Inservice Exam - 2005
Cosmetic Blepharoplasty, Browlift and Fillers

A 42-year-old woman has diplopia and pain in the left eye six days after undergoing bilateral upper eyelid blepharoplasty. Which of the following findings in this patient’s left eye confirms a suspected injury to the left superior oblique muscle?

(A) Absent adduction
(B) Absent depression, extorsion, and adduction
(C) Absent elevation, intorsion, and adduction
(D) Absent extorsion, elevation, and abduction
(E) Absent intorsion, depression, and abduction

The correct response is Option E.

In this patient, an attempt to resect orbital fat caused injury to the left superior oblique muscle. Because the superior oblique muscle is primarily responsible for intorsion, depression, and abduction of the eye (see below), an absence of these actions confirms suspected injury to this muscle.

References:
1. Doxanas MT, Anderson KL. Clinical Orbital Anatomy. Baltimore: Williams & Wilkins; 1984.
2. Putterman AM. Cosmetic Oculoplastic Surgery. 3rd ed. Philadelphia: WB Saunders; 1998.



A 52-year-old man has tearing, burning, and sensation of presence of a foreign body six months after undergoing bilateral transcutaneous lower eyelid blepharoplasty. Examination shows normal position of the lower eyelid of the right eye; examination of the left eye shows 5 mm of inferior scleral show with lid retraction and lateral ectropion of the lower eyelid. Which of the following is the most appropriate surgical procedure to correct this patient’s deformity?

(A) Lateral canthoplasty
(B) Lateral tarsal strip with full-thickness skin grafting
(C) Lateral tarsorrhaphy of the left lower eyelid
(D) Tarsal strip with reattachment of the left lower eyelid retractors
(E) Wedge resection of the left lower eyelid

The correct response is Option B.

In this patient, examination shows cicatricial ectropion of the left lower eyelid, which is associated with shortening of the anterior lamella of the eyelid and horizontal laxity of the lower eyelid. A tarsal strip with skin grafting is the treatment of choice for this disorder because it corrects the horizontal and vertical laxities seen with cicatricial ectropion.


The other surgical procedures are not appropriate for this patient. Lateral tarsorrhaphy is useful in treating patients with exposure keratopathy and paralytic ectropion, such as in facial (VII) nerve palsy. Neither lateral tarsorrhaphy nor lateral canthoplasty addresses the horizontal laxity of the eyelid. Wedge resection would address the horizontal laxity of the left lower eyelid but not the vertical shortening of the anterior lamella of the eyelid. Use of a tarsal strip with reattachment of the lower eyelid retractors is the treatment of choice for involutional or senile entropion of the lower eyelid, which this patient does not have.


References:
1. McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring. Plast Reconstr Surg. 2003;112(1):222-236.
2. Glat P, Jelkes GW, Jelks EB, et al. Evolution of the lateral canthoplasty. Plast Reconstr Surg 1997;100(6):1396-1405.




Which of the following best differentiates the Asian upper eyelid from the Occidental upper eyelid?

(A) Fibers of the levator apparatus insert into the orbicularis muscle closer to the superior tarsal border in the Asian eyelid
(B) Müller’s muscle inserts into the tarsal plate more inferiorly in the Asian eyelid than in the Occidental eyelid
(C) Orbital septum fuses with the levator aponeurosis cephalad to the superior tarsal border in the Asian upper lid
(D) Preaponeurotic fat rests in a more caudal position in the Asian, creating the appearance of a fuller eyelid
(E) Upper eyelid crease is higher in the Asian than the Occidental


The correct response is Option D.


There are several differences in anatomy in the Asian orbital region compared with the Occidental orbit. These include more shallow orbits, prominent globes, and epicanthal folds. In the upper eyelid, the orbital septum fuses with the levator aponeurosis caudal to the superior tarsal border. This allows the preaponeurotic fat to lie in a more caudal position in the lid, with some fat lying superficial to the tarsal plate, giving the impression of a fuller upper lid. In addition, the levator muscle fibers insert into the orbicularis muscle closer to the inferior tarsal border in the Asian upper lid, causing the lid crease to be much closer to the inferior tarsal border compared with the Occidental upper lid. There is no racial difference in the Müller’s muscle.


References:
1. Doxanas MD, Anderson RL. Oriental eyelids. Arch Ophthalmol. 1984;102:1232-1235.
2. Shamoun JM, Ellenbogen R. Blepharoplasty, forehead and eyebrow lift. In: Georgiade GS, Riefkohl R, Levin LS, eds. Georgiade Plastic, Maxillofacial, and Reconstructive Surgery. 3rd ed. Baltimore: Williams & Wilkins; 1997:575.




Which of the following anatomic structures is incised during transconjunctival blepharoplasty?

(A) Arcus marginalis
(B) Capsulopalpebral fascia
(C) Orbital septum
(D) Tarsal plate
(E) Tenon’s capsule

The correct response is Option B.

During transconjunctival blepharoplasty, the incision is placed in the lower conjunctiva and divides the capsulopalpebral fascia (lower lid retractors). Dissection proceeds posterior to the orbital septum and tarsal plate. The transconjunctival approach provides access to deeper structures without a visible scar and eliminates the need to transect the orbicularis muscle and orbital septum. It can be useful for cases of steatoblepharon (fat herniation) and exposure to the orbital floor. However, the resultant loss of orbital and septal tone may contribute to scleral show and ectropion formation.

The other anatomic structures are not involved in transconjunctival blepharoplasty. The arcus marginalis is the junction at which the orbital septum and periosteum meet. An incision just caudal to the arcus marginalis can facilitate exploration of the orbital floor. The orbital septum is not transected in transconjunctival blepharoplasty. The capsulopalpebral fascia originates from the inferior rectus muscle and inserts into the inferior aspect of the tarsal plate. The tarsal plate provides the structural framework of the eyelids. Tenon’s capsule (bulbar fascia) is a fascial structure that surrounds the globe and divides the bony orbit in halves. The anterior half contains the globe; the posterior half consists of fat, nerves, muscles, and vessels that supply the globe and extraocular muscles.

References:
1. Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York: Raven Press; 1985:28-30.
2. Tomlinson FB, Hovey LM. Transconjunctival lower lid blepharoplasty for fat removal. Plast Reconstr Surg. 1975;56:314-318.
3. McCord CD, Shore J. Avoidance of lower lid blepharoplasty. Ophthalmology. 1983;90:1039-1046.




A 57-year-old woman is scheduled to undergo coronal brow lift because she has deep transverse creases at the level of the radix of the nose as well as glabellar creases and brow ptosis. For effective reduction of the transverse creases at the level of the radix, which of the following muscles should be addressed during the procedure?

(A) Corrugator supercilia
(B) Frontalis
(C) Nasalis
(D) Orbicularis oculi
(E) Procerus


The correct response is Option E.


Transverse creases at the level of the radix of the nose are caused by contraction of the procerus muscle, which runs perpendicular to these creases from the level of the nasal bone to the skin of the forehead. Therefore, for effective reduction of this patient’s transverse creases, this muscle should be addressed.

The corrugator supercilii muscles give rise to oblique and longitudinal lines at the glabella. The fibers of the procerus muscle blend with the fibers of the frontalis muscle at the glabella and with the nasalis muscle at the tip of the nose. The frontalis muscle causes prominent transverse lines on the forehead. The nasalis muscle runs transverse from the lower nose to the maxilla and affects the lower nose. The orbicularis oculi muscles cause crow’s feet.


References:
1. Koch RJ, Troell RJ, Goode RI. Contemporary management of the aging brow and forehead. Laryngoscope. 1997;107(6):710-715.
2. Williams PL, Warwick R, Dyson M, et al, eds. Gray’s Anatomy. 37th ed. New York: Churchill Livingstone, 1989:572.




A 55-year-old man requests cosmetic blepharoplasty. On examination, the eyelid skin exhibits moderate thickness, hooding of the upper eyelid skin bilaterally, and pseudoherniation of intraorbital fat at the lower eyelids. Eyelid excursion is normal, and the “snap test” is unremarkable. Which of the following is the most likely diagnosis?

(A) Blepharochalasis
(B) Blepharoptosis
(C) Dermatochalasis
(D) Hypotonia
(E) Proptosis

The correct response is Option C.

Traditionally, the terms “blepharochalasis” and “dermatochalasis” have been used interchangeably to characterize the baggy eyelid deformity. In reality, they are different disorders. Blepharochalasis describes the condition resulting form recurrent bouts of nonspecific inflammatory edema of the eyelids that results in thinning and redness of the overlying skin. Affected individuals have repeated episodes of eyelid swelling and thin, excess skin of the upper lids, blepharoptosis, pseudoepicanthal folds, and disinsertion of the lateral canthal tendon.

Dermatochalasis of the eyelids describes the cosmetic deformity of baggy eyelids and is common in middle age, when loss of elasticity resulting from the aging process leads to eyelid skin redundancy, and is usually more pronounced in the upper eyelids.

The resting position and excursion of the eyelids should be determined during evaluation of a patient for blepharoplasty. A resting-level difference of 1 mm or more is usually visible and may require repair. The method of ptosis repair depends on the degree of the deficit, levator function, and strength of Müller’s muscle and the levator aponeurosis.

Forward projection of the cornea normally varies less than 3 mm between eyes. Unilateral proptosis may indicate a retrobulbar mass. Bilateral proptosis may indicate thyroid disease. In the proptotic eye, skin resection must be more conservative to avoid excessive widening of the palpebral fissure and increasing corneal exposure.

The “snap test” can be used to determine the resting tone of the lower lid. If diminished, even limited skin resection in older patients with weak or stretched pretarsal orbicularis can produce ectropion if the lid suspensory tone is not augmented.
References:
1. Callahan MA. Congenital ptosis. In: Nesi FA, Levine MR, Lisman MD, eds. Smith’s Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. St. Louis, MO: Mosby-Year Book; 1998:375.
2. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient: bypassing the pitfalls. Clin Plast Surg. 1993;20:213.





A 35-year-old woman comes to the office for evaluation and consultation regarding removal of wrinkles around the eyes and forehead, especially in the glabellar region. Physical examination shows that the lateral brow is slightly low. To raise the lateral brow using botulinum toxin (Botox) therapy, which of the following muscles must be treated?

(A) Corrugator
(B) Depressor supracilii
(C) Frontalis
(D) Orbicularis oculi
(E) Procerus
The correct response is Option D.

The orbicularis oculi muscle is the primary depressor of the lateral brow. Therefore, paralysis of this muscle with botulinum toxin raises the lateral brow. Paralysis of the other muscles listed does not produce this effect. The corrugator muscle is responsible for producing vertical wrinkles in the glabellar area. The depressor supracilii muscle is the primary depressor of the medial brow. The frontalis muscle is the primary elevator of the brow. The procerus muscle is responsible for producing transverse wrinkles in the glabellar area.


References:
1. Fagien S. Bolox for facial aesthetic enhancement. Plast Reconstr Surg. 2003;112:65-185.
2. Ahn M, Catter M, Maas C. Temporal browlift using Botox. Plast Reconstr Surg. 2003;112:985.




Which of the following characteristics of hyaluronic acid dermal fillers is responsible for more prolonged results?

(A) Cross-linking
(B) Nonanimal source
(C) Particle size
(D) Viscosity


The correct response is Option A.


The ideal injectable filler is biocompatible, readily available, and easy to inject, with long-lasting effect and minimal complications. Hyaluronic acid fillers have less risk of immunogenicity because, in contrast to collagen, hyaluronic acid is chemically identical across all species. Stabilization (cross-linking) of the molecule results in improved resistance to degradation without compromising its biocompatibility. Hyaluronic acid fillers are available from a nonanimal source (streptococcus) and animal sources (rooster comb). No skin testing is required for nonanimal sources. The product produced via fermentation results in less likelihood of contamination with antigenetic proteins, decreasing the risk for hypersensitivity.
Particle size is important when evaluating dermal fillers and relates more to depth of injection rather than persistence. Larger particles must be injected deeper into the dermis or subcutaneously to avoid visibility. Viscosity of the filler has more to do with ease of injection and pain at the injection site than soft-tissue persistence.

Complications include bruising, redness, swelling, pain, tenderness, and itching.

References:
1. Narins RS, Brandt F, Leyden J, et al. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg. 2003;29(6):588-595.
2. Duranti F, Salti G, Bovani B, et al. Injectable hyaluronic acid gel for soft tissue augmentation: a clinical and histological study. Dermatol Surg. 1998;24(12):1317-1325.
3. Saylan Z. Facial fillers and their complications. Aesth Surg J. 2003;23(3):221-224.




Which of the following soft-tissue fillers is most effective in achieving permanent results?

(A) Artecoll
(B) Cymetra
(C) Fascian
(D) Isolagen
(E) Restylane

The correct response is Option A.

Artecoll (Artefill) is a permanent soft-tissue filler composed of small, smooth microbeads of polymethylmethacrylate (PMMA) in a collagen matrix. The smooth PMMA beads elicit a soft-tissue response that leads to a permanent soft-tissue augmentation effect. Artecoll has been used for many years in Europe; however, it is now recommended for approval in the U.S. marketed under the name Artefill.

Although a permanent result may seem a desirable trait, the use of any permanent soft-tissue filler must be performed with great care, because any potential deformity will also be permanent. Furthermore, there may also be long-term issues including granuloma formation and other delayed soft-tissue responses that may not be clinically apparent for five to six years postimplantation.

Isolagen is an allogeneic nonpermanent filler. Fascian is a nonpermanent allogeneic fascial particulate injectable. Restylane is a biologically prepared hyaluronic acid nonpermanent filler. Cymetra is made of human dermis in injectable form.

References:
1. Cheng JT, Perkins SW, Hamilton MM. Collagen and injectable fillers. Otolaryngol Clin North Am. 2002;35:73-85.
2. Saylon Z. Facial fillers and their complications. Aesth Surg J. 2003;23(3):221-229.