Briggs E. Cook

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.

Eyelid lymphatics II: a search for drainage patterns in the monkey and correlations with human lymphatics.

Purpose To study the lymphatic drainage of the cynomolgus monkey through the use of lymphoscintigraphy. Methods Lymphoscintigraphy with 500 &mgr;Ci of 99mTechnetium sulfur colloid injected at specific sites around the eyelids was performed with five cynomolgus monkeys in lateral and ventral positions. Results Lymphoscintigraphy of the monkey eyelid and periocular tissue revealed lymphatic drainage to the parotid lymph nodes from the entire upper eyelid, medial canthus, and lateral lower eyelid and drainage to the submandibular lymph nodes from the medial and central lower eyelid. In addition to draining to the parotid lymph nodes, the central upper eyelid was also seen to drain to the submandibular lymph nodes. Conclusions Lymphoscintigraphy of the cynomolgus monkey eyelids reveals discrete lymphatic drainage pathways for the upper and lower eyelids and a dual pathway for the central upper eyelid. Future studies will help to clarify the lymphatic drainage pathways of human eyelids.

Eyelid lymphatics I: histochemical comparisons between the monkey and human.

Purpose: To study the lymphatic drainage of the cynomolgus monkey and human eyelid and periocular tissue by means of histochemistry. Methods: Eyelid and periocular tissue from three cynomolgus monkeys undergoing sacrifice for glaucoma and retina research purposes and discarded tissue from a wedge resection of one human eyelid were used for histochemical analysis. Lymphatic capillaries were distinguished histochemically in monkey and human eyelids by light microscopy with a 5′-nucleotidase (5′-Nase) staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5′-Nase staining. Results: Histochemical analysis with 5′-nucleotidase revealed a subcutaneous and pretarsal lymphatic plexus in both the human and monkey. Conclusions: Histochemical results demonstrate similar lymphatic plexi in the monkey and human. Future studies will help to clarify the lymphatic drainage pathways of monkey and human eyelids.

Canthus-sparing ectropion repair.

Purpose To describe a novel surgical technique for lower eyelid ectropion repair that avoids canthotomy and cantholysis and can be used in combination with external levator repair and/or in combination with blepharoplasty. Methods A retrospective analysis of lower eyelid procedures with the use of the canthus-sparing technique between January 1, 1998, and December 31, 1999, was performed. The canthus-sparing approach was used in 198 eyelid procedures for the correction of lower eyelid ectropion. Seventy-four (37.4%) procedures involved the correction of lower eyelid ectropion alone and 25 (12.6%) procedures involved the correction of lower eyelid ectropion during upper eyelid small-incision external levator repair. In these cases, an incision was made lateral to the lateral canthus and a periosteal flap was created at the lateral orbital rim. The inferior crus of the lateral canthal tendon was then attached to this full-thickness elevated periosteum. Twenty (10.1%) procedures involved the correction of ectropion during upper blepharoplasty and 79 (39.9%) procedures involved the correction of ectropion during combined upper eyelid ptosis repair and blepharoplasty. In these cases, the inferior crus of the lateral canthal tendon was attached to a periosteal flap created through the lateral portion of the blepharoplasty incision. Results The mean age of patients undergoing ectropion repair was 74.3 ± 9.3 years (range, 42–93 years). The average duration of symptoms (most commonly tearing and/or ocular irritation) was 20 ± 14 months (range, 3–84 months). Recurrences of lower eyelid ectropion or symptoms occurred in 4 (2%) eyelids. The average follow-up interval was 54 ± 65 days (range, 3–330 days). Conclusions The canthus-sparing approach to ectropion repair promotes a secure adhesion to the lateral orbital wall with minimal violation of normal anatomic structures and relations. It is time-efficient and reduces postoperative morbidity.

Surgical Anatomy of the Eyelid

Proper diagnosis and management of eyelid disorders, both functional and cosmetic, hinge upon a thorough understanding of the location of critical eyelid structures and the anatomic relationships between them. Accurate intraoperative identification of anatomy is fundamental in performing eyelid surgery and preventing complications.

The Depressor Supercilii Muscle: Anatomy, Histology, and Cosmetic Implications

Introduction: This article describes the anatomy and histology of the depressor supercilii muscle and discusses cosmetic implications. Materials and Methods: The depressor supercilii muscle was studied in detail by using gross anatomic dissections carried out on 8 sides of 4 fresh cadaver heads and 10 sides of 5 preserved cadaver heads. Histologic 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 onto the undersurface of the skin. Results: The depressor supercilii muscle was demonstrated to be a muscle distinct from the corrugator supercilii muscle and the medial head of the orbital portion of the orbicularis muscle. The depressor supercilii muscle was noted to be vertical 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 2 distinct heads in most specimens — a novel finding. In specimens containing 2 heads of the depressor supercilii muscle, the angular vessels passed between the 2 muscle heads. In specimens containing 1 muscle head, the angular vessels were found anterior to the muscle. The insertion of the depressor supercilii muscle into the dermis lay approximately 13 to 14 mm directly above the medial can-thal tendon. Discussion: 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 can be addressed and inactivated through the placement of botulinum toxin into its muscle belly or subcutaneously along its course. The depressor supercilii can also be inactivated by surgical resection through an upper eyelid blepharoplasty incision in concert with corrugator supercilii or procerus resection.

The cynomolgus monkey eyelid as an anatomic model for oculoplastic surgery.

Purpose To investigate the Cynomolgus monkey eyelid as an experimental model for oculoplastic surgery Methods Eyelid and periocular tissue were removed from Cynomolgus monkeys being euthanized. After fixation, the macroscopic and microscopic characteristics of the Cynomolgus monkey eyelid were studied. Results Macroscopic and microscopic characteristics of the Cynomolgus monkey eyelids were described. The Cynomolgus monkey eyelid bears resemblance to the human eyelid in its compartmentalization and complexity. Conclusions The Cynomolgus monkey eyelid is a suitable experimental research model. Its compartmentalization resembles that of the human eyelid both microscopically and macroscopically.

Lower Eyelid Rejuvenation with Skin/Skin-Muscle/Fat Repositioning Techniques

A preoperative examination of the cosmetic patient considering lower eyelid blepharoplasty is essential. The preoperative examination allows the patient to express his or her concerns and desires and allows the physician to establish a healthy physician-patient relationship, which is vital in the treatment of the patient. The preoperative examination also allows the physician to explain the surgery and possible complications. As opposed to the aging patient with severe dermatochalasis and orbital fat prolapse, the cosmetic patient considering lower eyelid blepharoplasty often has specific areas of the eyelids to address. It is important for the surgeon to identify these areas and understand exactly what the patient wishes to accomplish with the surgery. One patient may wish to diminish the prominence of the central and lateral fat pads, whereas another may wish to reduce redundant lower eyelid skin. It is often helpful to have the cosmetic patient hold a hand mirror and point out to the surgeon exactly the areas of concern. Both anterior and posterior approaches to the lower eyelid exist. The anterior approach to lower eyelid blepharoplasty is made through an infraciliary skin incision, and most patients require excision of excess skin, orbicularis oculi muscle, and fat. In these patients, a skin-muscle flap is removed. If only loose and redundant skin is present, a skin flap with resection of the redundant skin is performed. If only excess fat needs to be removed, a skin-muscle flap is raised, excess fat is removed, and little or no excess skin or muscle is removed.