the orbito palpebral region: CLASSIC EYE - THE STAR’S EYE Is the most frequent. It is most beautiful in shape and most favorable for surgery. This is the one described in all textbooks and manuals. COCKER SPANIEL EYE Anti-mongoloid palpebral fissure. It exists in two forms: • Orbital form: the lateral cantus is lower than the medial one. A blepharoplasty should be combined with a reasonable lateral canthopexy • Palpebral form: associated brow ptosis. Classic blepharoplasty is enough. SUNKEN EYE Large orbit with protruding superior rim; high position of eyebrow; long upper eyelid with a high palpebral fold - 10-15mm from the lid margin. Eye globe is well protected, but with age (between puberty and middle age) ptosis frequently appears. In this case aesthetic blepharoplasty is limited to skin excision but should include ptosis correction by levator muscle repositioning (plication or lower reinsertion on the tarsus) as well as orbital frame remodelling. GLOBULAR EYE Rounded palpebral fissure, long upper lid and short lower lid, soft tissue protrusion to a varied degree. There are two types: • Fatty tissue hypertrophy • Small and shallow bony orbit. It is the one that makes most problems. In childhood and in their prime these people have big, beautiful eyes but in the long run the eyelids distend and the eyeball is progressively denuded. Very often yet the youth has a scleral show. Globe protrusion causes recurrent conjunctivitis. Aesthetic surgery is particularly risky and presumes orbital remodeling. There are different associations between the described morphotypes. For example “cocker spaniel” eyes which are also sunken – in this case standard blepharoplasty would always impose problems – from scleral show to ectropion. A meticulous preoperative assessment would spare the whole series of complications. A successful reconstruction is less feasible and would include
lifting of the facial mask and heteropalpebral flaps. We attribute equal importance to the mechanism of aging. It is by: - Relaxation – most frequent. The skin folds in large deep wrinkles, there is brow ptosis, blepharochalasis, ectropion or entropion with trichiasis - Hollowing – The skin relaxes in fine wrinkles and lines the skull relief. In addition to the lid hollowing a senile ptosis, mostly asymmetric, is a frequent finding, as well as levator muscle desinsertion - Retraction – least frequent in plastic surgery practice. The skin gets tight and smooth. Few wrinkles are present. Eyebrows stay in place but lids shorten which causes ectropion and épiphora. Often patients see first the ophthalmologist. Aesthetic surgery is very risky because the skin is inelastic and insufficient. Of course as with morphotypes pure forms are rarer than associations. As far as surgical experience is concerned we would like to conclude that maximalism in aesthetic surgery requires global approach, i.e. a thorough preoperative assessment and choice of optimal and spearing surgical technique or association of techniques. Unfortunately this is often mistaken for a maximal excision following maximal pulling which results in the above mentioned “surgical look” accompanied or not by specific pathology: scleral show, recurrent conjunctivitis and keratitis. REFERENCES 1. Krastinova, D. Le lifting coronal. Expérience personnelle. Congrès SOF.CPRE, Paris, 1986 2. Krastinova, D. The mask-lift. In: Practical Cosmetic Plastic Surgery. P. 361-70, China 2002 3. Tessier, P. Aesthetic aspects of bone grafting to the Face. Clin Plast Surg; Philadelphia; Saunders ed., 1981 4. Tessier, P. Mask Lift. Presentation to SOFCEP, Paris, September 17, 1988 5. Krastinova, D. Le lifting facial sous-périosté. Ann. Chir. Plast. Esthét. 34:199, 1989 6. Krastinova, D. Mask-lift and facial aesthetic sculpturing. Plast. Reconstr. Surg. 95:21, 1995 7. Carraway, J.H., Mellow, C.G., The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 85:971, 1990 8. Hamra, S.T. The aging face: Analysis, surgical approach and result assessment. Aesthetic Surg. J. 16:65, 1996 9. Rohrich, R.J. The post-meeting “Wear–you-out” syndrome in cosmetic surgery. Plast. Reconstr. Surg 108:1044, 2001 10. Miller, T. Face lift: Which technique? Plast. Reconstr. Surg. 100:501, 1997
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