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D. T. Hudak, A. B. Weinfeld, P. A. Brannan, P. Afrooz, B. Guyuron; The Role of Middle Lamella in Tear Trough: An Anatomical Appreciation and Associated Clinical Application. Invest. Ophthalmol. Vis. Sci. 2007;48(13):3583. doi: https://doi.org/.
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© ARVO (1962-2015); The Authors (2016-present)
Observation of 346 lower blepharoplasties during recent years revealed that not every patient with aging lower eyelids had a tear trough and of those patients that did, not all had it bilaterally. The purpose of this manuscript is to describe the results of measurements made and to recommend an anatomically based approach for the rejuvenation of the senescent lower lid.
Intraoperative measurements were made to assess the depth of insertion of the middle lamella relative to the inferior orbital rim on consecutive patients with deep tear trough and those with no tear trough.
Patients who demonstrated a deep tear trough (n=20 lids) were noted to have an insertion that was further posterior than those who had no or minimal tear trough (n=20 lids). On average, in patients who had a deep trough, the insertion of the middle lamella was approximately 4.7 mm deep in the mid-portion of the inferior orbital rim wall, 3.8 and 3.4 mm medially and laterally, respectively. In patients who did not have a deep tear trough, the insertion of the middle lamella was approximately 1-2 mm posterior to the inferior orbital rim centrally and 1 mm laterally. These findings have lent credence to an anatomically based surgical technique that includes 1) elevation of a skin-muscle flap or transconjunctival elevation of a muscle flap, 2) disinsertion of the middle lamella, 3) repositioning of the middle lamella and lower lid fat pads with attachment to the anterior orbital rim using 6-0 Vicryl, (septal reset) and 4) the use of canthopexy to produce a more elegant and rejuvenated appearance to the tarsal area. .
An anatomic explanation for and an anatomically guided surgical approach is described to correct the tear trough deformity with a predictable outcome.
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