(A) Frontal bone
(B) Lacrimal gland
(C) Lateral orbital fat pad
(D) Orbicularis oculi muscle

The correct response is Option B.

Excessive fullness of the lateral orbit, especially in men, is most often caused by the lacrimal gland; this structure is implicated in 10% to 15% of patients with lateral orbital fullness. Residual fullness can be diminished by resuspending the gland beneath the supraorbital rim. This procedure involves suturing the capsule to the periosteum posteriorly to anteriorly. Excision of the lacrimal gland is not recommended because it can lead to keratoconjuctivitis sicca.

The frontal bone is a potential cause of frontal bossing but would be firm to palpation. A contour burr can be used intraoperatively to improve bossing.

The lateral orbital fat pad is located beneath the lower eyelid and would not cause fullness in the lateral orbital region.

The orbicularis oculi muscle is a soft, mobile structure that surrounds the orbit; it would not cause an isolated, firm mass.

References
1. Beer GM, Kompatscher MD. A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthet Plast Surg. 1994;18:65-69.
2. McLeish WM, Anderson RL. Cosmetic eyelid surgery and the problem eye. Plast Reconstr Surg. 1992;19:357-368.

A 50-year-old woman says she has "sad eyes" two years after undergoing four-eyelid blepharoplasty. She smokes two packs of cigarettes daily and developed skin hyperpigmentation after undergoing laser facial resurfacing seven years ago. Physical examination shows excess scleral show bilaterally; retraction of the skin following snap-back testing is slowed.

Which of the following is the most appropriate management?

(A) Eyelid massage and taping
(B) Release of outer lamellar scars and coverage with a thin split-thickness skin graft
(C) Lateral canthopexy
(D) Malar augmentation
(E) Extended SMAS rhytidectomy

The correct response is Option C.

This patient has excess scleral show and poor skin retraction on snap-back testing two years after undergoing blepharoplasty. Lateral canthopexy is most likely to improve the "sad eye" appearance seen in this patient. Tightening of the lower eyelid will give the patient a more youthful appearance and correct the conjunctival complications. Lateral canthopexy is associated with minimal scarring and few complications. In patients with more severe scleral show, grafting may be required for increased support of the lower eyelid.
Massage and taping of the eyelid are unlikely to be effective in a patient who has had scleral show for two years. Full-thickness skin grafts can be transferred to improve scleral show and decrease the potential for graft contraction that occurs with split-thickness grafts; however, hyperpigmentation is a likely complication of grafting. Malar augmentation should be performed concomitantly with an eyelid tightening procedure; implantation alone will worsen scleral show. Smoking is a relative contraindication to extended submuscular aponeurotic system (SMAS) rhytidectomy.

References
1. Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1990;85;971.
2. Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg. 2000;106:438-453.

In a 55-year-old woman who underwent transcutaneous blepharoplasty of the lower eyelids one month ago, which of the following is the most likely unfavorable result?

(A) Contour irregularity
(B) Diplopia
(C) Lagophthalmos
(D) Malpositioning of the lower eyelids
(E) Tear trough deformity

The correct response is Option D.

The most common unfavorable result following transcutaneous blepharoplasty of the lower eyelids is malpositioning of the eyelid. Malpositioning can result from excessive removal of skin, muscle, or fat, injury to the orbicularis oculi muscle, or scar contracture.

Knowledge of the anatomy of the lower eyelid is essential for the surgeon performing the transcutaneous blepharoplasty procedure. The tarsus and canthal ligaments act to suspend the eyelid, while the pretarsal fibers of the orbicularis oculi muscle support the lower eyelid. Careful preoperative evaluation and intraoperative use of appropriate techniques will prevent postoperative malpositioning.

Eyelid massage and/or corticosteroid injections can be used to resolve early malpositioning. Eyelid taping and use of Frost sutures have also been advocated. If conservative measures are unsuccessful, tarsal stripping or grafting procedures or wedge tarsectomy may be required to restore the appropriate eyelid position.

Contour irregularities typically result from inadequate or excessive resection of fat.

Diplopia can be caused by intraoperative injury to the inferior oblique muscle. Affected patients typically have vertical diplopia that becomes worse on gaze to the contralateral side. Because this condition typically resolves spontaneously, observation is recommended.

Patients with lagophthalmos cannot close the eyelids. This problem is associated with excessive resection of skin.
Tear trough deformity also results from excess skin excision, which is less common than inadequate excision but is also more difficult to correct. Grafting procedures are required for reconstruction in patients who have this deformity.

References
1. Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1990;85:971-981.
2. Putterman AM. Cosmetic Oculoplastic Surgery: Eyelid, Forehead, and Facial Techniques. Philadelphia, Pa: WB Saunders Co; 1999:429-456.