pulsed alexandrite, and long-pulsed diode lasers. Dermatol Surg 30:498-502, 2004 9. Brackup AB: Advances and controversies in face lift surgery. Curr Opin Ophthalmol 14:253--9, 2003 10. Brandt FS, Boker A: Botulinum toxin for rejuvenation of the neck. Clin Dermatol 21:513--20, 2003 11. Bulstrode NW, Grobbelaar AO: Long-term prospective follow-up of botulinum toxin treatment for facial rhytides. Aesthetic Plast Surg 26:356--9, 2002 439 12. Byrd HS: The extended browlift. Clin Plast Surg 24:233--46, 1997 13. Byrd HS, Burt JD: Achieving aesthetic balance in the brow, eyelids, and midface. Plast Reconstr Surg 110:926--33, discussion 934--9, 2002 14. Cahill KV, Burns JA: Volume augmentation of the anophthalmic orbit with cross-linked collagen (Zyplast). Arch Ophthalmol 107:1684--6, 1989 15. Carruthers A: History of the clinical use of botulinum toxin A and B. Clin Dermatol 21:469--72, 2003 16. Carruthers J, Carruthers A: BOTOX use in the mid and lower face and neck. Semin Cutan Med Surg 20:85--92, 2001 17. Carruthers J, Carruthers A: The adjunctive usage of botulinum toxin. Dermatol Surg 24:1244--7, 1998 18. Carter SR, Seiff SR, Choo PH, et al: Lower eyelid CO(2) laser rejuvenation: a randomized, prospective clinical study. Ophthalmology 108:437--41, 2001 19. Castro E, Foster JA: Upper lid blepharoplasty. Facial Plast Surg 15:173--81, 1999 20. Chiu ES, Baker DC: Endoscopic brow lift: a retrospective review of 628 consecutive cases over 5 years. Plast Reconstr Surg 112:628--33, discussion 634--5, 2003 21. Cobb DB, Watson WA, Fernandez MC: Botulism-like syndrome after injections of botulinum toxin. Vet Hum Toxicol 42:163, 2000 22. Dailey RA, Saulny SM: Current treatments for brow ptosis. Curr Opin Ophthalmol 14:260--6, 2003 23. de Bree R, Middelweerd MJ: van der Waal I: Severe granulomatous inflammatory response induced by injection of polyacrylamide gel into the facial tissue. Arch Facial Plast Surg 6:204--6, 2004 24. De Cordier BC, de la Torre JI, Al-Hakeem MS, et al: Endoscopic forehead lift: review of technique, cases, and complications. Plast Reconstr Surg 110:1558--68, discussion 1569--70, 2002 25. de la Plaza R, Arroyo JM: A new technique for the treatment of palpebral bags. Plast Reconstr Surg 81:677-87, 1988 26. Erol OO, Sozer SO, Velidedeoglu HV: Brow suspension, a minimally invasive technique in facial rejuvenation. Plast Reconstr Surg 109:2521--32, discussion 2533, 2002 27. Ferri M, Oestreicher JH: Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting. Orbit 21:281--8, 2002 28. Fitzpatrick RE, Rostan EF, Marchell N: Collagen tightening induced by carbon dioxide laser versus erbium: YAG laser. Lasers Surg Med 27:395--403, 2000 29. Flowers RS: Canthopexy as a routine blepharoplasty component. Clin Plast Surg 20:351--65, 1993 30. Flynn TC: Periocular botulinum toxin. Clin Dermatol 21: 498--504, 2003 31. Fodor L, Peled IJ, Rissin Y, et al: Using intense pulsed light for cosmetic purposes: our experience. Plast Reconstr Surg 113:1789--95, 2004 32. Freeman MS: Transconjunctival sub-orbicularis oculi fat (SOOF) pad lift blepharoplasty: a new technique for the effacement of nasojugal deformity. Arch Facial Plast Surg 2: 16--21, 2000 33. Garcia A, Fulton JE: Cosmetic denervation of the muscles of facial expression with botulinum toxin. A dose-response study. Dermatol Surg 22:39--43, 1996 34. Goldberg DJ, Samady JA: Intense pulsed light and Nd:YAG laser non-ablative treatment of facial rhytids. Lasers Surg Med 28:141--4, 2001 35. Goldberg RA: Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg 105:743--8, discussion 749--51, 2000 36. Goldberg RA, McCann JD, Fiaschetti D, et al: What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg 115:1395--402, discussion 1403--4, 2005 37. Goldberg RA, Yuen VH: Restricted ocular movements following lower eyelid fat repositioning. Plast Reconstr Surg 110:302--5, discussion 306--8, 2002 440 Surv Ophthalmol 53 (5) September--October 2008 38. Good CD, Cassidy LM, Moseley IF, et al: Posterior optic nerve infarction after lower lid blepharoplasty. J Neuroophthalmol 19:176--9, 1999 39. Gryskiewicz JM: Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates. Plast Reconstr Surg 112:1393--405, discussion 1406--7, 2003 40. Hacker HD, Hollsten DA: Investigation of automated perimetry in the evaluation of patients for upper lid blepharoplasty. Ophthal Plast Reconstr Surg 8:250--5, 1992 41. Hamra ST: Prevention and correction of the ‘‘face-lifted’’ appearance. Facial Plast Surg 16:215--29, 2000 42. Hamra ST: The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clin Plast Surg 23:17--28, 1996 43. Hamra ST: Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 96:354--62, 1995 44. Hankins C, Strimling R, Rogers GS: Botulinum A toxin for glabellar wrinkles: dose and response. Dermatol Surg 24: 1232--4, 1998 45. Har-Shai Y, Hirshowitz B: Extended upper blepharoplasty for lateral hooding of the upper eyelid using a scalpelshaped excision: a 13-year experience. Plast Reconstr Surg 113:1028--35, discussion 1036, 2004 46. Hernandez-Perez E, Ibiett EV: Gross and microscopic findings in patients undergoing microdermabrasion for facial rejuvenation. Dermatol Surg 27:637--40, 2001 47. Hexsel D, Dal’forno T: Type A botulinum toxin in the upper aspect of the face. Clin Dermatol 21:488--97, 2003 48. Honrado CP, Pastorek NJ: Long-term results of lower-lid suspension blepharoplasty: a 30-year experience. Arch Facial Plast Surg 6:150--4, 2004 49. Horlock N, Sanders R, Harrison DH: The SOOF lift: its role in correcting midfacial and lower facial asymmetry in patients with partial facial palsy. Plast Reconstr Surg 109: 839--49, discussion 850--4, 2002 50. Huang T: Reduction of lower palpebral bulge by plicating attenuated orbital septa: a technical modification in cosmetic blepharoplasty. Plast Reconstr Surg 105:2552--8, discussion 2559--60, 2000 51. Hwang IP, Pratt DV, Jordan DR: Cerebrospinal fluid leakage during endscopic forehead lifting. Am J Ophthalmol 128:531--2, 1999 52. Hwang K, Joong Kim D, Chung RS: Pretarsal fat compartment in the lower eyelid. Clin Anat 14:179--83, 2001 53. Jacob CI, Kaminer MS: The corset platysma repair: a technique revisited. Dermatol Surg 28:257--62, 2002 54. Jacono AA, Moskowitz B: Transconjunctival versus transcutaneous approach in upper and lower blepharoplasty. Facial Plast Surg 17:21--8, 2001 55. Januszkiewicz JS, Nahai F: Transconjunctival upper blepharoplasty. Plast Reconstr Surg 103:1015--8, discussion 1019, 1999 56. Jasin ME: Submentoplasty as an isolated rejuvenative procedure for the neck. Arch Facial Plast Surg 5:180--3, 2003 57. Jelks GW, Glat PM, Jelks EB, et al: The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg 100:1262--70, discussion 1271--5, 1997 58. Johnson C, Alsarraf R: The Aging Face: A Systematic Approach. Philadelphia, PA, WB Saunders, 2002 59. Jones BM, Grover R: Reducing complications in cervicofacial rhytidectomy by tumescent infiltration: a comparative trial evaluating 678 consecutive face lifts. Plast Reconstr Surg 113:398--403, 2004 60. Jones BM, Grover R: Endoscopic brow lift: a personal review of 538 patients and comparison of fixation techniques. Plast Reconstr Surg 113:1242--50, discussion 1251--2, 2004 61. Kamer FM, Mingrone MD: Experiences with transconjunctival upper blepharoplasty. Arch Facial Plast Surg 2:213--6, 2000 62. Kang S, Leyden JJ, Lowe NJ, et al: Tazarotene cream for the treatment of facial photodamage: a multicenter, investiga- BEN SIMON AND MCCANN 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. tor-masked, randomized, vehicle-controlled, parallel comparison of 0.01%, 0.025%, 0.05%, and 0.1% tazarotene creams with 0.05% tretinoin emollient cream applied once daily. Arch Dermatol 137:1597--604, 2001 Kawamoto HK, Bradley JP: The tear ‘‘TROUF’’ procedure: transconjunctival repositioning of orbital unipedicled fat. Plast Reconstr Surg 112:1903--7, discussion 1908--9, 2003 Kim IG, Oh JK, Baek DH: Personal experiences and algorithm of endoscopically assisted subperiosteal face lift in orientals for 5 years. Plast Reconstr Surg 108:1768--79, discussion 1780--1, 2001 Kim SK: Endoscopic forehead-scalp flap fixation with K-wire. Aesthetic Plast Surg 20:217--20, 1996 Kim YW, Park HJ, Kim S: Secondary correction of unsatisfactory blepharoplasty: removing multilaminated septal structures and grafting of preaponeurotic fat. Plast Reconstr Surg 106:1399--404, discussion 1405-6, 2000 Klein AW: Skin filling. Collagen and other injectables of the skin. Dermatol Clin 19:491-508, ix, 2001 Kligman LH, Akin FJ, Kligman AM: The contributions of UVA and UVB to connective tissue damage in hairless mice. J Invest Dermatol 84:272--6, 1985 Kligman LH, Akin FJ, Kligman AM: Prevention of ultraviolet damage to the dermis of hairless mice by sunscreens. J Invest Dermatol 78:181--9, 1982 Kokoska MS, Thomas JR: The subgaleal endoscopic browlift. Arch Facial Plast Surg 2:202--8, 2000 Kosmin AS, Wishart PK, Birch MK: Apparent glaucomatous visual field defects caused by dermatochalasis. Eye 11:682-6, 1997 Kuprianova OO, Nidekker IG, Kozhevnikova OV: [A method of computer analysis of cardiac rhythm in children based on 24-hour monitoring]. Dermatol Surg 21:160--4, 1995 Kurwa HA, Yong-Gee SA, Seed PT, et al: A randomized paired comparison of photodynamic therapy and topical 5fluorouracil in the treatment of actinic keratoses. J Am Acad Dermatol 41:414--8, 1999 Lacombe VG: Laser hair removal. Facial Plast Surg 20:85--9, 2004 Landecker A, Buck JB, Grotting JC: A new resorbable tack fixation technique for endoscopic brow lifts. Plast Reconstr Surg 111:880--6, discussion 887--90, 2003 Le Louarn C: Botulinum toxin A and facial lines: the variable concentration. Aesthetic Plast Surg 25:73--84, 2001 Lemperle G, Morhenn V, Charrier U, et al: Human histology and persistence of various injectable filler substance for soft tissue augmentation. Aesthetic Plast Surg 27: 354--66, 2002 Lemperle G, Romano JJ, Busso M: Soft tissue augmentation with artecoll: 10-year history, indications, techniques, and complications. Dermatol Surg 29:573--87, discussion 587, 2003 LeWitt PA, Trosch RM: Idiosyncratic adverse reactions to intramuscular botulinum toxin type A injection. Mov Disord 12:1064--7, 1997 Little JW: Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication. Plast Reconstr Surg 105:267--85, discussion 286--9, 2000 Loeb R: Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 8:757--76, 1981 Lombardi T, Samson J, Plantier F, et al: Orofacial granulomas after injection of cosmetic fillers. Histopathologic and clinical study of 11 cases. J Oral Pathol Med 33: 115--20, 2004 Lowe NJ, Maxwell CA, Lowe P, et al: Hyaluronic acid skin fillers: adverse reactions and skin testing. J Am Acad Dermatol 45:930--3, 2001 Maas CS, Papel ID, Greene D, et al: Complications of injectable synthetic polymers in facial augmentation. Dermatol Surg 23:871--7, 1997 Marchac D, Ascherman J, Arnaud E: Fibrin glue fixation in forehead endoscopy: evaluation of our experience with 206 cases. Plast Reconstr Surg 100:704--12, discussion 713--4, 1997 COSMETIC EYELID AND FACIAL SURGERY 86. Matarasso SL: Comparison of botulinum toxin types A and B: a bilateral and double-blind randomized evaluation in the treatment of canthal rhytides. Dermatol Surg 29:7--13, discussion 13, 2003 87. McKinney P, Sweis I: An accurate technique for fixation in endoscopic brow lift: a 5-year follow-up. Plast Reconstr Surg 108:1808--10, discussion 1811--4, 2001 88. Mendelson B, Muzaffar AR, Adams WP, et al: Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 110:805, 2002 89. Mühlbauer W, Holm C: Orbital septorhaphy for the correction of baggy upper and lower eyelids. Aesthetic Plast Surg 24:418--23, 2000 90. Münker R: Laser blepharoplasty and periorbital laser skin resurfacing. Facial Plast Surg 17:209--17, 2001 91. Nouri K, Chen H, Saghari S, et al: Comparing 18- versus 12mm spot size in hair removal using a gentlease 755-nm alexandrite laser. Dermatol Surg 30:494--7, 2004 92. Olver JM: Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy. Br J Ophthalmol 84:1401--6, 2000 93. Pakkanen M, Salisbury AV, Ersek RA: Biodegradable positive fixation for the endoscopic brow lift. Plast Reconstr Surg 98:1087--91, 1996 94. Papadavid E, Katsambas A: Lasers for facial rejuvenation: a review. Int J Dermatol 42:480--7, 2003 95. Parkes M, Fein W, Brennan HG: Pinch technique for repair of cosmetic eyelid deformities. Arch Ophthalmol 89:324--8, 1973 96. Pastorek N: Upper-lid blepharoplasty. Facial Plast Surg 12: 157--69, 1996 97. Patipa M: Transblepharoplasty lower eyelid and midface rejuvenation: part I. Avoiding complications by utilizing lessons learned from the treatment of complications. Plast Reconstr Surg 113:1459--68, discussion 1475--7, 2004 98. Persichetti P, Di Lella F, Delfino S, et al: Adipose compartments of the upper eyelid: anatomy applied to blepharoplasty. Plast Reconstr Surg 113:373--8, discussion 379--80, 2004 99. Pessa JE, Garza JR: The malar septum: the anatomic basis of malar mounds and malar edema. Aesthetic Surg J 17:1, 1997 100. Peter S, Mennel S: Retinal branch artery occlusion following injection of hyaluronic acid (Restylane). Clin Experiment Ophthalmol 34:363--4, 2006 101. Psillakis J, Rumley TO, Camargos A: Subperiosteal approach as an improved concept for correction of the aging face. Plast Reconstr Surg 82:283--94, 1988 102. Quatela VC, Jacono AA: The extended centrolateral endoscopic midface lift. Facial Plast Surg 19:199--208, 2003 103. Ramirez OM: The subperiosteal approach for the correction of the deep nasolabial fold and the central third of the face. Clin Plast Surg 22:341--56, 1995 104. Requena C, Izquierdo MJ, Navarro M, et al: Adverse reactions to injectable aesthetic microimplants. Am J Dermatopathol 23:197--202, 2001 105. Rittes PG: The use of phosphatidylcholine for correction of lower lid bulging due to prominent fat pads. Dermatol Surg 27:391--2, 2001 106. Rizk SS, Matarasso A: Lower eyelid blepharoplasty: analysis of indications and the treatment of 100 patients. Plast Reconstr Surg 111:1299--306, discussion 1307--8, 2003 107. Rohrich RJ, Rios JL, Fagien S: Role of new fillers in facial rejuvenation: a cautious outlook. Plast Reconstr Surg 112: 1899--902, 2003 108. Romo T, Jacono AA, Sclafani AP: Endoscopic forehead lifting and contouring. Facial Plast Surg 17:3--10, 2001 109. Rosenberg GJ: Temporary tarsorrhaphy suture to prevent or treat scleral show and ectropion secondary to laser resurfacing or laser blepharoplasty. Plast Reconstr Surg 106:721--5, discussion 726--7, 2000 110. Saylan Z, et al: The S-lift: less is more. Aesthetic Surg J 19: 406, 1999 111. Schanz S, Schippert W, Ulmer A, et al: Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol 146:928--9, 2002 441 112. Scott AB: Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. Ophthalmology 87:1044--9, 1980 113. Scott AB, Kennedy RA, Stubbs HA: Botulinum A toxin injection as a treatment for blepharospasm. Arch Ophthalmol 103:347--50, 1985 114. Scott AB, Rosenbaum A, Collins CC: Pharmacologic weakening of extraocular muscles. Invest Ophthalmol 12: 924--7, 1973 115. Seckel BR, Kovanda CJ, Cetrulo CL, et al: Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: a safe and advantageous technique. Plast Reconstr Surg 106:1127--41, discussion 1142--5, 2000 116. Shao W, Byrne P, Harrison A, et al: Persistent blurred vision after blepharoplasty and ptosis repair. Arch Facial Plast Surg 6:155--7, 2004 117. Starck WJ, Griffin JE, Epker BN: Objective evaluation of the eyelids and eyebrows after blepharoplasty. J Oral Maxillofac Surg 54:297--302, discussion 302--3, 1996 118. Stern RS: Clinical practice. Treatment of photoaging. N Engl J Med 350:1526--34, 2004 119. Stern RS, Dover JS, Levin JA, et al: Laser therapy versus cryotherapy of lentigines: a comparative trial. J Am Acad Dermatol 30:985--7, 1994 120. Stern RS, Weinstein MC, Baker SG: Risk reduction for nonmelanoma skin cancer with childhood sunscreen use. Arch Dermatol 122:537--45, 1986 121. Stiller MJ, Bartolone J, Stern R, et al: Topical 8% glycolic acid and 8% L-lactic acid creams for the treatment of photodamaged skin. A double-blind vehicle-controlled clinical trial. Arch Dermatol 132:631--6, 1996 122. Sullivan SA, Dailey RA: Endoscopic subperiosteal midface lift: surgical technique with indications and outcomes. Ophthal Plast Reconstr Surg 18:319--30, discussion 329--30, 2002 123. Syniuta LA, Goldberg RA, Thacker NM, et al: Acquired strabismus following cosmetic blepharoplasty. Plast Reconstr Surg 111:2053--9, 2003 124. Taub AF: Treatment of rosacea with intense pulsed light. J Drugs Dermatol 2:254--9, 2003 125. Teimourian B: Blindness following fat injections. Plast Reconstr Surg 82:361, 1988 126. Tonnard P, Verpaele A, Monstrey S, et al: Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg 109:2074--86, 2002 127. Trelles MA: Sight lost after lower lid laser blepharoplasty. Ann Plast Surg 45:678--9, 2000 128. Tsui JK, Eisen A, Mak E, et al: A pilot study on the use of botulinum toxin in spasmodic torticollis. Can J Neurol Sci 12:314--6, 1985 129. Veloudios A, Kratky V, Heathcote JG, et al: Cyanoacrylate tissue adhesive in blepharoplasty. Ophthal Plast Reconstr Surg 12:89--97, 1996 130. Wearne MJ, Sandy C, Rose GE, et al: Autogenous hard palate mucosa: the ideal lower eyelid spacer? Br J Ophthalmol 85:1183--7, 2001 131. Weinstein C: Ultrapulse carbon dioxide laser removal of periocular wrinkles in association with laser blepharoplasty. J Clin Laser Med Surg 12:205--9, 1994 132. Weiss RA, Weiss MA, Beasley KL: Rejuvenation of photoaged skin: 5 years results with intense pulsed light of the face, neck, and chest. Dermatol Surg 28:1115--9, 2002 133. Wilhelmi BJ, Mowlavi A, Neumeister MW: Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. Plast Reconstr Surg 108:2137--40, discussion 2141--2, 2001 134. Withey S, Witherow H, Waterhouse N: One hundred cases of endoscopic brow lift. Br J Plast Surg 55:20--4, 2002 135. Yaremchuk MJ: Restoring palpebral fissure shape after previous lower blepharoplasty. Plast Reconstr Surg 111: 441--50, discussion 451--2, 2003 442 Surv Ophthalmol 53 (5) September--October 2008 136. Yoon ES, Han SK, Kim WK: Advantages of the presence of living dermal fibroblasts within restylane for soft tissue augmentation. Ann Plast Surg 51:587--92, 2003 137. Yousif NJ, Matloub MD And H, Summers AN: The midface sling: a newtechnique to rejuvenate the midface. Plast Reconstr Surg 110:1541--1553; discussion 1554--7, 2002 138. Zarem HA, Resnick JI: Minimizing deformity in lower blepharoplasty. The transconjunctival approach. Clin Plast Surg 20:317--21, 1993 BEN SIMON AND MCCANN 139. Zarem HA, Resnick JI: Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg 88:215--20, discussion 221, 1991 The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article. Reprint address: Guy J. Ben Simon, MD, Goldschleger Eye Institute, Tel Hashomer, Israel 52621.