Chapter 4: Upper & Midfacial Rejuvenation

Comprehensive Facial Rejuvenation : CHAPTER FOUR: UPPER AND MIDFACIAL REJUVENATION

CHAPTER FOUR: UPPER AND MIDFACIAL REJUVENATION

Overview
At first, a chapter devoted to both upper and midfacial rejuvenation rather than an individual chapter for each topic would seem illogical. However, after completing this chapter, the reader should appreciate how these two facial zones are intimately linked. Midfacial elevation may be achieved via a browlift incision, which is the authors’ preferred approach. Alternatively, the midface may be lifted through an extended lower blepharoplasty incision. This approach is less ideal for reasons that will be enumerated but is still a viable technique. The authors discourage midfacial rejuvenation via a rhytidectomy incision, as the favored vector of lift is vertical, which cannot be easily accomplished with a laterally based incision.
This chapter will cover the pertinent details in brow elevation via a minimal-incision technique that can rejuvenate the upper and midface as a unit.Midfacial rejuvenation is also described via a lower-blepharoplasty incision and via alloplastic implantation. Eyelid rejuvenation is discussed in the many complex variations that exist to achieve the desired objective:ptosis repair, upper-lid blepharoplasty with and without medial fat excision, transconjunctival lower-lid blepharoplasty with and without skin pinch, and transcutaneous skin-muscle flap with or without midfacial extension.The proper selection of technique is as critical as the execution, and the relevant preoperative considerations are also addressed. Finally, the reader is guided through the postoperative period to care for the patient during the normal postoperative course as well as to formulate appropriate decision-making required if complications should arise.

Preoperative Considerations: Patient Selection & Relevant Anatomy
Upper Face (Brow & Eyelid) Rejuvenation Interestingly, the authors have observed that many patients begin to exhibit brow ptosis about ten years before any evidence of lower facial jowl formation. Obviously, this finding is not universally present. (On the other hand, submental fullness, as an independent phenomenon, can occur at any age as a consequence of heredity, obesity, or aging.) Surgeons in the past have been reluctant to undertake brow elevation because of the apprehension over the potential morbidity associated with traditional coronal-type browlifts. Patients in turn have at times expressed some reticence to accept the added recovery time associated with this technique. Newer minimally invasive techniques have been able to restore the upper face with potentially less morbidity (smaller incisions, faster recovery, shorter and temporary scalp anesthesia, and less risk of scarring and alopecia) than the coronal lift while maintaining commensurate longevity and achieving equally favorable aesthetic results. Despite fanfare that accompanied the midbrow lift, it still may be an arduous task to convince a patient, especially younger, to agree to a brow lifting procedure that involves incisions in a highly visible location. Similarly, the direct browlift (at the eyebrow) has assumed a less prominent role in brow rejuvenation for a host of reasons, including poor scar camouflage, irregular alopecia, and technical difficulty. The authors rely on the “endoscopic” approach (5 abbreviated incisions) to rejuvenate the brow but have eliminated use of all endoscopic equipment and further can achieve midfacial rejuvenation via the same incision by carrying the dissection over the zygomatic arch.

Unlike the traditional facelift that solely addresses an aesthetic deficit along the lower face, brow and eyelid surgery may restore youth but also correct a functional visual impairment. Furthermore, the somewhat prosaic aphorism still captures the essence of upper facial rejuvenation: “the eyes are the window to the soul.” When an individual engages in conversation or even casually gazes at another, he or she usually fixates on the others’ eyes, which makes upper facial rejuvenation a critical aspect of restoring vibrancy and vitality to an individual that a facelift can rarely accomplish. Patients who exhibit brow and eyelid aging often are accused of looking “angry”, “sad”, or “tired” – comments that belie that individual’s true temperament and disposition. These unjustified remarks levied at the patient add another dimension of psychological burden for which the patient may desire a remedy other than correction for the stigma of aging alone. Patients often present to the physician confused about what they actually want corrected. Oftentimes, the mass media has indoctrinated them into equating blepharoplasty with the cure for their woes. However, the surgeon must carefully select between upper-lid blepharoplasty (pinch with or without fat removal), lower-lid blepharoplasty (transconjunctival with or without skin removal versus transcutaneous), browplasty, and blepharoptosis repair, or a combination thereof to achieve the proper desired result. This section will endeavor to elucidate this thinking process so that the surgeon will possess a systematic appraisal of the aesthetic and functional deficits that require surgical intervention.
First, a simplified algorithm should be introduced that may facilitate easy analysis (but should be used with discretion and judgment). A vertical line can be drawn through the midpupil. Generally, any tissue ptosis medial to this line may be thought of as upper eyelid in origin and may be corrected with an upper-lid blepharoplasty. Conversely, any ptosis that presents lateral to this imaginary line may be assumed to be principally due to brow ptosis rather than excessive upper-lid skin (or dermatochalasis) (Figure 4-1). The fallacy that bedevils many junior surgeons is the same unsophisticated thinking that encumbers patients, viz., that all upper-lid tissue ptosis is a byproduct of redundant eyelid skin rather than brow ptosis. Quite the contrary is true: the brow tends to age chronologically earlier than the onset of upper-eyelid skin redundancy. Furthermore, the absence of a developed lateral depressor brow complex (the orbicularis oculi provides weak counterpull to the brow laterally) as opposed to the well-developed medial depressor brow complex (corrugator and procerus) may contribute to the disproportionate lateral-brow descent. Anatomic studies have also highlighted the weaker development of the lateral-brow musculature that may serve as the principal cause for more significant lateral-brow ptosis among other factors. , , If an upper-lid blepharoplasty is performed in lieu of a recommended browplasty, the brow may actually be further depressed; and if excessive upper-lid skin is removed, a browlift may be precluded in the future due to risk of lagophthalmos. Also, an aggressive upper-lid blepharoplasty alone, especially if the adjacent, thicker brow skin is removed together with the thinner upper-lid skin, an unnatural appearance may result.
The aesthetic position of the brow should always be recalled when considering a browlift. In the ideal female eyebrow, the eyebrow configuration assumes a tapered contour with a thicker, medial club of the eyebrow narrowing laterally to a fine point. The medial brow should rest at or slightly below the orbital rim with the peak of the eyebrow situated either at the lateral limbus (classical description, Figure 4-2A) or at the lateral canthus (revised description, Figure 4-2B) lying above the orbital rim. Laterally the eyebrow descends somewhat to end at a point drawn through the imaginary line that joins the alar-facial groove through the lateral canthus. The descended brow often assumes a more flattened appearance that resembles the ideal male eyebrow, i.e., a straight line that runs along the orbital rim (Figure 4-3). Because the ideal female brow is arched laterally and because the brow descends disproportionately laterally, the primary efforts to raise the brow position should be concentrated laterally. As will be discussed, all fixation sutures are laterally based and no medial suspension is undertaken. This surgical technique properly restores the ptotic brow without unnaturally producing a startled or frightened appearance that is a stigma of an improper browlift. Another fallacy that has ensnared the neophyte surgeon is the thought that the eyebrow (the hairy portion of the brow) is the exclusive aspect of the brow that requires rejuvenation. Instead the entire lateral brow complex should be viewed as a unit, which includes both the hair-bearing eyebrow and the adjoining soft-tissue. As part of the physical assessment, the surgeon should place his or her thumb along the ptotic lateral brow and lift the tissue upwards, carefully observing the improved position of the descended soft tissue and hair-bearing eyebrow. The patient should also be educated about this aesthetic deficit and confronted with the rejuvenated appearance using a mirror while the surgeon gently lifts the ptotic brow. Any excessive eyelid skin that remains after appropriate brow elevation may be pinched with a forceps or between the surgeon’s fingers to illustrate how a concomitant blepharoplasty would further enhance the intended objective. If the patient however desires only an upper-lid blepharoplasty despite a thoughtful education, the surgeon should plan for a conservative upper-lid skin excision that would not compromise a prospective future browlift or exacerbate the brow ptosis.
After a careful inspection of the lateral brow for signs of ptosis, the surgeon should then pay meticulous attention to the upper lid that lies medial to the imaginary vertical midpupillary line. Again, this area represents principally upper-eyelid pathology, i.e., excessive upper-lid skin and/or pseudoherniation of fat (steatoblepharon). The redundant upper-eyelid skin should be pinched with a pair of fine forceps to determine the amount of skin that must be excised to achieve the optimal rejuvenation and to demonstrate to the patient the intended surgical goal. Unlike the lower lid, which may have pseudoherniation of fat along the entire border, the upper lid suffers from fat protrusion chiefly medially. The central pocket is less likely to be herniated, and the lateral pocket is comprised entirely of the lacrimal gland, the repair of which lies beyond the scope of this textbook. This medial fat bulge should be noted and explained to the patient so that a proper preoperative plan for fat excision can be established.
The last consideration for upper brow and eyelid pathology that should be studied is evidence of blepharoptosis, i.e. levator dysfunction and actual eyelid descent over the pupil. This condition should be differentiated from pseudoptosis that results from excessive upper-eyelid skin (dermatochalasis) that causes the lid to appear descended.Both true ptosis and pseudoptosis can obscure the visual axis and lead to visual field restriction. Most cases of eyelid ptosis are a result of senility and exhibit the following characteristic hallmarks:
1. Normal lid excursion (usually 8 to 12 mm), which can be tested by fixating the brow in position with a finger so that brow elevation is eliminated and true lid excursion can be assessed.
2. High or absent supratarsal lid crease due to disinsertion of the levator.
3. Thin upper eyelid skin so that the iris may be visible through the attenuated skin.
The palpebral fissure should be about 7.5 to 10 mm in distance. However, a more useful measurement is the margin reflex diameter-one (MRD-1), which is defined as the distance from the corneal light reflex (situated at the midpupil during primary gaze) to the upper-lid margin (Figure 4-4). A normal MRD-1 should be 2.5 to 5 mm, and an abnormal value is considered less than 2 mm. If the lid overhangs the corneal light reflex, then every mm below the light reflex is considered a negative value. The MRD-2 is defined as the distance from the corneal light reflex to the lower-lid margin and is important in the evaluation of lower-lid malposition. A normal value of the MRD-2 is 4 to 5.5 mm. If the patient exhibits unilateral ptosis, then the ptotic lid should be elevated to the normal position during which time the contralateral lid position is observed. Oftentimes the contralateral lid will be seen to descend due to a central tonic mechanism that maintains lid position until the affected ptotic lid is digitally suspended. This phenomenon is known as Hering’s Law. During assessment of lid ptosis, formal visual-field assessment should be obtained by an ophthalmologist or optometrist. If Hering’s Law appears to be in effect, the ptotic lid should be taped in an elevated position while the contralateral visual field is measured.
Finally, the lower lid should be assessed for its aesthetic qualities. Pseudoherniation of fat, dermatochalasis, and hypertrophic roll of the orbicularis oculi muscle are typically the targets for rejuvenation. Pseudoherniation of fat can be effectively assessed on the frontal and lateral views and accentuated on upward gaze. Patients with significant amount of fat protrusion may even show well-demarcated fat pockets (medial, central, and lateral). Dermatochalasis, or excessive lid skin, may be assessed with a simple pinch using forceps to estimate amount needed for removal. A hypertrophic orbicularis oculi muscle may be evident as a roll of tissue that is exaggerated during muscular contraction such as smiling.
Besides these aesthetic issues, the surgeon must be fully cognizant of the potential for postoperative lid malposition, which may arise even in the most qualified hands. Preoperative evaluation of lid tone and position must be an integral facet to every physical examination before embarking on a surgical undertaking. Lower-lid position should be assessed on primary gaze without digital distraction or other manipulation. If the patient already exhibits scleral show, lateral rounding, or frank ectropion, then a lid shortening procedure, e.g., tarsal strip, should be entertained. A lid distraction test should be performed in which the lower lid is pulled downward with one finger in order to assess lower lid laxity. If the lid is in normal position before distraction and can be pulled downward with little resistance, then a lid shortening procedure should be considered. However, if the lower lid is already malpositioned and moves very little with distraction, then vertical shortening of the lower lid may be present, e.g., an anterior, middle, or posterior lamellar deficiency. Usually, vertical shortening arises due to overzealous blepharoplasty in the past and requires replacement with the appropriate tissue. It is recommended that ophthalmologic guidance be sought if such a deficiency exists. A lid retraction test (or snap test) should also be performed to test the resilience of the lower lid. The lower lid is pinched between the index finger and thumb and pulled away from the globe. If the lid returns to contact the globe after one second or not at all, then poor lid elasticity is diagnosed and a lid shortening procedure may be indicated. The patient should also be assessed in the lateral position to determine the relative globe to orbital-rim position. A prominent globe and recessed orbital rim predisposes the patient to the potential for postoperative lid malposition. This relationship is known as the negative vector in that the line drawn from the midpupil to the orbital rim on lateral view falls backward from superior to inferior (Figure 4-5). If a lower lid is tightened in this situation, the lid may actually assume a worse, or lower, position, like an obese man’s belt slipping further down his paunch when the belt is cinched tighter. The mnemonic “big eyes, big trouble” is a worthy phrase that the prudent facial aesthetic surgeon should always heed. A careful ophthalmologic history is also critical, e.g., history of dry eyes, ocular surgery, glaucoma, prior blepharoplasty are all important clues to establish the patient’s candidacy for elective eyelid surgery.
Besides evaluating the patient for possible eyelid surgery, the surgeon should recall the benefit that Botox alone may provide in the younger patient, who only exhibits rhytidosis during animation. Please refer to Chapter 8 on Adjunctive Procedures for Rejuvenation for a detailed discussion of this treatment modality. Lower-lid resurfacing (CO2 laser or TCA peel) may also be frequently incorporated with lower-lid surgery to efface fine rhytidosis.

Midfacial Rejuvenation
One of the most challenging areas in facial-rejuvenation surgery is the aging midface. Several approaches have been advocated to address the midface: laterally via a deep-plane rhytidectomy incision, superiorly via a lower-eyelid incision, and superior-laterally via a temporal-brow incision. , , , Despite these varied options, enthusiasm for these procedures has been tempered by the potential complications of each technique. The favored plane of dissection that unites these disparate approaches is subperiosteal, in which the malar fat pad and orbicularis-oculi muscle may be elevated as a unit. Since 1996, the authors have performed a midface lift via the temporo-parietal browlift incision.However, reluctance has been noted in the literature to endorse this approach fully due to perceived concomitant morbidity. Protracted dissection time, risk to the frontal branch of the facial nerve, temporal wasting, and unnatural elevation of the lateral canthus have all been cited as drawbacks to this surgical approach to the midface. , , Due to these touted shortcomings, the authors critically reviewed the technique, outcome, and complications in an objective scientific study that revealed little morbidity combined with dramatic improvement.
The midface may be an elusive entity to some but may be simply defined as the facial zone that overlies the malar eminence. As one ages, two principal pathologies contribute to an unattractive midfacial appearance: draping of the orbicularis oculi muscle (festooning) and malar fat ptosis (malar bagging). These two entities may appear indistinguishable at first glance, as they both manifest as unsightly bulges in the cheek region. However, orbicularis redundancy and ptosis may be effaced when the patient squints and contracts the muscle: this finding may not always be evident. Malar fat descent usually does not respond to contraction of the orbicularis oculi muscle. This distinction between festooning and malar bagging however may be a bit arcane, as the surgical treatment for both is essentially the same, i.e., a midface lift.

Intraoperative Considerations: Technique & Salient Technical Points
Basic Soft-Tissue Instrument Set
Army-Navy retractors (2)
#3 knife handles (2)
Tonsil clamp

Medicine glass (1)
Suction, 10 French
Small double-pronged hook retractors (2)
Large double-pronged hook retractors (2)
Single hooks (2)
Bayonet forceps (for bipolar cautery)
Brown-Adson forceps (2)
Toothed Adson forceps
Bayonet toothed forceps
Bishop-Harmon toothed forceps
Castro-Viejo toothed forceps
Towel clip
Curved Mayo scissors
Medium Metzenbaum scissors
Serrated scissors
Tenotomy scissors
Iris scissors
Small curved sharp scissors
Needle holders (with scissors built-in) (2)
Needle holders (without scissors) (2)
Straight hemostats (2)
Curved Crile clamps (2)
Curved plane Crile clamps (2)
Converse retractor
Bowl
Freer elevator

(Note: These instruments constitute the basic instruments used on most major facial procedures. Other instrument lists that include a “Basic Soft-Tissue Instrument Set” refer to the above catalog of equipment.)

Instrumentation/Equipment for Brow/Midface Lift
Prep Stand:
Non-sterile gloves
10 cc syringe (2), 27-gauge (1 1/4 inch long) needle (2) with
lidocaine 1% and 1:100,000 epinephrine
Hair comb
1/2″ Micropore tape (to bind hair)
Surgical marking pen

Instruments:
Basic soft-tissue instrument set (see above)
Stryker hand-drill set (mention more specifics here)
Drill bit, 1.5 x 6 mm (2)
Bovie handpiece and tip
Three curved, ebonized brow elevators: (reference figure here)
1. small, flat dissector
2. large, flat dissector
3. round dissector

Sutures:
CV-3 Gore-Tex, Th-26 needle

Other Supplies:
Skin stapler
Laparotomy pads
10 cc syringe (2), 27-gauge (1 1/4 inch long) needle (2) with
lidocaine 1% and 1:100,000 epinephrine

Dressing:
4 x 4 gauze
3″ Kling (3)
Cotton padding
Bacitracin ointment in 5 cc syringe
1″ clear tape
Scissors

Instrumentation/Equipment for Blepharoplasty/Ptosis Repair

Prep Stand:
Non-sterile gloves
1 cc tuberculin syringe (2), 27-gauge (1 1/4 inch long) needle (2) with lidocaine 1% and 1:50,000 epinephrine
Bowl with eyepads (2) soaked in iced saline
Surgical marking pen
4 x 4 gauze

Instruments:
Basic Soft-Tissue Instrument Set
Allis Clamp
Castro-Viejo needle holder
Jaeger plate
Handheld hot-tip wire-loop cautery
Bipolar cord and handpiece

Sutures:
6-0 silk, P-1(PRE-1) [C1]? needle (traction suture)
7-0 nylon, P-1 (PRE-1) [C1] needle (for wound closure)
5-0 polydioxanone (for ptosis repair)
4-0 polydioxanone PS-3 (PRE-3) [PC-34] (for an extended skin-muscle
dissection to tack the flap to the lateral-canthal periosteum)

Other Supplies:
Steri-Strips (to hold medial end of lower blepharoplasty suture in place)
Cotton-tip applicators
4 x 4 gauze

Dressing:
Bacitracin ointment
Aquaphor ointment (for lower-lid resurfacing)
N-terface dressing (for laser resurfacing)

Instrument/Equipment for Malar Augmentation

Prep Stand:
10 cc syringe (2), 27-gauge (1 1/4 inch long) needle (2) with
lidocaine 1% and 1:100,000 epinephrine

Instruments:
Basic Soft-Tissue Instrument Set
Hand Drill with a drill bit sized 1.5 mm x 12 mm
(use screw sized 2 mm x 10-12 mm)

Other Supplies:
EPTFE (Gore-Tex) Malar Implant

Dressing:
None

A. Lower Blepharoplasty (Transconjunctival with Chemical Peel or CO2 Laser)
For fine rhytidosis of the lower lid without significant lower-lid redundancy, a Jessner’s/TCA peel serves as an effective adjunct for rejuvenation. The peel is performed first, as the patient should be under no or minimal sedation during this part of the procedure. In addition, the patient should be positioned upright during the peel (about 60 degrees inclined). A detailed review of technique may be found in Chapter 9 (Cutaneous Resurfacing) and will not be repeated herein. If deeper etched lines are present, then CO2 laser resurfacing may be required, so long as the patient is amenable to the longer recovery period (upwards of 3 months versus 2 weeks for the peel). Laser resurfacing may be undertaken before or after blepharoplasty, but as routine the authors elect to perform laser ablation at the end of all surgical intervention. The surgeon should be extremely wary about performing additional skin excision after lower-lid resurfacing, as the risk of ectropion or of vertical lid shortening is increased. After resurfacing, the lid continues to undergo some contraction and may pull away from the globe even without skin removal. The inexperienced surgeon is advised to wait several weeks if uncertain about the extent of additional skin excess and to undertake a pinch of skin as needed in the office setting at this later date.
A transconjunctival approach is preferred for the majority of lower-lid blepharoplasties, as the integrity of the orbicularis oculi is maintained and if no skin redundancy exists, an external incision is circumvented. Both the skin and muscle sling act to retain the lower-lid position against the globe, and a skin-muscle flap predisposes to a higher likelihood of lid malposition. If a browlift is carried out concomitantly, a transconjunctival blepharoplasty should be performed first, as the brow suspension increases lower-lid tension and makes transconjunctival entry particularly arduous. The first step in performing a lower-lid blepharoplasty involves proper local anesthetic placement, which is achieved with a mixture of 1% lidocaine to 50,000 epinephrine. The local anesthesia is injected into the conjunctiva in the medial, central and lateral aspects in the preseptal plane while the conjunctiva is exposed with a Desmarres or wide two-pronged retractor. If skin excision is planned, then additional local may be infiltrated into the lower-lid skin as well. The patient should be under sedation or general anesthesia for the infiltration of anesthesia as well as for the actual procedure, as transconjunctival surgery may elicit patient discomfort. The anesthesiologist should also be advised that ocular lubrication should not be performed before a transconjunctival blepharoplasty, as the ophthalmic gel tends to obscure the surgical field.
After ten minutes are allowed to transpire for maximal hemostasis, the Desmarres or wide-two pronged retractor is properly positioned to retract the lower lid by the first assistant (who is stationed to the right of the surgeon and patient) while the surgeon (above the head of the patient) gently protects the globe and applies countertraction with a Jaeger plate. With a bipolar cautery, the surgeon seals the superficial conjunctival vessels before transconjunctival entry (Figure 4-6). A hand-held hot-tip wire-loop cautery is used to incise the conjunctiva just past 5 mm from the lid margin (i.e., beyond the edge of the tarsal border) (Figure 4-7).? The Jaeger plate is removed and the inferior aspect of the transected conjunctival border (i.e., the side closest to the surgeon) is grasped with a Bishop forceps, and a 6-0 silk suture with a P-1 needle is passed through the conjunctiva so that the superior conjunctival flap can be retracted upwards over the globe for protection and retraction (Figure 4-8). The silk loop is secured with a hemostat and placed on the patient’s forehead resting on a moist 4 x 4 gauze to provide adequate tension on the conjunctival flap.
The surgeon again picks up the inferior (proximal) conjunctival flap with a pair of Bishop forceps carefully observing for the wisp-like adhesions that traverse vertically from the orbicularis oculi (anteriorly) to the septum (posteriorly) and that define the preseptal plane (Figure 4-9). The dissection is carried out with the hot-tip handheld cautery. The authors prefer a preseptal dissection because of a more controlled and natural dissection plane than afforded by postseptal entry. The preseptal dissection plane is defined as the natural cleavage plane that separates the septum and postseptal fat posteriorly from the orbicularis-oculi muscle anteriorly (Figure 4-10). (Conversely, a postseptal dissection involves direct entry into the postseptal fat without defining the orbital septal plane.)
A small puncture is made in the orbital septum over the medial fat pocket with the hot-tip cautery, and the fat is gently teased out while the other hand applies gentle pressure on the globe (Figure 4-11). The amount of fat that protrudes is correlated with the preoperative images that should be prominently displayed in the operating suite for reference. These standardized preoperative portraits, particularly the close-up frontal view, act as indispensable guides, as the supine patient reveals little information about the amount of herniated fat that is present. If any arcades of vessels traverse the fat to be removed, they can be teased back into the globe with a cotton-tip applicator rather than clamped and cauterized. This maneuver may reduce the risk of postoperative retroseptal hemorrhage. No additional local anesthesia is administered to the dissected fat, as the authors believe that the few seconds that transpire between anesthetic injection and fat removal do not permit sufficient time for the local to function properly. (If the reader should elect to inject local postseptally, he or she is reminded of the necessity to use only plain lidocaine to avoid the risk of vasospasm and consequent visual loss.)
The dissected adipose is then clamped with a hemostat and held in position by the surgical assistant (Figure 4-12). The surgeon applies bipolar cautery along the clamp (Figure 4-13) and then excises the fat along the clamp with a pair of tenotomy scissors (Figure 4-14). Additional bipolar cautery is applied to the adipose cuff that remains along the hemostat after fat excision (Figure 4-15). Prior to the assistant’s release of the hemostat tines, the surgeon grasps the remaining fat below the clamp with a pair of Bishop forceps. As the clamp is released, the surgeon carefully observes for any signs of uncontrolled hemorrhage, which is promptly addressed with bipolar cautery (Figure 4-16). The reader is also reminded about the risk of inadvertent injury to the inferior oblique muscle, which separates the medial from the central fat pockets. The surgeon then progresses laterally to the central and lateral fat pockets in a similar fashion, as dictated by the patient’s pathology. The conjunctiva is left to heal without suture closure.
If any skin redundancy is evident, an Allis clamp is used to clamp the excess skin about 1 mm from the lid margin while undesirable lid eversion is carefully noted during clamping. The crimped excess skin is then removed with Bishop forceps and fine iris scissors. Any irregular skin edges are not corrected by additional corrective trimming, as this predisposes to vertical lid shortening and is simply unnecessary for favorable healing. Hemostasis is obtained with hot-tip cautery, and the wound edges are approximated with a running, non-locking 7-0 prolene suture with the medial extent fastened to the skin with a steri-strip rather than tied. Leaving the medial end untied allows for edema to loosen the suture appropriately and facilitates suture removal. Sutures are removed at 6 days postoperatively.

B. Lower Blepharoplasty (Skin-Muscle/Extended Skin-Muscle)
As mentioned, the transconjunctival approach remains the authors’ mainstay for lower-lid blepharoplasty. However, a skin-muscle flap is indicated in certain select conditions that favor this technique. If excessive lower-lid laxity or frank ectropion is present, then a lower-lid shortening procedure (e.g., tarsal strip) may be required. Alternatively, a lateral-canthal fixation suture may be required to suspend the lower lid sufficiently in proper position. Albeit counterintuitive in that lower-lid malposition may be thought to be avoided with a transconjunctival blepharoplasty, excessive lower-lid laxity may require the above two types of more aggressive intervention. If a tarsal strip or lateral-canthal plication suture is required, then a skin-muscle flap is advised. Furthermore, if the patient suffers from malar descent (festooning or malar bagging) and declines a browlift/transbrow midface lift, then an extended skin-muscle flap may be undertaken instead. For any of these reasons, a skin-muscle type flap may be the approach of choice.
If an extended blepharoplasty is to be carried out, then an extended incision that follows a natural skin crease radiating from the lateral canthus should be marked out with a surgical marking pen. 1% lidocaine with 1:50,000 epinephrine is injected along the line of incision and inferiorly over the area of dissection. The appropriate ten minutes of hemostatic time is allowed to transpire before the initial incision is made. A No.15 Bard-Parker blade is used to make the first few millimeters of an incision approximately 1 to 2 mm from the inferior lid margin at the most lateral extent through both skin and muscle. A pair of iris scissors are then inserted through this incipient incision and gently spread to develop the plane of dissection below the skin-muscle flap from lateral to medial. One blade of the scissors is then inserted into the incision with the other blade remaining externally, and in this way the incision is opened laterally to medially as far as required but always lateral to the medial punctum (to minimize risk of medial-canthal web formation) (Figure 4-17). The bleeding muscle edge is then cauterized with a hot-tip handheld electrocautery.
A 6-0 silk suture is passed through the superior aspect of the incision and clamped with a hemostat in order to retract the lower lid upwards, protecting the globe and providing countertraction. Bishop forceps or a wide, double-pronged retractor is then used to retract the skin-muscle flap inferiorly while the handheld or monopolar cautery dissects the skin-muscle flap from the underlying orbital septum. This flap is carried downward onto the midface under the malar bag/festoon if an extended lower-lid blepharoplasty is intended (Figure 4-18). If pseudoherniation of fat exists, then the orbital septum is entered and the fat clamped and removed as described above for the transconjunctival approach. If an extended blepharoplasty is undertaken to efface a malar bag/festoon, then the malar bag/festoon is suspended to the lateral orbital rim using a 4-0 polydioxanone (PDS [Ethicon], Maxon [Davis & Geck]) or 4-0 Gore-Tex suture (Figures 4-19,20,21). A single pronged hook is placed into the lateral aspect of the incision to provide proper tension and alignment prior to skin-flap excision (Figure 4-22). Any excessive skin-muscle flap is then trimmed with curved serrated iris scissors erring on the conservative side to avoid unintended lid eversion and vertical shortening, especially medially (Figure 4-23). The incision line is then reapproximated with a running, non-locking 7-0 prolene suture. A lateral canthal suspension suture should still be considered for a standard skin-muscle blepharoplasty to lessen the probability of postoperative lid malposition. This suture is placed in a similar fashion as described for the extended technique but often with less vertical elevation (as the midface does not require suspension in this circumstance.)
If a tarsal strip is to be conducted, then this may be performed after the skin-muscle flap has been properly elevated and in lieu of the above described suspension suture. A pentagonal wedge is not preferred for risk of lid notching. The tarsal strip procedure will be briefly reviewed herein, as would be performed as part of a lower-lid skin-muscle blepharoplasty rather than as an independent procedure. The posterior lamella (tarsus-conjunctiva) is divided at the lateral canthus (Figure 4-24A), and the amount of excess posterior lamellar tissue is measured by retraction of the freed lower-lid segment upwards and laterally so that the lid rests on the globe about 1 mm above the inferior limbus (Figure 4-24B). The excessive conjunctiva is abraded away with the belly of the No.15 blade to create the tarsal strip (Figure 4-24C). The tarsal strip is then suspended to its physiologic locus (at Whitnall’s tubercle) through the periosteum with a double-armed 5-0 white Mersiline suture in a vertical mattress configuration (Figure 4-24D). The authors have noted that actual suspension to Whitnall’s tubercle, located in the inner aspect of the orbital rim, causes undue prolonged eyelid distortion and may be avoided by simply tacking the tarsal strip to the anterior-medial border of the orbital rim instead. The excessive tarsal strip is then trimmed away. Skin closure is accomplished with the above-described method.

C. Upper Blepharoplasty (Pinch w/Medial Fat Dissection)
If an upper blepharoplasty is to be performed in conjunction with a browlift, it should always be done after the browlift so that proper estimation of excess skin tissue may be assessed. Some surgeons prefer to wait for 6 weeks after a browlift so that some inevitable brow descent will not create a recurrent problem with upper-lid skin excess. However, the authors believe that this delayed return of excess lid skin is minimal to none, and if it should arise this situation can be addressed with an additional skin pinch at that time. If a patient has already undergone a prior upper-lid blepharoplasty and/or browlift, the surgeon should exercise greater caution regarding skin removal, and it may be warranted under this circumstance to wait several weeks before electing to remove lid skin.
The supratarsal crease is first marked out with a fine marking pen. If it cannot be readily visualized with the lid closed, the lid can be gently retracted until the crease is apparent. 1% lidocaine with 1:50,000 epinephrine is instilled under the skin, carefully avoiding injection of the underlying muscle, which can lead to untoward ecchymosis and hematoma formation. An Allis clamp is used to pinch the excess skin so that minimal, incipient lid eversion is noted (Figure 4-25). The inferior aspect of the skin clamped is the supratarsal crease, as all skin removed is superior to this line. The clamped skin is removed with a pair of tenotomy scissors (Figure 4-26). Hemostasis is achieved with a handheld hot-tip cautery (Figure 4-27).
If medial fat protrusion exists (as confirmed by preoperative photographs), then the muscle and septum must be transected medially over the fat pad for exposure. Small double-hooked forceps are used to retract opposing sides of the septum upwards and away from the wound (Figure 4-28). A hot-tip cautery is used to transect the muscle and septum (Figure 4-29), and the globe is gently balloted to determine the amount of fat to be removed. Bishop forceps are employed to tease out the excessive adipose tissue (Figure 4-30), and the same technique as described above is enlisted to clamp and remove the fat (Figures 4-31, 32, 33, 34). It should once more be emphasized that irregular skin edges should not be further tailored for risk of excessive skin removal, and furthermore such action is unnecessary. Wound closure is achieved with the above-described running 7-0 prolene suture with only minimal skin purchase on both sides of the wound to avoid unwanted lid eversion (Figure 4-35). Care should be heeded to avoid violating the underlying muscle with the skin suture because of the preventable outcome of potential hematoma and added ecchymosis.

D. Ptosis Repair (External Approach)
Although ptosis repair may appear to be beyond the confines of expertise for the facial plastic surgeon, an external approach may be easily and effectively combined with an upper-lid blepharoplasty to effect the maximal aesthetic and functional outcome for the patient. Clearly, more advanced eyelid pathologies should be relegated to the oculoplastic colleague for advice and care. The internal (Muller resection) approach is not discussed herein in order to maintain simplicity and minimize confusion. Furthermore, the internal approach has more restricted applications and is really more suited for younger patients who exhibit only a marginal degree of lid ptosis. If browlift surgery is planned, it should be undertaken several weeks before ptosis repair is considered, as brow elevation may exacerbate blepharoptosis.
The reader is advised to review the salient points of preoperative assessment described in detail in the previous section before studying the operative technique. First, the patient should be under minimal to no sedation so that the patient may cooperate with lid opening and closing during the procedure. The supratarsal crease is marked out with a surgical marking pen first. In addition, the superior half of the limbus may be traced out over the eyelid, when the lid is in primary gaze and fully open (Figure 4-36). The migration of this line upwards after injection with local anesthesia containing epinephrine will inform the surgeon how much the stimulation of Muller’s muscle has contributed to lid elevation. The surgeon will then need to overcorrect the ptotic lid by this additional amount to compensate for Muller’s activity. The alternative method of using plain lidocaine is less than desirable given the vascularity of the orbicularis muscle that must be transected.
After the local anesthesia has achieved the desired effect, the redundant upper-lid skin is clamped in a similar fashion to that described for an upper-lid blepharoplasty (Figure 4-37). A strip of orbicularis muscle is removed with a hot-tip cautery device along the superior aspect of the wound incision to avoid injury to the underlying levator complex (Figure 4-38). The orbital septum is widely incised with iris scissors at the midpoint of the wound (Figure 4-39). Any excessive herniated fat is clamped and removed in a fashion described above for blepharoplasty (Figure 4-40). The remaining postseptal adipose is gently swept upwards to reveal the glistening white sheet of the levator aponeurosis (Figure 4-41). If the surgeon is uncertain whether the levator is in view, then the patient may be asked to look upwards and downwards as the levator is noted to move in a similar fashion. If the levator is fully dehisced then a thickened white roll may be seen that represents the separated inferior edge of the muscle. At times, the surgeon must search superiorly, as the muscle edge may have retracted upward. If the levator edge is only attenuated, then this prominent white roll will not be found. Fatty infiltration along the attenuated levator may also be visible. The attenuated or dehisced levator edge is then sutured in a horizontal mattress fashion to the tarsal border at the midpupil with a 5-0 polydioxanone suture and a slip-knot is used, which can be unfastened if the knot needs to be adjusted (Figure 4-42). A strip of orbicularis-oculi muscle along the inferior wound wedge may need to be removed first in order to expose the superior tarsal border. One should be extremely cautious not to catch any orbital septum with the suture needle because of the risk of lagophthalmos.
The patient is inclined to a near upright position and asked to open and close the lid. The position of the upper lid is noted at rest with the eyes open and at primary gaze. The lid should be at the superior limbus or slightly above if overcorrection is required. Any lagophthalmos that is noted usually resolves after a week. The patient is returned to a fully reclined position and the slipknot is passed such that the knot is secured rather than unraveled if the surgeon is contented with the lid position. Similar technique is applied to fixation sutures temporally located (at the lateral limbus) and nasally (at the medial limbus). Surgeons have described use of only the central suture with success, but this technique may predispose the patient to an unnatural notched lid appearance. Of note, the patient may have to be evaluated several times before the suture position is deemed suitable. Due to the tedious nature of this procedure, some surgeons may elect to carry out only one side at a time if bilateral blepharoptosis is present. The upper-lid skin incision is then closed with a 7-0 prolene suture in the method described above for blepharoplasty.

E. Endoscopic Brow & Midface Lift
The patient is administered anesthesia via intravenous sedation and monitored anesthesia care as the preferred route of anesthetic delivery unless the patient is believed to require general anesthesia. With proper consultation with the anesthesiologist, the surgeon may prefer to undertake general anesthesia (with laryngeal mask or endotracheal tube) for several reasons: (1) the anesthesiologist or anesthetist is inexperienced or uncomfortable with intravenous sedation (2) the patient expresses undue anxiety about sedation or (3) a strong history of alcohol or narcotic usage may make maintenance of monitored sedation difficult. Unlike in rhytidectomy, the ventilating tube does not readily interfere with surgical access.
After appropriate anesthesia is initiated, the patient’s hair is secured with brown, paper tape (Micropore) to expose the planned surgical-incision sites. Of note, tape is much easier and faster to apply than traditional rubber bands. Prior to surgery, the patient is instructed to cleanse his or her hair and scalp with an antibacterial shampoo the morning of the procedure, and no additional sterile preparatory solution is applied before the commencement of the procedure. Five, standard endoscopic-brow lift incisions are marked out with a surgical marking pen with one situated in the midline; two located lateral to the midline in the paramedian position (approximately at the lateral canthus) just posterior to the hairline; and two, additional, longer incisions located more temporally also camouflaged by the hairline and extending over a 4-cm distance above the helical crus and over the temporalis muscle and fascia (Figure 4-43).
One-percent lidocaine with 1:100,000 epinephrine is then infiltrated into the above described incision sites and along the entire orbital rim, zygomatic arch, and midface bilaterally. Of note, the forehead region, lying between the orbital rim and the incision sites, is spared local anesthesia, as the authors have found that this area does not require the anesthetic or hemostatic properties of the lidocaine-epinephrine mixture (Figure 4-44, 45). A full, ten minutes are allowed to transpire prior to the first incision in order to ensure adequate anesthesia and hemostasis. As part of the surgical draping of the patient, a moistened laparotomy sponge is draped over the patient’s head behind the incision sites and secured with an overlying surgical towel and clip. A moistened pad significantly absorbs any bleeding and prevents blood from trickling back into the remaining occipital hair.
If a transconjunctival lower-lid blepharoplasty is entertained, then this procedure should be undertaken prior to midfacial suspension. After midfacial elevation, the lower lid becomes excessively taut restricting ease of a transconjunctival entry to the lid. This increase in lower-lid tension after brow and midface suspension has been remarked by Quatela et al. (unpublished data). Conversely, an upper-lid blepharoplasty should be deferred until the brow and midface are appropriately elevated so that an accurate assessment of residual cutaneous redundancy can be made.
At the outset of the brow lift, the patient is inclined approximately 60 degrees in a semi-sitting position. This upward position facilitates ease of bone tunneling and visualization of the midface using the headlight and retractor (see below). Proper patient positioning cannot be over emphasized, which permits ease of inspection and dissection.
First, the right, paramedian incision (vertically situated in the hairline approximately above the lateral canthus) is made with a No.15 Bard-Parker blade down through the periosteum (Figure 4-45). Monopolar electrocautery is used to achieve hemostasis along the cut edges of the wound, being careful not to apply excessive cautery to the exposed hair follicles. The cautery device is also used to ensure that the periosteum is completely incised (Figure 4-46). A small, sharp, flat periosteal elevator is used to dissect subperiosteally for a distance of a few centimeters circumferentially around the incision site (Figure 4-47). Little additional dissection is carried out posterior to the incision site beyond the initial few centimeters, as extensive dissection toward the occiput provides limited benefit in transposition of the brow upward. With proper wound retraction using wide-double pronged hooks, a Stryker hand drill outfitted with a 1.5-mm wide x 6-mm long drill bit is used to enter the outer calvarial table at 30 degrees (to the horizontal) and joined with an opposing entry of the drill in order to form a bone tunnel through which the brow-fixating suture may be passed at the end of the case. The drill should be initially aimed perpendicular with the skull to engage the drill for the first 1 to 2 mm before angling the instrument forward in the prescribed 30-degree angle. In addition, the bone tunnel should be made in the posterior aspect of the incision, as suspension of the brow upward will cover the bone tunnel if the tunnel is created too anteriorly relative to the incision. An expanded polytetrafluoroethylene (ePTFE, or Gore-Tex; W.L. Gore and Associates, Inc.; Flagstaff, AZ) CV-3 needle is passed through the tunnel to ensure easy passage of the needle at the end of the case (Figure 4-48A, B, C, D). The authors have found that a 6-mm long recessed drill bit permits ease of bone-tunnel creation while minimizing inadvertent entry through the full thickness of the skull if the drill bit is angled approximately 30 degrees to the skull contour. Similarly, a 1.5-mm wide bit will accommodate the desired caliber of needle.
A larger, sharp, flat periosteal elevator, that reduces the risk of periosteal shearing, is then introduced into the same paramedian incision where the bone tunnel was just made in order to elevate the remaining periosteum toward the arcus stopping short before actually breaking the arcus (Figure 4-49). (The smaller, sharp elevator is used to free the periosteum at the arcus marginalis.) Of note, the technique described herein has now evolved to eliminate use of endoscopic instrumentation of any kind.? All dissection is conducted either blindly with tactile feedback (the so-called “smart-hand” technique) or under direct vision with a headlight and Converse retractor. The authors have found that reliance on endoscopic equipment is both an unnecessary and time-consuming endeavor. Tactile feedback is used to elevate the central pocket (i.e., the three central incisions); whereas direct vision is needed to elevate the lateral, temporal pocket and the contiguous extension of the midface. When approaching the arcus, the smaller, sharp periosteal elevator is again used in order to release the arcus more definitively than can be achieved with the larger, flat periosteal elevator. When the elevator tip approaches a 1-to-2-cm distance above the supraorbital notch, the elevator is handled only in an upward, lifting motion in order to avoid any paresthesias or neuropraxias that may ensue from violating the supraorbital neurovascular bundle (Figure 4-50).
The midline incision is then carried out in order to access the medial-brow complex (Figure 4-51). (If the patient has a relatively short forehead, this incision may be eliminated; and the medial brow accessed from the paramedian incisions. However, given the limited morbidity associated with this additional incision, the authors favor carrying out this incision for a more direct release of the medial brow in most cases.) The principal objective is release of the periosteum at the arcus in order to achieve unrestricted brow elevation (Figure 40-52); and aggressive dissection of the musculature has been abandoned, as return of muscle function has been often observed despite the most meticulous removal of the procerus-corrugator complex. In addition, significant morbidity may arise from aggressive muscular resection, including contour irregularity, asymmetric brow depression, and the most dreaded outcome, frank cutaneous necrosis. Instead, chemical ablation with botulinum toxin type A has been the preferred method to address the medial depressor complex. The midline incision is closed with surgical clips before continuing to the left side (Figure 4-53). The left paramedian incision is then made, and the same method of bone-tunnel creation and periosteal release is carried out as previously described for the contralateral, paramedian incision.
After the surgical maneuvers have been completed in the central pocket (medial to the conjoined tendons of the temporalis muscle), the longer, lateral temporo-parietal incisions are then addressed (Figure 4-54, 55). Dissection is carried down through the temporo-parietal fascia (TPF) so that a proper tissue plane may be achieved between the TPF and the true temporalis fascia to avoid injury to the frontal branch of the facial nerve. The incision should be situated approximately 1 cm behind the hairline to lie over the temporalis muscle and not more posteriorly to avoid transection of the superficial temporal artery and to minimize the long trajectory of dissection needed to reach the midface. Initial dissection is performed with a large, blunt elevator over the true temporalis fascia (Figure 4-56), and then the larger, flat periosteal elevator is used to break the conjoined tendon of the temporalis muscle that divides the central and lateral pockets (Figure 4-57). It is imperative that the surgeon aim the elevator superiorly to ensure that the entire length of the conjoined tendon has been freed. Aiming up toward the right paramedian incision and passing the instrument through that incision will ensure that complete release of the tendon has been accomplished. Of note, only three periosteal elevators are used for the entire case (the small, sharp, flat elevator; the large, sharp, flat elevator; and the large, rounded, blunt elevator). Further, all three instruments are coated with an ebonized finish to minimize unwanted, reflective glare off the surface.
Under direct vision with a headlight and Converse retractor, dissection is taken down to the orbital rim with the small, sharp periosteal elevator, carefully looking for the presence of the cephalic vein (Figure 4-58). If the vein lies in the direct path between the upper and midface, then it may be skeletonized and cauterized with a bipolar device and transected with scissors in order to permit entry into the midface. Injudicious cautery of the cephalic vessel, especially if the bipolar cautery tips are aimed superficially may jeopardize the frontal branch of the facial nerve. The arcus marginalis is then released from the supero-lateral orbital rim near the lateral canthus with the periosteal elevator. The assistant places a finger along the lateral margin of the orbital rim to limit the surgeon’s dissection and to avoid excessive release of periosteum from the lateral canthus, which may otherwise contribute to undesirable, lateral-canthal elevation (Figure 4-59).
Again under direct view, the large, sharp periosteal elevator is guided downward to enter the temporal fat pad and then to release the periosteal attachments overlying the zygomatic arch itself. This technique offers the surgeon direct access to the midfacial structures. Next the periosteal elevator is continued inferiorly over the malar eminence to release the zygomaticus major and minor muscular attachments and malar fat pad from the underlying malar bone (Figure 4-60). Although minimal, medial dissection limits both lateral-canthal distortion and potential facial-nerve injury, the dissection is continued until the midfacial structures are adequately released. Once the zygomatic muscular attachments have been severed, the surgeon should be wary of further inferior dissection and unintended masseteric elevation that may result in trismus. A CV-3 Gore-Tex suture is passed through the temporalis fascia and muscle just antero-inferior to the temporo-parietal incision (Figure 4-61) and then passed through the malar fat pad with a long needle driver (Figure 4-62). This maneuver is technically difficult to perform and requires a learning curve to be proficient. The suture is pulled superiorly to test if sufficient release of the midfacial tissues has been achieved (Figure 4-63). If not, then further dissection medially and inferiorly is carried out until appropriate release of the midface is observed. Before the suture is fastened superiorly to the temporalis muscle, the paramedian suture on the same side is tied down first. The paramedian suture is fixated first in order to relieve any tension on the suture that elevates the midface and to permit better brow positioning by suspending the most superior suture first. The CV-3 Gore-Tex suture is used to secure the overlying frontalis muscle through the bone tunnel in the paramedian incision. A technical consideration that should be observed is a generous bite of frontalis muscle needs to be grasped with the suture needle to achieve a secure and adequate suspension (Figure 4-64). The suture is secured using a square knot tied in the air, which is then fastened down: unlike most other sutures, Gore-Tex permits sliding a square knot down into place. After the paramedian suspension has been completed and the incision closed (Figure 4-65), the surgeon should return to the lateral temporal incision to suspend the already distally placed suture through the malar fat pad to the proximal temporalis muscle and fascia at the incision site (Figure 4-66). The vector of suspension should be vertically oriented, and the suture through the malar fat pad should be situated more laterally over the malar prominence – both of which will minimize untoward distortion of the lateral canthus. Next, the TPF just anterior to the temporo-parietal incision is sutured to the temporalis muscle and fascia more superiorly with the CV-3 Gore-Tex suture to pull the overlying brow and soft tissue supero-laterally (Figure 4-67A,B). This suture placement is undertaken twice. All incisions are then closed with surgical clips. Suturing in the hair-bearing scalp is both unnecessarily laborious in placement and removal, and the senior author has achieved a very favorable cosmetic result with surgical-clip closure. Therefore, surgical clips are recommended to close the hair-bearing scalp. Bacitracin ointment is applied to the external incisions, and a pressure dressing is fashioned into place. Stepwise approach to the brow and midface will ensure consistent, reproducible results (Figure 4-68 A, B, C; 4-69)
Of note, if cutaneous resurfacing is entertained to efface deep horizontal rhytids (which are usually not amenable to surgical correction with brow elevation alone), the surgeon may carry out resurfacing with impunity as far as vascular integrity to the underlying flap is concerned because the plane of dissection is subperiosteal. Jessner’s solution followed by 35% tricholoroacetic acid (TCA) is preferred for mild to moderate rhytidosis, and carbon-dioxide laser is reserved for deeper rhytidosis (especially glabellar) and more severe actinic damage. All resurfacing is undertaken prior to performing the above brow and midface lift.

F. Alloplastic Malar Augmentation
The cheek complex can be restored with an alloplastic malar implant as well. As one ages, skeletal support is lost and the bony malar prominence may become less so. If significant malar soft-tissue ptosis is evident, however, then an alloplast is usually insufficient to buttress the ptotic tissue. The primary goal of a malar implant is to achieve a more youthful bony cheek structure.
The surgical technique begins with adequate anesthesia. The authors prefer general endotracheal anesthesia to achieve the desired level of sedation. Hemostasis is obtained with 1% lidocaine and 1:100,000 epinephrine infiltrated into the gingivo-buccal sulcus bilaterally. The malar implant is then placed on the cheek skin where the desired position will be and outlined with a marking pen. After ten minutes are permitted to transpire, Army-Navy retractors are used to elevate the lip away from the gingiva. A monopolar cautery is used to enter the gingivo-buccal sulcus leaving a generous 1 cm cuff of buccal mucosa to the attached gingiva in order to facilitate easy mucosal approximation at the end of the case (Figure 4-70).
Dissection is taken straight down to the anterior face of the maxilla through the periosteum. A large periosteal elevator is used to dissect an adequate pocket to accommodate the implant. Generally, the direction of dissection should commence medially and aimed upward while inspecting for the infraorbital nerve that may come into view. The dissection is then aimed laterally until the lateral zygomatico-maxillary (ZM) buttress is encountered. The implant is placed into the pocket and the overlying skin outline is used to confirm proper position (Figure 4-71). A drill hole is then created through the implant and the ZM buttress using a 1.5 mm x 10-12 mm hand drill. A 2 mm x 12 mm screw is secured into position so that the malar implant is fixated at this point. The screw should be inserted such that the screw head is recessed into the malar implant, i.e., the head remains buried below the outer contour of the implant (Figure 4-72). The same technique is used for the contralateral placement of the implant. Symmetry is confirmed by simultaneous, bilateral palpation and observation before closure (Figure 4-73). The gingivo-buccal incision is closed with a running 3-0 chromic suture.
Salient Technical Points

Transconjunctival Lower-Lid Blepharoplasty
1. A chemical peel may serve to remove fine rhytidosis that could not be achieved with skin removal. The peel should always be done first when the patient is still awake and in the semi-inclined position so that inadvertent entry of peel solution can be reported to the physician and promptly irrigated out.
2. Additional skin should only be cautiously removed if concurrent resurfacing is undertaken.
3. Transconjunctival blepharoplasty should always precede a brow/midface lift because the tightening of the lid secondary to brow/midface suspension does not permit easy entry through the conjunctiva.
4. A 6-0 silk is used to retract the conjunctival flap and to protect the globe. No corneal shield is used, which would otherwise make the surgery more difficult and prevent easy ballottement of the globe when assessing fat herniation.
5. No monopolar cautery should be used near the eye because of the risk of eyelid incineration.
6. A preseptal plane of dissection (between the orbital septum and orbicularis-oculi muscle) is favored.

Skin-Muscle Lower-Lid Blepharoplasty
1. Although a transconjunctival approach is preferred, a skin-muscle flap is indicated if
a. A lower lid shortening procedure is planned
b. A lateral canthal plication suture is required
c. Extension to the midface is desired
2. If a lid-shortening procedure is planned, the authors advocate that a lateral tarsal strip be undertaken rather than a central-lid pentagonal wedge to minimize risk of lid notching. For tarsal-strip suspension, the suture should be placed through the anterior-medial aspect of the orbital-rim periosteum rather than the more physiologic inner aspect (Whitnall’s tubercle) because of protracted lid malposition.

Upper-Lid Blepharoplasty
1. The supratarsal crease should be delineated with a surgical marking pen at the outset and should define the lower extent of skin removal.
2. Local anesthesia should remain superficial to the orbicularis-oculi muscle to minimize hematoma formation and added ecchymosis.
3. Upper-lid blepharoplasty should always follow a browlift.
4. The amount of skin excision should only just begin to evert the lid margin.
5. Any irregular skin edges that remain after removal of the excess skin should not be trimmed, as this is both unnecessary and predisposes to lagophthalmos.
6. Only the skin edges should be taken with the suture needle to avoid inadvertent lagophthalmos.

Ptosis Repair
1. If a browlift is required, it should be performed first and the ptosis repair deferred until at minimum several weeks later because brow elevation may exacerbate blepharoptosis. Therefore, ptosis elevation may be more accurately assessed only after brow elevation.
2. Local anesthesia with minimal to no sedation is required for patient cooperation during the procedure.
3. The remaining portion of the limbus may be traced out over the eyelid so that after anesthesia is infiltrated the effect of Muller’s muscle may be observed. Accordingly, the amount of overcorrection can then be assessed.
4. No orbital septum should be sutured
5. The levator may be identified by the glistening white quality of its surface and its mobility upon the patient’s upward and downward gaze.
6. A slipknot may facilitate easy removal of the fixation suture if it is not properly positioned.