INTRODUCTION
Gravitational forces and facial mimicry cause anatomical changes that result in aging1. For example, the action of the corrugator muscles favors the ptosis of the eyebrow,
which causes a pseudo cutaneous excess of the upper eyelid1. Classic blepharoplasty, without eyebrow elevation, can make your ptosis more evident,
as the frontal muscle will not be stimulated for suspension1,2.
On the aged face, the skin of the lower eyelid stretches, exposing the lower orbital
margin and herniations of orbital fat3. The elongated and excavated lower eyelid combines with the deepening of the nasojugal
and nasolabial line3,4 and with the decrease in skin vitality1,3, resulting in senile physiognomy. These changes should be addressed to achieve better
aesthetic results.
There are many techniques described for eyebrow elevation: direct skin excisions in
supraorbital, temporal, or frontal areas, coronal lifting, frontal endoscopic elevation
and transpalpebraal approaches4-6. The middle third of the face approach is usually done by time incisions, before
and after the ear, to tract the skin and the Superficial Musculoaponeurotic System
(SMAS), which can result in visible scars, hairline displacement, or alopecia.
The treatment of the structures mentioned here is described only with the incisions
of the upper and lower blepharoplasties.
OBJECTIVE
Describe a surgical procedure of the periorbital region, which allows the management
of the upper two-thirds of the face in a single surgical procedure, using only blepharoplasty
incisions.
Present a 10-year review of complications related to the technique.
METHODS
From 1996 to 2019, 338 patients with signs of aging in the upper two-thirds of the
face (11.8% men and 88.2% women) underwent upper blepharoplasties associated with
the transpalpebral suspension of the eyebrows and myectomy of the glabella muscles.
Also, lower blepharoplasties associated with a mediofacial survey with a detachment
of orbital ligaments, repositioning and fixation of the orbicularis muscle of the
eyes in the superolateral direction7,8. In addition, canthopexy was routinely performed, and canthoplasty was performed
when necessary.
All patients underwent standard preoperative evaluation. The surgeries were invariably
bilateral and photographic records were performed before surgery and 6 and 12 months
later.
This study was submitted to the research ethics committee (COEP) from Hospital Felício
Rocho/MG, via Plataforma Brazil, on 07/31/2021, with CAAE designated 50441821.4.0000.5125.
Markings
With the patient lying down, the frontal dissection area is marked as an arch over
the eyebrow, 2.5cm long. A medial triangle delimits the area corresponding to the
supraorbital and supratrochlear nerves (Figure 1).
Figura 1 - Marcações cirúrgicas. Área delimitada para dissecção, com 2,5cm de extensão em direção
craniana sobre a sobrancelha. Um triângulo medial é marcado bilateralmente, delimitando
a área de onde os nervos supraorbitais e supratrocleares emergem e devem ser preservados.
A margem inferior da ressecção da pele das pálpebras superiores segue a dobra palpebral
superior e sua margem superior é estimada por pinçamento, após posicionar-se manualmente
as sobrancelhas na altura desejada.
Figura 1 - Marcações cirúrgicas. Área delimitada para dissecção, com 2,5cm de extensão em direção
craniana sobre a sobrancelha. Um triângulo medial é marcado bilateralmente, delimitando
a área de onde os nervos supraorbitais e supratrocleares emergem e devem ser preservados.
A margem inferior da ressecção da pele das pálpebras superiores segue a dobra palpebral
superior e sua margem superior é estimada por pinçamento, após posicionar-se manualmente
as sobrancelhas na altura desejada.
The upper eyelids' lower margin of skin resection is marked following the upper eyelid
groove, from the medial corner to approximately 0.5cm of the lateral palpebral fissure,
where a periorbital wrinkle is followed by about 2.0cm laterally. The upper margin
of skin resection is estimated by pinching after manually positioning the eyebrows
at the desired height (Figure 1). The five points in Figure 2 show the fixation locations of the eyebrows.
Figura 2 - Desenho esquemático mostrando a projeção de cinco suturas de fixação para a sobrancelha.
A incisão da pálpebra inferior é subciliar. Um triângulo equilátero é marcado no canto
lateral, com lados de 0,5cm e um vértice apontando para baixo. As incisões laterais
para pálpebras superiores e inferiores devem ter de 0,5 a 1,0cm de distância entre
si e são ligeiramente divergentes a partir de seu aspecto medial.
Figura 2 - Desenho esquemático mostrando a projeção de cinco suturas de fixação para a sobrancelha.
A incisão da pálpebra inferior é subciliar. Um triângulo equilátero é marcado no canto
lateral, com lados de 0,5cm e um vértice apontando para baixo. As incisões laterais
para pálpebras superiores e inferiores devem ter de 0,5 a 1,0cm de distância entre
si e são ligeiramente divergentes a partir de seu aspecto medial.
The incision of the lower eyelid is subciliary, and after the lateral corner leans
slightly down, following a periorbital rhythm. An equilateral triangle is marked in
the side corner, with sides of 0.5cm and a vertex pointing down. Half of its base
will be medial to the lateral eyelid fissure and the other half lateral to it9,10. The lateral incisions for upper and lower blepharoplasties should be 0.5 to 1.0
cm apart and slightly divergent10 (Figure 2).
Surgical technique
The procedure can be performed under sedation combined with local anesthesia or general
anesthesia. Local anesthesia involves supraorbital, supratrochlear, and infraorbital
nerve blocks using 1% ropivacaine. An 80ml solution consisting of 55ml of saline,
20ml of ropivacaine 1%, 1ml of a deposit steroid and 4ml of diluted epinephrine (totaling
a concentration of 1:200,000) is prepared. This will be used to infiltrate the eyelids,
the upper detachment area and around the lower orbital margin, in a range of 2.0cm.
A tarsorrhaphy is performed with nylon 6.0 before resection of skin and orbicularis
muscle in the upper eyelid. The fat bags are treated, saving them for use as grafts.
The blunt dissection towards the upper orbital margin is performed through the blepharoplasty
incision, forming three tunnels: the first at the midpoint of the incision and the
other two near the lateral and medial ends. The orbital margin is exposed by fusing
the dissection tunnels with scissors, allowing the marked area to be dissected in
the supragaleal plane10 (Figure 3). The aponeurotic galea is a strong tissue, preserved in this case to receive the
fixation sutures and protect the deep branch of the supraorbital nerve, which is found
between the deepest layer of the galea and the periosteum, to which it adheres anatomically
in the first 2.0 cm superior to the edge orbit1,10 (Figure 4).
Figura 3 - Dissecção supraorbitária. Dissecção romba em direção à margem orbital superior através
da incisão de blefaroplastia. A margem orbital é exposta, permitindo que a área marcada
seja dissecada no plano supragaleal (1), preservando o nervo supraorbital (2). As
aderências ao coxim adiposo galeal e ao músculo frontal são liberadas em aproximadamente
2,5cm.
Figura 3 - Dissecção supraorbitária. Dissecção romba em direção à margem orbital superior através
da incisão de blefaroplastia. A margem orbital é exposta, permitindo que a área marcada
seja dissecada no plano supragaleal (1), preservando o nervo supraorbital (2). As
aderências ao coxim adiposo galeal e ao músculo frontal são liberadas em aproximadamente
2,5cm.
Figura 4 - Anatomia cirúrgica: anatomia da área de dissecção frontal, observando o plano galeal
destacado.
Figura 4 - Anatomia cirúrgica: anatomia da área de dissecção frontal, observando o plano galeal
destacado.
Dissection is laterally limited by the projection of the orbital ligament and its
upper extension, the support zone. Adhesions to the galeal adipose cushion and frontal
muscle are released in approximately 2.5cm1.10 (Figure 4). Medially, supraorbital, and supratrochlear nerves are identified, and corrugating
muscles are individualized between them (Figure 5) for minor resection and cauterization10,11. Fat grafts are positioned in muscle resection areas, avoiding depressions2,10,12,13.
Figura 5 - Tratamento dos corrugadores. Músculo corrugador do supercílio individualizado entre
os nervos supraorbital (1) e supratroclear (2), mantido com pinças de Kelly para pequena
ressecção e cauterização.
Figura 5 - Tratamento dos corrugadores. Músculo corrugador do supercílio individualizado entre
os nervos supraorbital (1) e supratroclear (2), mantido com pinças de Kelly para pequena
ressecção e cauterização.
The eyebrows are fixed with nylon sutures 5.0 (Figure 2), connecting the cool soft tissues (the needle is passed from its inner surface to
near the dermis and returned to the inner surface) to the galea. The sutures should
be firm, without excessive tension. The first suture is positioned laterally to the
supraorbital nerve and the subsequent one, just below it. The following two sutures
are similar but in the projection of the tail of the eyebrow. The fifth and last suture
is central10 (Figure 2). The ideal fixation of the eyebrows in women varies from 0.5 to 1.0 cm above the
orbital margin; in men, it is along this orbital margin. The sutures form fixation
loops that naturally descend with the patient standing; therefore, a higher galeal
suture area is marked (1.5 cm from the orbital margin in women) for proper final positioning
of the eyebrows (Figure 6).
Figura 6 - Refixação das sobrancelhas. Ancoragem estável da sobrancelha ao plano galeal. Observe
a descida diferente das sobrancelhas com a mesma força aplicada por ambos os dedos.
Figura 6 - Refixação das sobrancelhas. Ancoragem estável da sobrancelha ao plano galeal. Observe
a descida diferente das sobrancelhas com a mesma força aplicada por ambos os dedos.
The incision of the lower eyelid begins laterally, reaching the marked triangle. The
blunt dissection under the orbicularis muscle is performed with a wide craniocaudal
opening of Kelly tweezers, supported on the orbital rim. The pre-tarsal part of the
muscle should be preserved along the incision, which proceeds on the subciliary skin,
from this triangle up to approximately 2.0 mm from the tear point (Figure 2). Lateral orbicular insertions lower than the bone margin (orbital retention ligaments
- ORL) are taken off, while fibers connected to the medial half of the orbital margin
should be preserved (Figure 7). The objective is to expose suborbicular fat (SOOF) inferiorly and laterally and
orbital thickening (LOT)14,15. The lower and lateral dissections mentioned extend for approximately 1.5 cm in the
thickness of the medial facial fat compartments15, dividing two thin layers of fat: one to be preserved on the periosteum (SOOF) and
the other adhered to the orbicularis muscle (medial fat of the cheek and lateral orbital
fat)15,16. Dissection is kept superficial to LOT for about 1.0cm laterally). During dissection,
branches of the zygomatic-facial nerve are individualized14 (Figure 7).
Figura 7 - Dissecção infraorbital. Plano de dissecção: liberação inferior entre músculo orbicular
e a margem orbitária (linha azul) (1). As inserções musculares são preservadas medialmente
(2). Inferiormente à linha azul, vemos a parte medial do SOOF (3); lateralmente, um
ramo nervoso zigomático-facial (4).
Figura 7 - Dissecção infraorbital. Plano de dissecção: liberação inferior entre músculo orbicular
e a margem orbitária (linha azul) (1). As inserções musculares são preservadas medialmente
(2). Inferiormente à linha azul, vemos a parte medial do SOOF (3); lateralmente, um
ramo nervoso zigomático-facial (4).
The fat pockets of the lower eyelid are treated, and a modified canthopexy, inspired
by the Lessa9 technique, is routinely performed: a nylon thread 5.0 crosses the fascia and the
periosteum of the upper orbital margin, just above the lateral cantal tendon. Next,
the needle is passed caudally under the skin and the muscle flap that sequesters upper
and lower blepharoplasty incisions, being externalized in the latter. Then, the suture
includes the superolateral part of the lower tarsal plate, where it joins the lateral
cantal tendon. Finally, the needle returns to the upper incision, repeating the anchorage
in the periosteum to complete the node without excessive tension. In secondary surgeries
or patients with significant horizontal eyelid laxity, especially the elderly, canthopexy
is replaced with a tarsal strip lateral canthoplasty technique.
The skin of the lower eyelid to be resected is calculated, extending the lower vertex
of the marked triangle (Figure 2) a few millimeters lower, with medial obliquity. Care should be taken at this stage,
calculating to remove a smaller amount of skin than is believed to be excisable. Over
the years, this skin has been caudally distended by the weight of the soft tissues
of the middle third of the face, which will be repositioned and fixed in a superolateral
area. Initially, one may think that all this skin is surplus, but it will retract
later, which can contribute to possible complications, such as scleral show and ectropion.
At the end of this incision in the lower eyelid, the skin is temporarily fixed to
the medial part of the marked triangle (Figure 2) for medial skin excision. The excised skin strip is always asymmetrical, with a
wider lateral part than the medial. Lateral to the triangle fixation, the orbicularis
muscle is dissected from the skin7 and resected in its redundant cranial portion (Figure 8). The remaining muscle flap will be fixed with four to five nylon 5.0 sutures in
the LOT located immediately under the lateral incision of the skin, starting at a
level just below the lateral cantal ligament at the lateral orbital margin.
Figura 8 - Retalho de músculo orbicular. Superior: O descolamento muscular da pele que será ressecada
lateralmente. Inferior: músculo orbicular dissecado (1). Este músculo será ressecado
em sua porção craniana redundante e fixado ao LOT e periósteo imediatamente inferior
à incisão lateral da pele.
Figura 8 - Retalho de músculo orbicular. Superior: O descolamento muscular da pele que será ressecada
lateralmente. Inferior: músculo orbicular dissecado (1). Este músculo será ressecado
em sua porção craniana redundante e fixado ao LOT e periósteo imediatamente inferior
à incisão lateral da pele.
These sutures efficiently pull the lower eyelid in a superolateral direction, providing
the desired mid-third lift with satisfactory support for mediofacial tissues. (Figure 9).
Figura 9 - Reposicionamento mediofacial. Retalho de músculo orbicular suturado à direita, fornecendo
suporte adequado para tecidos mediofaciais. Observe a descida diferente do terço médio
com a mesma força aplicada por ambos os dedos.
Figura 9 - Reposicionamento mediofacial. Retalho de músculo orbicular suturado à direita, fornecendo
suporte adequado para tecidos mediofaciais. Observe a descida diferente do terço médio
com a mesma força aplicada por ambos os dedos.
Excess superolateral skin is carefully resected at this time. The lateral incisions
of the upper and lower blepharoplasties are 0.5 to 1.0 cm from each other and are
slightly divergent (Figure 2). This allows large skin resections in the region with skin flaps of the upper and
lower eyelids anchored in these two almost parallel margins. This fact makes it unnecessary
to use peripheral incisions to consume this excess skin.
The same surgical steps are performed on the contralateral eyelid, and the skin closure
is completed with monofilament nylon 6.0. Postoperative care is like conventional
blepharoplasty, except for the greater edema. It is recommended to use cold compresses
for 10 minutes, several times in the first 36 hours and then moderately heated bags
and lymphatic drainage after the fifth day. We removed the stitches on the fourth
or fifth postoperative day.
RESULTS
The procedure successfully achieves rejuvenation of the forehead and middle third
of the face. With corrugator myectomy, the glabella wrinkles are attenuated, and the
eyebrows move away. Depressions where the corrugator muscles were resected, were avoided
with grafts from resected fat bags. There were no complaints about open palpebral
fissures.
Eyebrow lifting was effective and was maintained in the long term. The most common
intercurrence was bilateral paraesthesia in the frontal and parietal scalp, spontaneously
resolved after a few months. In most cases, temporary paralysis of the frontal muscle
was observed to varying degrees10.
The elongation of the lower eyelids, the skeletonized infraorbital appearance, the
prominent nasojugal sulcus, and the malar fat pad ptosis17,18 were adequately treated as the eyelid/cheek junction was raised (Figures 10 to 16). In addition, the repositioning of the orbicularis muscle creates a belt8, which, together with the canthopexy 9,17, avoids complications such as scleral show or ectropion.
Figura 10 - Resultados. Paciente 1. Paciente de 44 anos antes (esquerda) e 6 meses após a operação
(direita).
Figura 10 - Resultados. Paciente 1. Paciente de 44 anos antes (esquerda) e 6 meses após a operação
(direita).
Figura 11 - Resultados. Paciente 2. Paciente de 59 anos antes (esquerda) e 9 meses após a operação
(direita).
Figura 11 - Resultados. Paciente 2. Paciente de 59 anos antes (esquerda) e 9 meses após a operação
(direita).
Figura 12 - Resultados. Paciente 3. Paciente de 60 anos antes (esquerda) e 12 meses após a operação
(direita). As linhas brancas verticais mostram a posição diferente dos tecidos mediofaciais:
um importante levantamento das estruturas pode ser observado, se tomarmos as duas
linhas horizontais brancas pontilhadas como referências às maiores projeções faciais
laterais esquerdas.
Figura 12 - Resultados. Paciente 3. Paciente de 60 anos antes (esquerda) e 12 meses após a operação
(direita). As linhas brancas verticais mostram a posição diferente dos tecidos mediofaciais:
um importante levantamento das estruturas pode ser observado, se tomarmos as duas
linhas horizontais brancas pontilhadas como referências às maiores projeções faciais
laterais esquerdas.
Figura 13 - Resultados. Paciente 4. Paciente de 56 anos antes (esquerda) e 12 meses após a operação
(direita).
Figura 13 - Resultados. Paciente 4. Paciente de 56 anos antes (esquerda) e 12 meses após a operação
(direita).
Figura 14 - Resultados. Paciente 5. Paciente de 54 anos antes (esquerda) e 22 meses após a operação
(direita).
Figura 14 - Resultados. Paciente 5. Paciente de 54 anos antes (esquerda) e 22 meses após a operação
(direita).
Figura 15 - Resultados. Paciente 6. Paciente de 53 anos antes (esquerda) e 18 meses após a operação
(direita
Figura 15 - Resultados. Paciente 6. Paciente de 53 anos antes (esquerda) e 18 meses após a operação
(direita
Figura 16 - Resultados. Paciente 7. Paciente de 52 anos antes (esquerda) e 9 anos após a operação
(direita). Após 9 anos, podemos ver as sobrancelhas mantidas elevadas em relação ao
período pré-operatório.
Figura 16 - Resultados. Paciente 7. Paciente de 52 anos antes (esquerda) e 9 anos após a operação
(direita). Após 9 anos, podemos ver as sobrancelhas mantidas elevadas em relação ao
período pré-operatório.
There is greater edema in the immediate postoperative period when compared to classical
blepharoplasties due to greater dissection and tissue mobilization.
The results were observed in a 23-year follow-up and were stable long-term (Figures 10 to 16).
Intercurrences and complications
We reviewed 139 medical records of operated patients from January 2010 to December
2019. We observed as intercurrence the temporary disconnection of the lateral part
of the lower eyelid of the globe treated conservatively. Complications were considered
when associated with the scleral show, observed in 15 cases (10.8%); the treatment consisted of elevating the skin from
the zygomatic region with Micropore® to the frontal area, on average for 41 days, leading to the proper positioning of
the structures during healing. A case of mild ectropion (0.72%) was recorded and thus
treated for 180 days. In these 16 complications, we identified as predisposing factors:
4 secondary blepharoplasties, two patients with exophthalmia and associated conjunctivitis
in two patients. Chemosis was observed, treated with eye drops with corticosteroids
and usually presenting rapid resolution. In 19 patients (13.7%), the chemosis persisted
for more than ten days (mean of 47 days), and only two cases (1.44%) required tarsorrhaphy
and conjunctival perforations for complete treatment19. The final scars needed revision by lateral retractions in 5 cases (3.6%). A small
hematoma (0.72%) on the left lower eyelid was surgically drained.
DISCUSSION
Dermatochalasis is often associated with frontoparietal soft tissue ptosis1,2 and mediofacial tissues17. The aesthetically ideal female eyebrow is arched, located 0.5 to 1.0cm above the
upper orbital margin. The male eyebrow is flatter and positioned on or just above
this orbital margin20.
Transpalpebral elevation was initially described in 198221, followed by numerous articles2,5,6,10,20,22-25. In 1990, McCord and Doxanas6 described a blepharoplasty associated with the transpalpebral suspension of the eyebrow
and the galeal adipose cushion treatment. They recommended less detachment (limiting
eyebrow elevation) and no treatment of depressive muscles, favoring ptosis recurrence.
Other techniques proposed this treatment2,11-13,22, allowing less downward traction in the eyebrows. However, they needed other incisions,
such as the2,26.
The orbicularis muscle flap showed efficiency in treating the lower eyelid and the
middle third of the face7,27,28. The risks are mispositioning of the eyelid and scleral show. A lateral canthopexy,
without the lateral cantal ligament section9, helps prevent such complications.
McCord et al. (1998) 8 Combined repositioning of the orbicular is repositioning to subperiosteal detachment
of the malar area to treat the middle third of the face. Hester et al. (1998) 3 also treated the middle third by a subciliary incision. After a 5-year experience,
the authors described the use of canthopexy in 90% of patients, avoiding poor positioning
of the lower eyelid17.
The technique described here treats the upper two-thirds of the face using only upper
and lower blepharoplasty incisions. The lower margin of skin excision made in the
upper eyelid fold ensures sufficient skin coverage to the eyeball (Figure 2). In addition, the upper orbital margin can be easily accessed through this incision,
without injury to any important structure. Next, dissection is performed in the galeal
plane, releasing the galeal adipose cushion and the frontal muscle (Figures 3 and 4)1,10.
The described transpalpebral elevation uses a modified McCord and Doxanas (1990)6 technique, with wider dissection of the frontal area in the galeal plane and more
fixation sutures, for a more effective ascent. Myectomy of corrugator muscles is associated2,11-13, resulting in smoothed glabella wrinkles and preventing ptosis recurrence. The supraorbital
nerve trunk is observed in direct vision, having the superficial branches preserved
over the frontal muscle and the deep branches under the galea, which receives the
eyebrow fixation sutures. Eyebrow elevation allows reduced excision of the upper eyelid
skin, safely achieving good results.
The mediofacial structures are effectively elevated with the repositioning of the
orbicularis muscle since the lower fat compartments are connected to it through the
SMAS8,14. As a result, the aspect of rounded and aged face changes to an inverted triangle
shape, with volumization of the zygomatic regions, leading to a rejuvenated facial
expression.
Long-term glucocorticoid infiltrated with anesthetics in the dissection area and postoperatively,
oral prednisolone, 40mg/day, five days, provides less edema and more comfort to the
patient 29.
CONCLUSION
Enlarged blepharoplasty, as we call it, can contribute to the surgical aesthetic and
functional improvement of the periorbital region by managing the upper two-thirds
of the face in a single surgical procedure and using only incisions of upper and lower
blepharoplasty.
It presented reduced rates of complications, and the outcomes were gratifying and
were maintained in the long term.
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1. Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
Corresponding author: Armando Chiari Júnior, Rua Herculano de Freitas, nº 58, Conj. 110 - Gutierrez, Belo Horizonte, Minas Gerais,
Brazil, Zip Code 30441-039. E-mail: chiari@chiari.com.br / drsergiorodrigues@gmail.com
Article received: November 17, 2020.
Article accepted: May 18, 2021.
Conflicts of interest: none.
