Center for Facial Appearances

Lower eyelid blepharoplasty is one of the most common procedures in aesthetic plastic surgery. Although patients desiring lower eyelid blepharoplasty typically describe their problem as "bags in the lower eyelids," there are many anatomical imperfections that should be assessed. With aging, the youthful single convexity of the lower lid separates into a double convexity with a valley at the intersection of the lower lid and midface. Midface descent further drags this intersection inferiorly, leading to a vertically lengthened lower eyelid. This article discusses how to clinically evaluate lower lid deformities, how to formulate a surgical plan, the preoperative assessment, and surgical markings. The rationale and anesthetic technique for outpatient versus in-office surgery is reviewed, and a detailed step-by-step approach with accompanying figures for lower lid blepharoplasty via a transconjunctival or transcutaneous incision is given. An approach to vertically supporting the lower eyelid is presented.

Benign essential blepharospasm (henceforth “blepharospasm”) and hemifacial spasm are conditions which are linked in the final manifestation of facial spasm and are similar in regard to basic approaches to treatment. These diseases are both movement disorders but have completely different pathophysiology. For this reason, the chapter is divided into separate sections, the first on blepharospasm and the second on hemifacial spasm.

Psychogenic excoriation is self-injurious behaviour characterised by compulsive picking of skin with negligible imperfections.1 Psychogenic parasitosis is an uncommon disorder in which patients have a false, fixed belief of being infested by an organism.2 Individuals may provide false evidence of infestation and frequently induce mechanical trauma to clear the purported organism.2 We present five unique cases of self-induced facial excoriations with psychiatric disease ranging from psychogenic excoriation to psychogenic parasitosis. Patient 1 presented with a vertical hypertrophic scar involving the forehead (figure 1A). The patient admitted to skin picking. Three years earlier, an abscess from repeated acne pustule manipulation required surgical drainage. The scar was injected with triamcinolone acetonide with improvement. Figure 1 (A) Case 1: central forehead scar at the hairline. …

To describe a surgical technique to treat postoperative conjunctival chemosis. Case report. Two cases of postoperative chemosis in which the conventional methods failed were successfully treated by snip conjunctivoplasty, without recurrence. Snip conjunctivoplasty is a simple and effective surgical approach to treat refractory postoperative chemosis.

Botox is extremely safe, with an LD50 of 3500 units in humans. Despite a high safety profile, non-life-threatening complications can be frequent and frustrating to both the patient and the physician. Proper understanding of oculofacial anatomy is paramount to correctly understanding the indications and proper administration of Botox. Botox will not address skin pigmentation/quality, excess skin, contour deformities, volume loss/deformities, or tissue drop. Botox therapy is ideal for initiating cosmetic surgery to patients into practice.

A half-inch 32-gauge needle (Air-Tite Products) minimizes injection discomfort. In the periorbital areas we inject in an oblique manner to the skin to lessen the chance of deep injections or even injury should a patient suddenly move. Pinching upward or gently rubbing the adjacent skin during injection minimizes patient discomfort by distracting the patient during the injection and “confusing” the sensory sensation of the injection (Figure 95.1). We recommend premarking the areas to be injected, and utilizing bright lighting and wearing magnification to avoid injury to eyelid vessels. We seldom use topical anesthetics, and some suggest a reduced duration of effect in patients treated with topical anesthetic prior to injection.1 We inject into the subcutaneous tissue planes to avoid the underlying muscle and neurovascular structures. This reduces patient discomfort and lessens the risks of bruising and deep dissemination. In general the injections can be given obliquely or perpendicular to the skin, but in the orbicularis areas it is critical to inject at as flat an angle as possible because of the thinness of the eyelid skin and to point away from the eye. It is also helpful when injecting the lower orbicularis areas to put the skin on stretch, which helps with placing the Botox in the subcutaneous plane. Botox must be avoided in the central upper eyelid to prevent ptosis and over the inferior oblique in the lower eyelid to avoid diplopia. Open image in new window Figure 95.1 Pinch technique during oblique injection of corrugator. This descreases discomfort and avoids neurovascular structures and bleeding.

Cosmetic applications of Botox continue to expand beyond the FDA-approved use for glabellar furrows. Patients should sign informed consent for off-label cosmetic uses. Treatment of eyelid and facial rhytids is gratifying for the patients and physicians. Not only do the eyelid injections improve current rhytids, but the future development of mimetic rhytids is prevented. It is paramount to understand the anatomy of the eyelid and facial muscles and that the rhytid-inducing musculature is the injection site rather than the actual wrinkles. Patient desires and expectations must be clearly defined as some patients may want to be smooth and adynamic, whereas others prefer a natural youthful appearance. We strongly encourage the latter. Aesthetic appreciation and training is essential in obtaining excellent cosmetic results.