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Background: Surgery involving massive inferior palpebral demolition often imposes the use of free flaps for the reconstruction of the anterior and posterior lamellae. Purpose: We describe a surgical technique which provides for the use of a homologous pedunculated elastic flap on which we wrap the free flap as in a pocket, in order to guarantee that the free flap itself takes root better. Methods: A study of 10 patients admitted to our hospitals for massive inferior palpebral demolition surgery between March 2002 and November 2004 was undertaken, and clinical records (age, sex, involved site of lesions, surgery technique) were accurately noted: in all patients we performed the ‘pocket technique’. Results: The pocket technique has encouraged optimal attachment of the implanted free tissue, in absence of necrotic phenomena or tissue extrusion. Conclusions: Reconstructive surgery of the inferior eyelid avails itself of consolidated techniques. In case of extreme tissue reduction, the variation we wish to suggest is simple to understand and easy to perform, significantly reducing inflammatory reaction and/or post-surgical rejection, allowing excellent aesthetic results.

Purpose To describe the technique of anterior approach white-line advancement for correction of ptosis. Methods Retrospective review of consecutive cases that underwent anterior approach white-line advancement for correction of aponeurotic ptosis. In this technique, the posterior surface of the levator aponeurosis (white line) is accessed through a skin crease incision (anterior approach) and advanced toward the tarsal plate. Surgery was considered successful if the following 3 criteria were simultaneously met: postoperative upper margin reflex distance of ≥2 and ≤4.5 mm, inter-eyelid height asymmetry of ≤1 mm, and satisfactory eyelid contour. Written informed consent was obtained from all the patients and the study was HIPPA compliant. Results Twenty patients (29 eyelids) were included in this study. Mean postoperative follow up was 1.25 months (1 to 6 months). Mean preoperative margin reflex distance was 0.38 mm (-1 to 2 mm) and the mean postoperative margin reflex distance was 3.16 mm (2 to 4 mm). Eighteen patients (90%) fulfilled the criteria set for success. The patients rated the outcome of surgery as follows: 80% completely satisfied and 20% significantly improved. Conclusion Anterior approach white-line advancement is a hybrid technique that incorporates the principles of both anterior and posterior approach ptosis correction techniques. The posterior surface of levator aponeurosis (white line) is exposed and advanced toward the superior border of tarsal plate with minimal disruption of eyelid anatomy including the orbital septum and preaponeurotic fat pad. Hence, this technique can achieve superior cosmetic results similar to a posterior approach procedure, without the need for a conjunctival incision.

PURPOSE Lower eyelid orbital fat hyperplasia has not been described in young age patients. METHODS A fourteen-year-old girl, a 29-year-old man, and 42-year-old man had visited our hospital complaining of a lower eyelid bulge. In orbital computed tomography examination, there was excess fat tissue compared with the opposite side, but no mass lesion matched with the area of lower eyelid bulge in our patients. The authors planned surgery for the removal of excess fat through the conjunctival incision. Intraoperatively, there was no real fat herniation through the septum. Septum continuity was maintained and thinning or distention of the orbital septum was not observed in our patients. The authors opened the orbital septum and removed the excess fat to make symmetry bilaterally. In the pathologic examination, removed fat tissue is not different with normal fat tissue. CONCLUSIONS The authors reported these findings at the first time. So they proposed the patient's condition as "lower eyelid orbital fat hyperplasia."

A good understanding of the anatomical details is required to ensure optimal results during surgery of the orbit. Several indications for orbital surgery require biopsy, resection, or reconstructive procedures. The intricate relationships between the orbital septum and adjacent structures of the upper orbit can cause difficulties in interpreting the surgical anatomy of this region. The purpose of this study was to acquire further insight into the anatomy of the superior part of the orbit, with special attention paid to the orbital septum.An ex-vivo study was performed using magnetic resonance imaging (MRI) at 9.4 Tesla (isotropic resolution = 20 μm) on six human cadaver specimens to examine the superior-medial half of the orbit. To visualise the posterior layers of the upper orbit, a dissection of three of the orbits was performed prior to the MRI examination, and a flexible PVC sheet was introduced above the levator muscle.The technique enabled a visualisation of anatomically important landmarks of the anterior and posterior parts of the upper orbit at a resolution near histological levels; to the authors' knowledge, this visualisation has not been reported previously. A posterior continuation of the orbital septum, which forms a distinct anatomical structure, is revealed.The posterior aspect of the orbital septum separates the levator muscle and the orbital fat pad. Between these two structures, a surgical corridor is formed using MRI, enabling alternative access to the superior part of the orbit; this alternative access might be less invasive because the orbital septum remains undamaged.

Purpose: To identify if isolated surgical violation of the orbital septum predisposes to “middle lamellar” scarring and subsequent postblepharoplasty lower eyelid retraction. Methods: A retrospective review of patients who underwent transconjunctival blepharoplasty in either a postseptal (orbital septum undisturbed) or preseptal (septal incision required) plane was performed. Patients undergoing skin excision, orbicularis muscle plication, and canthal suspension were excluded. The presence of clinically apparent postoperative lower eyelid retraction and limitation of forced superior eyelid excursion (forced traction testing) were assessed. Results: Two hundred eighty-eight patients (576 eyelids) were evaluated. One hundred fifty-eight patients (316 eyelids, 55%) had transconjunctival blepharoplasty performed in a postseptal plane and 130 patients (260 eyelids, 45%) in a preseptal plane. Two hundred two patients (404 eyelids, 70%) had forced traction testing performed postoperatively. After surgery, there were no patient complaints of change in lower eyelid position, subjective physician assessment of clinically apparent lower eyelid retraction, and only 1 case (0.5%) of a positive forced traction test in a patient with conjunctival scarring after significant postoperative infection. Conclusions: Lower eyelid scars leading to eyelid retraction after blepharoplasty are not likely related to “isolated” orbital septal scars (middle lamellar scars). Their designation as a “multilamellar scar” is more appropriate. (Ophthal Plast Reconstr Surg 2015;XX:00–00)

A 9 year old boy presented to the emergency department with a one day history of generalised swelling of the right eye, conjunctival oedema, and difficulty opening the eye (fig 1⇓). In the preceding two weeks he had experienced coryzal symptoms. Fig 1 Periorbital swelling of the right eye ### 1. What is the diagnosis? #### Short answer Periorbital (preseptal) or orbital (post-septal) cellulitis. #### Long answer The terminology used in the literature is often ambiguous, with the terms “periorbital” and “preseptal” cellulitis used interchangeably. Similarly, the terms “orbital” cellulitis and “post-septal” cellulitis are also used interchangeably. The orbital septum is a tough fibrous membrane that forms the scaffold for the eyelids. It also provides a barrier to infection between the superficial tissues of the face and the deep tissues within the orbits.1 2 Infection superficial to this layer (preseptal) is termed periorbital cellulitis, whereas infection deep to the orbital septum (post-septal) is termed orbital cellulitis. ### 2. What is the likely infective source? #### Short answer Infection of the paranasal sinuses (most commonly ethmoid sinusitis). Causative organisms tend to reflect the underlying involvement of sinus disease, with Streptococcus pneumoniae , Streptococcus pyogenes , Staphylococcus aureus , and Haemophilus species most commonly being cultured.3 #### Long answer Periorbital and orbital cellulitis can have a sinugenic or non-sinugenic cause. Given the history of coryzal symptoms, this patient’s infection probably originated from the paranasal sinuses (maxillary, ethmoid, frontal, or sphenoid sinusitis). Anatomically, the ethmoid sinuses lie directly medial to the orbits and are separated from the orbital cavities by a ‘paper thin’ layer of bone called the lamina papyracea. This makes the orbital cavities vulnerable to direct spread of infection from the nose.1 2 Non-sinugenic causes of infection are less common but …

Summary Introduction Orbital floor fractures may be reached through 2 types of conjunctival approaches, the preseptal one and the retroseptal one. While the retroseptal approach offers a more direct and easier route to the orbital rim and floor, it is associated with a significantly higher rate of lower lid complications compared to the preseptal approach. We will focus on the preseptal transconjunctival approach. Technical note The conjunctival incision is performed with a guarded needle-tip electrocautery or with a long-handled scalpel (blade No. 15) from the inferior extremity of the semilunar fold to the lateral canthal region. The subconjunctival plane is divided with Stevens scissors medially and laterally. This plane, located between the preseptal cranial conjunctival flap covered by the orbital septum and the caudal conjunctival flap covered by the orbicular muscle's fascia, is opened with the scissors toward the inferior orbital rim. The periosteum over the inferior orbital rim is incised and reflected. The subperiosteal dissection is continued toward the orbital floor. The incarcerated periorbital tissues are repositioned to expose the stable bone margins of the fracture before orbital reconstruction. The closure of the periorbita is performed with uninterrupted 5-0 Vicryl sutures. The conjunctiva is closed with a running 6-0 Maxon suture. Discussion Although technically more demanding than the retroseptal approach, the preseptal approach enables a large and safe access to the entire orbital floor by passing through an anatomical bloodless plane. This approach can also be combined with a lateral canthotomy/cantholysis and with a medial caruncular transconjunctival incision, thus providing extended exposure of the entire orbit.

The experiences of sutureless levator plication by conjunctival route surgery are described in 80 primary operations performed for all grades of congenital ptosis in the past 2 years. The surgical steps, postoperative care and postoperative complications are reviewed.

Purpose To examine whether the lower eyelid retractor consists of a single layer or multiple layers. Design Retrospective clinical case series and dissectional study. Participants Fifty-one lower eyelid retractors (31 right, 20 left) of 44 patients (ages, 63–95 years) during entropion surgeries and 10 lower eyelids (5 right, 5 left) of 5 Oriental cadavers (73–91 years old at death) were observed macroscopically. Specimens from 20 postmortem lower eyelids of 12 Orientals (11 right, 9 left; 66–96 years old at death) were used for microscopic observations. Methods Macroscopically, we bluntly or, in parts, sharply dissected lower eyelid retractors into 2 layers during entropion surgeries. Cadaveric lower eyelids also were used to investigate relationships between the lower eyelid retractor and the Lockwood ligament. Cadaveric lower eyelids with sagittal full-thickness sections of the central part were examined microscopically using Masson trichrome staining. Main Outcome Measures Anatomical findings in the lower eyelid retractor. Results Lower eyelid retractors easily were detached into 2 layers. Macroscopically, the anterior layer was defined as a coarse tissue continuing from the Lockwood ligament, which joined with the lower orbital septum, and constituted the lower conjoined fascia. The posterior layer appeared to be a dense fibrous sheet with a lustrous surface. Microscopically, the lower eyelid retractor consisted of a definite double layer. The anterior layer, a coarse fibrous tissue, consisted of the suborbicularis fascial layer, orbital septum, and superficial part of the capsulopalpebral fascia, which continued to the anterior lamellae of the lower eyelids. The posterior layer consisted of dense fibers of the capsulopalpebral fascia with smooth muscle continuing to the tarsus. Conclusions The lower eyelid retractor consists of a definite double layer. The posterior dense layer containing smooth muscle is the main tractional component of the lower eyelid retractor.

Background The author found that nonexcisional techniques commonly used to create a double eyelid in Asian patients did not create a natural-looking fold, while most transcutaneous double-lid procedures involved unnecessary excision of eyelid skin and orbicularis muscle, which could increase tension on the scar and make it more noticeable. Objective The author describes a technique for creation of a double eyelid, based in part on new anatomic findings, that uses a short incision to minimize the scar. Methods The thick orbital septum was opened, the supratarsal tendon was divided, the central fat compartment was removed, and the dermis was fixed to the tarsal plate. Results Between January 2000 and December 2004, 652 patients were operated using this technique. The mean age of the patients was 24 years. There were no serious complications. Four hundred twenty patients (64.4%) were followed up to 2 months, and 162 patients (24.8%) had 1-year follow-up. All had satisfactory results, except for 8 patients who underwent a second procedure to correct unequal folds 2 months postoperatively. Ten patients lost their supratarsal folds within 1 year postoperatively; all had satisfactory results after reoperation. Conclusions The short incisional technique for creation of a double eyelid described here provides excellent results with no visible scar and no serious complications.

The stigmata of midfacial ageing are the malar descent, lateral orbital festoon formation, tear-through deformity, deep melojugal sulcus, buccal fat pad and sub-orbicularis oculi fat (SOOF) prolapse, deep nasolabial folds and cutaneous and muscular descent. The signs of periorbital ageing include dermatochalasis, skin hooding of the upper eyelids, lacrimal gland prolapse, adipose prolapse, and lateral canthal descent and orbital septum diastasis. All of these deformities can be addressed through upper and lower blepharoplasties with arcus marginalis release, lateral canthopexy, sub-periosteal midface rhytidectomy with temporal suspension of the malar mound and SOOF repositioning. The same technique can be utilized for the restoration of facial symmetry after Bell's palsy. In the following report the technique and the authors' experience in the rejuvenation of the periorbital and midface region are presented. There were a total of 20 patients in this series. Sixteen were female and 4 were male. All the patients were followed-up on a monthly basis after surgery for the first 6 months. They were then seen at 1 year post-surgery. All of the patients were evaluated by the senior author. In the beginning of the study there was 1 Asian female patient with mild postoperative ectropion, which resolved and did not require operative intervention. The patients experienced prolonged postoperative oedema. The patients were satisfied with their postoperative outcomes. In all patients, the goals of periorbital and midfacial rejuvenation were achieved with the above technique. Simultaneous periorbital and midfacial rejuvenation can be achieved via upper and lower blepharoplasties, lateral canthopexies and sub-periosteal midface rhytidectomy.

I prefer using the Ellman radiofrequency unit with a microdissection tip or the monopolar unit with a Colorado tip to incise the skin, as these afford simultaneous cutting and excellent hemostasis. The skin and orbicularis muscle are removed as single flaps generally, although a skin flap alone could be removed if there is preoperative concern for poor eyelid closure function. Next, the fat pads are addressed if prominent on the preoperative evaluation (Figure 27.1). In general, limited fat removal should be performed in order to avoid the appearance of a hollow superior sulcus. The trend in upper eyelid blepharoplasty has shifted to preservation, repositioning, or filling of the upper lid fat, rather than aggressive removal. If debulking is indicated, the fat should be conservatively removed over a curved hemostat in order to avoid orbital hemorrhage. Medial fat pad removal should bear in mind the location of the trochlea and superior oblique tendon, as well as the numerous fibrous attachments of these structures to the orbital fat. Generally, the orbital fat pads can be thermally sculpted with the Ellman roundball tip or the Colorado tip over an intact orbital septum, which limits the risk of hemorrhage or injury to adjacent structures, as well as requires much less operative time. Open image in new window Figure 27.1 Introperative view of upper eyelid fat pads posterior to the orbital septum. The levator aponeurosis lies posterior to the orbital fat pads. MFP, medial fat pad; CFP, central fat pad; LV, levator aponeurosis.

We present a modified transconjunctival blepharoplasty technique that has proved very effective in patients desiring rejuvenation of the lower eyelids that do not need skin or orbicularis resection. Double-armed sutures are placed through the tip of each fat pedicle, and the needles are passed through the intra-SOOF pocket out through the skin below the tear trough and tied over a foam bolster.

Orbital cellulitis is the infl ammation of the tissues of the eye behind the orbital septum. The disease is mainly caused by either bacteria or fungal organisms. Orbital cellulitis is an emergency condition that requires prompt hospitalization and appropriate antibiotic cover without which there will be visual loss and even death! It affects all ages but more common with the younger age groups and males are more prone to the disease. It is a unilateral disease commonly but in rare situations both eyes are affected. We report a case of a bilateral disease in a healthy middle-aged man who presented with fevers, diminished vision, eye pains, lid swellings, severe ptosis, axial proptosis and ophthalmoplegia in both eyes. Our impression was that of Class 5 orbital cellulitis according to Chandler’s classifi cation. His laboratory investigations revealed positive growths of Staphylococcus otherwise his laboratory investigations were all normal. He responded well to intravenous cefuroxime and oral ofl axacin and metronidazole with diclofenac and was discharged from hospital within 1 week. We conclude that prompt hospitalization and appropriate intravenous and oral antibiotics can successfully treat this orbital emergency.Keywords: Appropriate antibiotics, bilateral orbital cellulitis, bilateral visual loss, orbital septum

The transconjunctival approach is the appropriate standard for lower eyelid blepharoplasty in patients presenting with lower eyelid herniated fat without excess skin. A transconjunctival incision is made approximately 2 mm below the tarsal border and extended inferiorly following a plane posterior to the orbital septum. No conjunctival suture is necessary. Although transconjunctival blepharoplasty diminishes the occurrence of postoperative complications when compared to the transcutaneous method and constitutes a more comfortable option for the patient, we always recommend a preoperative test of the eyes. Patients must be informed of the risk of amaurosis.

PURPOSE To investigate the two-fold structure of the levator aponeurosis, which is partly composed of independent smooth muscles. MATERIALS AND METHODS Fifteen upper eyelids of 12 Asian postmortems, with age at death ranging from 72 to 91 years, were examined. In 9 eyelids, posterior lamella tissue of the upper eyelid was removed to observe the stratified structures of the levator aponeurosis. Six full-thickness eyelids were used to observe the attachment site or the continuity between the levator aponeurosis and its surrounding tissues. The eyelids were incised perpendicularly in the center of the eyelid; samples were stained with Masson trichrome and antismooth muscle actin antibody and examined microscopically. RESULTS Masson trichrome staining demonstrated the two-layered nature of the levator aponeurosis. The anterior layer was characterized by thick, robust fibrous tissue, and the posterior by thinner fibrous tissue. Although both layers contained muscle structures, the posterior layer contained more than the anterior. Immunostaining with antismooth muscle actin antibody revealed that the muscle in both layers was smooth muscle. The anterior layer continued to the orbital septum and the submuscular fibroadipose tissue; the posterior layers, located in front of Muller muscle and its tendon, attached to the anterior inferior one-third of the tarsus. Part of the anterior layer went through the orbicularis oculi muscle and attached to the subcuticular tissue. CONCLUSIONS The levator aponeurosis is stratified, consisting of two layers than contain smooth muscle components in their proximal portions. It pulls mainly the preaponeurotic fat and anterior eyelid lamella. This partially regulates the tension of the eyelid and contributes to the ordered movement of the upper eyelid.

WOS: 000320721700006, PubMed ID: 23627253, Prolapse of the lacrimal gland is an unusual condition. An appearance of bilateral dermatochalasis was observed in the medical examination of a 30-year-old female patient with bilateral upper eyelid edema. The patient underwent bilateral blepharopylasty. During the surgery, it was noticed that in the temporal portions of the eyelids, there was a prolabed tissue-like lacrimal gland. We did incisional biopsy from the prolabed tissue that was thought to be orbital lobe of the lacrimal gland and carried out reposition of the orbital rim with 5-0 polyester suture and closed the orbital septum. Lacrimal gland reposition is a procedure which entails the separation of such anatomic structures as orbital septum, adipose tissue, and levator complex. However, failure to recognize a prolapsed lacrimal gland may mistreat by simple excision, and will lead to important alterations in ocular lubrication. In our case, repositioning of the glands was successfully performed during upper-lid blepharoplasty.

Acute bacterial sinusitis is usually a clinical diagnosis. Orbital complications require emergent evaluation with computed tomography. Using the orbital septum as an anatomic landmark, such infections can be classified as pre- or postseptal and treated with the most adequate therapy, ie, oral or intravenous antibiotics or surgical endonasal drainage. Intracranial complications can be seen in 3.7% to 11% of these patients, often with subtle clinical symptoms and signs. Radiologists play a decisive role in the final management of these patients and should be familiar with the most relevant complications. In this article, we present a retrospective review of all pediatric patients referred to our department for paranasal sinuses and orbital computed tomography because of acute complicated bacterial sinusitis. They were studied with an emergent enhanced facial and cranial computed tomography within 24 hours of admission, followed by magnetic resonance imaging when intracranial complications were suspected. Particular emphasis is placed on the imaging algorithm and the most relevant complications; we correlate imaging findings with clinical and bacteriological data.

Background: Three principal techniques exist with which to create the Asian double eyelid: the suture, partial-incision, and full-incision methods. The partial-incision method is reliable and long-lasting without many of the drawbacks of the full-incision method. Objective: The surgical technique of the partial-incision method is reviewed in a stepwise fashion so that the reader can reproduce this method for double-eyelid creation. Methods: Preoperative lid measurements were made with the patient in an upright sitting position to account for the effects of gravity on the lid. An incision was made through both the skin and orbicularis muscle to expose the underlying orbital septum. The lateral septum was lifted upward and a small wedge of elevated septum removed to permit entry into the preaponeurotic adipose tissue, which was then teased forward through the aperture in the orbital septum. Normally, only half of the exposed fat is removed, leaving a small adipose cuff on the hemostat. The remaining adipose cuff was cauterized and the wound inspected for hemostasis. Suture fixation was accomplished with a 7-0 nylon suture to tack the levator aponeurosis to the inferior skin edge along the incision line. The suture was passed through the epidermis to ensure permanence. Results: We have successfully used the partial-incision method of double-eyelid correction in 1500 cases. The 3 notable complications that can occur are loss of the lid crease, suture extrusion, and asymmetry. All of these complications occur in approximately 2% to 3% of cases but are easily corrected. The apparent elevated appearance of the lid height during the postoperative period is attributed to edema and diminishes by 1 to 2 mm to a more natural position after 3 to 12 months. Conclusions: The partial-incision approach is a simple, safe, and straightforward approach to double-eyelid creation that can be performed even by surgeons with relatively little experience in the technique. (Aesthetic Surg J 2003;23:170-176.)

Based on the detailed anatomy, the orbicularis oculi muscle and the orbital septum are the continuation of the frontalis muscle and its fascia. Therefore, the shortened orbicularis oculi muscle and orbital septum would transmit the frontalis muscle action more effectively. The superior-based orbicularis oculi muscle and orbital septum flap, as a single flap, were advanced and attached to the tarsal plate for the correction of blepharoptosis. Six patients with undercorrected blepharoptosis were included in this study. Each patient had undergone more than two levator resection procedures by ophthalmologists or plastic surgeons. Conventionally, the frontalis suspension procedure was the next choice in these cases. The shortened orbicularis oculi muscle and orbital septum flap was used in these cases. Postoperative results were satisfactory after 3-year follow-up.

In standard blepharoplasty, the orbital septum is opened commonly to enter the preaponeurotic space. This is to anchor the leading edge of the levator palpebral fascia to the skin of a proposed supratarsal fold and to remove supraorbital fat. Incision of the orbital septum is involved occasionally with accidental injury to an inconstant arterial branch at its lateral side, which causes severe bleeding. Anatomic knowledge of the vessel on the orbital septum is conducive to preventing accidental arterial injury. The authors encountered a relatively large artery running vertically at the lateral side of the orbital septum in 50 eyelids of 230 blepharoplasty patients (460 eyelids). They investigated the branch by injecting red latex into the ophthalmic arteries in 20 hemidissected faces of fresh cadavers. At the lateral aspect of the orbital septum, a branch of the superior lateral palpebral artery, which we named the lateral septoaponeurotic artery (LASA), was confirmed in five of 13 specimens. The LASA originates from the superior lateral palpebral artery just after it divides into peripheral and marginal arcades. The LASA pierces the levator aponeurosis and orbital septum at the upper level of the tarsal plate. It anastomoses with a branch of the supraorbital artery at the superior aspect of the orbit. The authors think severe bleeding occurs when the LASA is injured during blepharoplasties. Cautious treatment of the lateral septoaponeurotic vessel minimizes undesirable complications.

PURPOSE Application of a grid of electrocautery to the orbital septum to treat anteriorly prolapsed eyelid fat pads during blepharoplasty has been previously described. A review of patients who underwent this technique was performed to determine if this technique led to a higher incidence of postoperative eyelid retraction. METHODS A retrospective case series of patients who underwent application of a grid of electrocautery to the orbital septum during blepharoplasty from 1979 to 1999 was reviewed. RESULTS There were 1492 patients (3018 eyelids) who underwent an application of a grid of electrocautery to the orbital septum during this period. Five hundred twenty-nine patients (1036 eyelids) underwent upper blepharoplasty, 91 patients (174 eyelids) underwent lower blepharoplasty, 149 patients (596 eyelids) underwent combined upper and lower blepharoplasty, and 723 patients (1212 eyelids) underwent a combined upper blepharoplasty and ptosis repair. All patients were followed for at least 3 months. Follow-up ranged from 3 months to 20 years. No patient had postoperative eyelid retraction. CONCLUSIONS The application of a grid of electrocautery to the orbital septum during blepharoplasty to treat anteriorly prolapsed eyelid fat pads is effective, safe, and does not lead to late postoperative eyelid retraction.

Objective: The aim of this study was to quantify the efficacy of three different surgical techniques for entropion repair in a 3-year follow-up study: (1) the Fox procedure, (2) everting sutures and (3) a modified technique of lower lid retractor plication. Methods: We included in our study 32 eyelids of 32 consecutive patients with involutional lower lid entropion; 10 lids underwent the Fox procedure, 13 the everting sutures and 9 the modified retractor plication. We evaluated the pre- and postoperative horizontal lid laxity (HLL), the pre- and postoperative lower lid excursion (LLE) and the number of recurrences in each patient group. Statistical analysis was performed with the non-parametric Mann-Whitney test and the exact Fisher’s test where appropriate. Results: Only the modified retractor plication technique showed statistically significant differences in HLL and LLE (p < 0.05). In the group treated with this technique, there was a lower incidence of entropion recurrence (p < 0.05). The everting suture technique showed a statistically significant improvement of the LLE only (p < 0.05). The Fox procedure did not show any statistically significant improvement of the studied parameters. Conclusions: The modified retractor plication technique gave the best results in terms of improvement of HLL and LLE and a lower incidence of entropion recurrence compared to the two other techniques studied.

The aim of this study was to reconfirm the detailed histologic structure of the levator aponeurosis and superior transverse ligament, which were first described by Whitnall. Twenty-eight upper eyelids from 28 Korean adult cadavers (mean age, 79.5 [SD, 11.3] years; 16 males and 12 females) were used. Sagittal sections on the midpupillary line were made, and 10-μm-thick sections were prepared. Twenty-five were stained with Masson trichrome, and 16 were prepared for immunohistochemical staining for smooth muscle fibers using mouse monoclonal anti-smooth muscle Ab. The levator palpebrae superioris muscle was covered with its fascial sheath along its course. The superficial part of the fascia sheath that covered the upper aspect of the levator palpebrae superioris just behind the aponeurosis was condensed to form a definite ligamentous band. In front of this ligamentous condensation, the sheath becomes abruptly so thin that it appears to end in a free border, but it could be traced forward as a very delicate layer up to the supratarsal border. The orbital septum consisted of 2 layers. The whitish outer (superficial) layer descends to interdigitate with the levator aponeurosis with loose connective tissue, and then it disperses inferiorly. The inner (deep) layer initially follows the superficial one, and then it reflects at the levator aponeurosis and continues posteriorly with the levator sheath. In most of the specimens, the levator aponeurosis consisted of a single layer in 27 (96.4%) of 28 eyelids. Only 1 eyelid has been observed to show a double-layered levator aponeurosis (3.6%). Some immunostained smooth muscle fibers in the lower side of the levator aponeurosis ran along its entire course. We reconfirmed the levator sheath covering the levator aponeurosis, and it continued anteriorly with the inner layer of the orbital septum, as Whitnall described. This information will be helpful when performing upper eyelid surgeries.

Background: Standard approaches for creating a double eyelid in Asian patients may cause hematoma, asymmetry, early release of the fold, or an unsatisfactory appearance. Objective: We report an approach to creating a double eyelid based on integration of the septoaponeurotic union into the dermis of the pretarsal skin. Methods: A preoperative design was drawn with the patient in the supine and sitting positions, with the fold level always located 8 to 10 mm from the lid margin. An incision was made and deepened by removal of a narrow strip of the orbicularis muscle until the anterior orbital septum was identified. The entire length of the anterior orbital septum was opened, and a dissection was performed along the avascular plane between the orbital fat and the posterior orbital septum. The septoaponeurotic union was sutured to the lower edge of the incised pretarsal dermis. The levels of the double-fold line were checked with the patient in the supine and sitting positions. Results: Results in a series of 610 patients treated between March 1996 and March 1999 were satisfactory. Complications included a 2% rate of diminution of the double fold occurring in patients treated early in the series, probably caused by loose sutures between the septoaponeurotic union and the lower edge of the incised pretarsal skin. In 10 patients, the fold line was asymmetric or too high. All patients with complications were treated successfully by reoperation with use of the same technique. Conclusions: Creation of a double eyelid through attachment of the septoaponeurotic union to the pretarsal dermis can provide a secure double eyelid with a more aesthetic appearance.

Correction of upper eyelid retraction can be achieved by numerous techniques. We have developed a new flap, the orbital septal flap, to interpose between the recessed levator complex and the tarsus to correct the retracted upper eyelid of a young girl. The orbital septum is a facial structure; it is readily available and easy to dissect. The flap acts like a vascularited spacer without the problem of resorption; normal anatomical continuity of the levator mechanism can be functionally restored. We believe the orbital septal flap is a promising technique for correcting upper eyelid retraction; however, more case studies are needed.

Orbital cellulitis is an infection of the orbital soft tissues posterior to the orbital septum. It has the potential to be affect sight and function of the eye and extraocular tissues. Although it is commonly seen in the pediatric age group, adult orbital cellulitis is not uncommon. Infection usually originates from sinuses but sometimes the nidus of infection is in the eyelids, from retained vegetative foreign bodies, or very rarely from distant infection spreading to the orbit spread from blood. It is characterized by pain, proptosis, chemosis, diminution of vision, fever, periorbital erythema, and limitation of ocular motility. Historically orbital cellulitis was a sight and life-threatening condition. However, with the advent of high quality imaging, antibiotics and early surgical intervention to drain the orbital abscess when indicated, the chances of visual loss have reduced significantly. The purpose of this review is to describe current investigative and management paradigms in the treatment of orbital cellulitis and current recommendation in the management of complications resulting from it.

The purpose of this study was to investigate the correlation between the oculocardiac reflex (OCR) and blepharoptosis surgery for safe eyelid surgery. Fifty-four consecutive patients with bilateral aponeurotic blepharoptosis were enrolled in this study. Changes in electrocardiography (ECG) monitoring were recorded during surgery. Preoperative pressing on the globe and intraoperative stretching of the levator aponeurosis were also carried out and the occurrence rate of the OCR was recorded. A positive OCR was observed in 12 patients (22.2%) in the preoperative globe-pressing test, whereas a positive OCR was observed in 22 patients (40.7%) in the levator-stretching test. The levator-stretching test did not indicate a significant difference in the rate of heart rate decrease with respect to laterality. No correlation was observed between age and the occurrence of OCR. On the other hand, there was a significant difference in the percentage of heart rate decrease between patients with positive OCR and negative OCR as determined in the globe-pressing test (mean = 13.1% vs. 5.4%). During the practical operative manoeuvre, no bradycardia was observed in any case. This study confirmed that a rapid and strong traction of levator aponeurosis induces the OCR regardless of laterality and age. Atraumatic and gentle handling are essential to prevent OCR. The preoperative globe-pressing test may be an index of the OCR in reflex-prone patients. Intraoperative ECG monitoring will be useful for early onset detection, although positive OCR was not observed in any patient during the practical surgical manoeuvre.

Periorbital ecchymosis is due to extravasations of blood into the periorbital skin and the subcutaneous tissues around the eyes. ‘raccoon eyes’ or ‘panda sign’ is a distinctive type of periorbital ecchymosis where the bruising is characterised by tarsal sparing. This sparing is due to an anatomical structure called the orbital septum, which limits the spread of the discolouration beyond the tarsal plate. Hence ‘raccoon eyes’ description should be limited to orbital ecchymosis due to basal skull fractures only. While the bilateral bruising due to direct trauma to the eyes, or non-traumatic medical conditions, can spread beyond the tarsal plate as in our case. The differential diagnosis varies from trivial benign conditions to serious life-threatening illnesses. We describe a case of recurrent bilateral periorbital ecchymosis and facial bruising due to vomiting.

The changes in the periorbital region are among the most prominent features of the aging process in the lower eyelids. Intense focused ultrasound (IFUS), known as the Ulthera System, was designed to correct this process. The current study assessed the safety and efficacy of the Ulthera System. This study enrolled seven adult patients who presented from March 2011 to May 2012 for correction of lower eyelid aging by Ulthera. The subjects were treated using Ulthera 1.5 and 3.0 mm probes. The 1.5 mm probe is used to tighten of loose eyelid skin and the deep dermis, whereas the 3.0 mm probe is used to tighten the orbicularis oculi muscle and the orbital septum. The patients were evaluated for allergic reactions and other side effects. The subjects’ satisfaction with clinical photographs and the degree of pain were evaluated. Moreover, orbital computed tomography (CT) and ophthalmologic examinations were performed. The study used CT both as a research tool and as a clinical score system for evaluating aging lower eyelids and performed statistical analysis. Based on the CT images, the difference between the pre- and postoperative distances from the baseline (line between the most inferior point of the supraorbital rim and the most superior point of the infraorbital rim) to the most protruding point of the orbital septum was 0.51 ± 0.23 for the right eye (p

The eyes are probably the most intimate aspect of anyone’s appearance. As cosmetic and plastic surgeons, we have mainly focused on the vertical dimensions of the upper eyelid and aspects of redundant fat or skin in the lower eyelid. By now, it should be apparent that there is an important three-dimensional element to the periorbital area—something that has largely been neglected until recently. Now, we understand the importance of not just lifting the tissues upward or removing “unwanted” fat, but rather of lifting the skin in a specific anterior direction away from the underlying skeleton and soft tissue structures it covers.

Background: The different possibilities for management of excessive or pseudoherniated fatty tissues in the lower eyelid are a subject of lively discussion in the field of aesthetic surgery. Objective: We present a technique that uses the transconjunctival approach for the simultaneous treatment of excessive or pseudoherniated fat and marked periorbital sulci, which is based on the sliding fat pad technique first described by Loeb. Method: Incision of the conjunctiva, inferior tarsal muscle, and capsulopalpebral fascia is performed about 3 mm above the fornix. Dissection is performed following the preseptal-suborbicularis dissection plane, freeing the arcus marginalis, traversing the malar septum, and passing below the palpebromalar and nasojugal sulci. Retraction is performed with a specially designed transconjunctival retractor and lower-lid retractor. The orbital septum is opened and blunt dissection of the inner and central fat bags is performed. The fat flap is secured with transcutaneous stitches tied over small pieces of silicone. A transcutaneous-transconjunctival suture is performed to reduce postoperative discomfort and promote scarring of the transected planes. Results: We have achieved aesthetically satisfactory results with no major complications. Conclusions: The sliding fat pad technique by the transconjunctival approach is a new technique that allows a natural and effective simultaneous correction of the lower eyelid, periorbital sulci, and mild cutaneous excesses with no disruption of the muscular and cutaneous planes, prompt recuperation, and a very low incidence of adverse effects when performed by surgeons experienced in transconjunctival procedures. ( Aesthetic Surg J 2001;21:487-492.)

Sunken and/or multiply folded upper eyelid is one of the common, troublesome complications that can occur after Oriental blepharoplasty. In addition to orbital volume depletion, the traumatic surgical procedure of excessive fat removal might result in a varying degree of adhesion and injury to the orbital septum. Adhesiotomy followed by a restoration of volume is generally believed to be the logical way to correct such deformity. To restore volume and prevent re-adhesion, local tissues of the upper eyelid, free-fat graft, and dermis-fat graft have been used. However, local tissues are usually insufficient because of previous surgery, and the survival rate of grafted fat is often unpredictable. Moreover, the heaviness of the dermis-fat composite makes it a less than satisfactory choice. The authors value the use of free fascia-fat composite grafts for the treatment of such disfigurements. The fascia-fat composite is expected to have a better survival rate than free fat alone and to be lighter than a dermis-fat composite. In addition, the fascia-fat composite is abundant throughout the body and provides anatomical structure more similar to that of the repair site, namely, the damaged orbital septum and fat. The authors prefer the mons pubis, preauricular, and temporal areas for the donor site depending on the status of the damage. They treated 13 patients with sunken and/or multiply folded upper eyelids by fascia-fat composite grafts and obtained satisfactory results.

Background Epiblepharon is a congenital eyelid anomaly frequently encountered in Asian infants and children. The purpose of this study was to describe the surgical technique of epiblepharon correction by applying both lash-rotating sutures in the inferior tarsus and the subcutaneous tissue of the upper skin flap and thermal cauterization in the septum. Methods A retrospective, interventional study was performed on 75 patients who underwent surgical correction of epiblepharon between August 2006 and July 2007 by 1 surgeon. The upper skin incisional line was just below the eyelash line, and the delineated ellipse extended from just lateral to the punctum to the site of lash inversion. Dissection was carried out between the tarsal plate and orbital septum and the skin-pretarsal and preseptal orbicularis oculi muscle flap, thus exposing the tarsal plate and orbital septum. Thermal cauterization was applied to the orbital septum to create a cicatricial barrier adhesion between the preseptal orbicularis oculi muscle and the septum to minimize vertical overriding of the orbicularis oculi muscle. Three to 4 interrupted sutures were placed in the inferior tarsus and the subcutaneous tissue of the upper skin flap to rotate the direction of the lashes. The small amount of pretarsal orbicularis oculi muscle and redundant skin overlying the lower lid margin were removed. Results A total of 150 eyes (75 patients) were followed for 24.1 weeks (range, 4-12 months). Patients ranged in age from 2 to 13 years (median age, 7.3 years). All patients were diagnosed with bilateral epiblepharon, and surgery was performed on both eyelids. After a mean follow-up period of 14.1 weeks, no patients had recurrence, and all patients had good cosmetic results. Symptoms disappeared in all patients. There were no cases of lid retraction, wound dehiscence, or ectropion. Conclusions Thermal cauterization of the orbital septum and lash-rotating sutures were very useful and effective for treating epiblepharon.

A 70-year-old man presented with a painless, solitary mass in the left upper eyelid. The mass moved freely in the whole upper eyelid. MRI revealed a 15×10×5 mm sized, well-circumscribed mass in the space between the orbital septum and the levator aponeurosis. The tumor was removed en bloc via a skin crease approach with simultaneous bilateral ptosis repair. The immunohistopathological diagnosis was a mucosa-associated lymphoid tissue (MALT) lymphoma. This is the first case of a freely movable MALT lymphoma in the preaponeurotic space.

Preseptal and orbital cellulitis occur more commonly in children than adults. The history and physical examination are crucial in distinguishing between preseptal and orbital cellulitis. The orbital septum delineates the anterior eyelid soft tissues from the orbital soft tissue. Infections anterior to the orbital septum are classified as preseptal cellulitis and those posterior to the orbital septum are termed orbital cellulitis. Recognition of orbital involvement is important not only because of the threatened vision loss associated with orbital cellulitis but also because of the potential for central nervous system complications including cavernous sinus thrombosis, meningitis, and death. Care for these patients is often shared between the pediatrician, ophthalmologist, and otolaryngologist. We review recent developments in the diagnosis, microbiology, and management of patients with preseptal and orbital cellulitis.

Objective The aim of this study was to develop an effective and minimally invasive operation to correct lower eyelid entropion that would address both the horizontal and vertical laxity. Design A prospective, noncomparative, interventional case series. Participants Thirty-five consecutive patients with involutional entropion, aged 62 to 92 years (mean, 77.1 years), had surgery on 45 lower eyelids. Of the 45 procedures, 33 (73%) had a primary procedure and 12 (27%) were reoperations. Intervention A lateral tarsal strip with diagonal tightening of the orbital septum and lower lid retractors to the lateral orbital rim was performed via a 1-cm lateral canthal incision. Main outcome measures Complications and surgical outcome were monitored clinically for between 12 and 24 months after surgery. Results The results were analyzed from 42 eyelids (33 patients) with a mean follow-up of 17.1 months (range 12–24 months). Two patients died and one dropped out of the study 3 months after the second eyelid operation. In 36 cases (86%), the entropion was cured. Transient lateral orbital rim tenderness was noted in six cases (14%), and one patient had a wound infection. Anatomic recurrences were detected in six eyelids of six patients, and five of these (83%) were asymptomatic. Conclusions This surgical approach has been found effective in 86% of eyelids. Adequate clinical followup has proven essential for accurate evaluation of entropion surgery.

The typical Mongoloid eye differs from the Occidental one in puffiness of the upper eyelid and narrowness of the palpebral fissure. We surmised that an anatomical structure might exist in the preaponeurotic fat space, which determines the features of the Mongoloid eye. The upper eyelids of 720 Japanese patients and eight Japanese cadavers were macroscopically investigated, and sagittal slices of the central upper eyelid of one patient and nine cadavers were microscopically analysed. Another, lower-positioned transverse ligament different from the higher-positioned Whitnall's one was identified just above the fusional line between the orbital septum and the levator aponeurosis in almost every upper eyelid. A robust ligamentous structure was observed in 331 patients (46%) with puffier eyelids and a narrower palpebral fissure, a diaphanous retinaculum in 381 patients (53%) and no transverse ligamentous tissue in eight patients (1%). Histological evaluation demonstrated that this ligament was composed of tight bundles of collagen fibres containing few elastic fibres. Examination of the preaponeurotic fat space indicated that the superficial expansion of the levator aponeurosis turned up around this transverse ligament to become the orbital septum. When the levator muscle contracts, the deep expansion of the levator aponeurosis retracts the tarsus, the middle expansion retracts the pretarsal orbicularis oculi muscle and skin, and the superficial expansion retracts the preaponeurotic fat against this ligament. This structure thus determines the low position of the preaponeurotic fat and restricts the vertical width of the palpebral fissure, causing the features of the Mongoloid eye.

Bulging of the lower eyelid is regarded as a sign of aging. "Herniation" of the periorbital fat pads is traditionally regarded as the factor responsible for the change. Excision of fat pads, therefore, has been the mainstay of treatment in reducing the palpebral bulge in cosmetic blepharoplasty. The surgical excision of"excess" and "herniated" fat pads, however, causes problems such as lid ecchymosis, chemosis, lid contour irregularity, ectropion, and retrobulbar hematoma formation. The author proposes that the loss of fat pad support caused by the attenuation of the orbital septa, not herniation of the excess fat pads, is the major factor responsible for the bulge. The author further proposes that the functional integrity of the orbital septum can be restored by plicating the attenuated orbital septa with 5-0 absorbable sutures. This technique of invaginating the protruded fat pad was performed in 138 individuals (276 lower eyelids). The operation was technically simple, and the approach was "tissue friendly." The results obtained, with the exception of a mild degree of puffiness encountered soon after the surgery, were satisfactory. Morbidity was minimal.

A 66-year-old man reported a slowly growing tumor on the lateral edge of his left upper eyelid. This lesion was hard but movable on palpation. A neoplasm of the lacrimal gland was suspected. CT showed a highly calcified lesion at the left upper eyelid. Resection of the tumor was performed, which was located just behind the orbital septum and in front of the lacrimal gland. Anatomopathologic investigation of the excised specimen with immunohistochemistry revealed a benign meningioma of a meningotheliomatous type, containing multiple bone elements. An ectopic orbital meningioma is rare, and this is the first case of a unique lateral localization of this lesion. Therefore, it should be included in the differential diagnosis of a lacrimal gland tumor.

The standard treatment for herniated "bags" of the lower eyelid is surgical removal of excess fat. Sachs and Bosniak in 1986 and de la Plaza and Arroyo in 1988 described a new technique for treatment of palpebral bags that consisted of returning the herniated fat to the orbital cavity and retaining it by continuous sutures of the capsulopalpebral fascia either to the dehiscent portion of the orbital septum or to the periosteum of the lower orbital rim. This article reports a prospective study of 26 patients who underwent standard blepharoplasty in one lower eyelid and capsulopalpebral fascia hernia repair in the other lower eyelid. All were evaluated at 6 weeks and at 6 months after surgery, and the outcomes were compared. The results of the two different techniques in the same patient have shown comparable aesthetic outcomes in the treatment of palpebral bags. However, results indicate that the capsulopalpebral fascia hernia repair technique carries less discomfort and pain during the operation and may be less prone to postoperative bleeding and hematoma formation. In addition, in contrast to standard lower blepharoplasty with fat resection, hollowing of the lower lid or potential sunken appearance of the globe may remain absent with capsulopalpebral fascia hernia repair beyond the 6-month period of this study.

The orbital region is sensitive to the undesirable effects of any surgical intervention, because of its anatomical location and the importance of the eyelids in facial sign language. The procedures performed for correction of baggy eyelids may have remarkable undesired results. In recent years, we have made a special effort to analyze the causes, to minimize these undesirable effects, and to be able to offer patients more natural and safer results. We have designed a new technique called septo-orbitoperiostoplasty for the treatment of baggy eyelids, based on preservation of orbital fat and correction of the supportive layer. This technique consists of placing the orbital fat back into the orbital cavity and its retention by suturing the lax septum to the periosteum of the orbital rim. Neither an incision on the orbital septum nor an excision of the orbital fat is performed. It can be performed for both upper and lower eyelids. This paper describes the surgical procedure and shows the results obtained from 74 patients who had been treated with this technique over a 10-year period. All patients were followed up for an average of 5 years. (Plast. Reconstr. Surg. 101: 1657, 1998.)

The anatomy of a black eye is examined in a series of cadaver dissections in which a previously unreported fascial system of the lower eyelid is identified. This fascia originates at the orbital rim, and is in continuity with the orbital septum and with the periosteum of the orbital floor and anterior maxillary wall. This fascia contributes to the thickened area along the orbital rim called the arcus marginale. At the level of the orbicularis oculi muscle, this fascia was noted microscopically to fuse with a fibrous septa of the superficial cheek fat. This creates one long continuous membrane from the orbital rim above to the cheek skin below. Dye injection techniques show that this membrane is impermeable and traps injected dye in the same place where a black eye forms. After periorbital injury, extravasated hemoglobin pigment is confined to the area above the cutaneous insertion of this membrane. This fascial system has been named the septum malaris: malar describes its origin along the orbital rim of the cheek, and septum further describes the partitioning nature of this ultra-thin membrane.

We describe in detail the anatomy and function of the "Lockwood suspensory ligament" and the interrelated function of the orbital contents responsible for the intraorbital position of the eyeball and fat. With age, or because of genetic disposition, the eyeball descends, reducing the space between it and the floor of the orbit. This will inevitably cause forward projection of the extraconical orbital fat, creating herniated fat pads and resulting in enophthalmia. Based on the volume of the bony orbit and its contents, it is likely that relocating, rather then removing, herniated fat pads will greatly improve and prevent the enophthalmia of aging and give the globe a position and a projection of youth. Based on the results of surgery using the capsulopalpebral flap, it is likely that a descended Lockwood suspensory ligament, rather than a weakened orbital septum, is the cause of herniated fat pads and enophthalmia. We feel neither a weakened orbital septum nor an overabundance of orbital fat nor a shallow orbit is responsible for either of these conditions. We give a detailed description of how to raise the globe, preserve and relocate herniated fat pads, and manage and prevent enophthalmia and obtain a beautiful, youthful looking eye.