- Clinton D McCord
Anchoring techniques are the heart of not only the prevention of problems but also the correction of problems.
The term ‘anchoring’ refers to the two main fixation points in a cheeklift:
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anchoring of the lateral eyelid tendons – canthoplasty or -pexy, which controls the shape of the eyelid fissure ; and
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anchoring of the inferior arch of the orbicularis muscle , which provides support for the lower lid and positions the mid-cheek .
The approach to the lower lid surgery is to perform cheeklifts through transcutaneous eyelid incisions with optimum redraping of skin.
The two most common problems after cheeklift are:
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abnormalities in the shape of the eyelid fissure from failure of canthal anchoring ; and
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retraction and sagging of the lower lid and cheek from failure of anchoring of the inferior orbicularis muscle .
Eyelid fissure shape is the result of the position and curvature of the upper and lower lids. Excellent studies have shown mathematically that upper lid curvature is almost solely the result of the indentation of the globe on the lid. This is not so with the lower lid, where indentation does play some role, but the tone and position and laxity of the canthal attachments of the lower lid are the most important.
Normal eyelid fissure shape varies, but, in general, the lower lid edge reaches the inferior limbus – the canthal angle is as high as the inferior pupillary edge.
The downward displacement of the canthus and lower lid that occurs with age is a constant.
Figure 9.1 summarizes the variety of modifications that must be made in lateral canthoplasties with the varying conditions of:
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a standard positioned eye;
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a lower lid with horizontal laxity;
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a prominent eye; and
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an enophthalmic eye.
Patients with a greater degree of eye prominence usually will require additional steps to prevent scleral show. Loosening of the retractors in the lower lid by recession of the capsulo-palpebral fascia will gain some upward movement of the lid edge in prominent-eyed patients (see Fig. 8.19 ). Those with very prominent eyes will require primary insertion of spacer material (see Fig. 8.20 ). This may include autogenous fascia lata or autologous dermis (Alloderm) primarily to elevate the lower lid margin to prevent scleral show.
It is the anchoring of the flap of the inferior arc of the orbicularis muscle that is the handle of the cheeklift and acts as a sling to support the lower lid.
The sub-orbicularis oculi fat (SOOF) and malar fat are fused to the muscle by the interdigitation of the superficial musculo-aponeurotic system (SMAS) and are redraped upward as the muscle is redraped .
Periorbital eyelid fat and prolapsed anterior orbital fat are repositioned by the tension of the reanchored flap on the orbital septum, which is on the posterior surface of the muscle flap.
Double anchoring of the orbicularis muscle flap is necessary: the base of the muscle flap is anchored in the periosteum at the lateral rim, while the tip of the muscle flap is anchored at varying places in the deep temporal fascia superolateral to the lateral orbital tubercle (see Fig. 8.24 ).
The vector of redraping of the muscle flap must vary according to eye prominence. In the non-prominent eye, a more oblique vector can be used for maximum smoothing ( Fig. 9.2 ). With prominent eyes, a vertical vector of redraping must be used to prevent the downward clotheslining effect.
There are many techniques described to perform the cheeklift from a distant incision, with different vectors needed for canthal anchoring and muscle flap anchoring. However, because of the variations in eye prominence and laxity, it is difficult to see how performing a cheeklift from a single remote vector can take into account these needed variations.
In many patients, there may be combined reasons for problems. When selecting a procedure to correct a problem following cheeklift, it is important to choose one that is anatomically appropriate.
The complications that occur following cheeklifts need to be accurately diagnosed as:
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primarily an anchoring problem;
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primarily a skin shortage problem; or
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failure to recognize eye prominence .
To summarize the techniques needed to correct postoperative problems following cheeklifts:
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anchoring – muscle flap, canthus – through lateral canthoplasty, orbicularis muscle flap, periosteal flap;
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skin recruitment – vertical skin recruitment with a secondary cheeklift, by reanchoring the orbicularis flap; and
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use of spacer – for prominent eyes and in scarring.
With regards to problems arising from poor anchoring at the canthus (canthal anchoring for fissure abnormalities), three reconstructive procedures are available:
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a repeat simple canthoplasty, for simple shape problems;
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periosteal flap canthoplasty ( Fig. 9.3A ); and
Figure 9.3
Reconstructive anchoring procedures for the lateral canthus. (A) Periosteal strip canthoplasty. (B) Fascia sling canthoplasty.
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canthoplasty with fascia sling to the lower lid ( Fig. 9.3B ).
If stronger anchoring is needed:
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Phimosis and too much upward slant is corrected by reanchoring with a simple canthoplasty at 1 week ( Fig. 9.4 ).
