diagnostic and surgical

DIAGNOSTIC AND SURGICALTECHNIQUESMARCO ZARBIN AND DAVID CHU, EDITORS

Cosmetic Eyelid and Facial SurgeryGuy J. Ben Simon, MD,1 and John D. McCann, MD, PhD2

1Goldschleger 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 withaging. 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 currentarticle reviews updates in cosmetic eyelid and facial surgery, including minimally invasive techniquessuch as cable suspensions, injections, and fillers. (Surv Ophthalmol 53:426--442, 2008. � 2008Elsevier Inc. All rights reserved.)

Key words. botulinum toxin injections � cosmetic surgery � endoscopic browlift � fillers �forehead � lower face / neck life � mid-face life

SURVEY OF OPHTHALMOLOGY VOLUME 53 � NUMBER 5 � SEPTEMBER–OCTOBER 2008

Ophthalmic plastic surgery has traditionally beendivided into four sub-disciplines: eyelid, lacrimal,orbit, and cosmetic. Twenty years ago the averagespecialist focused on the first three disciplines withfew surgeons having any interest in cosmetic surgeryand even fewer with an emphasis on cosmeticsurgery. This trend has reversed in the last decade.Today most specialists perform some cosmeticsurgeries and many emphasize this area of theirpractice. A good metric of the growth of thesubdiscipline of cosmetic surgery is the annualtwo-day national meeting of the American Societyof Ophthalmic Plastic and Reconstructive Surgery,which devotes half of the meeting to cosmeticsurgery. Cosmetic surgery is no doubt the mostrapidly changing subdiscipline of ophthalmic plasticsurgery. The recent trend toward greater interest inthis subdiscipline has generated much recent

42

� 2008 by Elsevier Inc.All rights reserved.

advancement. It is exciting to see the ophthalmol-ogist bring the traditions of precision and finessethat characterize ocular microsurgery to the field ofcosmetic facial surgery. This review should serve asan update of recent major changes in the field.

Upper Face

UPPER LID BLEPHAROPLASTY

The eyes are an important component of facialaesthetics. Cosmetic surgery of the eyelids can havea dramatic effect on facial harmony and the percep-tion of aging. Upper and lower blepharoplasties arecommonly performed together. Occasionally otherfacial and skin rejuvenation procedures such asbrow/midface lift and laser or chemical skin resur-facing are also performed at the same time.54

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0039-6257/08/$--see front matterdoi:10.1016/j.survophthal.2008.06.011

COSMETIC EYELID AND FACIAL SURGERY 427

Upper eyelid blepharoplasty (Fig. 1) is one of themost common cosmetic procedures performed bygeneral and ophthalmic plastic surgeons. Both menand women complain about tired-looking eyes,excess skin, droopy eyelids, or circles around theeyes. Several distinct anatomic features may contrib-ute to patients’ perception of the need for uppereyelid blepharoplasty.19 Excess and laxity of uppereyelid skin can cause superior visual field defectsthat are usually temporal rather than nasal, reflect-ing the tendency of the eyelid skin to be moreextensive temporally. This may even confounddiagnostic automated field testing in patients withglaucoma or ocular hypertension.71

PREOPERATIVE EVALUATION

Preoperative evaluation includes a thorough andcomplete eye and facial clinical examination. Thepatient must undergo a complete medical work-up,with the emphasis on ocular surface disease and dryeyes, as well as establishment of rapport and realisticpatient expectations. Patients should discontinueuse of acetylsalicylic acid and other anticoagulantssuch as plavix, nonsteroiodal anti-inflammatorydrugs (NSAIDs), vitamin E, and herbals two weeksbefore surgery. Coumadin should be stopped aftergeneral practitioner/cardiologist approval. Smokersshould also be advised to stop smoking two weeksbefore the procedure, as smoking can delay woundhealing.54 The relationship of concomitant eyelidand eyebrow malposition should be evaluated anddocumented. Evaluation of pre-septal and eyebrowfat pads is important in redefining the superiorsulcus. In recent years there has been an increas-ingly popular belief that fullness of the eyelids isa sign of youth; this has led most cosmetic surgeonsto preserve as much pre-septal fat as possible.Standard pre- and postoperative photography, ona blue background with diffused overhead lighting,are of utmost importance in aesthetic surgery and

can provide a useful method of evaluating improve-ment and anatomical changes in the eyelid positionin relation to the globe, orbit, and eyebrow.117

Standard preoperative and postoperative photo-graphs are as important to cosmetic surgery as pre-and postoperative visual acuities are to cataractsurgery. Photographs should be taken without flashin order to see wrinkles and bags.

SURGICAL TECHNIQUE

Surgery is designed primarily to enhance aestheticappearance and improve visual field deficits. Im-provement in visual field is a function of excision ofredundant eyelid tissue and is most dramatic inpatients with a margin reflex distance equal to orsmaller than 3.5 mm.40

Knowledge of the eyelid anatomy is an absoluteprerequisite for performing blepharoplasty. Thereare two fat compartments in the upper eyelid: a paleyellow medial compartment, which derives from theadipose body of the orbit; and a deep yellow lateralcompartment, derived from the preaponeurotic fat.Accessory or ectopic fat compartments have alsobeen described in 20% of cases and may representan extension of the lateral preaponeurotic fat pad.98

The superolateral aspect of the adipose part of theorbit does not reach the upper eyelid and thereforeis not resected in blepharoplasty. The superomedialpart, which is located between the superior obliqueand medial rectus muscles and reaches the orbitalseptum, represents the medial compartment of theupper eyelid and is usually removed in upperblepharoplasty when fat sculpturing is performed.The preaponeurotic fat pad is located under theorbital roof and lies on the aponeurosis of the levatorpalpebrae muscle, in contact with the orbital septum.Laterally it extends behind the lacrimal gland, andmedially a fibrous structure containing the reflectedtendon of the superior oblique muscle separates itfrom the nasal fat pad. This preaponeurotic fat is the

Fig. 1. Before (left) and after upper lids blepharoplasty.

428 Surv Ophthalmol 53 (5) September--October 2008 BEN SIMON AND MCCANN

lateral fat compartment that is resected in upperblepharoplasty.

Skin margins are outlined with the patient insitting position, these marks should be checked withthe patient lying supine. The lower margin of theincision is made along the eyelid crease, beginningmedially above and lateral to the medial canthus.Care must be taken not to include the naso-orbitaldepression, as this can cause webbing. Laterally, theline is extended to the sulcus between the orbitalrim and the eyelid, and may be directed slightlyupward.96 It is important to lift the eyebrowmanually, elevating the excess of skin. The amountof skin to be excised is checked with toothed forcepsto ensure that overcorrection of the skin is avoided.In our experience, it is important to leave 22�24mm of anterior lamella to prevent postoperativeshortening and lagophthalmos. These numbersshould be adjusted upward for proptotic patients,patients with deep superior sulcus, and for thenovice surgeon.

Usually, a crescent-shaped incision is made in theupper eyelid. However, in advanced age lateralhooding with greater excess of eyelid skin laterallyis commonly seen, so it might be preferable to usea scalpel-shaped incision that is widest laterally andtapers medially. That incision can provide indirectupward support of the lateral eyebrow.45

The eyelid is then injected with 1% lidocaine with1:100,000 epinephrine. The initial skin incision isusually made with a sharp no. 15 scalpel, monopolarcautery, radiofrequency (Ellman) or laser. Beforethe skin muscle flap is excised with sharp scissors,laser, or Colorado needle-tip electrocautery (Colo-rado Biomedical, Evergreen, CO), bleeding vesselsshould be cauterized; this can be done by electro-cautery or by defocusing the laser 6�8 inches (15--20 cm) away from the tissue.115

A survey conducted among plastic surgeonsdetermined that 70�90% of all surgeons use laseras the only tool for cutting and hemostasis inblepharoplasty, and that carbon dioxide (CO2)lasers are the most common. The laser hasa hemostatic effect of up to 0.1 mm on bloodvessels, creating a nearly blood-free surgical sitewhile the skin and orbicularis are being dissectedand the retro-septal fat is being excised.90 Advan-tages of CO2 laser blepharoplasty are reducedbleeding; shorter intraoperative time and postoper-ative recovery period; improved anatomic dissec-tion; and less pain, edema, bruising, andscarring.72,90 It is imperative to protect the patientby using stainless steel corneal shields whenperforming laser blepharoplasty because of the riskof globe perforation.115 Many general plastic sur-geons in public academic centers, however, do not

use laser and would rather use sharp blade or radio-surgery (Ellman unit).

After skin and orbicularis removal, if fat sculptingis desired, the orbital septum is gradually opened,using sharp and blunt dissection, thermal cautery, orlaser. One or more passes of the laser are madethrough the septum, permitting orbital fat to bulge.Fat is resected to the desired amount. Of the medialand central fat, only fat that comes easily into thewound is excised. It is important not to actively pullfat from the orbit. Medially the fat is whiter than inthe central compartment and its anatomic positionmay vary. Because blood vessels present in themedial fat compartment are larger, they cannot becoagulated with the CO2 laser and must becauterized.90 Gentle pressure on the globe causesherniation of the medial fat compartment and mayhelp in identification. If lower eyelid blepharoplastyis planned, the skin incision is left unsutured untillower blepharoplasty is completed. This is especiallyimportant in cases where incision in the uppereyelid crease is planned for lateral canthopexy.

The skin incision can be closed using running orinterrupted sutures with various absorbable or perma-nent materials, with no apparent effects on aestheticoutcome. The use of tissue-adhesive cyanocrylate gluein skin closure has also been reported.129

The sub-brow fat pad can be repositioned duringwound closure with use of eyelid suspension sutures.This can be done with 2�3 absorbable sutures thatincorporate the orbicularis from the lower andupper sides of the incision along with the supero-lateral arcus marginalis. Placing of the sutures inthis way might result in early over-correction of theupper eyelid, which, however, softens within daysafter the surgery.

The transconjunctival approach to upper eyelidblepharoplasty is of limited usefulness in primary orsecondary cases with pseudo-herniation of themedial fat pad.54,55,61

POSTOPERATIVE CARE

Postoperatively, patients should be advised to useice packs on the surgical site for 3 days to minimizepostoperative swelling, and erythromycin ophthal-mic ointment on the incision sites for 2 weeks. Non-absorbable sutures, if used, can be removed 7�10days after the procedure.

COMPLICATIONS

The most common complication of cosmeticsurgery is failure to meet the patient’s expectations.This can be avoided by preoperative counseling ofwhat reasonably can be achieved with surgery. Insuch a way patients with unreasonable expectations


can be identified. From a medico-legal standpoint, itis probably best for the surgeon to define reasonableexpectations as a statement that is read and signed bythe patient.66

Possible complications include upper eyelidretraction with scleral show from anterior lamellarinadequacy, lagophthalmos, and corneal exposure.Patients might present with various degrees ofscleral show, tearing, ocular discomfort, and dryeyes. Acquired strabismus accompanied by persis-tent diplopia can occur, and superior oblique palsyand acquired Brown syndrome have beendescribed.123,133 Blurred vision from induced cor-neal astigmatism usually lasts for up to 3 monthsafter surgery, and subjective visual disturbancesmight last for 1 year.116

ENDOSCOPIC BROW LIFT

The endoscopic approach to forehead and midfacelift has become a popular method of facial rejuvena-tion, requiring minimal incision (Figs. 2 and3).13,20,22,60 The use of endoscopy has led to improvedaesthetics with respect to postoperative scarring, aswell as to decreased healing time and greater patientsatisfaction. In the past, most browlifts involvedbicoronal dissection with a large incision;108 theendoscopic browlift is less invasive, better tolerated,and less prone to intra- and postoperative complica-tions.70 The goal of forehead rejuvenation is toelevate the brows and midface, depending on theextent of dissection, and to address glabellar frownlines by weakening the corrugator and procerusmuscles. It is best suited for brows with mild tomoderate ptosis of up to 1.5 cm.70,108,134

A thorough understanding of the temporalanatomy, location of the retaining ligaments of thecheek, and relationship of the facial nerve to thetemporal planes is of utmost importance in order toachieve aesthetic improvement and preventcomplications.

In younger patients it allows repositioning of theorbital portion of the orbicularis oculi muscle; inmidface rejuvenation it lifts the malar pads, allowinga smooth transition onto the upper face that blendsnicely into the lower face. In older patientsendoscopic brow lift serves as a useful adjunct toeyelid and midface surgery. It corrects orbitalfestoons and lower eyelid bags and smoothens theupper third of the nasolabial fold.12

SURGICAL TECHNIQUE

Preoperative marking is done with the patient inan upright position for placement of temporal andparamedian incisions, the desired brow elevation(5�8 mm medially and 8�10 mm laterally), and theanticipated course of the temporal branch of thefacial nerve.108

The surgery can be performed under intravenoussedation or general anesthesia. Lidocaine 1% andepinephrine 1:100,000 are locally injected at theincision sites and to block the supraorbital andsupratrochlear neurovascular bundles. The fore-head and upper midface are injected with 0.01%lidocaine and 1:10,000,000,000 epinephrine solu-tion (tumescent solution) to facilitate dissection andreduce bleeding. Incisions are made behind thehairline and include one central or paracentral andtwo temporal incisions, which are placed on a lineconnecting the ala nasi and the lateral canthus.Some surgeons make two additional paracentralincisions. Incisions are made to the depth of theperiost centrally and to the depth of the deeptemporalis fascia laterally. The central pocket isdissected in the sub-galeal or subperiosteal planesusing a curved semi-sharp dissector. The lateralpockets are dissected toward the central pocket,while taking care to detach the conjoint fascia.Endoscope-assisted dissection is done from 1 cmabove 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-eyelidblepharoplasty. Note marked improvement in eyebrow position, forehead rhytids, and lower eyelid bags.

Fig. 3. Before (left) and after (right) forehead lift, and upper and lower eyelid blepharoplasty.


supraorbital and supratrochlear neuromuscularbundles. It is important to lyse periosteal attach-ments at the superior and lateral orbital rims untilthe sub-brow fat pad is visualized. If midface lift isdesired, dissection is extended to the zygomatic archand the lateral canthus. Medially, the corrugatormuscles located adjacent to the neurovascularbundles can be lysed or sharply dissected. Theprocerus muscle can be dissected in a similarfashion. Prior to fixation the amount of dissection,residual adhesions, and desired lift are examined bya finger test (passing index finger in the superiororbital margin to evaluate residual adhesions thathold the eyebrow and may prevent it from adequateelevation postoperatively).

There are several methods of suture fixation. Thetemporal pockets are fixated to the deep temporalisfascia. It is important to grasp a robust part of thesuperficial temporalis fascia distally and adjustthe tension to the desired amount by fixating it tothe deep fascia precisely at the location needed,usually in a mattress suture.

Centrally, the forehead can be sutured to absorb-able75 or titanium screws that are drilled in the frontalbone, or to a cortical tunnel on the outer table of thecalvarium.87 Some surgeons use 2/0 monofilamentnylon sutures to secure the forehead to the subgalealtissue posteriorly. These can create bolsters, whichdisappear when the sutures are removed 2 weekspostoperatively. Additional fixation techniques in-clude the use of fibrin glue, K-wire fixation, andtemporary titanium screws.65,70,85,93 Skin incisionsare sutured using absorbable sutures or surgicalstaples. Some surgeons advocate the use of dressingand elastic band for 1 week; sutures or staplers areremoved 14 days postoperatively.

A described limitation of endoscopic browlift isthe inability to predict the long-term results offorehead elevation.108 Minimally invasive browsuspension has been described using subcutaneoussuspension sutures with no open dissection, but itslong-term outcome in comparison to endoscopicbrow lift is not known.26

COMPLICATIONS

Possible complications, which may vary withdifferent dissection planes, include frontal branchweakness, temporary numbness, hematoma, seroma,incisional alopecia, temporal fat atrophy, wounddehiscence, suture abscess, unbalanced eyebrows,and in cases of lower blepharoplasty incisionendoscopic midface lift lower eyelid retraction withlagophthalmos.24,64 Leakage of cerebrospinal fluidafter endoscopic browlift was reported in a patientwith a previous history of head trauma.51

Lower Face

LOWER EYELID BLEPHAROPLASTY

Aging in the lower eyelid can cause a number ofaesthetic changes, including skin laxity or excess,orbital septum laxity, orbicularis laxity or hypertro-phy, herniation of the orbital fat, canthal laxity, malarfestoons, crow’s feet, and periocular wrinkles(Fig. 4).25,115 Common complaints include eyelidbags, circles under the eye, wrinkles around the eye,or a tired look. In the past a simplified approach wastaken for patients seeking surgical treatment foreyelid bags. Only patients whose problem wasamenable to removal of skin and fat were consideredsuitable candidates for classic blepharoplasty.36,106

Anatomically, relaxation of the orbital septum,orbicularis muscle, and skin can cause protrusionand shifting of intraorbital fat and eyelid bags. Thetraditional procedure in lower eyelid blepharoplastywas to remove the pseudo-herniated fat via skinincision. A recent, more conservative approachincludes repositioning of the herniated fat in casesof tear trough deformity into the subperiostealspace. Both of these approaches may be accompa-nied by strengthening procedures for the attenu-ated septum or septorhaphy and tightening of theorbicularis muscle and skin.52,89 Defocused CO2

laser irradiation of the undersurface of the orbicu-laris results in persistent shortening and tighteningof the muscle tissue.115

Fig. 4. A 40-year-old woman, before (left) and 2 years after (right) four-eyelid blepharoplasty, upper eyelid skin muscleremoval and fat sculpting, and lower eyelid transconjunctival fat removal.


Most cosmetic surgeons today have developeda customized approach to eyelid surgery in whichthe specific anatomic problems are identified andthe operation is individualized to address theseproblems. Additional anatomic changes that con-tribute to eyelid bags include pseudoherniation offat pads, damaged skin, orbicularis muscle hyper-trophy, eyelid fluid, tear trough deformity, andtriangular malar mound.36,106

SURGICAL TECHNIQUE

In cases of fat removal or repositioning orpseudoherniation of orbital fat, enhancement ofthe deficient suborbital portion of the malarcomplex is the principal component of modernlower eyelid blepharoplasty. Skin removal is usuallyunnecessary because there is typically inelasticityrather than actual excess of skin. The widelypreferred approach is transconjunctival incision,which results in less eyelid retraction, less scleralshow, and less postoperative ectropion than othermethods.106,138,139 Some surgeons prefer a transcu-taneous approach in patients who have hypertrophyof the orbicularis oculi muscle and thereforerequire muscle excision.1 The inferior fornix, eyelidskin, and lateral canthus are anesthetized with 1%lidocaine containing 1:100,000 epinephrine. Thelower eyelid is retracted with a lacrimal or Desmarreretractor. A tarsoconjunctival incision is made 4�6mm below the lid margin through the conjunctivaand lower eyelid retractors; this can be done usingsharp dissection, monopolar cautery, or laser. Inlaser blepharoplasty, protective shields for thepatient’s eyes must be used. The eyelid can beretracted using forceps with a 0.5-mm tip or byplacement of a 6�0 silk suture. Gentle retropulsionon the globe helps to identify the fat compartments.The medial, central, and lateral fat pads areidentified and conservative, individualized fat re-moval is accomplished. Hemostasis is achieved usingmonopolar or bipolar cautery or by defocused laserapplications. Care must be taken not to damage theinferior oblique muscle that separates the medial

from the central fat pocket. The endpoint forexcision is reached when gentle retropulsion onthe globe results in the anterior aspect of the orbitalfat being flush with the orbital rim.

The tarsoconjunctival incision is left unclosed, butthe inferior and superior edges of the tarsoconjunc-tival incision are properly apposed and the lowereyelid is pulled up to make sure there is no overlapbetween the cut edges of the conjunctiva.15

Some surgeons routinely perform canthopexy inlower eyelid blepharoplasty. This can be donethrough a lower or upper eyelid; it eliminatesunnecessary skin resection and is believed to restoretone and youthful contour.29,48,115 Through anincision in the upper eyelid crease,57 dissection isextended inferiorly to the level of the lateral orbitalrim, leaving the periosteum intact. This stage ofdissection can facilitate lateral fad pad resection ifthis was not fully addressed during lower blepharo-plasty. The inferior limb of the lateral canthaltendon can be cut with scissors under visualinspection. A double-armed suture on a semicircularneedle is placed 2 mm above Whitnall’s tubercleinside the orbital rim. The suture then travelsthrough the orbital rim periosteum and emergesin half-buried horizontal mattress fashion throughthe inferior canthal tendon. Additional sutures canbe used to tighten the orbicularis muscle to thesuperficial orbital rim. Alternatively, lateral canthalresuspension can be performed using the lateralcanthal strip procedure described by Anderson andGordy.5

Wrinkles and excess of vertical skin can be dealtwith by skin resurfacing techniques, such as chem-ical peeling and CO2 or erbium�YAG laser resurfac-ing. These techniques are applicable in patients withFitzpatrick skin types I--III. Patients with darker skinare at risk of pigmentary changes; these can bemanaged by the pinch technique. Excess skin iscrushed using a straight hemostat 1�2 mm sub-ciliary and excised. Care must be taken to excise aslittle as possible of the orbicularis muscle. The skinis closed with a running suture.95 Regardless ofthe timing of laser treatment, transconjunctival


blepharoplasty with adjunctive CO2 laser resurfacingresults in improvement of lower eyelid bulging andskin wrinkling.18

Another modification of lower blepharoplastyinvolves transcutaneous plication of the orbitalseptum.50 An interesting report describes non-surgical treatment for pseudoherniation of orbitalfat pads by phosphatidylcholine injection, withmarked improvement over a 2-year period.105

COMPLICATIONS

Severe complications, such as visual loss fromorbital hemorrhage, orbital injection, or posterioroptic nerve infarction have been described.38,127

Other possible complications are lower eyelid re-traction with scleral show, lagophthalmos, andcorneal exposure. As with upper lid blepharoplasty,patients might have various amounts of scleral show,tearing, ocular discomfort, and dry eyes. Varioussurgical techniques have been described to addressscleral show, eyelid retraction, and ectropion afterlower eyelid blepharoplasty, including free tarsocon-junctival graft,27 grafting of autogenous hard palatemucosa,130 and cheek suspension using transoss-eous fixation and titanium screws.135 Temporarytarsorrhaphy can be used to prevent and treat scleralshow and ectropion secondary to laser resurfacingor blepharoplasty.109

Acquired strabismus that includes incomitantvertical deviation consistent with an inferior rectusparesis has been described.123 In some patients,upward rotation of the globe was found to bemechanically restricted.

FAT REPOSITIONING

In young people the eyelid--cheek complex isa single smooth convex profile. Aging causesdescent of the globe and pseudoherniation ofintraorbital fat, producing a double convex or teartrough deformity on the eyelid profile and a nasoju-gal groove at the medial aspect of the lower eyelid.43

With advancing age this depression appears moreprominent because of attenuation and descent ofthe orbicularis oculi and cheek fat, resulting inskeletonization of the orbital area and revealing thetopographical contour of the inferior orbital rim.6

Simple removal of orbital fat can result in a hollowappearance of the lower eyelid.

Preservation of the lower orbital fat is a newconcept in facial rejuvenation, designed to preventthe hollow appearance that may follow the removalof excess fat in lower eyelid blepharoplasty. Suchpreservation creates a smooth transition to themalar eminence, blending nicely into the upperface.42,43 Aging causes progressive exposure of the

underlying skeletal anatomy in the periorbital area,unlike in the lower facial area, where thicker softtissue continues to cover bony landmarks.

SURGICAL TECHNIQUE

The basic surgical technique includes release ofthe arcus marginalis and advancing of the subseptalfat beyond the infraorbital rim and underneath theorbicularis muscle. The fat pedicles are temporarilyexternalized to the midface by suturing. They can beplaced in the sub- or supra-periosteal planes, with noapparent effect on aesthetic results. This techniquecamouflages the lower orbital rim anatomy andprovides more youthful rejuvenation of themidface.35,43,81

Other methods suggested to correct tear troughdeformity include orbital fat removal, fat injectionsor grafts, and alloplastic cheek implants. In general,trans-conjunctival fat repositioning results in level-ing of the tear trough deformity, a smooth contourof the lower eyelid, and high patient satisfaction.63

COMPLICATIONS

Possible complications are incomplete resolutionof pigmentary changes (dark circles), temporaryskin irregularities from fat and edema, hardening ofrepositioned fat, granuloma formation, restrictedocular movements, or new-onset diplopia.37

SUBORBICULARIS OCULI FAT / MIDFACE LIFT

The midface lies between the lateral canthal angleand the top of the nasolabial fold. It includes themedial and lateral canthal tendon, lower eyelids,suborbicularis oculi fat pad (SOOF), malar fat pad,orbitomalar ligament, orbital septum, and origins ofthe zygomaticus major and minor muscles andlevator labii superioris. 88,99

Volumetric distribution of the midface soft tissuesis an important factor in the youthful appearance ofthe human face (Fig. 5). If these tissues are fullrelative to the lower face, the individual appearshealthy and young.80 A fuller midface can beachieved by an open surgical or endoscopic tech-nique.101,103,122 Indications for midface lift includelower eyelid retraction secondary to lower blepha-roplasty, cicatricial ectropion, and paralytic ectro-pion due to palsy of the 7th cranial nerve.49,92,122

Aesthetically, the goal of midface lift is to achievefacial rejuvenation by increasing malar fullness,decreasing skeletonization of the lower eyelid atthe inferior orbital rim, and reducing prominenceof the nasolabial and nasojugal (tear trough) folds.

Fig. 5. A 65-year-old woman, before (left) and 8 months post (right) transconjunctival lower eyelid retraction as a result oflower blepharoplasty. Note marked improvement in lower eyelids position.


SURGICAL TECHNIQUE

In patients with tear trough deformity, trans-conjuctival SOOF lift is adequate and yields goodaesthetic results. Dissection is carried out in the pre-periosteal plane, extending beyond the inferiormargin of the tear trough deformity until the SOOFis identified. An anchoring suture from the SOOFpad to the periosteum of the infraorbital rim isplaced along the width of the deformity. Afteradequate suspension, a single buried absorbablesuture is used to close the conjunctival incisionlateral to the cornea.32

When a more robust midface suspension isrequired, effective reshaping of the soft tissue ofthe aging midface necessitates freeing of the cheeksoft tissue, both superficially and deeply, from itsattachment to skin and bone. Incisions are made atthe temporal scalp, inferior conjunctiva, and alveo-lar oral mucosa. Dissection is aimed at creatinga temporal pocket, mobilizing the midface bysubperiosteal dissection, and lifting the mobilizedface to the deep temporalis fascia while securing theSOOF pad to the inferior orbital rim.122 Dissectionis performed as far as the oral commissure inferiorlyand toward the zygoma and lateral buttress of themaxilla, along the infraorbital rim, and around theinfraorbital nerve in the subperiosteal plane. Caremust be taken to identify and preserve the infra-orbital nerve. In the lateral orbit, a small area ofdeep temporalis fascia is cleared near the lateralcanthus. No dissection is carried out at themasseteric tendon or the zygomatic arch.80

Techniques used to re-shape the midface, oncethe subperiosteal tissue has been freed, includemalar imbrication, insertion of suspension suturesinto the deep temporalis fascia, and mechanicalanchoring.

If the neck is to be treated, this is done beforethe cheek is lifted. To avoid traction of themidface, lateral plication of the superficial muscular-aponeurotic system (SMAS) is performed onlyafter the midface has been adequately lifted.137

To avoid postoperative complications the follow-ing steps are suggested: Reattach the lateral canthusto its proper anatomic position; address the orbitalfat via a trans-conjunctival approach to preventmiddle lamellar scarring and orbital septum re-traction; and place a suture at the inferior lateralorbital rim that stimulating the orbitomalar liga-ment that elevates the midface and suturing of theorbicularis oculi muscle.97

COMPLICATIONS

Possible complications include temporary facialnerve trauma (in up to 5% of cases), significantorbital edema, and chemosis especially when com-bined with lower blepharoplasty, prolonged swell-ing, and skin dimpling along the suspensionsutures.102

LOWER FACE AND NECK REJUVENATION

Deep plane facelift techniques developed assurgeons became more aware that elevation of thedeeper tissue layers of the aging face could achievelonger lasting and more natural results.3,58

SURGICAL TECHNIQUE

The procedure is best carried out under generalanesthesia. The face and neck are infiltrated withtumescent solution.59 Incisions are marked andmade through the temple hairline, above the earand down a natural skin crease in the pre-tragalarea, and continued post-auricularly to the level ofthe superior conchal bowl. Pre- and post-auricularskin flaps are elevated and over the sternocleido-mastoid region and over a distance of 5�6 cm (2inches) in the face, while taking care to dissectsuperficial to the greater auricular nerve. In theneck the platysma muscle is identified below theangle of the mandible, and dissection is extended tothe submental region anteriorly and to the lowestneck rhytid. To prevent damage to the facial nerve,the deep plane is kept above the level of the


masseteric fascia. Care is taken to limit dissection tothe undersurface of the platysma musculature in theSMAS flap. At the level of the malar eminencedissection is carried out toward the bone to identifythe zygomaticus major muscle, and the SMAS flap iselevated anteriorly. Throughout the procedure thisflap is kept above the anterior border of the parotidgland. Buccal fat can be resected as needed.

If needed, submental platysmoplasty with directfat excision is performed (Fig. 6).39,53,56 An incisionis made 2 cm posterior to the mandibular pro-tuberance, the subdermal fat is lifter off theunderlying muscle, and the skin flap is connectedbilaterally to the pre-platysmal flaps. Fat and re-dundant muscle are removed, and buried suturesare used to reattach the muscle edges. Finally, theSMAS flaps are repositioned and sutured alonga postero-superior vector. Prolene sutures are usedto attach the deep plane flap by tucking it into thepreauricular area and back to the mastoid fascia.The skin is slightly lifted to prevent puckering andthe excess skin is trimmed. A drainage device is usedin the early postoperative period. A light pressuredressing with fluffed cotton and Kerlex isapplied.3,4,9,41

COMPLICATIONS

Possible complications include hematoma, pares-thesia, and facial nerve paresis. These can beavoided by careful and meticulous dissection andby operating only at the level of tissue planes knownto be safe.3

S LIFT

A recently developed technique requiring mini-mal incision for mid-lower face rejuvenation isperformed via an S-shaped pre-auricular incision,followed by elevation of the facial skin and SMASwith the aid of two purse-string sutures.

SURGICAL TECHNIQUE

The procedure is performed on an outpatientbasis and under local anesthesia. As in most facialrejuvenation procedures the operative area isinfiltrated with tumescent solution to facilitatedissection and minimize bleeding. Incision sitesare anesthetized with 1�2% lidocaine containing1:100,000 epinephrine. Following the S-shapedincision, a limited skin flap is undermined in anoval area extending from 1 cm above the zygomaticarch to the mandibular angle caudally and 5 cmanteriorly. Dissection is in the subcutaneous plane.Superiorly the deep temporalis fascia is exposed,while care is taken not to damage the superficialtemporal vessels. For the first purse-string suturea 2�0 nylon or prolene suture is inserted in a U-shaped fashion, descending to the mandibularangle and engaging the parotid fascia. The sutureallows the anterior neck region to be lifted. Thesecond purse-string suture, directed at a 30� angle, isextended to the edge of the undermined area,allowing the jowls to be lifted. The periocular regionis sutured under minimal tension.110,126

A number of alternative approaches have beenintroduced for face and neck rejuvenation, andthere is controversy over the relative advantagesof the more extensive and the minimal techniqueswith respect to longevity and postoperativecomplications.3,9

Skin Rejuvenation

PHOTODAMAGE

Exposure to the sun induces skin damage re-ferred to as photoaging, which may be manifestedclinically as wrinkles, dryness, irregular pigmenta-tion, telangectasias, brown spots, and seborrheickeratosis. Premalignant sun-induced lesions includeactinic 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 andplatysmoplasty. Note marked improvement in platysmal bands.


and squamous cell carcinomas. Patients with photo-induced skin damage should be examined period-ically for premalignant lesions. Sun protectionduring childhood and throughout life has beenshown to reduce the risk of malignant skincancers.69,120 Ultraviolet A and B (UVA and UVB)contribute to pigmentary changes, as well as towrinkles, telangectasias, and lentigines.68

Actinic keratosis, which is premalignant to squa-mous cell carcinoma, can be treated with cryosur-gery, topical 5% fluorouracil cream, andphotodynamic therapy with aminolevulinic acid.73

The effects of photoaging can be reduced toa limited extent by the use of topical lotionscontaining alpha- and beta-hydroxyl acids that areexfoliants and moisturizers. Some of these materialscontain 5% glycolic acid and 8% lactic acid, bothshown to add to the improvement in roughness andmottled pigmentation.121 Topical vitamin A deriva-tives (retinoids) can be used to improve fine wrinklesand irregular pigmentation.62 Peeling makes the skinmore vulnerable to UV radiation, and therefore sunprotection is of utmost importance after this pro-cedure. Deep chemical peeling can be achieved bytrichloroacetic acid 35%, higher concentration than50%, and phenol (Fig. 7). Possible complications ofchemical peeling include keloids, hypertrophicscars, and hypopigmentation. Other modalities usedto treat photoaging damage include cryosurgery,microderm abrasions, chemical and laser peeling,tissue augmentation by injectable fillers, and botuli-num injection to treat dynamic rhytides.46,119

LASER

Photodamaged skin and acne scarring can beimproved by treatment with different types of lasers:ablative (high energy pulsed or scanned) CO2 lasers,single or variable pulse or dual ablative/coagulativemode erbium:yttrium aluminum garnet (Er:YAG)lasers, non-ablative Q-switched neodymium:yttriumaluminum garnet (Nd:YAG), diode lasers, andcombined wavelength systems. The pulsed Er:YAGlaser has poor penetration and is therefore used totreat superficial rhytides; the CO2 laser is better fordeep rhytides and scars.94

Pulsed CO2 laser resurfacing causes ablation ofnormal tissue with subsequent collagen regenera-tion, and remodeling occurs by heat-inducedcollagen contraction. A similar degree of skintightening can be achieved with the erbium laser.Laser-induced skin contraction is usually not long-lasting; the postoperative decrease with the CO2

laser ranges from an average of 42% 1 monthpostoperatively to 36% on average at 6 months. Witherbium laser treatment the skin contraction is less

but is more stable.28 With the advent of new-generation ultra-pulse CO2 lasers, the skin can besuccessfully resurfaced with minimal risk or sideeffects.131

Laser resurfacing of the lower eyelid skin andperiocular skin is done with the ultra-pulse CO2

laser. After each pass with the laser, debris should beremoved using saline-soaked gauze, and the areadried with dry gauze. One pass usually suffices forthe pre-tarsal skin, whereas 2�3 passes should beapplied for the pre-zygomatic skin and lateral crow’sfeet area. After laser application the treatment areashould be covered with a moist dressing. 115

Fig. 7. A 42-year-old woman before (top), 5 days (middle)and 3 months after (bottom) trichloroacetic acid 25% peelfor skin rejuvenation.


The Er:YAG laser is also used to treat periocularskin deformities. In many cases, skin resurfacing byCO2 or Er:YAG yields good results even withoutlower eyelid surgery. Combined use of Er:YAG andCO2 lasers was recently described (Derma-K).90

Because the eyelid skin is only 0.25 mm thick, twopasses with decreasing power of the CO2 laser areadequate for its removal. To avoid ectropion, thetriangle below the lateral corner of the eye must beapproached with restraint. An occlusive dressingwith polyurethane film is applied. Epithelializationoccurs after 6 to 7 days. Erythema lasts for severalweeks after resurfacing with the CO2 laser and foronly 2 weeks with the Er:YAG laser. This is becausethe Er:YAG laser does not cause thermal damage; onthe other hand, it does not induce collagenshrinkage, and deep wrinkles are therefore moresuccessfully treated with the CO2 laser. Promisingresults have been obtained with the CO2/Er:YAGcombination laser, with post-treatment erythema of3 weeks. Sun protection of the treated area ismandatory for 6 months.90

Possible complications include persistent ery-thema, allergic dermatitis, mild post-inflammatoryskin hyperpigmentation, hypopigmentation, and lidretraction.18

INTENSE PULSED LIGHT

Intense pulsed light, a non-coherent light pro-duced by a flash lamp, has been used in recent years totreat photodamaged skin. By using filters withdifferent cutoff values, it is possible to select thedesired wavelength; long waves that reach the deepdermal collagen tighten the skin, improving itstexture. Vascular and pigmented lesions are treatedby photodermal damage either through hemoglobinabsorption or melanin-pigmented lesions. Thermaldamage is avoided by controlling the duration of lightpulses and the interval between them, the latter mustbe shorter than the thermal relaxation time in thetarget lesion in order to ensure its destruction.31

Intense pulsed light was recently shown to be effectiveand safe for treating senile pigmentation, telangec-tasias, and rosacea, as well as for improving skintexture in facial and non-facial rejuvenation. Com-plications can include redness, blisters, swelling, scarformation, and hyperpigmentation.34,124,132

LASER HAIR REMOVAL (PHOTOEPILATION)

Selective laser thermolysis is currently the treat-ment of choice for hair removal. By using a laser beamwith a defined wavelength and pulse duration tospecifically target the melanin, it is possible toselectively destroy the chromophore while protectingthe surrounding tissue. Patients require a minimum

of three treatments at 1.5- to 2-month intervals forbody hair and five or six treatments for facial hair. Thereported success rate at 6 months is 60�95%.74 Lasersused for hair removal include long-pulsed alexan-drite, 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 moreeffective for hair removal, probably because it deliversmore total energy per pulse and results in increasedpenetration.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 powerfultoxins known in toxicology. It acts via parasympa-thetic acetylcholine inhibition (chemodenervation),which prevents fusion of the acetylcholine-filledvesicle with the plasma membrane, thereby alsopreventing the release of acetylcholine into thesynaptic cleft. The exotoxin produced from Clostrid-ium botulinum temporarily paralyzes the mimic facialmusculature.7

Botulinum toxin was first used in 1973 and 1979for the treatment of strabismus, and in 1985 theindication was extended to blepharospasm anddystonia.7,112--114 Aesthetic indications were addedafter patients noticed that treatment in the browarea produced a relaxed, unworried appearance(Figs. 8--10 ).15,113,128 Three commercial botulinumtoxin preparations are currently available: Botox(botulinum toxin type A [C. botulinum type Atoxin]; Allergan, Irvine, CA), Dysport (type Atoxin�haemagglutinin complex; Ipsen, Maiden-head, Berkshire, UK), and botolinum toxin type B,available as Myobloc (injectable solution; ElanPharmaceuticals, South San Francisco, CA).44,47

Botulinum toxin, used alone or in combinationwith other modalities of facial rejuvenation, such aschemical peel, laser resurfacing, dermabrasion, orsoft tissue augmentation, offers safe and effectivetreatment of upper face wrinkles. It has also beenused in surgery for facial rejuvenation.47

Dynamic changes are caused by muscle hyperto-nicity and are manifested as lines or rhytids of theforehead and glabellar areas. Improvement afterintramuscular injection of botulinum (type A or B)first appears after 24�72 hours, reaches a peak by 1month after injection, and lasts usually for 3�4months, but might persist for 6�8 months orlonger.17,86 Previous botulinum toxin treatmentmight extend the efficacy of additional BTX in-jections because of attendant muscle atrophy; it was


Fig. 8. A 26-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to corrugators andprocerus muscles. Note marked improvement in frowning appearance.

also noted that repeated injections prolong theclinical effect.33,76 Among the many cosmetic in-dications are lateral canthal lines (crow’s feet),horizontal forehead lines, brow ptosis, orbicularisoculi hypertrophy and periocular skin wrinkling,30

facial asymmetry, masseteric hypertrophy to reducea prominent mandibular angle,2 neck rejuvenation10

(platysmal bands), and decollete folds.7 Because ofasymmetric results, cosmetic indications that includenasolabial folds and platysma and mouth frown arestill a subject of controversy. As our understanding ofthe anatomy and combined mentalis and depressoranguli improves, the results of treatment are likely tobe increasingly satisfactory.16

Systemic complications are rare because clinicaldosages of botulinium toxin are measured in nano-grams, and as it is injected locally into the muscle, verylittle enters the systemic circulation. Complicationscan be classified as local, regional, or systemic.124

Possible systemic complications are thirst, flu-likeillness, and mild urticarial rash, as well as potentiationof neurological diseases such as myasthenia gravisand amyotrophic lateral sclerosis. Rare reports in-clude anaphylaxis and respiratory arrest.21,79 Patientswith human albumin allergy should avoid treatmentwith botulinum toxin. Possible regional complica-tions are unwanted weakness or paralysis adjacent tothe point of injection, such as droopy eyelid, browptosis or elevation, diplopia in the periocular areafrom inadvertent orbital injection, lip drooling and

asymmetry in the perioral area, dysphagia (after deepneck muscle injection), reduction in facial expres-siveness, and a mask-like appearance.11,15,16 Localeffects can include erythema, rash, ecchymosis, andhematoma.124

Contraindications for botulinum toxin injectioninclude pregnancy and lactation, neuromusculardiseases, peripheral neuropathy, and use of medica-tions such as quinine, calcium channel blockers,penicillamine, or aminoglycoside antibiotics.47

FILLERS

Attempts have been made over the years toaugment facial soft tissue for aesthetic and re-constructive purposes. Fillers are used for thetreatment of deep wrinkles and non-dynamicfurrows.67,77,107 They are also useful for correctionof facial, bony, and soft tissue defects of congenitalor traumatic origin, and in patients suffering fromscleroderma, Romberg disease, facial wasting, orAIDS-associated lipodystrophy.14,77,78 Many mate-rials have been used, including organic particlessuch as autologous fat, sea coral, and injectablebovine collagen. The latter, along with inorganicliquid silicone gel, have been used increasingly inrecent years. None of the proposed materials hasproved entirely satisfactory because of migration,host immune response, or transitory cosmeticimprovement.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 forlower eyelid orbicularis hypertrophy and crows feet. Note marked improvement in lower eyelid and lateral canthal area.

Fig. 10. A 48-year-old woman, before (left) and 1 month after (right) Botulinum toxin A injection to orbicularis musclefor crows feet.


and its fate is unpredictable. The effect of soft tissueaugmentation using fillers typically lasts 6 months.

The search for newer and better materials led to theintroduction of polyacrylamide, which was consid-ered biologically inert; however, recently reportedsevere granulomatous reaction to polyacrylamidecasts doubt on this assumption.23 A filler commonlyused in the United States is an injectable bovinecollagen preparation. Other common fillers includePMMA (polymethylacrylate), microspheres, siliconeoil, polylactic acid microspheres, and dextran micro-spheres. Recently, hyaluronic acid filler (Restylane;non-animal stabilized hyaluronic acid; Medicis Aes-thetics, Scottsdale, AZ) was approved by the FDA.Long-term retention of its effect has been demon-strated in a mouse model using Restylane mixed withcultured human dermal fibroblasts (Fig. 11).136

In a recent investigation of human host responseto intradermal injection of various soft tissue fillers,all of the examined substances appeared to beclinically and histologically safe, but all showed hostinflammatory reaction from encapsulated fibroustissue, granulomatous reaction with giant cells, andchronic foreign body reaction.77 A less severeinflammatory response was obtained with polyme-thylacrylate particles, polyacrylamide, polyvinylhydr-oxide microspheres, and calcium hydroxylapetite.Other fillers have also had destructive inflammatoryeffects on soft tissues.82--84

Other possible complications of soft tissue aug-mentation include blindness and cutaneous necro-sis from treatment in the glabellar area30,125 andarterial embolization following hyaluronic acid in-jection (Restylane).100,111

Summary

In many ways cosmetic surgery is very differentfrom the rest of ophthalmology. The goal of most

ophthalmic procedures is to improve or preservevision. The success of the surgery can be readilymeasured with visual acuity.

The goals of cosmetic surgery are more varied andsuccess must be defined on a patient-by-patientbasis. The most common goal of cosmetic surgery isto reverse anatomical changes that occur in the facewith aging. Just as a successful ophthalmologist mustunderstand the anatomy and physiology of visiona successful cosmetic surgeon must understand theanatomy and physiology of facial aging. The success-ful cosmetic surgeon must be able to listen to

Fig. 11. A 56-year-old man, before (upper image) and 6months after Restylane injection for lower eyelid teartrough deformity, note marked improvement achievedwith no incisional surgery.


a patient’s concerns about how their appearance hasbeen altered by age, understand the underlyinganatomical and physiological changes that causethese changes, describe to the patient what sort ofsuccess they might expect in reversing thesechanges, and then master and stay current ona number of rapidly evolving techniques.

It is a truly fascinating and challenging area ofophthalmology. For those who embrace the disci-pline it can be very rewarding.

Method of Literature Search

Medline and Medical Subject Headings search(1966--2007) was conducted using the followingterms: eyelid, ptosis, blepharoplasty, eyelid bags, forehead,face-lift, midface-lift, neck-lift, rhytidectomy, browlift, chem-ical peel, blepharoplasty, facial implants, fat transfer,liposuction, botulinum toxin, fillers, Restylane, chemicalpeel, cosmetic surgery, aesthetic surgery. The search waslimited to English language publications. All manu-scripts’ abstracts were examined. Publications wereincluded if they studied any aspects of cosmetic eyelidand facial surgery with emphasis on new surgicaltechniques and new cosmetic procedures. Compara-tive prospective studies were preferred; case-serieswere also included if they studied an important aspectof a specific cosmetic procedure. Abstracts identifiedwere assessed for eligibility. If the abstract was unclearthe full-text of the article was obtained and assessed.

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The authors reported no proprietary or commercial interest inany product mentioned or concept discussed in this article.

Reprint address: Guy J. Ben Simon, MD, Goldschleger EyeInstitute, Tel Hashomer, Israel 52621.

diagnostic and surgical

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