(Original PDF) Video Atlas of

Oculofacial Plastic and Reconstructive

Surgery
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15. Frontalis suspension with silicone rod • Sang-Rog Oh and Bobby S. Korn 104
16. Repair of conjunctival prolapse • Bobby S. Korn 111
17. Upper eyelid retraction repair • Bobby S. Korn 115
18. Levator extirpation and frontalis suspension • Tammy H. Osaki, Midori H. Osaki and Bobby S. Korn 120
19. Upper eyelid loading with platinum weight • Bobby S. Korn and Don O. Kikkawa 132
20. Direct browplasty • Bobby S. Korn and Don O. Kikkawa 138
21. Internal browplasty • Bobby S. Korn, Weerawan Chokthaweesak and Don O. Kikkawa 143
22. Endoscopic browplasty • Don O. Kikkawa and Bobby S. Korn 147
23. Pretrichial browplasty • Bobby S. Korn and Don O. Kikkawa 156
24. Facelift by minimal access cranial suspension (MACS) • Bradford W. Lee and Bobby S. Korn 163
25. Ectropion repair by retractor reinsertion and lateral tarsal strip • Bobby S. Korn and Don O. Kikkawa 176
26. Ectropion repair by medial spindle • Bobby S. Korn and Don O. Kikkawa 182
27. Ectropion repair with full thickness skin grafting • Bobby S. Korn 185
28. Canthus sparing drill hole canthoplasty • Bobby S. Korn and Don O. Kikkawa 194
29. Entropion repair by transconjunctival approach • Bobby S. Korn and Don O. Kikkawa 205
30. Entropion repair by Wies procedure • Don O. Kikkawa and Bobby S. Korn 210
31. Entropion repair by posterior tarsotomy • Karim G. Punja, Bobby S. Korn and Don O. Kikkawa 215
32. Epiblepharon repair • Audrey C. Ko and Bobby S. Korn 220
33. Limited upper eyelid protractor myectomy • Bobby S. Korn and Don O. Kikkawa 227
34. Lower eyelid retraction repair with porcine acellular dermal collagen matrix • Bobby S. Korn and
Don O. Kikkawa 234
35. Lower eyelid retraction repair with dermis fat • Bobby S. Korn and Don O. Kikkawa 247
36. Lower eyelid retraction repair with hard palate grafting • Bobby S. Korn and Don O. Kikkawa 257
37. Lower eyelid wedge resection and reconstruction • Patrick Yang and Bobby S. Korn 265
38. Lower eyelid reconstruction with periosteal flap and upper eyelid rotational flap • Don O. Kikkawa and
Bobby Korn 273
39. Lower eyelid reconstruction with semicircular flap • Don O. Kikkawa and Bobby S. Korn 283
40. Lower eyelid reconstruction with Hughes’ tarsoconjunctival flap • Lee Hooi Lim and Bobby S. Korn 292
41. Lower eyelid reconstruction with Mustardé flap • Richard L. Scawn and Bobby S. Korn 300
42. Lateral canthal reconstruction with rhomboid flap • Bobby S. Korn 307
43. Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft • Bobby S. Korn and Don O. Kikkawa 315
44. Temporal artery biopsy • Don O. Kikkawa and Bobby S. Korn 333
45. Conjunctival pillar tarsorrhaphy • Bobby S. Korn 340
46. Lateral tarsorrhaphy • Bobby S. Korn and Honglei Liu 347
47. Autologous fat transfer to the tear trough • Morris Hartstein and Bobby S. Korn 352
48. Hyaluronic acid gel filler to the inferior periorbita • Guy G. Massry 359
49. Botulinum toxin treatment for lateral canthal rhytids (crow’s feet) • Michael S. McCracken and Eric M. Hink 364

Contents

vi
50. Botulinum toxin treatment for glabellar rhytids • Michael S. McCracken and Eric M. Hink 369
51. Botulinum toxin treatment for forehead rhytids • Michael S. McCracken and Eric M. Hink 373
52. Thermal conjunctivoplasty • Bobby S. Korn 377

SECTION III Lacrimal system

53. Endoscopic dacryocystorhinostomy • Bobby S. Korn and Don O. Kikkawa 383
54. Endoscopic dacryocystorhinostomy with osteotome • Bobby S. Korn 392
55. Endoscopic dacryocystorhinostomy with lacrimal sac biopsy • Bobby S. Korn and Masashi Mimura 399
56. Endoscopic revision of failed dacryocystorhinostomy • Don O. Kikkawa and Bobby S. Korn 403
57. Endoscopic dacryocystorhinostomy with intranasal flap suturing • Nattawut Wanumkarng 410
58. Endoscopic dacryocystorhinostomy with balloon dacryoplasty • Don O. Kikkawa, Suk-Woo Yang and Bobby S. Korn 417
59. Endoscopic conjunctivodacryocystorhinostomy • Don O. Kikkawa, Kanjana Leelapatranurak and Bobby S. Korn 421
60. Bicanalicular intubation with silicone stent • Bobby S. Korn 428
61. Treatment of canaliculitis • Ramzi M. Alameddine and Bobby S. Korn 433
62. Silicone stent intubation with pigtail probe • Bobby S. Korn 437
63. Snip punctoplasty • Don O. Kikkawa and Bobby S. Korn 441

SECTION IV Orbit
64. Three wall orbital decompression • Bobby S. Korn and Don O. Kikkawa 444
65. Lateral orbitotomy with rim removal • Bobby S. Korn and Don O. Kikkawa 455
66. Inferior orbitotomy for cavernous hemangioma • Bobby S. Korn 460
67. Orbital fracture repair • Don O. Kikkawa and Bobby S. Korn 468
68. Orbital floor reconstruction in silent sinus syndrome • Bobby S. Korn 476
69. Transcaruncular approach to ethmoidal artery ligation • Don O. Kikkawa and Bobby S. Korn 487
70. Reposition of prolapsed lacrimal gland • Bobby S. Korn and Don O. Kikkawa 493
71. Optic nerve sheath fenestration • Bobby S. Korn and Don O. Kikkawa 499
72. Evisceration with orbital implant placement • Bradford W. Lee, Don O. Kikkawa and Bobby S. Korn 506
73. Enucleation and orbital implant placement • Jeremiah Tao and Bobby S. Korn 518
74. Orbital exenteration • Bobby S. Korn and Don O. Kikkawa 529
75. Orbital implant exchange with dermis fat graft • Bobby S. Korn 538
76. Multidisciplinary management of orbital varix • Jack Rootman 546

Index 551

Contents

vii
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 Video table of contents

Eyelid and face

Chalazion incision and drainage • Chapter 2, Video 1 – Bobby S. Korn
Upper blepharoplasty • Chapter 3, Video 2 – Bobby S. Korn
Asian upper blepharoplasty • Chapter 4, Video 3 – Bobby S. Korn
Asian eyelid crease formation (double eyelid operation) by suture ligation method • Chapter 5, Video 4 – Yoon-Duck Kim
Revision of Asian upper eyelid crease • Chapter 6, Video 5 – Yoon-Duck Kim
Root Z-epicanthoplasty • Chapter 7, Video 6 – Kyung In Woo
Mustardé’s epicanthoplasty • Chapter 8, Video 7 – Dongmei Li
Transconjunctival lower blepharoplasty with fat redraping • Chapter 9, Video 8 – Bobby S. Korn
Transcutaneous lower blepharoplasty with orbitomalar suspension and fat redraping • Chapter 10, Video 9 – Bobby S. Korn
Ptosis repair by external levator advancement • Chapter 11, Video 10 – Bobby S. Korn
Ptosis repair by small incision external levator advancement • Chapter 12, Video 11 – Bobby S. Korn
Ptosis repair by conjunctival Müller’s muscle resection • Chapter 13, Video 12 – Bobby S. Korn
Congenital ptosis repair by levator resection • Chapter 14, Video 13 – Bobby S. Korn
Frontalis suspension with silicone rod • Chapter 15, Video 14 – Bobby S. Korn
Repair of conjunctival prolapse • Chapter 16, Video 15 – Bobby S. Korn
Upper eyelid retraction repair • Chapter 17, Video 16 – Bobby S. Korn
Levator extirpation and frontalis suspension • Chapter 18, Video 17 – Bobby S. Korn
Upper eyelid loading with platinum weight • Chapter 19, Video 18 – Bobby S. Korn
Direct browplasty • Chapter 20, Video 19 – Bobby S. Korn
Internal browplasty • Chapter 21, Video 20 – Bobby S. Korn
Endoscopic browplasty • Chapter 22, Video 21 – Bobby S. Korn and Don. O. Kikkawa
Pretrichial browplasty • Chapter 23, Video 22 – Bobby S. Korn
Facelift by minimal access cranial suspension (MACS) • Chapter 24, Video 23 – Bobby S. Korn
Ectropion repair by retractor reinsertion and lateral tarsal strip • Chapter 25, Video 24 – Bobby S. Korn
Ectropion repair by medial spindle • Chapter 26, Video 25 – Bobby S. Korn
Ectropion repair with full thickness skin grafting • Chapter 27, Video 26 – Bobby S. Korn

ix
Canthus sparing drill hole canthoplasty • Chapter 28, Video 27 – Bobby S. Korn
Entropion repair by transconjunctival approach • Chapter 29, Video 28 – Bobby S. Korn
Entropion repair by Wies procedure • Chapter 30, Video 29 – Don O. Kikkawa
Entropion repair by posterior tarsotomy • Chapter 31, Video 30 – Bobby S. Korn
Epiblepharon repair • Chapter 32, Video 31 – Bobby S. Korn
Limited upper eyelid protractor myectomy • Chapter 33, Video 32 – Bobby S. Korn
Lower eyelid retraction repair with porcine acellular dermal collagen matrix • Chapter 34, Video 33 – Bobby S. Korn
Lower eyelid retraction repair with dermis fat • Chapter 35, Video 34 – Bobby S. Korn
Lower eyelid retraction repair with hard palate grafting • Chapter 36, Video 35 – Bobby S. Korn
Lower eyelid wedge resection and reconstruction • Chapter 37, Video 36 – Bobby S. Korn
Lower eyelid reconstruction with periosteal flap and upper eyelid rotational flap • Chapter 38, Video 37 – Bobby S. Korn
Lower eyelid reconstruction with semicircular flap • Chapter 39, Video 38 – Don O. Kikkawa
Lower eyelid reconstruction with Hughes’ tarsoconjunctival flap • Chapter 40, Video 39 – Bobby S. Korn
Lower eyelid reconstruction with Mustardé flap • Chapter 41, Video 40 – Bobby S. Korn
Lateral canthal reconstruction with rhomboid flap • Chapter 42, Video 41 – Bobby S. Korn
Upper eyelid reconstruction with Cutler-Beard flap and free tarsal graft • Chapter 43, Video 42 – Bobby S. Korn
Temporal artery biopsy • Chapter 44, Video 43 – Bobby S. Korn
Conjunctival pillar tarsorrhaphy • Chapter 45, Video 44 – Bobby S. Korn
Lateral tarsorrhaphy • Chapter 46, Video 45 – Bobby S. Korn
Autologous fat transfer to the tear trough • Chapter 47, Video 46 – Morris Hartstein
Hyaluronic acid gel filler to the inferior periorbita • Chapter 48, Video 47 – Guy G. Massry
Botulinum toxin treatment for lateral canthal rhytids (crow’s feet) • Chapter 49, Video 48 – Michael S. McCracken and Eric M. Hink
Botulinum toxin treatment for glabellar rhytids • Chapter 50, Video 49 – Michael S. McCracken and Eric M. Hink
Botulinum toxin treatment for forehead rhytids • Chapter 51, Video 50 – Michael S. McCracken and Eric M. Hink
Thermal conjunctivoplasty • Chapter 52, Video 51 – Bobby S. Korn

Lacrimal system
Endoscopic dacryocystorhinostomy • Chapter 53, Video 52 – Bobby S. Korn
Endoscopic dacryocystorhinostomy with osteotome • Chapter 54, Video 53 – Bobby S. Korn
Endoscopic dacryocystorhinostomy with lacrimal sac biopsy • Chapter 55, Video 54 – Bobby S. Korn
Endoscopic revision of failed dacryocystorhinostomy • Chapter 56, Video 55 – Don. O Kikkawa
Endoscopic dacryocystorhinostomy with intranasal flap suturing • Chapter 57, Video 56 – Nattawut Wanumkarng
Endoscopic dacryocystorhinostomy with balloon dacryoplasty • Chapter 58, Video 57 – Don O. Kikkawa
Endoscopic conjunctivodacryocystorhinostomy • Chapter 59, Video 58 – Don O. Kikkawa
Bicanalicular intubation with silicone stent • Chapter 60, Video 59 – Bobby S. Korn
Treatment of canaliculitis • Chapter 61, Video 60 – Bobby S. Korn

Video table of contents

x
Silicone stent intubation with pigtail probe • Chapter 62, Video 61 – Bobby S. Korn
Snip punctoplasty • Chapter 63, Video 62 – Don. O. Kikkawa

Orbit
Three wall orbital decompression • Chapter 64, Video 63 – Bobby S. Korn
Lateral orbitotomy with rim removal • Chapter 65, Video 64 – Bobby S. Korn and Don O. Kikkawa
Inferior orbitotomy for cavernous hemangioma • Chapter 66, Video 65 – Bobby S. Korn
Orbital fracture repair • Chapter 67, Video 66 – Don O. Kikkawa
Orbital floor reconstruction in silent sinus syndrome • Chapter 68, Video 67 – Bobby S. Korn
Transcaruncular approach to ethmoidal artery ligation • Chapter 69, Video 68 – Bobby S. Korn
Reposition of prolapsed lacrimal gland • Chapter 70, Video 69 – Don O. Kikkawa
Optic nerve sheath fenestration • Chapter 71, Video 70 – Bobby S. Korn
Evisceration with orbital implant placement • Chapter 72, Video 71 – Don O. Kikkawa
Enucleation and orbital implant placement • Chapter 73, Video 72 – Bobby S. Korn
Orbital exenteration • Chapter 74, Video 73 – Bobby S. Korn
Orbital implant exchange with dermis fat graft • Chapter 75, Video 74 – Bobby S. Korn
Multidisciplinary management of orbital varix • Chapter 76, Video 75 – Jack Rootman

Video table of contents

xi
Foreword to the second edition
This is a first for me. I have had the honor of writing the fore-
word for several books but never for a video atlas. As I reviewed
the first edition of this work and the revisions that will be incor-
porated into the second edition, I found myself wishing that
such a resource had been available in the 1980s when I first
began teaching residents and fellows. Intraoperative photo-
graphs are helpful but static and inherently limiting. As I watch
the videos, however, I am impressed by how much more effec-
tive they are in demonstrating the myriad points that we wish
to make when assisting trainees as they operate. A few exam-
ples that our residents have heard me mumble more than once:
• Inject the anesthetic sloooooowly to minimize discomfort.
• Keep the skin on stretch during the incision but don’t place
pressure on the eye.
• Keep the scalpel parallel to the skin…but bevel it here.
• Incise the skin uphill, or stay ahead of the blood if going
downhill.
• Don’t punish the skin; grasp the edge gently yet firmly, and
only once.
• The scissors are curved for a reason; use that to your
advantage.
• Cut purposefully; don’t nibble or gnaw.
• Sew as closely as possible to the wound edge and space
your sutures closely to avoid a ropey closure.
• Evert the wound edges; approximate, don’t strangulate.
• Don’t let the tissue slip off the needle.
• Don’t let the patients’ eyelids open while you’re closing the
skin; she is having a nice nap and won’t appreciate being
disturbed.
Although as teachers we usually want to critique each of the
dozens (? hundreds ?) of subtle but important steps that we
xii
wish to share with our residents and fellows, most of them have
difficulty remembering more than a few “pearls” from each case
– it’s simply a matter of information overload during what can
be a stressful experience. The opportunity to review the work
of masterful surgeons such as Drs. Korn and Kikkawa and their
collaborators – and to do so at leisure, without the challenges
of communicating, often cryptically with hand signals, while the
patient is awake and listening acutely to every word – is a major
advance.
This new edition has increased its scope from 43 procedures
to more than six dozen, including new information on eyelid
surgery in Asian patients, additional options for the reconstruc-
tion of periocular and facial defects following tumor excision,
multiple perspectives on endoscopic dacryocystorhinostomy,
and chapters on aesthetic topics such as fat grafting, injection
of fillers, and face lifts. In addition to the step-by-step instruc-
tions offered for each procedure, I like the accompanying tables
that summarize potential complications and ways to reduce the
risk of such, as well as the helpful listing of “consumables”
needed for the operation.
I predict that this atlas will be even more successful than its
original iteration – to the benefit of new residents, fellows on
the steep slope of the learning curve, experienced surgeons
who wish to hone their skills, and, most importantly, to the
patients we serve.
George B. Bartley, M.D.
The Louis and Evelyn Krueger Professor
of Ophthalmology, Mayo Clinic
Chair Emeritus, Department of Ophthalmology, Mayo Clinic
Chief Executive Officer Emeritus, Mayo Clinic in Florida
 Foreword to the first edition
This oculofacial video atlas is a true gem. It is the next best
thing to being there in the operating room with the authors.
Drs. Korn and Kikkawa are dedicated teachers who take a “belt
and suspenders ” approach to teaching in this text. First, they
provide exquisite, carefully edited, high-definition videos of all
the surgical procedures. Then, to further clarify each proce-
dure, they have all of the important steps described with high-
definition still frame photographs taken from the videos and
placed in a standard text. Important anatomic structures are
emphasized with color shading overlays in many of the photo-
graphs. Details about the fine points of each procedure are
described in the captions as well.
This video atlas should be helpful to the beginning surgeon
as well as the more experienced surgeon. The procedures
covered range all the way from surgical management of a
chalazion to endoscopic dacryocystorhinostomy and compli-
cated orbital operations. Both functional and cosmetic proto-
cols are carefully and elegantly delineated.
I have known Drs. Korn and Kikkawa very well for many years
and can attest to their vast surgical experience, attention to
every detail, and their unusual ability to transmit their extensive
knowledge to others. Dr. Korn was an outstanding fellow under
Dr. Kikkawa, and I had the distinct privilege of having Dr.
Kikkawa as an exceptional fellow. We have given lectures and
courses together and have collaborated on publications, so I
know well their intellectual integrity, bright minds, surgical skill,
and impeccable academic credentials.
This video atlas combines all of the elements of a true learn-
ing experience for anyone performing oculofacial plastic and
reconstructive surgery.
Richard K. Dortzbach MD, FACS
Professor Emeritus
Former Peter A. Duehr Chair
Department of Ophthalmology & Visual Sciences
University of Wisconsin School of Medicine and Public
Health
Madison, WI
xiii
Preface
Five years ago we embarked on a mission to bring the realm
of oculofacial plastic surgery directly from the operating room
to the practicing surgeon. We are now pleased to release the
Second Edition of the Video Atlas of Oculofacial Plastic and
Reconstructive Surgery. This video atlas is the product of hun-
dreds of hours of oculofacial surgery captured in high definition,
edited and narrated with anatomic overlays and step-by-step
diagrams.
We have made it our goal to include only the highest quality
videos to guide the surgeon through even the most complex
of operations. Highlights of the second edition include new
chapters on fat grafting, face-lifting, orbital fracture repair and
expanded section on Asian eyelid surgery and epicanthoplasty.
xiv
In addition, revised chapters from the first version with re-edited
videos are also included.
The field of oculofacial plastic surgery is still in its infancy.
Many time-honored procedures from the past are no longer
being performed today, being replaced by techniques that
allow for improved results and faster healing. Since inception,
oculofacial plastic surgery has been a discipline passed from
mentor to student and from colleague to colleague. We have
endeavored to maintain this close personal instructional method
in this atlas and hope that the readers enjoy this format.
Bobby S. Korn
Don O. Kikkawa
 List of contributors
Ramzi M. Alameddine, MD Don O. Kikkawa, MD FACS
Senior Clinical Instructor Professor of Ophthalmology and Plastic Surgery
Department of Ophthalmology Vice Chair, Department of Ophthalmology
University of California, San Diego School of Medicine University of California, San Diego School of Medicine
Shiley Eye Institute Shiley Eye Institute
La Jolla, CA La Jolla, CA
USA USA
Christine C. Annunziata, MD Yoon-Duck Kim, MD
Attending Oculofacial Plastic Surgeon Professor of Ophthalmology
Metrolina Eye Associates Samsung Medical Center
Matthews, NC Sungkyunkwan University School of Medicine
USA Seoul
Korea
Weerawan Chokthaweesak, MD
Assistant Professor of Ophthalmology Audrey C. Ko, MD
Mahidol University Senior Clinical Instructor
Ramathibodi Hospital Department of Ophthalmology
Bangkok University of California, San Diego School of Medicine
Thailand Shiley Eye Institute
La Jolla, CA
Morris E. Hartstein, MD, FACS
USA
Director, Oculoplastic Surgery
Assaf Harofeh Medical Center Bobby S. Korn, MD PhD FACS
Department of Ophthalmology Associate Professor of Ophthalmology and Plastic Surgery
Zerifin, Israel University of California, San Diego School of Medicine
Clinical Associate Professor Shiley Eye Institute
Saint Louis University La Jolla, CA
Department of Ophthalmology USA
St. Louis, MO
Bradford W. Lee, MD, MSc
USA
Assistant Professor of Ophthalmology
Eric M. Hink, MD Bascom Palmer Eye Institute
Assistant Professor of Ophthalmology University of Miami, Miller School of Medicine
University of Colorado Miami, FL
Denver, CO USA
USA

xv
Kanjana Leelapatranurak, MD Sang-Rog Oh, MD
Attending Ophthalmologist Attending Ophthalmologist, Division of Oculofacial and
Department of Ophthalmology Reconstructive Surgery
Bumrungrad International Hospital Department of Ophthalmology
Bangkok The Permanente Medical Group
Thailand Sacramento, CA
USA
Dongmei Li, MD
Professor of Ophthalmology Midori H. Osaki, MD, MBA
Beijing TongRen Eye Center Chief, Division of Ophthalmic Plastic and Reconstructive Surgery
Capital Medical University Department of Ophthalmology and Visual Sciences
Beijing Paulista School of Medicine/Federal University of Sao Paulo
China Sao Paulo
Brazil
Lee Hooi Lim, MBBS
Senior Consultant and Director Tammy H. Osaki, MD PhD
Eye Etc. Partners Pte. Ltd. Attending Ophthalmologist, Division of Ophthalmic Plastic and
Reconstructive Surgery
Singapore
Department of Ophthalmology and Visual Sciences
Honglei Liu, MD, PhD Paulista School of Medicine/Federal University of Sao Paulo
Associate Professor of Clinical Ophthalmology Sao Paulo
Vice Chair, Department of Ophthalmology Brazil
No. 4 Hospital
Ayelet Priel, MD
Xi’an City
Goldschleger Eye Institute
China
Sheba Medical Center
Guy G. Massry, MD Ramat-Gan
Clinical Professor of Ophthalmology Israel
University of Southern California, Keck School of Medicine
Karim G. Punja, MD, FRCSC
Los Angeles, CA
Clinical Associate Professor
USA
Department of Surgery, Division of Ophthalmology
Michael S. McCracken, MD University of Calgary
Medical Director, McCracken Eye and Face Institute Calgary, Alberta
Assistant Clinical Professor Canada
University of Colorado Health Science Center
Jack Rootman FRCS
Denver, CO
Professor (Emeritus)
USA
Department of Ophthalmology and Visual Science
Masashi Mimura, MD Department of Pathology and Laboratory Science
Chief, Clinic of Lacrimal Drainage Surgery and Ophthalmic University of British Columbia
Plastic and Reconstructive Surgery
Vancouver, British Columbia
Department of Ophthalmology
Canada
Osaka Medical College
Osaka
Japan

List of contributors

xvi
Mr Richard L. Scawn, MBBS, FRCOphth Patrick T. Yang, MD
Locum Consultant University of Toronto
Adnexal Service Department of Ophthalmology and Vision Sciences
Moorfields Eye Hospital Toronto
London Canada
UK
Suk-Woo Yang, MD
Jeremiah Tao, MD, FACS Professor of Ophthalmology
Associate Professor Department of Ophthalmology and Visual Sciences
Chief, Oculofacial Plastic Surgery Division of Ophthalmic Plastic and Reconstructive Surgery
Department of Ophthalmology Seoul St. Mary’s Hospital
Gavin Herbert Eye Institute The Catholic University of Korea
University of California Seoul
Irvine, CA Korea
USA
Nattawut Wanumkarng, MD
Attending Ophthalmologist
Department of Ophthalmology
Bumrungrad International Hospital
Bangkok
Thailand
Kyung In Woo, MD
Professor of Ophthalmology
Samsung Medical Center
Sungkyunkwan University School of Medicine
Seoul
Korea

List of contributors

xvii
Acknowledgements
We are indebted to the editorial staff at Elsevier for their
support of this project. In particular, we are grateful to Russell
Gabbedy (Executive Content Strategist) who has been a tire-
less supporter of this project since he commissioned the first
edition of the Atlas. We would also like to acknowledge Nani
Clansey (Senior Content Development Strategist) for doing
her best to manage this complex project, Andrew Riley (Project
Manager), Jonathan Davis (Multimedia), Alex Baker (Medical
Illustrations).
This book would not be possible without the support of col-
leagues and friends. First, we thank our teachers for instilling
in us the desire to continue to learn and the passion to practice
Dedication
For our parents, Tom and Tuanjai (BSK) and Robert and Alice
(DOK)
For Wanya, Justin and Bryan (BSK) and Cheryl, Jason, Claire
and Alina (DOK)
xviii
the highest form of art possible. Second, we thank our distin-
guished colleagues for their valued contributions to this book
and for their friendship. Third, we thank all of our fellows and
residents for continually challenging us to find the best surgical
approaches in the care of our patients. Many of our fellows
have contributed to this book making it even more meaningful
to us. Fourth, we thank the members of our academic office,
Annaleah Ariola and Denise Adame for their administrative
support.
Finally, we acknowledge our families for without their unwa-
vering love, patience and support this book would not be
possible.

CHAPTER 1
Foundations of oculofacial plastic surgery
Bradford W. Lee • Ramzi M. Alameddine • Don O. Kikkawa • Bobby S. Korn
INTRODUCTION
Oculofacial surgery is a unique specialty that combines
aspects of ophthalmology, general plastic surgery, head and
neck surgery, dermatology, neurological surgery, and craniofa-
cial surgery. With advances in endoscopic and small incision
techniques, many oculofacial procedures can now be per-
formed safely and effectively with minimal scarring and excel-
lent aesthetic results.
EVALUATION
Oculofacial surgery encompasses both functional and aes-
thetic goals. As such, the evaluation of the oculofacial patient
requires a complete history and physical examination with par-
ticular attention to medical, functional, aesthetic, and psycho-
social details.
A complete medical history should be elicited, with particular
attention to hypertension, diabetes, liver disease, immune
status, current or prior cancer, and trauma. Surgical history
should include any previous facial surgery, ophthalmic surgery
(such as refractive surgery), use of neurotoxins and dermal
fillers, and chemical- or energy-based skin treatments. Medica-
tions, including anticoagulants, tobacco, and alcohol, should
be documented. A history of implanted cardiac devices should
also be noted since this determines which types of cautery can
be safely used. The use of medications, tobacco and alcohol
should be documented.
The physical examination should focus on the areas of patient
concern and the proposed surgical procedure. The entire face
should be examined and the patient can be allowed to point
to areas of concern using a handheld mirror. For most eyelid,
facial, and orbital procedures, documentation of visual acuity,
pupillary function, color vision, slit-lamp examination, intraocu-
lar pressure, eyelid position and closure, and tear film are
minimum requirements. Dilated fundoscopic examination may
be required in select cases if there is any evidence of optic
nerve compromise. Ocular motility in nine positions of gaze
SECTION ONE INTRODUCTION
(Figure 1.1) and globe position by exophthalmometry (Figure
1.2) should be carefully documented for any orbital procedure.
The Naugle exophthalmometer is useful for measuring propto-
sis or enophthalmos when prior surgery has been performed
to remove the lateral orbital rim. Vertical and horizontal globe
displacement should be noted as well. Evaluation of lacrimal
diseases requires functional and anatomic testing. Both dye
disappearance testing and lacrimal probing and irrigation are
useful.
Ancillary testing for oculofacial surgery may include visual
field testing for functional eyelid conditions, dacryoscintigraphy
for lacrimal obstructions, and imaging studies for orbital dis-
eases. Computed tomography (CT) is useful for evaluation of
bony structures and general screening for orbital disease. Mag-
netic resonance imaging (MRI) is better suited for soft-tissue
lesions and optic nerve diseases. Angiography is indispensable
for evaluating vascular malformations.
Photography is an essential component of the oculofacial
examination. Ideally, photographs should be taken during all
aspects of patient care from the preoperative evaluation, intra-
operatively when indicated, and at postoperative visits. Many
third-party insurance carriers require photographic documenta-
tion prior to authorization of functional oculofacial surgeries.
Additionally, photographs are important for the aesthetic patient
to document changes after treatment and for medical legal
protection. Photographs should be taken in the frontal, side,
and three-quarter views. For orbital diseases, eye movements
in the nine positions of gaze are taken. Additionally, a worm’s
eye view (Figure 1.3) is used to document globe position and
closure of the lids to document the presence or absence of
lagophthalmos (Figure 1.4).
Modern digital single lens reflex (DSLR) cameras are ideal in
the oculofacial setting. These DSLRs allow for rapid sequence
photography with excellent resolution and dynamic range com-
pared to pocket-sized cameras with smaller imaging sensors.
Uniform lighting can be difficult and variable depending on
the clinical situation. In general, flash photography is used to
1
Figure 1.1 Standard version photographs showing the eyes in nine positions of gaze.

Figure 1.2 Globe position as measured using a Naugle Figure 1.3 Worm’s eye view in a patient with thyroid-related orbitopathy.
exophthalmometer.

Figure 1.4 Worm’s eye view of a patient gently closing her eyelids with
lagophthalmos on the right side.

SECTION ONE • INTRODUCTION

Chapter 1 Foundations of oculofacial plastic surgery
2
normalize lighting. A dedicated photo room with a blue back-
drop and diffuse lighting is ideal, but for most surgeons, a
DSLR using the pop-up or external flash will suffice. The use
of a 50 mm macro lens is ideally suited for full-time use. Using
the macro function, this lens allows close-up photography of
small lesions on the face. Furthermore, with its fixed focal
length, facial photographs will appear square and consistent,
avoiding the barrel distortion seen when the camera is too
close to the subject. Finally, to achieve uniform focus across
the entire photograph, a small aperture (at least greater than
f/10) should be set to allow for a deep depth of field.
ANESTHESIA
The choice of anesthesia depends on patient age, medical
condition, as well as physician and patient preference. Patient
safety and comfort are an absolute priority, and intraoperative
patient cooperation may be needed during certain oculofacial
procedures. A combination of various anesthetic modalities is
frequently utilized to provide an optimal surgical experience.
Topical anesthesia
Topical anesthetic drops such as proparacaine or tetracaine
are useful for conjunctival procedures and also to prevent
ocular discomfort from prep solutions (e.g., Betadine solution).
Topical anesthetic gels, such as lidocaine gel, with concentra-
tions ranging from 1% to 4%, can be used in more involved
procedures because of their longer-lasting effect. Also, topical
anesthetic creams can be applied to the skin before injection
procedures or minor cutaneous biopsies.
Local infiltration
In most oculofacial procedures, local infiltration of involved
tissues is the preferred method of anesthesia. It entails minimal
risks while allowing adequate patient comfort and cooperation.
Local anesthetic agents include short-acting lidocaine and pro-
caine, or long-acting bupivacaine. A mixture of short-acting and
long-acting anesthetic agents is often used to have a rapid
onset and long duration of action. The mixture of equal parts
of 2% lidocaine with epinephrine at 1 : 100,000 and 0.75%
bupivacaine is an effective combination. The vasoconstrictive
effect of epinephrine improves hemostasis, reduces vascular
absorption, and increases duration of action of the anesthetic.
Other potential additions include hyaluronidase, which facili-
tates anesthetic dispersion through tissues, and bicarbonate,
which buffers the pH, reducing the stinging sensation during
infiltration. The surgeon should be vigilant for possible cardiac
or neurologic side effects, particularly with inadvertent intravas-
cular injections. By withdrawing the plunger and ensuring that
there is no reflux of blood prior to injecting, the risk of intravas-
cular injection can be further reduced. Local anesthetic should
be injected sparingly during external levator advancement and
eyelid retraction repairs, since infiltrating the levator with anes-
thetic can cause artificially reduced levator function. Other risks
include tissue necrosis, although this is unlikely due to the
abundant vascularity of the periorbital area.
When local anesthesia is administered in a clinic setting
without oral or IV sedation, several maneuvers can be per-
formed to minimize discomfort. Performing massage or vibra-
tory distraction at or near the site of injection may decrease
pain perception according to the gate control theory. Dilution
of lidocaine/bupivacaine with sodium bicarbonate (in a 1 : 10
ratio) raises the pH to minimize injection site burning. Pre-
cooling the target area with ice packs is another adjunct, as is
use of topical lidocaine cream for the skin or 4% lidocaine on
cotton tip applicators for mucous membranes. Finally, slow
injection, handholding and talking “talkesthesia” are all useful
in fully conscious patients. Minimizing pain during injection will
go a long way towards maintaining the confidence of your
patients and ensuring subsequent cooperation during the
procedure.
Regional block
Regional blocks can be useful in oculofacial procedures but are
rarely used as a standalone means of anesthesia due to redun-
dant innervation in the facial region (Figure 1.5). It allows the
surgeon to minimize the volume of local infiltration needed,
anesthetize broad regions of the face, and minimize tissue
distortion from local infiltration. Regional blocks of the face
must address one or more branches of the ophthalmic, maxil-
lary, and mandibular divisions of the trigeminal nerve.
Lacrimal nerve
The lacrimal nerve branches off the ophthalmic division of the
trigeminal nerve and supplies the lateral upper eyelid and lac-
rimal gland. It can be blocked by injecting the needle along the
superolateral orbital rim behind the lacrimal gland. Potential
risks include injury or injection into the lacrimal artery. This block
is useful when performing lacrimal gland biopsies or resuspen-
sion procedures (Chapter 70).
Frontal nerve
The frontal nerve is a branch of the ophthalmic division of the
trigeminal nerve. It further divides into the supraorbital and
supratrochlear nerves and supplies the medial and central
upper eyelids and the forehead. It can be fully blocked by inject-
ing anesthetic deep in the orbit along the central orbital roof.
Alternatively, the supraorbital nerve can be selectively blocked
by injecting near its exit from the orbit, at the supraorbital notch
or foramen, around the medial third of the superior orbital rim.
A supraorbital block anesthetizes the central eyelid, eyebrow,
and forehead. Similarly, the supratrochlear nerve can be
blocked by injecting anesthetic near the trochlea at the junction
of the medial and superior orbital rim. A supratrochlear block
anesthetizes the medial eyelid and eyebrow. Prior to injecting,
the surgeon should withdraw the plunger on the syringe to
ensure that inadvertent intravascular injection into the supraor-
bital or supratrochlear arteries does not occur. This block can
be used for any upper eyelid procedure and is well suited for
limited upper eyelid protractor myectomy (Chapter 33).
Nasociliary nerve
The nasociliary nerve is the third branch of the ophthalmic divi-
sion of the trigeminal nerve. It supplies the nasal mucosa and
skin through the anterior and posterior ethmoidal nerves, as
well as the medial canthus and lacrimal sac via the infratroch-
lear nerve. An infratrochlear block is achieved by injecting
deeply under the trochlea above the level of the medial canthal
tendon. A deeper injection at the same location would block
the ethmoidal nerves, but possible injury to the corresponding
3
 Supraorbital
nerve

Supratrochlear
Supraorbital Supratrochlear nerve
Infratrochlear

Lacrimal Infratrochlear nerve

nerve
Zygomatic

Lacrimal
Zygomaticofacial
nerve
Infraorbital

Nasal

Supraorbital nerve

Frontal nerve

Supratrochlear
nerve

Infraorbital
nerve
Mental
nerve

Figure 1.5 Periocular sensory nerves.

ethmoidal arteries can cause orbital hemorrhage. Ethmoidal
nerve blocks can be performed prior to dacryocystorhinostomy
or medial-wall decompression (Chapters 53–59, 64).
Infraorbital nerve
The infraorbital nerve branches off the maxillary division of the
trigeminal nerve and supplies the lower eyelid skin and con-
junctiva, in addition to the medial canthus, lacrimal sac, mid-
face, and maxilla. It can be blocked where it exits the infraorbital
foramen around 7–10 mm inferior to the infraorbital rim. Either
the transconjunctival or sublabial routes can be used for admin-
istration. The foramen can be palpated where it intersects a
line drawn from the nasal ala to the lateral canthal angle. Alter-
natively, deeper orbital injection along the orbital floor can block
the nerve more proximally. This block is useful for nasolacrimal
intubation in the clinic setting (Chapter 60).
Zygomaticofacial nerve
The zygomaticofacial nerve is another branch of the maxillary
division of the trigeminal nerve; it supplies the lateral canthus
and lateral lower eyelid. It can be blocked where it exits the
zygomatic bone through a foramen around 10 mm inferior to
the lateral canthus. This block is useful for adjunctive anesthe-
sia during a zygomaticomaxillary complex fracture repair.

SECTION ONE • INTRODUCTION

Chapter 1 Foundations of oculofacial plastic surgery
4
Mental nerve block
The mental nerve is a branch of the mandibular nerve. Blocking
this nerve can be useful in administering fillers in the lower lip
and chin region. This block can be given through the lower
gingival sulcus just as the mental nerve exits its foramen.
Oral sedation
Oral sedation in conjunction with local anesthetic administration
is preferred for most in-office procedures. Oral benzodi-
azepines such as diazepam are given at least 30–60 minutes
prior to the procedure. Clonidine can be used for both its
anxiolytic and anti-hypertensive properties. Oversedation is
the most common risk, especially with benzodiazepines, in
which case flumazenil (a benzodiazepine antagonist) can be
administered.
Monitored anesthesia care
Monitored anesthesia care combined with local or regional
block is preferred in more complex procedures. It is popular
because of its ability to provide sedation, amnesia, and anxioly-
sis. Intravenous propofol may be given as a bolus at the time
of local anesthetic injection, followed by a steady-state infusion
supplemented with opioids (fentanyl) or benzodiazepines. Pos-
sible side effects include apnea, myocardial depression, and
decreased vascular resistance. For this reason, close monitor-
ing of vital signs, ECGs, and pulse oximetry is necessary.
General anesthesia
General anesthesia is reserved for more prolonged and stimu-
lating procedures, when nasal bleeding is expected, or in chil-
dren and other patients who may have difficulty following
instructions. Local anesthesia with epinephrine is typically
administered as an adjunct for hemostasis and postoperative
pain. Risks involved include laryngospasm, malignant hyper-
thermia, myocardial infarction, and even death. A careful family
history looking for unexplained anesthesia death or malignant
Figure 1.6 Sequential compression device.
hyperthermia should be obtained, since these life-threatening
conditions are more commonly associated with musculoskel-
etal ocular conditions. All cases of surgery under general
anesthesia should employ the use of sequential compression
devices (SCDs) to minimize risk of deep venous thrombosis
(Figure 1.6).
Tumescent anesthesia
Tumescent anesthesia is a technique that provides effective
pain control and hemostasis for larger regions of the face and
body. It can be effectively used in liposuction/lipotransfer, face
and neck lifting, and endoscopic or pretrichial brow lifting
(Chapters 22–24, 47). Care should be taken to ensure the
meticulous dilution and labeling of tumescent anesthetic solu-
tions and to consider the total amount of anesthetic delivered
in order to prevent anesthetic or epinephrine toxicity.
HEMOSTASIS
Hemostasis in oculofacial surgery is of vital importance, since
an orbital hemorrhage can cause compartment syndrome and
possible blindness. Even for non-orbital surgeries, postopera-
tive bleeds or hematomas can result in blood loss and patient
anxiety, compromise of flaps or grafts, inflammation, and
increased postoperative healing time. Prolonged epistaxis after
lacrimal surgery can result in significant postoperative morbidity
and discomfort.
Anticoagulants
Prior to surgery, patients on anticoagulants should be advised
to discuss with their internist, cardiologist, or other prescribing
physician the possibility of stopping them in the perioperative
period. A decision must be made balancing the risks of
intra- and postoperative bleeding versus the risk of potentially
life-threatening thromboembolic events. Where appropriate,
coagulation studies should be ordered preoperatively.
5
Another random document with
no related content on Scribd:
 (1875.0)
No. Class Description
α δ
22 31.3 7 27 10 e eF, vS, bet. 2*.
23 34.9 7 31 47 e vF, S.
24 36.0 7 30 3 f vF, vS.
25 36.2 7 42 4 f vF, vS.
26 37.5 7 41 4 f vF, vS.
27 41.8 7 29 40 h FN, mE160°, 80″×20″.
28 41.8 7 13 46 f pF, vS, bM, Δ with 2 faint *.
29 42.4 7 44 32 e eF, eS,*14m1′sp.
30 46.1 7 32 31 n pFN, eccentric, mE90°.
31 46.2 7 29 21 i pF, vS, R.
32 52.8 6 40 49 f st. 14m.
33 54.9 7 32 39 e F, S, 1E.
34 56.2 7 10 7 i vF, S, E, *14m30″sf.
35 56.9 6 47 41 e vF, 1E, *15m30″s.
36 58.5 7 33 24 e vF, vS, *17m30″f.
37 23 15 5.9 7 51 23 e vF, R, lvM,40″d, *12.1′n.
38 11.1 7 20 15 f vF, S, E, *14m30″sp.
39 16.9 7 34 23 e vF, vS, *15m1′np.
40 20.4 7 38 15 d vF, vS.
41 21.8 8 18 24 h vF, E, *9m, superimposed.
42 26.0 8 23 37 d pF, pL, R, lbM.
43 28.7 7 29 43 f F, S.
44 53.0 8 15 14 e eF, pL, iR, no nuc.
45 56.3 7 46 32 e eF, S, *16m40″p.
46 23 16 24.2 7 40 32 e vF, E, *17m40″f.
47 38.8 8 18 39 h₀ eF, no nuc., vmE175°, 150″×30″.
48 42.5 7 33 39 g vF, S, E.
49 43.4 7 36 39 e eF, pS, no nuc. Trapz. of 4*.
50 55.3 7 51 8 e vF, S, *12m1′s.
51 23 17 14.2 7 37 37 e eF, vS, *12m2′nf.
 (1875.0)
No. Class Description
α δ
52 34.9 6 55 40 d eF, pS, no nuc.

Nebulae Previously Known in Field VII

N.G.C.
7604 23ᴴ 11ᵐ 31.7ˢ +6°44′48″ f F, R, bM.
7605 32.6 6 41 46 f F, R, bM, *15m70″p.
7586 36.1 7 54 7 f pF, st.
7608 23 12 55.5 7 40 6 h pF, sharp nuc., mE20°,100″×25″.
7611 23 13 16.6 7 22 45 g₀ pB, gbM, mE140°, 80″×30″.
7612 24.7 7 53 38 g pB, mbM, cE170°, 80″×40″.
7615 35.0 7 42 58 f F, E130°, * 14m involved.
7617 49.2 7 28 54 e pF, pS, mbM, vlE20°.
7619 54.8 7 31 19 f B, R, 90″d.
7621 23 14 5.0 7 40 56 g pF, pS, mbM, E0°.
7623 10.4 7 42 45 f pB, R, mbM, 60″d.
7626 22.8 7 31 56 f B, R, bM, 90″d, *14m60″p.
7631 23 15 7.1 7 31 59 g pB, mbM, mE80°, 110′×40″.
7634 22.3 8 12 14 f F, R, *10m20″p.
2d I.C.
5309 23 12 51.8 7 25 32 g pF, mbM, E0°, 50″×30″,
*14m on south edge.

Yerkes Observatory
May, 1917
Plate III
Wolf’s Classes of Nebulae
(Copied from the Königstuhl [Heidelberg] Publications)
 Plate IV

Enlarged Negative of Field III

 Center at Center at α=11ᴴ 4ᵐ, δ=+29°30′
For identification of lettered stars see footnote 7 page 5.

Footnotes:
[1] A dissertation submitted to the Faculty of the Ogden Graduate
School of Science of the University of Chicago in candidacy for
the degree of Doctor of Philosophy.
[2] Nucleus is eccentric and undefined on the photograph, hence
the photographic position is probably in error by several seconds
of arc.
[3] Mean of the positions given in Vols. III and IV. N.G.C. 7621 is
5ˢ.4 preceding, and 1′ 49″ south of 7623. There is a double star in
the position published in the Strassburg Annals.
[4] Mean of the positions given in Vols. III and IV. N.G.C. 7621 is
5ˢ.4 preceding, and 1′ 49″ south of 7623. There is a double star in
the position published in the Strassburg Annals.
[5] Mean of the positions given in Vols. III and IV. N.G.C. 7621 is
5ˢ.4 preceding, and 1′ 49″ south of 7623. There is a double star in
the position published in the Strassburg Annals.
[6] Mean of the positions given in Vols. III and IV. N.G.C. 7621 is
5ˢ.4 preceding, and 1′ 49″ south of 7623. There is a double star in
the position published in the Strassburg Annals.
[7] See Plate IV, enlarged from negative R 3352, taken with 120ᵐ
exposure on February 26, 1916. The numbers were marked on
only those nebulae which promised to be readily visible on the
engraving, and which were separated enough to give room for
inscribing the number. The B.D. stars are designated by letters,
for which the key is as follows.

FIELD III
STAR B.D.
A = +30°2107
B = +30°2108
C = +30°2109
D = +30°2110
 E = +30°2115
F = +30°2121
G = +30°2123
H = +29°2123
J = +29°2125
K = +29°2126
L = +29°2128
M = +29°2129
N = +29°2130
P = +29°2133
R = +29°1970
S = +28°1971

[8] Popular Astronomy, 24, 111, 1916.

[9] Journal of the R.A.S., Canada, 10, 134, 1916.
[10] Field IV covers the position of a group of 18 small nebulae
announced by E. E. Barnard in Astronomische Nachrichten, 125,
369, 1890. The positions there given were rough estimations from
the stars B.D. +56°.1679 and B.D. +56°.1682. On the
photographs, the nebulae in this region are so small and so
crowded that I have been able to identify only three individuals of
the group. Barnard’s Nos. 4, 7, and 18 are very probably my Nos.
41, 43, and 62.
 Transcriber’s Notes:

Ancient words were not corrected.

The illustrations and tables have been moved so that they do not break up
paragraphs and so that they are next to the text they illustrate.
Typographical and punctuation errors have been silently corrected.
 *** END OF THE PROJECT GUTENBERG EBOOK
PHOTOGRAPHIC INVESTIGATIONS OF FAINT NEBULAE ***

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