A transverse ligament located anterosuperiorly in the lower orbital fat space restricts lower eyelid retraction in the Mongoloid eye

Reducing the Volume of Upper Eyelids in East Asians Increases Vertical Palpebral Height

BACKGROUND

Correcting puffy eyelids is important for improving the first impression. The puffiness is most predictable corrected by tissue resection and fat excision. Fold asymmetry, overcorrection, and recurrence can sometimes occur after levator aponeurosis manipulation. The objective of this study was to introduce a method of volume-controlled blepharoptosis correction (VC) without levator manipulation.

METHODS

The medical records of patients who had undergone upper blepharoplasty between 2017 and 2022 were retrospectively reviewed. Questionnaires, digital photographs, and charts were used to evaluate the surgical outcomes and complications. The degree of levator function was graded as poor, fair, good, or very good. Levator function must be above good (>8 mm) to employ the VC method. Poor and fair grades of levator function were excluded because they require levator aponeurosis manipulation. The margin to reflex distance (MRD) 1 was assessed preoperatively, 2 weeks postoperatively, and at follow-up visits.

RESULTS

Postoperative satisfaction was 4.3 ± 0.8 with no postoperative discomfort (0%), and the duration of swelling was 10.1 ± 2.0 days. Regarding other complications, no fold asymmetry (0%) was observed, although hematoma formation was observed in 1 (2.9%) patient in the VC group. Significant differences were observed in the changes in palpebral fissure height over time (p < 0.001).

CONCLUSIONS

VC can effectively correct puffy eyelids and create natural-looking, beautiful, and thin eyelids. Thus, VC is associated with higher patient satisfaction and surgical longevity without serious complications.

LEVEL OF EVIDENCE IV

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Anatomy of arcuate expansion of capsulopalpebral fascia

The aim of this study was to elucidate the detailed anatomic structure of arcuate expansion (AE) and its nearby structures. Eighteen orbits of 13 Korean adult male cadavers of a mean age of 76.5 years (range, 75-78 years) were used. Sixteen specimens were grossly dissected, and 2 were for histologic study.Arcuate expansion is a fibrous band expanding from the inferolateral orbital rim to the medial canthal ligament. A sector (fan shaped) of AE originated in the angle of 5 to 80 degrees at the circumference of the inferolateral orbital rim circle, falling within the range of 3 to 5.5 o'clock, and tapered and attached to the inferior border of the medial canthal ligament. Arcuate expansion was located deep to the orbital septum and superficial to the inferior oblique (IO) muscle. It overlapped the middle part of the IO muscle as it crossed and connected to the capsulopalpebral fascia. The tensile strength of the 5-mm width of AE at halfway was 6.7 +/- 3.8 N, and that at the orbital margin was 5.4 +/- 2.7 N.We think that AE prevents the protrusion of the eyeball and orbital fat and functions as a pulley holding overcontraction of the IO muscle.

Surgical anatomy of the lower eyelid relating to lower blepharoplasty

The aim of this review is to familiarize the reader with the critical lower eyelid anatomy as is related to lower blepharoplasty or a midface lift. The contents include 1) the lacrimal canaliculus in the lower eyelid: the depth and width (diameter) of the vertical portion were 2.58±0.24 mm and 0.44±0.07 mm, respectively. A vertical portion of the canaliculus was about 1 mm (1.11±0.16 mm) deep, and the horizontal portion was about 2~3 mm (2.08±2.74 mm) long 2 mm below the mucocutaneous junction, which is where an incision may be made when performing epicanthoplasty. 2) Motor innervation to the lower orbiculis oculi muscle: the pretarsal and preseptal OOMs were innervated by five to seven terminal twigs of the zygomatic branches of the facial nerve that approached the muscle at a right angle. The mean horizontal distance between the lateral canthus and the zygomatic branch was 2.31±0.29 cm (range: 1.7~2.7 cm) and the vertical distance was 1.20±0.20 cm (range: 0.8~1.5 cm). 3) Sensory innervation of the lower eyelid skin: the majority of the terminal branches (93.8%) of the ION were distributed to the medial to the lateral canthus. Most (99.4%) of the terminal branches of the ZFN were distributed to lateral to the lateral canthus. 4) Retractor of the lower eyelid; capsulopalpebral fascia (CPF): the orbital septum blended with the CPF most closely at 3.7~5.4 mm beneath the lower tarsal border and differently at 3.7±0.7 mm on the medial limbus line, 4.3±0.8 mm on the midpupillary line and 5.4±1.0 mm on the lateral limbus line. 5) Arcuate expansion (AE): The AE was a fibrous band expanding from the inferolateral orbital rim to the medial canthal ligament. A sector (fan-shaped) of the AE originated in the angle of 5 to 80 degrees at the circumference of the inferolateral orbital rim circle, falling within the range of 3 to 5.5 o'clock, and then it tapered and attached to the inferior border of the medial canthal ligament. 6) Suborbicularis oculi fat (SOOF) in the lower eyelid: the SOOF was located in the inferolateral side of the orbit within a range between medial +15 and lateral -89 degrees to a vertical midpupillary line. Histologically, the SOOF was situated deep to the Orbicularis oculi muscle and superficial to the orbital septum and periosteum. The SOOF consisted more of fibrofatty tissue rather than being the pure fatty nature like orbital fat. I hope surgeons can achieve desirable outcomes with the knowledge reviewed in this article.