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Periorbital aging typically manifests with dermatochalasis and depression of the upper eyelid. While blepharoplasty is a popular choice for addressing upper eyelid skin laxity, it is not effective for treating sunken eyelids. This study introduces an innovative approach for periorbital rejuvenation by simultaneously addressing dermatochalasis and sunken upper eyelids in aging Asian women. This study involved 45 patients with upper eyelid dermatochalasis accompanied by moderate to severe depression. Sub-brow blepharoplasty was performed in conjunction with upper eyelid granular fat grafting in the orbital septum for these patients. Preoperative measurements of the depth and volume of the upper eyelid depressions were taken, and surgical outcomes were assessed at 3 and 6 months postoperatively using the Global Aesthetic Improvement Scale (GAIS) score and the Antera 3D camera. The average depth of the upper eyelid depression before surgery was 6.501 ± 1.473 mm, and the average volume was 0.579 ± 0.144 cm3. Significant improvements in both the depth and volume of the depressions were observed at 3 and 6 months after surgery compared to preoperative measurements. The GAIS scores were also improved and postoperative outcomes were deemed satisfactory. For patients with dermatochalasis accompanied by moderate to severe upper eyelid depression, standard blepharoplasty alone is insufficient to correct the sunken eyelid. This novel technique, which combines autologous granular fat injection into the orbital septum with blepharoplasty, effectively addresses periorbital aging, enhancing facial rejuvenation. [ABSTRACT FROM AUTHOR]

PurposeMethodsResultsConclusionTo disclose the precise attachment site of the orbital septum in the lateral canthus.Nine specimens of 7 Japanese cadavers aged 66 to 85 years at death were included. The attachment site of the orbital septum in the lateral canthus was grossly dissected. Two of the 9 specimens were exenterated and used to explore the anatomy from lateral and superior aspects, respectively.The orbital septum in the lateral canthus attached slightly lateral to the outer edge of the lateral commissure with the levator aponeurosis and the lower eyelid retractors in the upper and lower regions, respectively. In addition, the orbital septum attached to the arcus marginalis with regard to the orbital bone. Fat tissue occupied the space between the orbital septum and the lateral retinaculum.The orbital septum in the lateral canthus attached around the lateral commissure and the orbital rim. [ABSTRACT FROM AUTHOR]

Objective To observe the connection of the orbital septum with surrounding structures and its histology in relation to mild ptosis in blepharoplasty patients. Methods From May 2018 to December 2019, 276 patients (549 eyes) who underwent blepharoplasty were divided into normal group and mild ptosis group according to the condition of upper eyelid, and the orbital septum was observed. The connection between the orbital septum and the surrounding structures, and the histologic structure of the orbital septum were observed. Results There were 498 eyes in the normal group and 51 eyes in the mild ptosis group. Comparing between the two groups, the incidence of adhesions between the orbital septum and the orbital lipid envelope was higher in the mild ptosis group (X² =95.00, P＜0.001), and the incidence of transverse ligament between the orbital septum and the levator aponeurosis was higher in the mild ptosis group (X² =99.00, P＜0.001). HE staining showed that the orbital septum in both groups was mainly a connective tissue structure that could be divided into two layers. The anterior layer was looser and the posterior layer was denser. In the mild ptosis group, the connective tissue fibers were less and looser than in the normal group. Masson staining showed that no muscular structures were found in the orbital septum of both groups. SMA staining showed that in the orbital septum of both groups, except for the blood vessels running through the orbital septum which were positive, the rest of the tissues stained negatively by SMA staining, and no smooth muscle structures were found in the orbital septum of both groups. Conclusion Adhesions between the orbital septum and the orbital lipid envelope and restrictive ligament between the orbital septum and the levator aponeurosis may be the cause of mild ptosis. [ABSTRACT FROM AUTHOR]

Objective: By comparing the position of the fusion point between the oriental orbital septum and the levator aponeurosis of the upper eyelid in Asian without and with mild ptosis, this study explores the relationship between the fusion point and mild ptosis, providing scientific basis for better utilizing the orbital septum to correct mild ptosis. Methods: In this study, the outpatients who underwent double eyelid blepharoplasty with incision method in the plastic laser cosmetology department of Hunan Provincial People's Hospital from October 2018 to April 2019 were divided into the normal group and the mild ptosis group. The position of the fusion part of the orbital septum and the aponeurosis of the levator palpebrae superioris was observed in the two groups. There are three types of this position: the height of the fusion part is greater than the width of the tarsal plate, the height of the fusion part is equal to the width of the tarsal plate, and the height of the fusion part is less than the width of the tarsal plate. After the fusion part was exposed during the operation, the width of tarsal plate and the height of fusion part were measured with a scale. The difference of the location of fusion part between the two groups was analyzed. Results: The tarsal plate width was 11.061 ± 0.635 mm in the normal group and 11.062 ± 0.675 mm in the mild ptosis group. There was no significant difference in tarsal plate width between normal group and mild ptosis group (t = 0.645, p = 0.16). The height of the fusion part was 11.032 ± 0.646 mm in the normal group and 11.645 ± 0.429 mm in the mild ptosis group. The fusion position of mild ptosis group was higher than that of normal group (t = 3.769, P < 0.05). There was significant difference in the distribution of fusion site between the two groups (x2 =38.00, P < 0.0001). Conclusion: The height of aponeurosis fusion of orbital septum and levator palpebrae superioris in mild ptosis group was higher than that in normal group, which may be the cause of mild ptosis. It is suggested that the appropriate treatment of orbital septum in clinical operation may be effective in the treatment of mild blepharoptosis. Level of Evidence III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266. [ABSTRACT FROM AUTHOR]

Objective: To observe the changes of pretarsal fat fascia histological structure after double eyelid blepharoplasty with the orbital septum method. Methods: From December 2019 to February 2022, the patients with congenital single eyelid who underwent double eyelid blepharoplasty with the orbital septum method at the Plastic and cosmetic surgery department of Hunan provincial people's Hospital and the same number of congenital double eyelid volunteers. Then divided into three groups: preoperative eyelid ultrasound images in Group A, postoperative eyelid ultrasound images in Group B, and congenital double eyelid volunteers in Group C. To study the histological differences of pretarsal fat fascia before and after double eyelid blepharoplasty with the orbital septum method and congenital double eyelid by ultrasound. Results: Ninety‐eight patients who underwent double eyelid blepharoplasty with the orbital septum method met the inclusion criteria. All 98 patients aged 22.88 ± 3.00 years, including 7 males and 91 females, followed up for 6–12 months. Included 98 volunteers with congenital double eyelid, aged 23.58 ± 2.59 years, including 49 males and 49 females. Ultrasound showed that the pretarsal fat fascia was divided into two layers. The dense layer adhered closely to the surface of the tarsus with no statistically significant differences. There was a statistically significant difference in the thickness of the pretarsal loose fat fascia layer between Group A and B. The points a b c in Group A were significantly thicker than those in Group B and C, and there was no significant difference between Group B and C. Postoperative evaluation: 83 cases were satisfied, 11 cases were basically satisfied and 4 cases were unsatisfied. Conclusion: After double eyelid blepharoplasty using orbital septum, the histological structure of pretarsal fat fascia is similar to that of congenital double eyelid, suggesting that double eyelid blepharoplasty with the orbital septum method can change the structure of pretarsal fat fascia and make it similar to congenital double eyelid, which is one of the anatomical bases for its good clinical effect. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the outcome of small incision levator advancement with septum-sparing technique and compare it with standard levator advancement. Methods: The surgical findings and clinical data of patients with aponeurotic ptosis who underwent small incision or standard levator advancement surgery in our clinic between 2018 and 2020 were analyzed retrospectively. For both groups; age, gender, systemic and ophthalmic comorbidities, levator function, preoperative and postoperative margin-reflex distance, change in margin-reflex distance after surgery, symmetry between the eyes, follow-up time, perioperative and postoperative complications (under/overcorrection, contour irregularity, lagophthalmos) were all evaluated and recorded. Results: The study included 82 eyes, 46 from 31 patients in Group I who had small incision surgery, and 36 from 26 patients in Group II who had standard levator surgery. There was no statistically significant difference in surgical success between the two groups (80% and 81% respectively, p = 0.692). The levator function and preoperative margin-reflex distance correlated positively with surgical success. Conclusion: Small incision levator advancement is a less invasive procedure than standard levator advancement because of the smaller skin incision and preservation of orbital septum integrity, but it requires good knowledge of eyelid anatomy and experience in eyelid surgery. In patients with aponeurotic ptosis, this surgery can be performed as a safe and effective surgical technique with a similar success rate as standard levator advancement. [ABSTRACT FROM AUTHOR]

Objective To observe the changes of tissue structure after double eyelid blepharoplasty with the orbital septum method. Methods From December 2019 to December 2021, this study included 110 patients who underwent double eyelid blepharoplasty with the orbital septum method and 110 congenital double eyelid volunteers. They divided into three groups: preoperative eyelid ultrasound images in group A, postoperative eyelid ultrasound images in group B, and congenital double eyelid volunteers in group C. Histological differences of pretarsal fat fascia before and after double eyelid blepharoplasty with the orbital septum method and congenital double eyelid were observed by ultrasound. Results Ultrasonography showed that the pretarsal fat fascia layer was divided into two layers. In Group A, B, and C, the dense layer was close to the surface of tarso. The pretarsal loose fat fascia layer thickness in group A were significantly thicker than those in group B and C (P＜0.05), and there was no significant difference between group B and C (P＞0.05). Postoperative evaluation: 98 cases were satisfied, 9 cases were basically satisfied and 3 cases were unsatisfied. Conclusion After double eyelid blepharoplasty with the orbital septum method, the histological structure of pretarsal fat fascia is similar to that of congenital double eyelid,which suggests that double eyelid blepharoplasty with the orbital septum method can change the structure of pretarsal fat fascia and make it similar to congenital double eyelid, which is one of the anatomical bases for its good clinical effect. [ABSTRACT FROM AUTHOR]

Objective: To observe the clinical effect between orbital septum incision and classical incision of double eyelid plasty. Methods: We retrospectively analyzed 381 patients who underwent double eyelid blepharoplasty in the Department of Plastic and Laser Cosmetology of Hunan Provincial People's Hospital from January 2019 to December 2019. The patients were divided into two groups according to different surgical methods: group A (n = 146) received the classical method and group B (n = 235) received the orbital septum method. The incidence of early postoperative complications, scar depression from 6 months to 1 year after the operation, the condition of 'meat strip' (the accumulation of soft tissue in front of the tarsal plate after double eyelid surgery, including skin, muscle, and fascia fat, results in a hypertrophic appearance of the upper eyelid) below the double eyelid line, and the symmetry of double eyelids were analyzed and evaluated. Results: The total number of early postoperative complications in group A was seven cases (incidence rate: approximately 4.80%), and the total number of early postoperative complications in group B was two cases (incidence rate: approximately 0.85%), with a statistically significant difference (P < 0.05). The degree of scar depression in group B was significantly lighter than that in group A from 6 months to 1 year after the operation (P < 0.05). The score of 'meat strip' below the double eyelid line in group B was significantly lighter than that in group A (P < 0.05). The symmetry of double eyelids in group B was better than that in group A (P < 0.05) Conclusion: Compared to the classical double eyelid method, the orbital septum method has the advantages of reducing early postoperative complications, reducing the severity of the scar, slighting the 'meat strip,' and improving symmetry, which results in higher postoperative satisfaction Level of Evidence III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266. [ABSTRACT FROM AUTHOR]

Yixin Sun,1,* Runzhu Liu,1,* Nanze Yu,1 Dingyue Zhang,2 Juan Chen,3 Jiuzuo Huang,1 Xiao Long1 1Division of Plastic Surgery, Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, People’s Republic of China; 2Department of Clinical Medicine, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, People’s Republic of China; 3Institute of Medical Information/Medical Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China*These authors contributed equally to this workCorrespondence: Jiuzuo Huang; Xiao Long, Division of Plastic Surgery, Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, People’s Republic of China, Tel/Fax +86-1069158730, Email hjz1983@126.com; pumclongxiao@126.comPurpose: Incisional double eyelid blepharoplasty is the most common cosmetic operation in East Asia. Although numerous articles on surgical techniques have been published, complications, such as fold loss, asymmetry, and visible scars, still exist. To create a stable and dynamic double-eyelid crease, the author has introduced a modified technique of double-eyelid blepharoplasty.Patients and Methods: The authors introduced a new surgical technique to reduce complications and create reliable and dynamic double eyelids. The orbicularis oculi muscle of the lower flap was anchored on the tarsus and sutured with the distal part of the septal flap. The skin incision was closed by skin–septal flap–skin suture. Postoperative evaluations were assessed at the twelfth postoperative month.Results: One hundred ninety-three patients underwent double eyelidplasty with the TOS fixation technique. The mean follow-up duration was 18.6 months (range, 12– 30 months). In the aesthetic outcome evaluation, 88 (45.6%) patients had very much improved results, 56 (29.0%) had much improved results, 29 (15.0%) had improved results, 8 (4.1%) had no change and 12 (6.2%) had worse results. Complications included crease asymmetry (n=7, 3.6%), partial fold loss (n=8, 4.1%) and complete fold loss (n =5, 2.6%).Conclusion: Tarsus-orbicularis-septum (TOS) fixation is a reliable and flexible surgical technique for creating stable and dynamic double-eyelid creases.Keywords: double eyelidplasty, primarily blepharoplasty, orbital septum, tarsus

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Lower eyelid function and appearance depend on the complex anatomic relationship between the soft tissue lamellae, supportive tarsoligamentous sling, and bone. Aging in the lower lid area may be caused by changes in the anterior lamella (skin and orbicularis oculi muscle), middle lamella (orbital septum and lower lid fat pads), posterior lamella (tarsus, lower eyelid retractors, and conjunctiva), tarsoligamentous sling (lateral retinaculum), or any combination of the previously described., Competing Interests: Disclosure The authors have no disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

SUMMARY: The construction of superior palpebral fold gained popularity in the far East and at the present time is the most frequently performed aesthetic operation in the Orient. Various incisional techniques have been reported to form upper eyelid crease, which also a confusion for plastic surgeons who lack clinical experience. It is essential to review the evolution of these incision techniques and outlined the pros and cons of each method. This study reviewed the anatomy theory of superior palpebral fold, and reported incision techniques according to different connecting tissue utilized.

Background: The orbital septum prevents both superficial eyelid infection and the spread of bleeding into the orbit. The fusion point between the upper eyelid orbital septum and the levator aponeurosis or the tarsal plate plays an important role in determining the width of the natural double eyelid. We observed a number of unsatisfactory upper eyelid blepharoplasty outcomes resulting from improper handling of the orbital septum—such as excessive destruction of orbital septum tissue and failure to form a firm attachment point between the orbital septum and the levator aponeurosis or palpebrae plate—during primary surgery. Objectives: The three most common types of unsatisfactory upper blepharoplasty outcomes include abnormally high double eyelid creases, multiple creases, and disappearance of creases. In the repair operation, we try to determine the remaining orbital septum tissue for reconstruction and form a firm attachment between the orbital septum and the levator aponeurosis or tarsal plate. Follow-up after surgery was performed to observe whether our technique can ensure effective and favorable long-term natural-looking upper eyelid blepharoplasty outcome. Methods: From January 2018 to January 2020, secondary blepharoplasty involving the above-mentioned unsatisfactory double eyelid results was performed in 83 patients, including 63 patients (141 eyes) with abnormally high skin creases, 6 patients (8 eyes) with multiple creases, and 14 patients (24 eyes) with double eyelid disappearance. The outcomes were assessed 6 months to 2 years after the surgery by reviewing the photographs to evaluate the esthetic outcomes including stability of double eyelid, double fold curve, symmetry, patient satisfaction, and the incidence of complications. Results: After an average follow-up of 12 months, most patients achieved a better double eyelid appearance. The esthetic outcome was graded as good in 80 patients, poor due to recurrence of double eyelid disappearance in 2, and poor because of asymmetry of the double eyelid curve in length or width in 1 patient. All patients had acceptable scars. No cases of infection or ptosis were observed. Conclusion: Reconstructing the orbital septum and ensuring a firm fixation with the levator aponeurosis or tarsal plate is an effective method to repair unsatisfactory upper eyelid blepharoplasty. Moreover, it is very important to protect the orbital septum and proper treatment during the initial surgery. Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. [ABSTRACT FROM AUTHOR]

Objective To explore the clinical efficacy of double-eyelid blepharoplasty with orbital septum for swollen upper eyelid. Methods From January to December 2019, 121 patients with swollen upper eyelid were collected. The incision was designed according to the conventional method. The excess skin, orbicularis oculi muscle and suborbicularis oculi fat within the designed line were removed, and the orbital septum was exposed. The myocutaneous flap below the incision was preserved, the loose fat fascia was removed and the dense pretarsal fascia was preserved. The orbital septum was cut horizontally along the muscular margin above the incision, the protruded orbital septal fat was removed and suborbicularis oculi fat was thinned. Using the fusion of levator aponeurosis with septum as a pedicle, the lower part of the orbital septum was turned downward and then sutured to the upper border of lower orbicularis oculi muscle and posterior pretarsal fascia. Finally sutured the skin, muscle, orbital septum (anterior tarsal fascia), muscle and skin. Results All 121 patients were followed up for 6 to 12 months, 109 cases were satisfied, 9 cases were basically satisfied and 3 cases were unsatisfied with the results. These 3 patients were basically satisfied with the results after repair. Conclusion Double-eyelid blepharoplasty with orbital septum is a good method for the treatment of swollen upper eyelid. It should be considerable for clinical promotion and application. [ABSTRACT FROM AUTHOR]

Background: In patients with mild superior sulcus deformity, pseudoptosis, or multiple eyelid folds, several bulky fibers can be found anterior to the orbital septum. These fibers, called preorbital septum fibers, may constrict protrusion of the fat pad and movement of the levator palpebrae muscle.Objectives: In this study, the authors illustrated the anatomy of these fibers and described the double-eyelid procedure to correct pseudoptosis, mild superior sulcus deformity, and multiple eyelid folds, which may be caused by these fibers.Methods: The bulky preorbital septum fibers were dissected and severed during upper blepharoplasty to release the orbital septum fat pad and levator palpebrae muscle. This procedure was performed between January 2016 and January 2018 in 56 patients with distinct preorbital septum fibers.Results: Of the 56 patients, 38 displayed mild to moderate upper eyelid depression and multiple eyelids, and 18 displayed pseudoptosis. Bulky fibers that existed in the superficial layer of the orbital septum were all dissected and removed. After 6 months' recovery, the superior sulcus deformity improved in all patients. No recurrence of multiple eyelids was observed. Patients with pseudoptosis showed a notable release of their upper eyelids.Conclusions: This is the first time to our knowledge that the preorbital septum fibers are described as a distinct anatomical structure. They are clinically important in upper eyelid anatomy and the improvement of sunken upper eyelids or pseudoptosis. The combination of blepharoplasty with release of these fibers is easy to perform and promote.Level Of Evidence:4: [ABSTRACT FROM AUTHOR]

Purpose: To disclose that the lacrimal sac is classified within the orbital tissue., Materials and Methods: Ten orbits of 9 Japanese cadavers aged 64 to 85 years at death were included. The attachment site of the orbital septum in the medial canthal area was grossly dissected. The relationship between the orbital septum attachment site and the location of the lacrimal sac was examined., Results: In the upper region, the orbital septum was attached to the most superior area of the lacrimal fossa and the medial canthal tendon. In the lower region, the septum was attached to the anterior lacrimal crest and the medial canthal tendon. In both the upper and lower regions, none of the septa attached to the posterior lacrimal crest. The lacrimal sac was situated behind the orbital septum., Conclusion: The lacrimal sac, which is situated behind the orbital septum, is classified within the orbital tissue.

The orbital septum is an anatomical landmark that separates two important regions: the face and the orbit. The continuity of the septum with the surrounding fibrous connective structures integrates this element into the anatomy of the face. The various pathological processes that can appear in these regions, the huge surgical implications (e.g. in Ophthalmology, Plastic Surgery and Neurosurgery) and the presence of the subcutaneous risk elements has determined us to start a meticulous dissection. We performed a layered dissection, highlighting the vital structures from superficial to deep. The skin of the eyelid is thin and easily mobilized, having its insertion base at the level of the free margin of the eyelid. After the removal of the skin, we can observe a layer of loose connective tissue, whose presence justifies the mobility of the eyelids. In the subcutaneous tissue, we then identified, in the internal angle of the orbit, on the fascia of the nose, and even on the orbital septum, the insertions of the elevator muscle of the nose wing. From a surgical point of view, the risk elements are represented by the angular artery and vein and by the supratrochlear veins, which perforate the orbital septum. It is significant to note that the supratrochlear vessels establish both an arterial and a venous anastomosis between the intra- and extraorbital circulation. The orbital septum appears as a dense and well-structured fibrous connective curtain, which is particularly resistant and closes the orbit towards anterior. After resecting the septum, we observed, inside the orbit, in the superior external angle, the lacrimal gland and its central depression, through which passes the lateral tendon of the elevator muscle of the superior eyelid. Due to the presence of all the described elements, this region is an area of risk in both surgery and periorbital injections. Their injuries may cause large regional hematomas, but for every surgery there are techniques which can avoid these complications. [ABSTRACT FROM AUTHOR]

Background: Double-eyelid blepharoplasty is one of the most popular aesthetic surgeries in China. But the traditional method produces a hidebound double eyelid due to its rigid suturing between the skin and the tarsus. The authors of this article concluded a novel technique of "flexible suspension technique" compared with traditional blepharoplasty which is considered as a "rigid fixation technique."Methods: This is a retrospective study of two groups of 100 Chinese Han females, on whom double-eyelid blepharoplasty was performed, 50 cases by "flexible suspension technique" and the other 50 by "rigid fixation technique." The basic procedure of "flexible suspension technique" is suturing the orbicularis oculi muscle to the septal extension. Thus, the surgical connection between skin and tarsus is flexible. The surgical results were evaluated and compared using the Global Aesthetic Improvement Scale and Visual Analogue Scale/Score.Results: The "very much improved" rate in the "flexible suspension technique" group was higher than that in the "rigid fixation technique" group (p < 0.05). Postoperative appearances of the "flexible suspension technique" group were also better than the "rigid fixation technique" group with less edema (p < 0.05) and slighter incision scars (p < 0.05). However, the incidences of asymmetry and fold loss were higher in the "flexible suspension technique" group (p < 0.05).Conclusion: The flexible suspension technique blepharoplasty can obtain a more natural appearance and has less adverse effects and shorter recovery time.Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. [ABSTRACT FROM AUTHOR]