FACIAL AESTHETIC SURGERY (Blepharoplasty, Forehead & Brow Procedures)

1. FACIAL AESTHETIC SURGERY-II
(Blepharoplasty, Forehead & Brow Procedures)

2. CONTENTS
▪ INTRODUCTION
▪ BLEPHAROPLASTY
▪ FORHEAD AND EYE LIFT
▪ CONCLUSION
▪ REFERENCE
2

3. BLEPHAROPLASTY
3

4. INTRODUCTION
▪ Beer published the first medical illustration of the aging eyelid in
1807.
▪ Von Graefe first used the term blepharoplasty to describe a case of
eyelid reconstruction following a cancer resection.
▪ The term blepharoplasty is strictly used as the surgical removal of
excess skin and muscle, with and without fat resection.
4

5. Anatomy
5

6. 6
▪ The upper and lower eyelids surround the palpebral
fissure and meet at the medial and lateral canthus.
▪ The lateral canthus is 2 mm higher than the medial
canthus.
▪ With the eye in primary position, the margin of the
upper eyelid should cover 1 to 2 mm of the cornea while
the margin of the lower eyelid is usually within 2 mm of
the inferior border of cornea.
▪ The lower lid and malar junction should be one
continuous plane

7. 7

8. 8

9. 9

10. ALTERATIONS
RESULTING
FROM THE
AGING PROCESS
10
Although these changes may
vary among individuals, there
are several changes that are
common to the aging process,
such as family traits, loss of
skin elasticity, sun damage,
periorbital tissue loss, and
deflation of periorbital fat.

11. 11
▪ The retentive ligaments of the periorbitary region
are rigid osteocutaneous ligaments, such as the
orbitomalar ligament and the zygomaticocutaneous
ligament.
▪ When periorbital soft tissues fall, they are contained
by these ligaments, thus producing a concavity in the
region, which the patient refers to as a “dark circle
around the eyes”, in addition to a swelling above the
ligament

12. 12
The surface anatomy of a
smooth, youthful face (left
side) compared with the
same face showing the
convexities and concavities
caused by the aging
process (right side)

13. 13

14. 14
• decrease of the lateral superciliary and a depression
of the temporal region.
• decrease in the distance between the eyebrow and
the ciliary line, creating a hooded look on the upper
eyelid.
• redundancy of skin and dermatocalase in the upper
eyelid.
• alterations, asymmetries of the eyelid sulcus height,
and even ptosis.
• Increase in ROOF (retro-orbicularis oculi fat).
• scleral show.

15. 15

16. Preoperative Evaluation
▪ presence of dry eye or lacrimation or epiphora complaints.
▪ ligament tarsal laxity measured through snap back test.
▪ the integrity of the anterior lamella
▪ the presence of Bell’s reflex.
▪ ocular extrinsic motility.
▪ the presence of existing lagophthalmos.
▪ prominent eyeball or even some degree of enophthalmus.
16

17. 17
Snap back test.

18. 18
The anterior lamellar
test without
deficiency. The lower
eyelid margin
reaches gently the
pupil.

19. Upper
Blepharoplasty
19

20. 20
▪ Measure the position of the lid crease centrally on each side with
calipers.
▪ Mark the existing eyelid crease.
▪ This should fall between 6 to 10 mm above the eyelid margin centrally.
▪ If the position of the lid crease is different on each side, choose one
crease height and mark symmetric incisions for each eyelid.
▪ If the crease is not obvious, manually move the eyelid up and down to
better visualize the crease.
▪ The lateral edge of the mark should be extended to the orbital rim
along a crow’s foot crease.
▪ Typically, this should be placed 4 to 5 mm above the lateral canthus to
avoid webbing.
▪ Placement of the incision along the lid crease results in a hidden scar.

21. 21

22. 22
• After marking, with the eyelids closed, use a smooth fine-
tipped forceps to pinch the excess skin.
• One tip of the forceps will grasp the skin along the marked
lid crease while the other end is used to grasp the
superior extent of the excess skin.
• Repeat this maneuver at several points along the eyelid
and connect the points to outline the upper limit of skin to
be removed.
• Mark this line and connect it with your lid crease marking
medially and laterally.
• A safe zone of skin resection is to preserve a brow-to-
margin distance of 15 to 20 mm.

23. 23
• Inject subcutaneous anesthetic
in the area to be resected, taking
care to inject superficially just
below the skin.
• Incise the skin along the marked
incision lines with a 15 blade.
• Some prefer to use a CO2 laser or
Colorado microdissection needle
to incise the skin.
• goal is to make a smooth
continuous incision line

24. 24
• Use forceps and iris scissors to excise the marked area of skin, taking
care to excise skin only and leaving the orbicularis intact.

25. 25
▪ Use cautery to achieve
hemostasis.
▪ At this point, prolapsed fat
may be removed if desired.
▪ a. The orbicularis and
septum are opened with iris
scissors or cautery to
expose the fat pads.
▪ b. Gentle pressure on the
globe will further prolapse
the fat

26. 26
• A hemostat is placed across the base of the prolapsed fat.
• Great care is taken to avoid any traction on the fat as this can
lead to bleeding posterior to the septum.
• The distal fat is excised and the clamped edge of the fat is then
cauterized and released.
• This can be repeated until a desirable amount of fat has been
removed.
• It is important to note that aggressive fat debulking of the
eyelids can result in a hollowed appearance and has generally
fallen out of favor.
• Minimal conservative fat removal is recommended.

27. 27

28. 28
• The skin is then closed with running 8-0 nylon.
• Apply antibiotic/steroid ointment to the incision
and eyes.

29. 29

30. Lower Lid
Blepharoplasty
30

31. 31

32. 32

33. Transcutaneous Approach
1. A subciliary incision 2 mm below the lower eyelid
lashes. The marking is extended along crow’s foot crease
at lateral canthus to lateral orbital rim.
2. Subcutaneous anesthetic is injected along the marked
incision.
3. A traction suture is placed through the lid margin and
is used to apply upward traction to the lower lid during
the procedure.
33

34. 34

35. 35
4. Incision along the previously marked line is completed.
5. Dissection using iris scissors is carried out inferiorly in a
subcutaneous plane to create a skin flap. Dissection is
carried out inferior to the extent of excess skin.
6. The orbicularis and orbital septum may be opened with
iris scissors or cautery to expose the lower eyelid fat pads.
Fat may then be resected as was described in the upper
eyelid blepharoplasty or can be redraped over the inferior
orbital rim to address any tear trough deformity

36. 36

37. Transconjunctival Approach
1. Trans conjunctival injection of anesthetic into the lower
eyelid is performed.
2. The lower eyelid is retracted anteriorly to expose the
palpebral conjunctiva.
3. Cutting cautery is used to incise the conjunctiva at the
lower edge of the tarsal plate, extending the incision through
the lower eyelid retractors to the level of the orbicularis.
37

38. 38
Transconjunctival
incisions to
remove the fat
bags on lower
eyelid

39. 39
4. Dissect inferiorly in a plane between the septum and
orbicularis to expose the fat pads.
5. The fat pads can then be excised, tightened with
cautery or redraped.
6. The conjunctival incision can be closed with 2 or 3
interrupted 7-0 chromic sutures or may be left open
after the procedure.

40. Postoperative Care
▪ Apply antibiotic/steroid ointment to the surgical incisions twice daily for
1 week.
▪ Ice therapy is applied in first 72 hours to reduce postoperative swelling.
▪ Avoid public swimming pools and hot tubs for 1 to 2 weeks.
▪ Avoid strenuous activity or bending below the waist for 2 weeks.
▪ Sutures can be removed 7 to 10 days after surgery.
▪ Expect postoperative swelling and bruising to persist for up to 3 to 4
weeks after surgery.
40

41. 41

42. 1. Orbital Hematoma
2. Asymmetry
3. Lagophthalmos
4. Lid Malposition
5. Ocular Surface Irritation
6. Dry Eyes
COMPLICATIONS
42

43. Orbital Hematoma
▪ result in an orbital compartment syndrome and vision loss.
▪ This can be avoided by being judicious with tissue handling to avoid
traction of the fat pads.
▪ Advising patients to stop anticoagulants or herbal medications that can
cause increased bleeding is a must.
▪ Severe pain, inability to open the eyelids, and sudden decreased vision
are hallmark signs that warrant the possibility of opening the incision
for evacuation of the hematoma.
▪ Timely recognition and evaluation are crucial in preventing visual loss.
43

44. Asymmetry
▪ Asymmetry of the upper lid creases can be avoided by careful and
equal marking of the eyelid crease at the beginning of the
procedure.
▪ Asymmetry of lid height and/or contour usually results from
uneven dissection of fat and/or preexisting lid or brow ptosis.
44

45. Lagophthalmos
▪ Mild postoperative lagophthalmos (inability to completely
close the eyes) is common and typically resolves in the
first few days after surgery.
▪ This can be managed with lubrication of the eyes.
▪ If it is present beyond the first week, it typically can be
managed with ointment and massage of the upper eyelids.
45

46. 46
▪ Persistent lagophthalmos is usually the result
of aggressive skin removal or scarring of the
orbital septum.
▪ Reoperation with lysis of scar tissue and/or
skin grafting may be required in severe cases.
▪ Conservative skin removal is always
preferred because further excision can be
performed if needed.

47. Lid Malposition
▪ Ptosis of the upper eyelids can occur due to injury to the
levator aponeurosis if surgical dissection was carried too
deep into the eyelid structures.
▪ Gentle handling of the tissue is key.
▪ Excessive scarring and wound infections are extremely rare
in the eyelids.
47

48. 48
• Complications of lower eyelid blepharoplasty
include lower eyelid retraction, ectropion, and
inferior scleral show.
• These typically occur when there is excessive
removal of skin and muscle.
• Upward massage of the lids can be attempted in the
acute postoperative period.
• However, persistent ectropion and/or retraction
may require surgical revision with skin graft.

49. 49

50. 50
Preseptal
Hematoma

51. 51
Retrobulbar
Hematoma

52. 52
Preseptal/
Orbital
Cellulitis

53. Ocular Surface Irritation
and Dry Eyes
▪ As mentioned previously, dryness can be transient in the
initial postoperative period which can be corrected with
aggressive use of artificial tears.
▪ However, sometimes ocular surface irritation and dryness
persist despite good position of the lids.
▪ It would be appropriate to refer the patient to an
ophthalmologist for further evaluation and management.
53

54. Forehead
&
Brow Lift
54

55. 55
▪ The forehead and brow lift is a comprehensive
operation and is not just a method used for raising
the brows.
▪ When used properly, it can address not only brow
ptosis but also dynamic muscular problems .
▪ This procedure yields more dramatic facial
improvement when properly and selectively
combined with other rejuvenation procedures such
as fat grafting, skin resurfacing, fillers, neurotoxins,
and bone remodeling.
▪ Correct diagnosis of age-related changes is critical.

56. ANATOMY
56

57. 57
Fascial
attachments
around the
orbital rim.

58. GALEA
58

59. 59

60. 60

61. 61
Frontalis acts to raise the
eyebrow complex.
Lateral orbicularis acts like a
sphincter, depressing the lateral brow.

62. Sensory
nerves
62

63. Motor
nerve
63
Facial nerve branches in the periorbital region. Note the
corrugator has dual innervation from the temporal branch
and the zygomatic branch. The temporal branch crosses
the middle third of the zygomatic arch as 2–4 branches.

64. Patient presentation Forehead Aging
64
Patient frowning. The paired
vertical folds are caused by the
corrugator supercilii and the
transverse lines at the nasal radix
are caused by the procerus. The
paired oblique lines are caused by
the depressor supercilii and the
medial orbicularis oculi. Laterally
the “crow’s feet” lines are caused
by the vertically running fibers of
the orbicularis oculi.

65. 65
Patient raising eyebrows. The transverse
forehead lines are caused by the frontalis.

66. 66

67. 67
Orbital changes with age: orbital volume expands, most marked superomedial and
inferolateral. (With permission from Kahn DM, Shaw RB. Aging of the bony orbit. A
three-dimensional computed tomographic study. Aesthet Surg J 2008; 28(3):258–264.)

68. 68
An oval formed by the eyebrow above, and the
nasojugular fold below, should have the pupil at its
equator. (Gunter J, Antrobus S. Aesthetic analysis
of the eyebrows. Plast Reconstr Surg 1997;
99:1808–1816.)

69. 1. Open coronal approach
2. Anterior hairline approach
3. Temple approach
4. Transpalpebral approach –
muscle modification
5. Lateral brow approach
6. Direct suprabrow approach
7. Subgaleal Endoscopic
Browlift with Absorbable
Fixation
Surgical
techniques
69

70. 70

71. Open coronal approach
The technique involves an
incision over the top of the
head, classically about 6–8 cm
behind the anterior hairline,
although this incision can be
placed almost anywhere in the
hairbearing scalp.
71

72. 72
• The incision is made full-thickness down to periosteum, and the anterior
flap can then be raised in either the subperiosteal, or more commonly,
the subgaleal plane.
• Under direct vision, the flap is elevated down to the orbital rim.
• If glabellar muscles are to be exposed, the galea must be breached on its
deep surface, entering the galeal fat pad for access to the muscles .
• The frown muscles, corrugator, depressor supercillii and procerus can
be removed or weakened as necessary.
• Typically, resection of the corrugator requires dissection of the
supratrochlear nerve branches which course through the substance of
this muscle.

73. 73

74. 74
Coronal approach showing corrugator muscles.

75. Anterior hairline
approach
▪ This incision is usually
placed along the anterior
hairline, until it reaches
the hairline laterally,
where it transitions into
the hair-bearing
temporal scalp.
75

76. 76
▪ From the anterior hairline incision, dissection of the
forehead flap can be done in one of three different
planes: subperiosteal, subgaleal, and subcutaneous.
▪ Regardless of the plane being used, the anterior
hairline approach offers the same advantage as the
coronal approach, namely excellent surgical
exposure, without the disadvantage of moving the
anterior hairline posteriorly.

77. 77
• Because there is no undermining of hair follicles, the
surgeon has the option of a subcutaneous dissection plane
which is done on the superficial surface of the frontalis
muscle.
• This allows brow elevation without the need to divide any
sensory nerves, and also provides a potential effacement of
deep transverse forehead lines.
• A popular modification of this method is a short incision in
the widow’s peak, which is used to target only the lateral
brow

78. 78
Limited hairline
subcutaneous
approach.

79. 79
• The anterior hairline approach can also be used to lower an
excessively high anterior hairline or to lower overly high
eyebrows.
• These problems may be congenital but often are the result of
previous brow lift surgery.
• Hairline lowering involves a posterior dissection past the
vertex of the skull, in order to extensively mobilize the scalp.
• Releasing incisions are made in the galea, and the scalp is
advanced, utilizing bony fixation to maintain the new
hairline position.
• If the anterior approach is used to lower the eyebrows, bony
fixation is done at the supraorbital rim.

80. 80
Anterior hairline incision to lower the anterior hairline Hairline lowering.

81. Endoscopic approach
▪ The principle advantages of the endoscopic brow lift
are a very good surgical exposure, magnification of
the surgeon’s view, and short, undetectable
incisions.
▪ In addition, the scalp denervation associated with
the open coronal approach is largely avoided
81

82. 82

83. 83
• Access for the procedure is through 3–5 small (1–2 cm)
incisions placed within the hair-bearing scalp.
• Forehead flap dissection is done to the same extent as
with the open coronal lift.
• Flap dissection can be done blindly at first, but is
completed under endoscopic control when approaching
the orbital rim in order to avoid damaging the
supraorbital nerve.

84. 84
Hair preparation
and preoperative
markings.

85. 85
Endotine Triple fixation device Placement of the lateral fixation suture
Drilling the hole. Inserting the Endotine Triple fixation device

86. 86

87. Trichophytic Endoscopic Forehead-
Lifting in High Hairline Patients
87

88. 88
Preoperative (A) and 1 year postoperative (B) photographs following
pretrichial endoscopic forehead lifting.

89. Subgaleal Endoscopic Browlift
with Absorbable Fixation
▪ The subgaleal plane allows direct
access to the corrugator,
procerus, and depressor
supercilii muscles for
conservative modification.
▪ The neurovascular bundles are
also easily visualized in this
plane, approximately 1 cm
superior to the orbital rim
89

90. 90

91. Temple approach
▪ A temple approach involves a full-thickness scalp incision in the
temple, lateral to the temporal crest line.
▪ Knize improved and popularized this approach with dissection
on the deep temporal fascia, releasing of the lateral orbital rim,
the supraorbital rim, and the zone of fixation with using an
endoscope.
▪ After flap mobilization, fixation is done with sutures between
the superficial and deep temporal fascia.
91

92. 92

93. 93
• Disadvantages of this method include limited
visibility of the central and medial supraorbital
rim, and the fact that the fixation vector applied
to the lateral eyebrow is oblique, rather than
vertical, which may be inappropriate for some
patients

94. Transpalpebral approach –
muscle modification
▪ Using the upper lid blepharoplasty approach, the glabellar
frown muscles can be approached directly.
▪ This is an excellent method to attenuate glabellar frown lines in
patients who do not require a forehead lift.
▪ It can also be used as an adjunct to the patient undergoing an
isolated elevation of the lateral third of the brow.
▪ The advantage of this method is a hidden incision, which may
be used for two purposes, blepharoplasty and frown muscle
ablation.
94

95. 95
The main disadvantages of
this approach include
potential damage to sensory
nerves (supraorbital &
supratrochlear), and
increased bruising and
edema compared to an
isolated upper lid
blepharoplasty

96. Lateral brow approach
▪ Laterally, the purple dashed lines mark the
expected course of the facial nerve temporal
branches.
▪ The purple dot represents the sentinel vein.
▪ The curved purple line marks the temporal
crest line which is accentuated when the
patient clenches her teeth, contracting the
temporalis.
▪ Medial to the crest line, the black cross
hatched band is the expected course of the
deep branch of the supraorbital nerve, in
purple.
▪ The corrugator supercilii, depressor
supercilii and procerus are marked in black.
96

97. 97
• The neurovascular bundle of the
deep branch of the supraorbital
nerve.
• The subperiosteal pocket has been
developed medially and the
temporal pocket against the deep
temporal fascia has been developed
laterally.
• The two pockets are joined along
the temporal crest line.
• When the lateral brow is raised, the
neurovascular bundle will
telescope up under the scalp
closure.

98. Direct suprabrow approach
▪ An excision of full-thickness skin is done along the
upper margin of the eyebrow, or alternatively within
a deep forehead crease.
▪ The principle disadvantages of this method are the
visible scar it creates and that fact that over time,
brow depressing forces will once again stretch out
the skin, causing a recurrence of brow ptosis.
98

99. Transpalpebral browpexy
▪ During upper lid blepharoplasty, the ptotic lateral brow can be
addressed through the same upper lid incision.
▪ The lateral portion of the superior orbital rim is easily exposed, and
dissection proceeds superiorly over the frontal bone, superficial to
the periosteum.
▪ Advantages of Transpalpebral browpexy are the ease of the
procedure and a hidden scar.
▪ The principle disadvantage is the limited effect achieved and
questionable longevity.
99

100. Suture suspension browpexy
▪ A number of methods have been developed to elevate the
brow only using sutures, with no dissection at all.
▪ Methods include barbed sutures or suture loops which are
placed blindly through subcutaneous tunnels.
▪ The obvious advantage of these methods is extreme
simplicity and relative safety, while the principle drawback
is their limited effect, and poor longevity.
100

101. Midforehead-lift (indirect
lift)
101
Planned midbrow incision.
• They are designed to be
camouflaged by excising a deep
forehead rhytid .
• A complete excision of one of
these rhytids is designed.
• The incision is typically broken
in the midline or paramedian
positions

102. 102
Preoperative (A) and postoperative (B) photographs of a midbrow-lift.

103. Endoscopic Brow-Lift with Deep
Temporal Fixation Only (DTFO)
103
Marking of the temporal incision (large arrow)
parallel to the tail of the brow with its medial extent
at the temporal conjoint fascia
The temporal incision has been made and
taken down to the deep temporal fascia

104. 104
Patient before (A) and 1 week
after (B) endoscopic brow-lift
with DTFO. (C) Intraoperative
photograph of the patient’s
elevated brow complex to an
unnaturally high position after a
complete release of all
periosteum and brow depressor
musculature
prior fixation.

105. COMPLICATIONS IN
BROW LIFT
1. Bleeding
▪ Adequate injection with a hemostatic agent, obtaining intraoperative
hemostasis, and avoidance of injury to the superficial temporal or
zygomaticotemporal arteries, supraorbital or supratrochlear vascular
bundles, and sentinel vein improves outcomes.
▪ If an injury to these structures is noted, it should be controlled before
suspension and closure. Slow postoperative bleeding may be
controlled with pressure alone, although hematomas necessitate
evacuation and control of bleeding.
105

106. 2. Nerve Injury
▪ Although peri-incisional ansesthesia is expected, this
should be temporary.
▪ The supratrochlear and supraorbital neurovascular
bundles should be identifiedand preserved to minimize
additional forehead hypoesthesia medially up to the
vertex.
▪ Direct injury is uncommon; however, traction neuropraxia
may occur secondary to suspension.
106

107. 107
• Temporally, dissection in a plane superficial to the superficial layer of
the deep temporal fascia minimizes injury to the zygomatico temporal
and auriculotemporal branches of the second division of the trigeminal
nerve and avoids temporal and lateral frontal parasthesias.
• Additionally, in the temporal region, great care must be taken to avoid
injury to the temporal branch of the facial nerve because this results in
paralysis and asymmetry of the forehead.
• Dissection in the plane superficial to the superficial layer of the deep
temporal fascia and identification and preservation of the sentinel vein
is important to protect this motor nerve.

108. Scarring and Alopecia
▪ Prominent scarring and alopecia often discussed with
open approaches typically results from poor incision and
closure technique.
▪ This complication may be minimized in open approaches
by making an irregular incision with an extreme bevel 4 to
5 mm posterior to the hairline in an area of consistent
follicular density to avoid dermal appendages and allow
for postoperative hair follicle growth through and around
the forming scar.
108

109. Brow Asymmetry and
Over/Under Elevation
▪ Postoperative asymmetry may be caused by unrecognized
preoperative asymmetries or blepharoptosis with failure.
▪ Iatrogenic causes include asymmetric muscle resection or
suspension.
▪ Proper patient selection, full bilateral release of the
conjoined tendon and arcus marginalis, and symmetric
suspension or skin excisions should be used to minimize
this risk.
109

110. 110
• Overelevation or underelevation of the brow may occur
with any approach to forehead rejuvenation.
• Overresection of skin in any variation of the coronal lift
or excessive suspension with any technique may result in
overelevation of brow with possible lagophthalmos.
• This may be temporary and resolve with time or
uncommonly may be permanent and difficult to address.
• This risk is increased when concomitant upper
blepharoplasty is performed.

111. 111
Christopher D. Pool and Jessyka G. Lighthall, The modified mini direct
bone-anchored browlift for frontal paralysis, Operative Techniques in
Otolaryngology - Head and Neck Surgery
• Under monitored anesthesia care, supratrochlear and supraorbital nerve blocks
were performed in addition to subcutaneous local anesthesia.
• Three, 7 mm incisions were marked on the operative brow just within the hair line
• The first incision was marked 2.5 cm off midline, medial to the supraorbital
neurovascular structures. The second and third incisions were made 1 cm lateral
to the other.
• Bone anchored-suture with 3-0 MaxBraid was placed into the pilot holes using the
included inserter with guide sleeve.
• The suture was then passed through the arcus marginalis with the galea and
frontalis and secured at the desired height with the desired shape.
• This was repeated at all three incision sites.
• The deep dermal layers were closed with 4-0 monocryl suture. Skin was closed
with 5-0 fast gut suture.

112. 112
Pre-operative left
brow ptosis
following frontal
branch injury.
Six-month post-
operative photo with
excellent brow height.

113. 113
Local retro-orbicularis oculus fat (ROOF) resection in upper
blepharoplasty: A retrospective evaluation study of 65 bilateral
upper blepharoplasties. Zhang et al
• A total of 65 patients (5 males, 60 females) with puffy upper eyelids recruited from
October 2015 to October 2016 were included in the study.
• Full-incision blepharoplasty combined with partial ROOF resection was performed
on all patients.
• The thickness of soft tissue in the upper eyelid was measured by ultrasound
biomicroscopy preoperatively and at 12 months postoperatively.
• 62 patients (124 eyes) were followed up for 12–15 months (mean 13.8 ±2.7
months).
• Before the surgery, the thickness of the ROOF was 0.35 ±0.12 mm on the left and
0.42 ±0.08 mm on the right.
• Twelve months postsurgery, the thickness of the ROOF was 0.18 ±0.03 mm on the
left and 0.20 ±0.02 mm on the right.
• Puffy upper eyelids can be corrected effectively by local ROOF resection in esthetic
blepharoplasty.

114. 114

115. 115
B. Chen, D.M.-d. Woo and J. Liu et al., Orbicularis Oculi Muscle Flap
Rotation for Correction of Sunken Eyelid in Cosmetic Blepharoplasty,
Journal of Plastic, Reconstructive & Aesthetic Surgery
(A) A 24-year-old woman
presented with sunken
eyelids. (B) Sunken grooves
aggravated in upgaze. (C)
The incision line and sunken
area were marked. (D) A
strip of muscle flap was
preserved.

116. 116
(E) The muscle flap
was shaped to fill the
sunken area. (F) The
muscle flap was
rotated and sutured to
the sunken area. (G-H)
Six-month
postoperative
appearance showed
satisfied double
eyelids without sunken
eyelid

117. CONCLUSION
▪ The face is considered as a three-dimensional dynamic
mosaic.
▪ Numerous techniques are available to improve the
arrangement of the pieces in the mosaic.
▪ The combination of various techniques can reduce the
aggressiveness of every single method.
▪ We can achieve more sustainable harmonic results while
also reducing the potential for risks and complications.
117

118. REFERENCES
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3. Morgan, J. M., & Farrior, E. (2006). Rejuvenation of the aging forehead. Facial Plastic Surgery Clinics
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4. Perkins, S. W., & Batniji, R. K. (2006). Trichophytic endoscopic forehead-lifting in high hairline
patients. Facial Plastic Surgery Clinics of North America, 14(3), 185–193.
5. Nassif, P. S. (2006). Endoscopic brow-lift with deep temporal fixation only (DTFO). Facial Plastic
Surgery Clinics of North America, 14(3), 203–211.
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