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Figure 1 Hyperpigmentation of blepharoplasty incisions after treatment (B)

The upper eyelid extends superiorly to the eyebrow,

which separates it from the forehead. The upper eyelid skin crease (superior palpebral sulcus) is approximately 8–11 mm superior the eyelid margin and is formed by the attachments of the superficial insertion of levator aponeurotic fibres (8–9 mm in men, 9–11 mm in women). The inferior eyelid fold (inferior palpebral sulcus), which is seen more frequently in children, runs from 3 mm inferior to the medial lower lid margin to 5 mm inferior to the lateral lid margin. The nasojugal fold runs inferiorly and laterally from

the inner canthal region along the depression of separation of the orbicularis oculi, forming the tear trough. The malar fold runs inferiorly and medially from the outer canthus toward the inferior aspect of the nasojugal fold. The open eye represents the palpebral fissure between

the lid margins, which is 28–30 mm in length and approximately 9 mm in maximum height. The distance between the medial canthus to the mid-line of the nose is approximately 15 mm. The skin of the eyelids is the thinnest of the body

tear film maintenance, by distributing a protective and

optically important tear film over the cornea during blinking; and in tear flow by their pumping action on the conjunctival and lacrimal sacs4

. The structures that must be considered

in eyelid anatomy are the skin, subcutaneous tissue, the orbicularis oculi muscle, the submuscular areolar tissue, the fibrous layer consisting of both the upper and lower tarsus and the orbital septum; the lid retractors of the upper and lower lids; and the retroseptal fat pads and the conjunctiva. The orbital septum represents the anatomic boundary

between the tissue of the lid and the orbital tissue. The upper and lower lids can be considered similar structures with differences mainly in the lid retractor arrangement.

The orbicularis oculi muscle can be divided into the orbital and

palpebral parts, with the latter being divided further into the pre-septal and pre-tarsal portions.

(≤1 mm). The nasal portion of the eyelid skin has fine hairs and more sebaceous glands than the temporal aspect. The transition from this thin eyelid skin to the thicker skin of the eye brow and the cheek skin is evident. Fat is sparse in pre-septal and pre-orbital skin, and is entirely absent from pre-tarsal skin. Subcutaneous tissue is absent over the medial and lateral palpebral ligaments, where the skin is adherent to the underlying fibrous tissue.

The orbicularis oculi muscle The orbicularis oculi muscle is one of the superficial muscles of facial expression.

Invested by the superficial muscle-aponeurotic system (SMAS), muscle contracture is translated to movement of the overlying tissues by the fibrous septa extending from the SMAS into the dermis. The orbicularis oculi muscle can be divided into the orbital and palpebral parts, with the latter being divided further into the pre-septal and pre-tarsal portions. The palpebral portion is used in blinking and voluntary winking, while the orbital portion is used in forced closure. Facial nerve innervation arises from the temporal branches and zygomatic branches of the facial nerves. The orbital portion extends in a wide, circular fashion

32 ❚

Figure 2 Laser blepharoplasty of upper and lower lids

November/December 2012 |

around the orbit. It has a curved origin from the medial orbital margin, being attached to the superior orbital margin, maxillary process of the frontal bone, and medial palpebral ligament. The fibres from the upper and lower lid join laterally to form the lateral palpebral raphe, which is attached to the overlying skin. The pre-tarsal portion lies anterior to the tarsus; submuscular areolar tissue consists of variable loose connective tissue. Superior continuance in this submuscular plane arrives at the retro-orbicularis oculi fat (ROOF), which is best developed in the eyebrow region. Additionally, the suborbicularis oculi fat (SOOF) is found in the lower lid in a continuance of this plane. The tarsal plates are composed of dense

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