Anatomical Study Of The Lower Eyelid And Systematic Therapy For The Lower Palpebral Bags

1.ObjectiveThis paper is to give a systemic and comprehensive anatomic study on the lower eyelid and its surrounding area,investigate the position, extent,appearance,character,and adjacent relationships of the postseptal eyelid fat,arcuate expansion,lower lid retractor and other structures,and present the anatomical basis for the execution of the more rational lower eyelid blepharoplasty.Also,this paper aims to summarize the 1990 consecutive cases which we cured since 2000,presents a better classification for the lower palpebral bags,and provides relative different operative techniques.2.Materials and methods(1)Basic anatomic part:Materials:10 antiseptic adult specimens(20 sides) were studied, ages ranged from 56 to 72.There were three males and seven females.Methods:1 side of the specimens was sagittal sliced;the other 19 sides were dissected layer by layer from surface to deep which aimed to observe the position,extent,appearance,character,and adjacent relationships of each anatomical structure in the lower eyelid and its surrounding area.These specimens were measured with the sliding caliper, and the result was recorded by words and photos.(2)Clinical part:Clinical documents:There were 1990 consecutive cases,and ages ranged from 17 to 71.There were 1923 females and 67 males.Methods:we recorded the different characters of each patient's lower palpebral bags,and cured them with relative different operative technique.We followed up 391 cases for a median time of 12.05 months.3.Results:(1)Basic anatomic part:â‘ The arcus marginalis of the orbital septum is found to insert the infraorbital rim not along the superior most point but to insert from the inner wall to the outer wall of the infraorbital rim.The thickness of the orbital septum is not uniform but getting thickening from medial to lateral.â‘¡The arcuate expansion is an accessory structure of the orbital septum.It originates from the orbital septum,and extends in a medial and deep way with the orbital septum sending strands to it all along the course.It joins the lower lid retractor in the 1/3 section of the inferior oblique muscle,and converges to the Lockwood's ligament in the end.â‘¢we incised the orbital septum along the arcus marginalia,and turned it over toward the eyelid margin.The postseptal eyelid fat is divided into two pads by the inferior oblique muscle.There is a membrane between the postseptal eyelid fat and the deeper retrobulbar fat,and their characters are different.We also found an inverse triangle fat below the lateral canthal tendon in 3 sides of the specimens.The fat came from the upper eyelid and fell into the lower eyelid through the pocket which bounded by the orbital septum anteriorly and the lateral canthal tendon posteriorly.â‘£The distinct junction of the lower eyelid retractor and the orbital septum was confirmed in all specimens,with the distance from the inferior tarsal border to the junction ranged from 2.5mm to 3.4mm.(2)Clinical part:â‘ The herniation of the orbital fat in the lower eyelid can be classified into 5 types:Herniation of the medial postseptal fat compartment and the medial part of the lateral postseptal fat compartment; Herniation of the medial and lateral postseptal fat compartment; Herniation of the medial postseptal fat compartment,the medial part of the lateral postseptal fat compartment and the lateral excrescent fat; Herniation of the medial and lateral postseptal fat compartment and the lateral excrescent fat;Herniation of the medial and lateral postseptal fat compartment,the lateral excrescent fat with/without the retrobulbar fat.â‘¡According to clinical pathological characters,the lower palpebral bags were divided into 4 types and 5 subtypes:â… Simple skin chalasis with /without orbicularis oculi pachynsis;â…¡Simple herniation of the postseptal eyelid fat with/without skin chalasis.It can be divided into two subtypes:â…¡₁ Herniation of the medial postseptal fat compartment and the medial part of the lateral postseptal fat compartment;â…¡₂ Herniation of the medial and lateral postseptal fat compartment;â…¢Herniation of the postseptal fat compartment with chalasis of the skin,the orbicularis oculi and the orbital septum;â…£Theâ…¢type combined with the chalasis of the support structures of the lower eyelid.â‘¢According to different patient's character,we used different operation technique among seven types:Simple excision the skin of palpebral margins lower eyelid blepharoplasty;Skin flap lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty combined with simple excision the skin of palpebral margins;Myocutaneous flap lower eyelid blepharoplasty;Myocutaneous flap lower eyelid blepharoplasty combined with suspending the orbicularis oculi to periosteum;Myocutaneous flap lower eyelid blepharoplasty combined with wedged excision of the palpebral margin.We followed up 391 cases of the 1990 cases for a median time of 12.05 months.we observed that the results were good in 333 cases till the last follow-up,others of them suffered different kinds of unpleasant appearance,but no severe complication is included.4.Conclusionâ‘ According to the resource and the membrane of the fat compartment, the postseptal eyelid fat is divided into medial postseptal fat compartment,lateral postseptal fat compartment and the lateral excrescent fat.The lateral postseptal fat compartment is divided into two parts by the arcuate expansion.â‘¡The observation of anatomy shows that the preseptal approach is better than postseptal approach of the transconjunctival lower eyelid blepharoplasty.The incision on the conjunctiva should be within 2.5mm below the inferior tarsal border.â‘¢According to clinical pathological characters,the lower palpebral bags were divided into 4 types and 5 subtypes:â… Simple skin chalasis with /without orbicularis oculi pachynsis;â…¡Simple herniation of the postseptal eyelid fat with/without skin chalasis.It can be divided into two subtypes:â…¡₁ Herniation of the medial postseptal fat compartment and the medial part of the lateral postseptal fat compartment;â…¡₂ Herniation of the medial and lateral postsepta]fat compartment;â…¢Herniation of the postseptal fat compartment with chalasis of the skin,the orbicularis oculi and the orbital septum;â…£Theâ…¢type combined with the chalasis of the support structures of the lower eyelid.â‘£According to different patient's character,we can use different operation technique among seven types:Simple excision the skin of palpebral margins lower eyelid blepharoplasty;Skin flap lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty combined with simple excision the skin of palpebral margins;Myocutaneous flap lower eyelid blepharoplasty;Myocutaneous flap lower eyelid blepharoplasty combined with suspending the orbicularis oculi to periosteum;Myocutaneous flap lower eyelid blepharoplasty combined with wedged excision of the palpebral margin.We must perform the corresponding lower eyelid blepharoplasty according to the different patient's requirement and the character of his/her lower palpebral bags observed before the operation.It can increase the post-operative satisfaction and reduce the complications.