Bradley N. Lemke

Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament.

Summary The orbital and eyelid relationships of the superficial musculoaponeurotic system (SMAS) were studied in human cadavers. Using gross and microscopic techniques, the SMAS was found to be intimately related to the eyelids and orbicularis oculi muscle, and to have distinct orbital bony attachments. Sub-SMAS fat in the malar region was found to be continuous with the submuscular fat in the eyebrow region. The malar sub-SMAS fat continued superiorly into the lower eyelid above the inferior orbital rim, as a postorbicularis layer. A bony attachment emanating from the inferior orbital rim, the orbitomalar ligament, traveled through the orbicularis oculi muscle in a lamellar fashion prior to inserting into the dermis. The cutaneous insertion of this attachment corresponds to the malar and nasojugal skin folds. With aging, relaxation of the orbitomalar ligament allows inferior migration of orbital fat, in addition to the anterior migration that occurs through an attenuated orbital septum. These findings have implications not only in cosmetic surgery but also in the understanding of facial soft tissue changes that occur with aging.

Problems Associated With Conjunctivodacryocystorhinostomy

Fifty-eight patients (69 eyes) underwent conjunctivodacryocystorhinostomy for lacrimal canalicular obstruction. The cause of lacrimal obstruction and the results and complications of the operation were analyzed. Trauma and idiopathic disease were the most common causes of lacrimal canalicular obstruction in 24 of 69 (34.8%) eyes each. Relief of epiphora was achieved in 68 of the 69 eyes (98.5%). The complications included tube displacement in 40 of the 69 eyes (57.9%), tube obstruction in 19 of the 69 eyes (27.5%), and infection of the lacrimal sac in four of the 69 eyes (5.8%). Despite frequent complications, most Jones tubes can be made to function satisfactorily. Conjunctivodacryocystorhinostomy remains the best surgical treatment at this time for permanent loss of canalicular function.

Levator aponeurosis elastic fiber network

This light and electron microscopic study demonstrates an elastic fiber network (EFN) for the levator palpebrae superioris muscle complex, which forms an intricate insertion into the upper eyelid. The EFN is examined in the monkey, in a fresh exenteration specimen, and in fresh frozen cadaver specimens from both sexes of different age groups. Multiple elastic insertions of the levator aponeurosis and Mullers muscle attachment with well-organized elastic fibers are demonstrated using special staining techniques and serial microscopic sectioning. Transmission electron microscopy (TEM) confirms the ultrastructure of “mature” elastin fibers in Mullers muscle tendon and their close relationship with the elastin-related fiber, oxytalan. Current thinking concerning the nature of elastic fibers and their possible implications in acquired involutional blepharoptosis is discussed. This microscopic study of the EFN of the upper eyelid focuses attention on the multiple elastic fiber insertions of the levator muscle complex that includes the levator aponeurosis, the conjoined fascia, the lid crease area, and Mullers muscle tendon, which have not been previously described.

Small incision external levator repair: technique and early results.

PURPOSE To describe a new surgical technique and early results of external levator repair performed through a small skin incision. METHODS A chart review of consecutive patients undergoing small incision external levator repair was conducted. This modified external levator repair was performed through an 8-mm eyelid crease incision. Patients with unilateral or bilateral aponeurogenic blepharoptosis were candidates for the technique. Patients with excessive horizontal upper eyelid laxity and those requiring blepharoplasty in addition to blepharoptosis surgery did not undergo this technique. Patients who underwent previous upper eyelid surgery or concurrent brow surgery were excluded from the review. Preoperative measurements included upper eyelid margin reflex distance, levator function, and degree of dermatochalasis, as well as Goldmann visual field results. Outcome measures included incidence and type of intraoperative complications, postoperative upper eyelid position (including margin reflex distance, eyelid contour, and symmetry), incidence and type of postoperative complications, and revisions or additional necessary surgery. RESULTS Twenty-eight eyelids of 17 patients met study inclusion criteria. Preoperative margin reflex distance +/- SD averaged 0.8 +/- 0.4 mm. Average length of follow-up was 28 +/- 5 weeks (range, 15 to 52 weeks). No significant intraoperative complications occurred. Postoperative margin reflex distance averaged 3.7 +/- 0.3 mm. Two eyelids were mildly undercorrected, and one demonstrated moderately peaked contour postoperatively. Satisfactory eyelid position and contour were achieved in 25 of 28 treated eyelids. No patient elected reoperation. CONCLUSIONS Early results demonstrated that small incision levator repair is safe and generally effective. This minimally invasive external levator repair is useful for a carefully selected subset of patients with aponeurogenic blepharoptosis.

The anatomy of midfacial ptosis

PURPOSE To investigate the anatomic and histologic changes present in midfacial ptosis. METHODS Experimental study applying gross anatomic and histologic techniques to formalin-preserved and fresh-frozen cadaver heads with and without midfacial ptosis. High-resolution surface coil magnetic resonance imaging (MRI) was performed to obtain radiologic correlations. RESULTS The orbitomalar ligament was further characterized by identification of a well-developed lateral component in the sub-superficial musculoaponeurotic plane; abnormalities of this important supporting structure were present in the subcutaneous plane in 8 of 10 specimens with midfacial ptosis. The zygomatic and masseteric cutaneous ligaments also were further characterized on a gross anatomic level, and histologic evidence of these two structures was produced. The subcutaneous components of the zygomatic and masseteric cutaneous ligaments were attenuated or not identifiable in 40% and 30% of specimens with midfacial ptosis, respectively. High-resolution surface coil MRI provided exquisite correlations of midfacial anatomy. CONCLUSIONS The lateral component of the orbitomalar ligament provides major osteocutaneous midfacial support. Subcutaneous attenuation of the orbitomalar, masseteric cutaneous, and zygomatic ligaments was associated with midfacial ptosis.

Histologic comparison of autologous fat processing methods.

Purpose: To perform a quantitative analysis of adipocyte viability after fat processing during autologous fat transfer, comparing the processing methods of washing, centrifuging, and sedimentation. Methods: An experimental study was conducted in which 24 fat samples were obtained after processing from 22 patients undergoing autologous fat transfer. Histologic analysis of periodic acid-Schiff–stained specimens was then performed. Results: Cell counts per high-powered field of intact adipocytes and nucleated adipocytes and adipocyte cross-sectional area were significantly greater in samples processed by sedimentation, compared with those by centrifuging or washing. Conclusions: Of the various processing techniques currently used during autologous fat transfer, sedimentation appears to yield a higher proportion of viable adipocytes than does washing or centrifuging.

Characterization of human orbital fat and connective tissue

Summary: This study was designed to evaluate the characteristics of human orbital fat and connective tissue. Two exenteration specimens were studied by light microscopy with special stains. Four distinct regions were identified on the basis of their connective tissue septa, which contained blood vessels and were composed of elastin and collagen types I, III, and IV. Transmission electron microscopy was performed on the opposite orbits. The fibroblasts and adipocytes appeared metabolically inactive and showed no regional differences. The fat was phase extracted from the connective tissue and subjected to biochemical analysis. No regional differences were found in the content of fatty acids and protein. The fatty acids included palmitic acid (22–24.6%), oleic acid (45–51.5%), and linoleic acid (15–18.6%). Despite demarcation of the orbital fat into distinct regions by the connective tissue septa, ultrastructural and biochemical analysis revealed no regional variations in the fat. The diagnostic and therapeutic implications of these findings are discussed.

Depressor supercilii muscle: Anatomy, histology, and cosmetic implications

Purpose: To describe the gross and microscopic anatomy of the depressor supercilii muscle and to discuss its cosmetic implications. Methods: The depressor supercilii muscle was studied in detail with the use of gross anatomic dissections carried out on eight sides of four fresh cadaver heads and ten sides of five preserved cadaver heads. Histological analysis was performed on parasagittal sections of one side of a preserved cadaver head. Measurements were taken on cadaver specimens to determine the insertion point of the depressor supercilii muscle on the undersurface of the skin. Results: The depressor supercilii muscle is distinct from the corrugator supercilii muscle and the medial head of the orbital portion of the orbicularis oculi muscle. The depressor supercilii muscle was noted to be superior in orientation and redder in color than the orbicularis oculi muscle. The depressor supercilii muscle arose from the frontal process of the maxilla approximately 1 cm above the medial canthal tendon and appeared to originate from two distinct heads in most specimens, a novel finding. In specimens containing two heads of the depressor supercilii muscle, the angular vessels passed between the two muscle heads. In specimens containing one muscle head, the angular vessels were found anterior to the muscle. The insertion of the depressor supercilii muscle in the dermis lay approximately 13 to 14 mm superior to the medial canthal tendon. Conclusions: The origin, insertion, and anatomy of the depressor supercilii muscle help it to act as a depressor of the eyebrow. Histologically, the depressor supercilii muscle arises distinctly from bone and has a unique insertion. The depressor supercilii muscle appears to be distinct from the corrugator supercilii and the orbicularis oculi muscles.

Donor site complications of hard palate mucosal grafting.

Summary The use of hard palate mucosal grafts (HPG) in eyelid surgery is becoming increasingly popular. We present two palatal donor site complications that have not been previously reported. The first is an oro-nasal fistula discovered 1 week following surgery. The second is oral candidiasis, which compromised healing of the palatal donor site. With appropriate treatment, both complications resolved shortly after surgery. Careful preoperative evaluation and postoperative follow-up is recommended to recognize and manage these complications.

Progressive Infraorbital Nerve Hypesthesia as a Primary Indication for Blow-out Fracture Repair

Summary Traumatic blow-out fractures of the orbital floor are a common injury that can lead to significant morbidity. Accepted indications for surgical repair include displaced fractures consisting of a defect >50% of the orbital floor, extraocular muscle entrapment, and clinically significant enophthalmos. Although infraorbital nerve hypesthesia has been reported as an indication for repair of fractures of the zygomatic complex and is often encountered as an associated finding in fractures of both the orbital floor and inferior orbital rim, it has not been generally regarded as a primary indication for blow-out fracture repair. We report two patients in whom severe, progressive infraorbital nerve hypesthesia served as the primary indication for surgical repair. Both patients experienced improvement in infraorbital nerve function following surgical repair, accompanied by persistent pain and paresthesias in the distribution of the infraorbital nerve. We suggest that progressive infraorbital nerve hypesthesia should be considered a primary indication for blow-out fracture repair in selected patients in whom hypesthesia is both severe and progressive.