Facebook
Twitter
LinkedIn
Email
 |
Checking for direct PDF access through Ovid | |
Excerpt
First, our clinical (operative) and experimental (cadaveric dissections, histopathology) findings definitively point to two separate, distinct layers posterior to the orbicularis oculi muscle: the investing suborbicularis fascia1,2 and the septal extension proper.3 To further characterize this distinction, an anatomical precedent stands before us: the multilaminated fascial system of the temporalis, well characterized by Stuzin et al.4 and Byrd and Andochick.5 Functionally speaking, just as the superficial layer of the deep temporal fascia (or innominate fascia) and its accompanying fat pad provide a gliding mechanism for the muscles of mastication, so is this distinction between the septal extension and other fascial layers important in the differential function of the orbicularis oculi and levator-septal complex. Similar to the suspension of the upper third of the face, which relies heavily on the dissection, elevation, and suture plication of the distinct layers of the temporalis,4 failure to recognize this multilaminated system of the upper eyelid may lead to faulty ptosis correction, as well as an inadequate result in septal reset procedures.
Furthermore, when this multilayered fascial system is disrupted, preaponeurotic fat becomes displaced toward the anterior lamella and, as our correspondents state, becomes surrounded by the suborbicularis fascia. This, compounded by attenuation or disruption of septal extension dermal attachments (Fig. 2 in our article3), leads to effacement of the upper eyelid crease. Certainly, an effective way to restore upper eyelid topography is to attach the suborbicularis fascia to the upper lid crease, which will indeed prevent spurious reattachment of the levator to a point higher and asymmetric to the unaffected side. Supratarsal fixation in this manner, which would include septal extension fibers and essential levator dermal attachments communicated through the septal extension, not only resets the lid crease but also prevents late postoperative ptosis, as pointed out by Codner.3 Lastly, future anatomical studies are warranted to relate corresponding lower lid fascial structures.
