lower eyelid blepharoplasty /> lower eyelid is a common space for elderly patients notice changes. This article describes the anatomy of the lower eyelid and the reasons for aging. It focuses on different operating principles, and variations in the practice and procedure and complications adjuvant

The introduction of the changes caused by aging was noted by first time around the eyes and then the neck and lower face. periorbital rejuvenation to further develop a more detailed understanding of the anatomy of the eyelid and their subsequent effects on the anatomy of aging. The procedures have been developed over time, with surgeons looking for a younger look.

anatomy
lower eyelid anterior lamella consists of skin and orbicularis muscle. The middle lamella consists of the orbital septum, arcus marginalis of the settings and its origin in the bottom of the shanks. The posterior including the conjunctiva and lower eyelid retractors.
The orbicularis oculi is immediately below the lower eyelid skin and extends from near the ciliary margin beyond the edge of infraorbital cheek. It has two components and preseptal pretarsal. Pretarsally is firmly attached to the tarsal orbicularis underlying. The part of the preorbital orbicularis has attachments to the orbital rim along the orbicularis retaining ligament and wrapped up along its caudal border of the fascia, the origin of upper lip levator muscles (zygomatic). The bands that bind tightly to maintain support for the orbicularis oculi underlying orbital rim and cheek muscle to serve this underlying facial structure.
The orbital septum below the orbicularis. A plane of loose connective tissue, the fascia is located between the orbicularis and orbital septum suborbicular. The eyelids suborbicular stout (SOOF) is on this plane and is the continuum of the malar stout pad14. The triangular malar stout pad has established its base at the nasolabial fold and its apex at the malar eminence, and is located between the skin and superficial musculoaponeurotic system (SMAS). It is loosely connected to the SMAS and firmly to the skin.
orbital septum fuses with the cranial and caudal tarsus to the periosteum of the infraorbital rim, the bottom of the wall system is the arch known marginalis. The granting marginal arch medial to the anterior lacrimal crest and thinner, like setting aside about 2 mm below the rim on the aspect of the zygomatic facial coverage. The orbital septum, orbital stout is within the orbit. The causes of stout mass, and surrounding the external ocular muscles in three blocks are divided into medial, central and lateral.

The pathogenesis of herniation of the lower orbital stout has been debated for decades. Whether the excess stout in ancient age appeared or whether this was the content of intra-orbital movement was unclear. The concepts of Manson et al et al Camirand, and lower stout extrusion due to a weakening of the AOS of suspensory ligament Lockwood septation in the presence of intraorbital stout compartments within the limitation of the degree of protrusion. De la Plaza and Arroyo first proposed the theory that stout edge is connected to a weak support system in the world to stay and the lower eyelid and causes pseudoherniation enopthalmos (bag).
The worst part is the M. orbicularis preseptal part and supporting this part of the orbicularis that the largest trend shows a decline. Since the maintenance of relaxation tapes with aging, disc herniation of the lower eyelid stout not only forward but also downward below the orbital rim. This is particularly clear in the center of the medial stout pad can be recorded too. It is unusual for a side note pad of stout beneath the infraorbital rim. In youth there is no herniation of orbital stout, the mixture lateral orbicularis oculi muscle to the cheek pad. malar bags are rarely visible, and is a smooth contour between the preseptal and preorbital orbicularis. In youth is SOOF relatively more on the lower lid and cheek subcutaneous stout. This helps the lower eyelid appears soft and supple, with no clear demarcation between the eyelid and cheek, with the aging workforce. Hamra />
The combination of falling orbicularis oculi muscle, the zygomatic bone and stout SOOF changes with aging, the convexity of a young single double-convex pattern aging.

historical correction of lower lid blepharoplasty eyelid aging
historically been regarded as an operation to remove skin and stout in the lower eyelid. The traditional open blepharoplasty covers the skin or skin-muscle flap between the infraorbital rim and the incision subciliary. orbital stout was removed, appeared excessive, but Crescent Aumale, AU or the bottom of the M. orbicularis from his position remained undisturbed on the malar eminence.
After the operation, the smooth appearance of the eyelids, usually lower, especially in patients with a negative vector. The appearance of the malar crescent “or less orbicular edge if present before the operation was unchanged. The orbital stout removal eventual collapse of the existing house, causing more wrinkles you made earlier. With the progressive aging , ptosis and loss of the orbicularis oculi leading to a typical appearance with sunken scleral show possible. repositioning

orbicularis orbicularis use M . was like a flap in lower eyelid surgery described by Adamson et al, Courtiss, Furnas and initially for the treatment of malar bags / garlands of Furnas is in favor of lateral stress placed on the orbicularis M..
Hamra said that by lifting the orbicularis may be changed from the malar eminence in a plane of the eye and repositioning suborbicular, the axis of the muscle medial orbital rim to the union side, and the muscles around the orbital bone around ring can be tightened. Hamra postulates that the vector of aging in the orbicularis oculi, an inferolateral direction of the malar eminence, which should deny superomedial vector of repair. The superomedial vector could be obtained by either a composite or facelift a lateral orbicularis muscle flap base. The lateral orbicularis muscle flap is based superiorly under the raphe and sutured back to extreme stress in the lateral orbital rim periosteum.
Hamra noted the limitations of this procedure, the long Odem occasional cheek and an inability to exert enough tension included in this flap of skin because of the dread of lower eyelid retraction. He adjusted the level of dissection suborbicular in medial dissection of the muscles zygomaticus minor and major still maintain adequate coverage of soft tissue in the periosteum. With this level of dissection, we found no need to disguise the origin of the zygomatic muscles, but could still orbicularis repositioning of tension, even more than before . This zygorbicular (zygomatic orbicularis) plane offered many advantages. Hamra reckon this is preferable zygorbicular dissection plane, subperiosteal plane through Tessier presented and recommended by Hester.
After flap dissection zygoorbicular used a 4-0 nylon thread through the longitudinal axis of the lateral canthal tendon and sew on the inner wall of the lateral orbital periosteum. This stabilizes your lower eyelid suture or a higher position to guarantee the stability of the eyelid with suture of the membrane with sufficient tension across the orbital rim. He called this a “transcanthal” canthopexy, or replacement of lateral canthal tendon remains a canthotomy necessary.

conservation of orbital stout / septal reset
Loeb was the first time the technique of mobilization of intra-orbital stout above the medial infraorbital rim describe. He used to fill and thus camouflage nasolabial folds. Hamra extends this concept to release the full subseptal marginal arc allows the stout to the level required for the orbital rim. Loeb extended approach to the development of all stout pads are underneath the eyelid in an attempt to hide the infraorbital rim and the fullness of new youth of the lower eyelid. As described in the beginning, the arcus marginalis is incised and the orbital stout alone was advanced and sutured the stout preperiosteal upper cheek. Then he refined his technique, leaving the orbital septum Hamra once removed intact and the restoration of the lower boundary of the septum arc marginalis release the orbital rim. The septal including orbital stout flap to make a smoother transition from the soft tissues of bony ridge and a smooth convex solid surface for the flap that covers the skin overlying muscles whereby wrinkles. Hamra called this procedure a restoration of the partition. Hamra showed a notable improvement with the repositioned orbicularis now rests on a solid surface of the septum, rather than being made in the vault, liposuction or abundance soft stout only.

Perioperatievly subciliary surgical technique of cutting the dermis layer is injected with local anesthesia with percutaneous injections of a few drops of local anesthesia epinephrine in the periosteum of the maxilla and malar.
subciliary skin incision is made through a skin flap dissection to the junction of the preseptal periorbital eye followed by part of the orbicularis muscle. The preseptal orbicularis opens to the pretarsal muscles undisturbed. After preparation by the orbital margin of the orbital septum, the dissection suborbicular still below the zygomatic muscles. The origins of the zygomaticus major and minor are intact and a layer adequate soft tissue remains above the periosteum. The dissection is cut with the cautery, scissors, or from time to time initiated a “Kitner continued.” This eliminates the possibility of blunt trauma to the nerves and pushes the dissection the border of the pars intermedia major and minor zygomatic and led to the zygomatic arch and lateral dissection zygoorbicular. The arcus marginalis is released by incising the junction of the orbital septum and the periosteum of the orbital cutting edge lower after cautery zygorbicular preparation was achieved. Decisions on stout removal and repositioning of the orbital rim is determined />
After the process is completed, the flap zygorbicular midface is advanced. Several are 3-0 Vicryl sutures between the flap and to reduce the tissue can zygorbicular preperiosteal dead space and the collection of serum. A lateral orbicularis pedicle base side of the leg Äúdog made Au blepharoplasty incision. This handle will be passed under the skin and muscle raphe secured with two sutures of 4-0 Monocryl the lateral orbital rim periosteum.’s latest go is the cutting the skin, if an adjustment is needed.

Before deciding on liposuction surgery, the surgeon, if the stout is to be resected must be or not, and if so how much. This is a pre-operative assessment by the anatomy of each patient, which is hard to assess whether the patient is anesthetized, dictation. eyelids positive and negative vectors are related to the axis point fell Earth’s most advanced on the cheek. The eyelid is usually the positive vector simpler for a excellent result in the use of conventional blepharoplasty, eyelid and the negative vector represents a challenge when using conventional blepharoplasty. In the case of a positive Vector eyes without excess stout, making the restoration of the partition a small amount of stout the new setting. In the case of a negative vector eye, most of the stout is needed to adequately fill in the depression between the line and subciliary cheek mound in order to make the contours of youth. Patients with a negative vector can be presented with a congenital excess stout. In these cases, conservative stout removal may be appropriate. In the lower eyelid hollow either natural or iatrogenic, all the stout as possible from the subseptal is hired to achieve effective correction.

transcutaneous vs transconjunctival.
The method of transcutaneous blepharoplasty lower eyelid was pushed in a rule with some resistance. Defenders of transconjunctival recommended method, as the fullness of the lower eyelid orbital stout attributable prominent addresses with a much lower risk of lid retraction without visible incisions and can be easily combined with techniques rejuvenation. Objections to the transconjunctival blepharoplasty are showing up in the middle of the lamellar contraction / reduction, lateral ectropion and scleral curves are related. The causal factors attributed to orbicular resulting in denervation of the orbicularis oculi is the injury. Hamra admits with the compound of the combination of elevation and repositioning of the orbicularis muscle that partial denervation of the orbicularis muscle can occur. While this could lead to a partial denervation in long-term effect postulated. Clinical studies have been mixed innervation of muscle showed both the medial and lateral branches of the facial nerve buccal branch of the temporal. reinnervation to normal function was detected after the operation. Even orbicular myomectomies studies for the treatment of blepharospasm have been no long-term denervation or loss of tone.
Honest review of 4395 cases showed that patients who can benefit from a transconjunctival blepharoplasty younger patients with a soft, stout and muscles are moderately pseudoherniation prey.
It is generally accepted that the method of transcutaneous orbicularis hypertrophy and excess skin, drooping eyelids or if necessary canthopexy is necessary, but transconjunctival methods have been adapted to address these problems. transconjunctival excision of excess stout can be replaced by a percutaneous approach, leaving the orbicularis / complex wall and remove the excess skin to be achieved. Kanthusplastik can also act as an adjuvant can be combined resurfacing procedure if necessary. transconjunctival orbicularis septum tightening laser CO2 in combination with periocular skin renewal also ran. It is proposed that prevents the removal of the orbicularis muscle / septum complex problems of the middle lamella tightening. Hester et al have raised the question of whether the media cover goals in transconjunctival approach procedures should be performed if the disease, less than a therapeutic procedure.
Hamra proposes, but, that the transconjunctival approach results in a sub optimal result.

reproducibility Hamra advocates to address the lid / cheek exhibition as part of a composite face lift. The lower eyelid blepharoplasty technique Hamra isolated, not very strong, though its concepts have proven accepted as reliable and reproducible by others. Barton et al described its use in the patient group, and that through the triad Äútear mark, Au.
These patients Äústout hernia, depression and prominent orbital rim retrusion zygomatic edge with a negative vector of gold. They introduced the technique in 71 patients show no middle lamella shortening or contracture. He said the drainage of a more extensive dissection infraorbital nodes on the cheek, which is sometimes interferes with prolonged edema. To avoid this, we used a rinse solution of triamcinolone in place before closing the lid suborbicular and defender of a manual of exercises.
orbicularis repositioning / canthopexy transcanthal /
zygoorbicular dissection plane The plane of dissection is discussed, Hester recommend a subperiosteal plane on the work of Tessier base. pseudoherniation For patients with orbital stout with the skin is minimal, excess muscle and patients with low minimal cap / Output cheek and malar prominence Hester recommends that a dissection of the cheek preperiosteal enough. This is due to recommend to his extensive review of 757 cases of complications transblepharoplasty approach that avoids both the edema and lower eyelid retraction. Also recommended is a minimum lower eyelid skin excision.
While Hester makes an arch subperiosteal dissection flap marginalis release, used the canthopexy transcanthal and orbicularis laterally transferred pedicle flap base under the leaf side. They found their home improvement and canthotomy Kanthusplastik technology. Hamra see this change in practice as a turning point in the author, the search for administrative and operational support for a natural look.
Despite orbicular techniques involving repositioning of a blow usually leads to the formation of lateral dog-ear, especially in patients with excess skin. The maximum distance to meet the dog’s skin side of the ear as recommended by Hester, which requires tolerance with minimal hassle .

stout repositioning and mobilization of stout
While conservation is a growing trend debate still centers on repositioning of stout versus stout mobilization. Repositioning subseptal stout in a bag with the support of subperiosteal Goldberg. repositioning is also supported by Moelleken, instead of a return wall, due to the risk of contracture laminar medium. Rohrich Hamra conclude that the technique is useful in the middle and outer lower eyelid but remains in the media, requiring autologous stout transfer is the central and lateral compartment or autologous stout injection at the level suborbicular, which soften the medial part of the nasolabial groove.
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resurfacing procedure adjuvant adjuvant therapies such as laser resurfacing have transcutaneous blepharoplasty, including injections of TCA / laser or injections of stout used. Hester or treatment using TCA laser over 60 percent of uncomplicated cases, and also suggested that restoration of volume of stout injection in the nasolabial folds. Hamra postulates that the best results are the same 1-2 years later, with or without therapy adjuvant.

complications complications following lower blepharoplasty techniques include full orbital lateral canthal webbing, small scleral show, ectropion, lower eyelid malposition, prolonged edema, and recurrence of the lateral folded nasolabial folds.
significant scleral show / ectropion Hester recommends Kanthusplastik. For recalcitrant malposition of the lower eyelid usually with symptoms of dry eye is not corrected by repeated and re Kanthusplastik -elevation of the lower eyelid to Hester et recommended lower eyelid spacers, such as ear cartilage, hard palate mucosa. Hamra AlloDerm recommended as an alternative.

advice
blephaoplasty for all, taking into account the importance of a surgeon with experience in all the above techniques have been consulted. For more information www. garylross.’s (c) Copyright 2009

About the Author Mr. Gary Ross Gary Ross is an NHS consultant plastic surgeon, specializing in Plastic Surgery GMC registration, a member of BAAPS and Bapro. He has trained in Australia , Britain and Canada, and has become a leading figure in the highly competitive field of plastic surgery. His own practice in Cheshire reflects his interest in head and neck and breast aesthetics. He has been named honorary professor University of Manchester and has more than 50 scientific papers and a series of chapters in books (including facelifts, brow lifts, blepharoplasty). He has presented over 200 times as many master speaker and presenter. He has organized a series of international conferences and training courses and provides non-surgical options, including laser, botox, fillers and peels. It offers the full range of cosmetic surgery procedures specializing in facial aesthetics, breast surgery and body contouring. For further information, visit www. garylross. is

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