Pearls and Pitfalls in Cosmetic Oculoplastic Surgery (eBook)

Foreword 5
Preface 7
Table of Contents 8
Contributors 21
Part I Preoperative Evaluation 30
1 Preoperative Evaluation of the Cosmetic Patient 31
Reference 33
2 Evaluation of the Cosmetic Patient 34
The Eightfold Path to Patient Happiness 34
Manage the Balance of Power Between Doctor and Patient 34
Listen to Your Patient Before Surgery (or you will surely have to listen to them after) 35
Document and Demonstrate 35
Ensure Appropriate Patient Motivation 35
Determine Realistic Surgical Goals 35
Screen Out the Diffificult Patient 36
Conduct a Thorough Informed Consent 37
Create an Aesthetic Environment 38
3 Preoperative Patient Counseling for Cosmetic Blepharoplasty 39
Part II Anesthesia 41
4 Guide to Local Anesthetic Medications 42
Topical Ocular Anesthetics 42
Lidocaine 42
Bupivacaine 42
Epinephrine 43
EMLA 43
Other Topical Anesthetics 44
Bicarbonate 44
Benzyl Alcohol 44
References 44
5 Motor Nerve Blocks in Oculofacial Surgery 45
Facial Nerve Blocks 45
Retrobulbar and Peribulbar Blocks 48
References 48
6 Regional Nerve Blocks in Oculofacial Surgery 49
Sensory Nerve Blocks 49
Lacrimal Nerve Block 49
Frontal Nerve Block 49
Nasociliary Nerve Block 50
Infraorbital Nerve Block 50
Zygomaticofacial Nerve Block 50
7 Procedural Sedation in Oculofacial Surgery 54
Staff 54
Monitoring 54
Minimal Sedation 55
Moderate Sedation 55
Antagonists/Reversal Agents 55
References 56
8 Preoperative Preparation and Anesthesia 57
Preoperative Regimen 57
Intraoperative Regimen 57
9 “Digital Diffusion” Technique for the Administration of Local Anesthetic in Eyelid Surgery 59
10 Anesthesia for In-Office Oculoplastic Surgery: How We Do It 60
Selection of Local Anesthesia 60
Selection of Oral Sedative Agent 61
Procedure 61
References 62
Part III Upper Lid Blepharoplasty 64
Section One Preoperative Evaluation 65
11 Upper Eyelid Blepharoplasty: The Evaluation 66
12 Preoperative Examination Checklist for Upper Blepharoplasty 69
13 Preoperative Evaluation and Documentation in Upper Blepharoplasty 71
Section Two Incision Planning 73
14 Marking Strategies for Upper Blepharoplasty 74
15 Orbit Size and Lid Marking in Upper Blepharoplasty 76
16 Incisional Guidelines When Marking the Skin in Upper Eyelid Blepharoplasty 79
17 Marking the Proposed Upper Eyelid Crease: Determining the Safe Amount of Skin Removal—The Pinch Technique 81
18 Preoperative Measurements in Upper Blepharoplasty: Patient Selection 84
19 Keys to Success When Marking the Skin in Upper Blepharoplasty 85
20 Skin Marking in Upper Blepharoplasty—Avoiding Pitfalls 88
Section Three Upper Blepharoplasty Procedure Pearls 92
21 Upper Blepharoplasty: Pearls for the Procedure 93
22 Fat Excision in Upper Blepharoplasty 95
23 Mobilizing and Excising the Nasal Fat Pad in Upper Blepharoplasty 96
24 Tissue Removal Considerations in Blepharoplasty Surgery 97
25 Fewer Hematomas in Upper Blepharoplasty 98
26 Blepharoplasty Incisional Modalities: 4.0 Radiowave Surgery vs. CO2 Laser 103
Study 104
Results 104
References 105
27 Fat Preservation and Other Tips for Upper Blepharoplasty 106
28 Asian Blepharoplasty 109
Section Four Adjunctive Procedures in Upper Blepharoplasty 114
29 Internal Brow Elevation with Corrugator Removal 115
30 Excision of ROOF During Upper Blepharoplasty 119
31 Addressing the Brow During Upper Blepharoplasty 120
Internal Browlift 120
Thinning of Brow Fat Pad 120
32 Transblepharoplasty Incision Lower Lid Canthopexy 122
33 Lower Lid Canthopexy Through Upper Lid Incision 124
References 124
Section Five Wound Closure and Postoperative Care 125
34 Avoiding Dog Ears During Upper Blepharoplasty Closure 126
Surgical Technique 126
35 Crease Formation in Upper Blepharoplasty 128
36 Use of Tissue Adhesive for Oculoplastic Incision Closure 130
37 Avoiding or Minimizing Postoperative Swelling 131
38 Management of Postblepharoplasty Dry Eye 133
Suggested Reading 134
Part IV Lower Lid Blepharoplasty 135
Section One Preoperative Considerations 136
39 Lower Eyelid Blepharoplasty: The Evaluation 137
40 Lower Eyelid Blepharoplasty Evaluation: Avoid the Cookie Cutter Approach 141
Section Two Lower Blepharoplasty Procedure Pearls 143
41 Three-Step Technique for Lower Lid Blepharoplasty 144
Step 1: Transconjunctival Fat Removal 144
Step 2: “V” Suture Lateral Lower Eyelid Horizontal Tightening After Creation of the Eyelid (skin muscle)–Cheek Flap with the Carbon Dioxide Laser 144
Step 3: Resuspension of the Anterior Lamella and Adjacent Malar Fat Pad to the Lateral Orbital Periosteum 146
Rationale for the Three-Step Procedure 146
Pearls 147
References 151
42 Lower Eyelid Blepharoplasty: Procedure Pearls and Pitfalls 152
43 Lower Blepharoplasty: The Bilamelar Approach 154
44 The Skin in Lower Lid Blepharoplasty: General Principles 155
45 Incising the Septum over the Nasal, Central, and Lateral Fat Pads in Lower Blepharoplasty 156
46 Prolapsing the Inferior Fat Pads and Fornix in Lower Blepharoplasty 158
Key Points 158
47 Identifying the Inferior Oblique in Transconjunctival Blepharoplasty 160
Key Points 160
48 Achieving Symmetry in Lower Blepharoplasty Fat Removal 162
Divide Each Fat Pad Flush with the Orbital Rim—Nasal and Central Fat Pads 162
Divide Each Fat Pad Flush with the Orbital Rim—Lateral Fat Pad 162
Reposition the Eyelid and Ballottement to Look for Any Residual Bulging Fat 162
49 Hemostasis in Lower Blepharoplasty 165
50 The Treatment of Festoons in Lower Blepharoplasty 166
Section Three Fat Repositioning in Lower Blepharoplasty 169
51 Fat Repositioning in Lower Blepharoplasty: Less Is More 170
52 Fat Repositioning in Lower Lid Blepharoplasty: General Principles 171
53 Transconjunctival Lower Lid Blepharoplasty with and Without Fat Repositioning 172
Surgical Technique 172
Postoperative Care 174
Complications 174
Comments 175
References 179
54 Transconjunctival Lower Blepharoplasty with Intra-SOOF Fat Repositioning 180
Patient Selection 180
Procedure 180
Postoperative 181
Conclusion 182
References 183
55 Lower Lid Blepharoplasty with Fat Repositioning Using a Foam Bolster 184
56 Use of Tisseel in Lower Eyelid Blepharoplasty with Fat Repositioning 186
57 Lower Blepharoplasty with Fat Repositioning Without Sutures 189
Fat-Repositioning Procedure 189
Section Four Management of Postblepharoplasty Lid Retraction 194
58 Managing Postblepharoplasty Lower Eyelid Malposition 195
References 198
59 Retroauricular Dermal Spacer Graft for Lower Lid Retraction Repair 199
60 Mid-Lower Eyelid Tarsoconjunctival Flap-Skin Graft: Treatment of Cicatricial Lower Lid Retraction 202
Indications 202
Complications 203
Procedure 203
Stage 1 203
Stage 2 204
Conclusions 204
References 209
61 Treatment of Postblepharoplasty Lower Eyelid Retraction with Dermis Fat Spacer Grafting 210
Surgical Technique 210
References 212
Part V Forehead Rejuvenation 213
Section One Preoperative Considerations 214
62 Which Browlift to Do? 215
63 Browlifting: Patient Evaluation 216
Evaluation 216
64 Preoperative Botox for Endoscopic Browlifting 218
Section Two Endoscopic Forehead Rejuvenation 219
65 Five Tips for Endoscopic Browlift 220
66 Anesthesia Options in Endoscopic Forehead Lifting 221
Local Infifi ltration 221
Tumescent Technique 222
Avoiding Anesthetic Toxicity 222
Tumescent Technique 223
References 223
67 Endoscopic Forehead Rejuvenation: How to Set Up the Operating Room and Trouble Shooting 224
68 Endoscopic Forehead Rejuvenation: Equipment and Setup 226
69 Incision Technique for Endoscopic Forehead Elevation 229
Central Incision 229
Paracentral Incisions 229
Temporal Incisions 230
Prevention of Alopecia 230
70 Endoscopic Forehead Elevation: Patient Marking and Preparation 232
71 Endoscopic Midforehead Techniques: Improved Outcomes with Decreased Operative Time and Cost 233
72 Fifteen Principles of Enhanced Success in Endoscopic Browlift 237
Suggested Reading 239
73 Dissection of Central Forehead and Temporal Pocket with Periosteal Release 240
Dissection of Central Forehead Space and Scalp 240
Dissection of Temporal Space 240
Release of Periosteum 241
74 Endoscopic Forehead Lifting: Dealing with the Central Brow Depressors 243
75 Elevation and Fixation of the Lateral Brow and Canthus 245
76 Fixation Methods in Endoscopic Browlifting 246
77 Endosocopic Browlift with Deep Temporal Fixation Only* 247
Endoscopic Browlift with Deep Temporal Fixation Only 247
Temporal Lift 247
Treatment of the Depressor Muscles with Botulinum Toxin 248
Surgical Technique 248
Incisions 248
Temporal Dissection and Release of the Periosteum and Lateral Supraorbital Orbicularis Oculi Muscle 248
Release of the Brow Depressor Muscles 249
Brow Elevation and Fixation 249
Results (Before and After Photographs) 250
78 Tridimensional Brow, Glabella, and Temple Enhancement with Micro Fat Injection During Endoscopic Forehead Rejuvenation 256
Introduction 256
Surgical Technique 256
Conclusions 258
References 262
79 Scalp Fixation in Endoscopic Browlift 263
Suggested Reading 265
80 Closing and Dressing the Wounds in Endoscopic Browlift 266
Closing the Wounds 266
Dressing the Head 266
81 Endoscopic Forehead Rejuvenation: Avoiding and Managing Complications 268
References 269
Section Three Nonendoscopic Browlifting 270
82 The Direct Browlift: Focus on the Tail 271
Patient Selection 271
Procedure 272
Postoperative 272
Complications 272
Conclusion 272
83 Soft Tissue Augmentation of the Temporal Brow in Browlifting Surgery 275
Introduction 275
Procedure 276
Conclusions 276
References 279
Part VI Mid-Face Lift 281
84 Mid-Face Lift: General Considerations and How I Do It 282
85 Ten Rules for Mid-Face Lifting for the Repair of Lid Retraction 284
86 The Subperiosteal Mid-Face Lift Using Bioabsorbable Implants for Fixation* 285
References 291
87 Cheeklifting Pearls 292
88 Mid-Face Implants 294
Part VII Botox 297
89 Introduction to Botox 298
Reference 298
90 Evaluating Potential Botox Patients 299
Evaluation of the Potential Botox Patient 299
91 Botox: General Principles of Treatment 301
92 Botox: Where It Works Best 303
Reference 304
93 Preparation of Botox 305
Bullet Points 305
94 Documentation of Treatment: Botox 306
95 Botox Injection Technique 308
Reference 309
96 Cosmetic Botox Applications: General Considerations and Dosing 310
97 Botox: Avoiding Pitfalls 312
98 Botox Injection Techniques: Minimizing Bruising and Discomfort 314
99 Botulinum Toxin Injections Pearls 316
100 Botox Complications 317
101 Glabella Treatment with Botox 319
102 Corrugator and Procerus Rhytid Treatment with Botox 321
Corrugator Treatment Keys 321
Procerus Treatment Keys 322
103 Frontalis Injection with Botox 323
Frontalis Treatment Keys 323
104 Frontalis Treatment with Botox 325
105 Shaping of the Eyebrows with Botox 327
Modifying the Position of the Medial Eyebrows 327
Modifying the Position of the Lateral Eyebrows 327
Arching and Lifting the Eyebrows 328
Lowering and Flattening the Eyebrows 328
Treating Eyebrow Asymmetry 328
Pitfalls 329
Conclusion 329
References 330
106 Botox Injection Techniques: Crow’s Feet 331
Crow’s Feet Treatment Keys 331
107 Orbicularis Oculi Treatment with Botox 333
108 Perioral Botox Injections 335
Orbicularis Oris Therapy 335
Depressor Anguli Therapy 335
109 Botox Injection to the Lacrimal Gland for the Treatment of Epiphora 337
110 Botox Therapy for Hyperhydrosis: How I Do It 340
111 Other Uses of Botox 341
112 Botox for Axillary Hyperhydrosis 343
Part VIII Fillers 344
113 Optimizing Outcome from Facial Cosmetic Injections and Promoting Realistic Expectations 345
Preparations 345
Posttreatment 346
Expectations 346
114 Filler Pearls: General Considerations 348
Reference 348
115 List of Fillers 349
116 Dermal Filler Pearls: the Hyaluronic Acids 355
117 Radiesse Pearls 357
118 Juvederm Pearls: Fine and Superficial Lines 359
Reference 359
119 Achieving Beautiful Lip Augmentation 360
Consultation 360
Anesthesia 360
Choice of Filler 361
Anatomic Guidelines 361
Technique 362
Summary 363
References 364
120 Restylane Injection for the Lower Eyelid Tear Trough 365
121 Liquid Injectable Silicone for the Upper Third of the Face 367
References 370
122 Periocular Injectables with Hyaluronic Acid and Calcium Hydroxyapatite 372
General Principles 372
Hyaluronic Acid (HA) 373
Calcium Hydroxyapatite 373
123 Pearls and Pitfalls of Botox and Filler Substances in the Upper Third of the Face 376
References 381
124 Periorbital-Facial Volume Rejuvenation for Focal Deficits 382
Reference 383
125 Pearls for Periorbital Fat Transfer 384
126 Complementary Fat Grafting in the Periorbital Region 387
127 Autogenous Orbicularis and Fat as a Filler 389
Reference 389
Part IX Skin Rejuvenation 390
Section One Skin Care 391
128 Skin Care 101: The Basics 392
Basic Skin Care 392
Preoperative Skin Care 392
Skin Care After Rejuvenation Procedures 393
129 Retinoids for the Cosmetic Patient 394
Background 394
Suggested Reading 396
130 Evaluation of Skin Lesions in the Cosmetic Patient Made Simple: Actinic Keratosis 397
Section Two Nonablative Therapy 400
131 Chemical Peels for Facial Rejuvenation 401
132 Nonablative Laser and Light Facial Rejuvenation 404
Patient Selection 405
Infrared vs. Pulsed Dye 405
Postoperative Care 406
Choosing a Device 406
Device-Specifific Pearls 406
KTP or Frequency-Doubled Nd:YAG laser (532 nm) 406
Pulsed-Dye Laser (585 nm, 595 nm) 407
Intense-Pulsed Light Device (500–1200 nm) 407
Long-Pulsed Nd:YAG laser (1064 nm) 407
Mid-Infared Lasers (1320 nm Nd:YAG, 1450 nm diode, 1540 nm Er: Glass) 407
Fractional Resurfacing Lasers 407
Low Intensity Sources 407
Laser and Light Sources for Skin Rejuvenation 408
133 Mesotherapy for Cosmetic Periocular Enhancement 409
Delivery 410
Phosphatidylcholine 410
Section Three Ablative Therapy 411
134 Skin Rejuvenation Techniques: General Considerations 412
Patient Evaluation 412
Surgical Planning 412
Anesthetic Techniques 413
Surgical Procedure 413
Postoperative Care 413
135 CO2 Laser Skin Resurfacing Prophylaxis 415
136 CO2 Laser Resurfacing Immediate Postoperative Care Prior to Complete Epithelialization 416
137 Products Used in CO2 Laser Resurfacing Wound Care: Late Postoperative Care After Complete Epithelialization 417
138 Monopolar Radiofrequency Tissue Tightening 418
Background 418
Technology 418
Patient Selection 419
Treatment 420
Conclusion 421
139 Dual-Mode Erbium-YAG Laser Skin Resurfacing 423
Key Elements of Procedure 424
Patient Selection and Preparation 424
Procedure 424
Postoperative 425
Conclusion 425
References 426
140 Fraxel Treatment 427
Part X Thread Lift 429
141 Pros and Cons of Contour Threads for Upper Facial Rejuvenation 430
Advantages 430
Disadvantages 431
142 Periocular Suture Lifts: Brow and Malar Repositioning 432
143 Contour Threads Technique Pearls 435
144 Combined Modalities for the Correction of Asymmetric Brow Position 437
Part XI Other Cosmetic Procedures 439
145 Repair of the Torn Earlobe 440
Questions to Ask the Patient 441
Basic Principles 441
Surgical Technique for Complete Earlobe Tears 441
Surgical Repair for Partial Torn Earlobes 442
References 446
146 Upper Lip Lift as a Complementary Technique in Facial Rejuvenation 447
Introduction 447
Preoperative Markings 447
Technique 447
Discussion 448
Conclusion 448
Reference 451
147 SMAS Malar Fat Pad Lift with Short Scar Face Lift 452
148 Ten Tips for a Reliable and Predictable Deep Plane Facial Rhytidectomy 455
Introduction 455
Tip 1. Marking (Figure 148.1) 455
Tip 2. Skin Flap Dissection (Figure 148.2) 456
Tip 3. Marking the Zygomatic Arch (Figure 148.3) 456
Tip 4. SMAS Flap Creation (Figure 148.4) 456
Tip 5. Creating the SMAS Flap (Figure 148.5 and 148.6) 456
Tip 6. SMAS Flap Fixation (Figure 148.7) 457
Tip 7. Skin Flap Fixation (Figure 148.8) 457
Tip 8. Addressing the Earlobe (Figure 148.9) 458
Tip 9. Skin Excision Tips (Figure 148.10) 458
Tip 10. Addressing the Neck (Figure 148.11) 458
References 465
Part XII Functional Lid Malpositions 466
Section One Ptosis: Anterior Approach 467
149 Advantages of Sequential Versus Simultaneous Bilateral Levator Advancement Surgery 468
Theoretical Advantages to Unilateral Surgery 468
150 Considerations in Simultaneous vs. Sequential Bilateral Levator Repair 469
151 Unilateral Levator Resection for Jaw-Winking Ptosis 471
Suggested Reading 471
152 Ten Steps to Making Ptosis Surgery More Predictable 472
153 Adjustable Suture Technique for Levator Surgery 474
Surgical Technique 474
Reference 476
154 Tarsal Switch Levator Resection for the Treatment of Myopathic Blepharoptosis 477
Surgical Technique 477
Suggested Reading 482
155 Modified Levator Advancement Ptosis Technique 483
156 Minimally Invasive Ptosis Repair 484
Mini-invasive Ptosis Surgery 484
Suggested Reading 484
157 Small Incision External Levator Repair 487
Further Reading 488
158 Ptosis Repair by a Single-Stitch Levator Advancement 490
Reference 492
159 Postoperative Care in Ptosis Surgery 493
Section Two Ptosis: Posterior Approach 494
160 Pearls for Müller’s Muscle–Conjunctival Resection–Ptosis Procedure Combined with Upper Blepharoplasty 495
References 496
161 Müller’s Muscle–Conjunctival Resection Pearls: Phenylephrine and Resection Considerations 498
Pearl 1. The Phenylephrine Test 498
Pearl 2. The Resection Nomogram 499
Level of Phenylephrine Response 499
162 Avoiding Lid Contour Abnormalitiesin Müller’s Muscle–Conjunctival Resection: Recognizing the Lateral Shift 500
163 Müller’s Muscle–Conjunctival Resection Procedure Tips 501
Pearl 1: Marking the Pupillary Axis 501
Pearl 2: 6-0 Prolene Suture 501
Reference 502
Section Three Entropion 503
164 Minimally Invasive, Three-Step, Transconjunctival Entropion Repair 504
165 Simple Entropion Repair Using the Orbicularis Strip 506
Suggested Reading 507
166 Simple “Bedside” Cautery Entropion Repair 508
Section Four Ectropion 509
167 “Simple-Dimple” Lateral Tarsus Fixation 510
168 Lower Lid Retractor Dissection 513
169 Simple Lower Lid Tightening Without Tarsal Strip 514
Further Reading 514
170 Technique for Medical Canthal Flap to Correct Lid Retraction/Medial Ectropion 515
171 Medial Canthorraphy 517
172 Myocutaneous Flaps and Canthopexy for Repair of Severe Cicatricial Ectropion 520
Index 522

"90 Evaluating Potential Botox Patients (p. 294-295)

Samuel M. Lam

Understanding the clinical bene? ts and limitations of Botox (BTX) therapy is important; these must be effectively communicated to every patient in order to ensure uniform satisfaction. As almost every practitioner of cosmetic enhancement, surgeon and physician alike, use Botox in his or her clinical practice, it is important to differentiate the quality of one’s Botox therapy from competitors. This chapter will recount how to attain consistently excellent results and to minimize patient discomfort so as to increase patient loyalty and repeat visits. Botox injection is easy to perform but must be undertaken with care and attention for optimal results.

Evaluation of the Potential Botox Patient

Botox therapy provides excellent and safe periocular cosmetic enhancement when applied in a deliberate and conscientious method. During the initial consultation, the physician should ask what experiences the patient may have had with Botox in the past and what expectations he or she should hold. Review of the patient’s prior experiences is informative as to what pitfalls the physician can avoid in the current session. For example, if the patient says that the brow position descended excessively with prior usage, the physician should pay particular attention to how to treat the frontalis.

Excessive ecchymosis from a previous treatment may re? ect careless or inadvertent venopuncture or a patient’s excessive usage of a nonsteroidal antiin? ammatory medication. Counseling a patient during the initial phone encounter to avoid aspirin, herbal therapies, or other blood-thinning medications is important as is avoiding treatment 1–2 weeks before an important professional or social engagement in case ecchymosis arises and cannot be entirely camou? aged.

It is helpful during the discussion to study the patient’s habits of animation and particular anatomic features before injection is undertaken. During discussion with a patient, the physician may glean clues that can be very informative. For example, the patient may constantly raise or hold the eyebrows skyward to compensate for brow ptosis. Treatment of these frontalis rhytids with Botox will compromise the patient’s ability to lift the brows and be quite devastating for the patient.

Having the patient close the eyes tightly and then slowly open them, concentrating all the while on not using the brow muscles, will prove conclusively to the patient that the frontalis is being used to alleviate brow ptosis and therefore should not be injected. Also, the surgeon may observe that the patient constantly frowns during pensive moments. Therefore, the surgeon can advise that therapy of the glabellar musculature may prove bene? cial to break this undesirable habit. In fact, treatment of this unin- tended habitual action over a period of a year may actually break the habit, as the patient unconsciously unlearns this behavior over time. These clinical clues can only be effectively discerned when the patient is unwittingly observed, so the initial cosmetic consultation can be invaluable in many respects for the physician."