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Here is an article I’m still proud of authoring and that is still proving to last the test of time in my practice, helping me to achieve superior results in addressing rejuvenation of the periocular aesthetic unit. In this article from 2013 published as a Surgical Technique in Ophthalmic Plastic Reconstructive Surgery Journal we defined the ageing process in the periocular aesthetic unit and proposed a combination of endoscopic face lifting called MIVEL for Minimal Incisions Vertical Endoscopic Lifting associated to fat grafting to address vertical descent and volume loss at the same time.

Full reference here: Francesco P. Bernardini, M.D, Alessandro Gennai, M.D. and Martin H. Devoto, M.D. Minimal Incisions Vertical Endoscopic Lifting and Fat Grafting as a Systematic Approach to the Rejuvenation of the Periocular Aesthetic Unit Ophthal Plast Reconstr Surg, Vol. 29, No. 4, 2013

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Francesco P Bernardini, MD
oculoplastic surgeon from Genova, Italy
Editorial board member @oprsjournal

Injectables to Shape the Periocular Region

Introduction
As expert of the eye and the periocular region ophthalmologists are theoretically the specialists better prepared and formed to use fillers to aesthetically treat this region safely and more effectively. The objective of the presentation, implemented by the corresponding outline is to help all the potential injectors in their progression towards a delivery of safe and pleasing aesthetic results to all of your patients.

Anatomy
The anatomy of the eyelids and neighbouring regions is probably the most complex of the entire face and it reflects the complicate functions and the primary role of the eye.
However, most of us as a category are surgeons and as such we are used to address conditions to which we provide direct surgical access and we therefore see the anatomy and the changes that our manipulation produces as we make them. Whether you are considering to start injecting fillers around the eye or you are already an injector, but willing to evolve and treat the periocular region, there are some important considerations that should taken in account and include regional anatomy, aesthetic assessment of the region and technical skill formation. It has been demonstrated that volume loss in the face plays a dominant role in determining facial ageing and this also applies to the periocular area. The individual fat compartments that seem to be confluent in the youthful face, when they show demarcations between them, represented by the retaining ligaments, cause the most common periocular aesthetic concerns. Recognising the anatomical structures functionally involved is of crucial importance, and the knowledge of the position of the individual fat compartments and retaining ligaments involved is the base of the injector, which should be able to mentally visualise the relevant anatomy as if he possessed an ultrasound probe in his hands along with the filler syringe.

Aesthetic Considerations
The role of volume restoration in the periocular area is of maximal relevance as the eyes are the first to show signs of ageing. Specific volume related conditions that affect the aesthetic appearance of the periocular region include tear trough deformity, orbito-malar sulcus, eyelid bags. The wise injector should not behave as a ‘dumper’ trying to fill a hole, but should take advantage of the filler properties to stretch and reposition the retaining ligaments and concomitantly offer support to the depleted fat compartments. This paradigm shift from overfill the center of the face to targeting the periphery to ‘lift’ first can be applied to all the different anatomical units of the face and helps to achieve natural results and reduce complications, so difficult to manage in the periocular region especially. I found there appears to exist various analogies between periocular filler injection and surgery, such as aesthetic and anatomical considerations and aesthetic goals, represented by correcting hollows, eliminating bags, tightening of the lid and improving the skin quality. As injectors we want to achieve surgical results with a non invasive office treatment. Combining the knowledge of the surgical and filler anatomy I have come to recognise the existence of a common aesthetic “G-Point”, which once properly addressed help the surgeon and the injector to achieve the aesthetic goals of rejuvenating the periocular aesthetic unit.

Figure 1: impact of the aesthetic G-point in addressing all of the aesthetic concerns occurring in the periocular unit.

Figure 2: The G-point can be found at the joining of the bisettrix among the Hinderer’s lines and line drawn from the lateral canthus, forming with it a 90 degrees angle.

Injections Skills
Instead of trying to fill the emptiness represented by the insertion of the orbito-malar ligament, which is very tight and difficult to elevate without releasing it, in my injection technique I target the G-point first with a deep bolus (defined as at least a .1cc) of a high G-prime filler (Figure 3: lateral grey dot) in order to provide lift and stretch of the tissues superficial to the ORL. Subsequently I provide central support at the apex of the V of the orbito-malar groove (Figure 3: central grey dot). In the end I finalise the treatment using a low-G-prime filler injected with a min-bolus technique (defined as .02-.03 boluses) to smooth the transitions (Figure 3: pink dots).

Figure 3: demonstration of the treatment planning (left) and the result right after injection of the right side (right); the aesthetic goals of the treatment, including hollows correction, bags elimination, tightening of the lid and improving the skin, quality appears to have been met.

The role of canthoplasty and canthopexy in aesthetic eyelid surgery

The shape of the eyelid fissure is a key feature of the aesthetic of the entire face, to the point that it has been showed that attractive Caucasian faces have a relatively narrower eyelid fissure width compared to the average Caucasian face (Seung Chul Rhee, et al. Biometric Study of Eyelid Shape and Dimensions of Different Races with References to Beauty. Aesth Plast Surg 2012; 36:1236–1245). Ageing has a significant impact on the lower eyelid, secondary not only to the gravity; its role in fact is that of support the weight of a relatively heavy structure such as the eye globe. The stretch of the suspensory tendons of the lower eyelid seems to affect more predominantly the lateral canthal angle. As beautifully depicted by Rembrandt in the XV century it causes medial displacement and rounding of the lateral corner, inverted canthal tilting, lateral rounding of the eyelid margin with consequent inferior scleral show. These laxity changes, combined to the ageing changes that affect the upper eyelid, such as upper sulcus deepening, cause a modification of the overall shape of the eyelid fissure from elongated, almond-shaped to saggy, round-shaped fissure. Quite commonly canthal and lower eyelid ‘malpositions’ can be of constitutional origin, minor forms of congenital euriblepharon with inferior scleral show, that give the impression of bigger, bulging eyes.
At the time of aesthetic rejuvenation or beautification of the periocular region it is crucial to recognise the position of the lower eyelid and lateral canthus to achieve improved our results. While I don’t perform nor advocate canthal surgery in primary blepharoplasty, I have a very low threshold to restore eyelid and canthal position when indicated.
In this respect there are many variant of canthal surgery that have been proposed during the last 20 years, and after having personally performed almost all of these variants I have now come to a rationalisation depending on the surgical indications: 1) if I want to correct an inverted canthal tilting with lateral scleral show, and restore an acute lateral angle I invariably perform a closed trans-canthal canthopexy as described by Hamra (Plast Reconstr Surg J 102:5, 1998) as this procedure is much more respectful of the anatomy of the lateral canthal structures while at the same time offering the right amount of correction with natural results.
2) if I need to correct lower eyelid and canthal malpositions secondary to a previous lower eyelid blepharoplasty, i.e. cicatricial ectropion i have come to rely primarily on the benefits of the endoscopic approach associated with Hamra’s canthopexy and lower eyelid retractors release. The endoscopic approach, offers to perform temporo-malar dissection associated with lateral canthal and orbital retaining ligament release under beautiful visualisation of the anatomy. The full release of the temple, cheek and lower eyelid offers an en-bloc mobilisation of these structures; proper suture fixation at the superior part of the malar eminence, near the lateral canthal area gives a strong elevation up- and outwardly. The lower eyelid retractor release allows to free the middle lamellar scarring from the eyelid margin and the associated trans-canthal canthopexy secures the canthal position firmly against the orbital rim, where it belongs. Compared to what has been previously reported, i.e. aggressive canthoplasties with bone screw fixation associated with trans-palpebral sub-periosteal mid-face lifting the endoscopic approach to the difficult lower eyelid offers a higher vector of tissue elevation with consequent improved effectiveness of the lifting factor on the lateral canthal/eyelid position allowing to minimise the amount of canthal surgery with consequent more natural results.

Autologous Fat Grafting For Treating Blepharoplasty-Induced Lower Eyelid Retraction

Summary: Autologous fat grafting for blepharoplasty-induced lower eyelid retraction offers potential for a long-term solution while avoiding the morbidity associated with posterior lamellar spacer grafts. By combining traditional methods of lifting the retracted lower eyelid with autologous fat grafting, both functional and aesthetic concerns can be successfully addressed in these patients.

(Plast Reconstr Surg Glob Open 2016;4:e1190; doi: 10.1097/GOX.0000000000001190; Published online 23 December 2016.)

Cosmetic Surgery: Do’s and Don’ts

Before electing to have cosmetic surgery, there are some things you should be aware of to make sure you are taking an intelligent, realistic approach to the procedure. Here are some Do’s and Don’ts to consider when considering cosmetic surgery.

DON’T (Cosmetic Surgery)

Do It For Anyone But Yourself 
Cosmetic surgery should be done for you and you alone. Having cosmetic surgery to please someone else, like a boyfriend or husband, is not a good reason. Nobody else but you can give you the self-esteem you need to have a healthy image of yourself.

Rush Into It
You must be in good health prior to any operation. Your surgeon will likely require you to be cleared by your primary care physician prior to surgery. It’s also best to be as physically fit as you can, which can make the recovery process go much smoother.

Have Unrealistic Expectations
If you’re looking to cosmetic surgery to transform your entire life, you’re going to be very disappointed. Talk to your doctor before undergoing cosmetic surgery to make sure you clearly understand what is attainable and what results you can reasonably expect.

DO (Cosmetic Surgery)

Ask your surgeon a number of questions before committing to cosmetic surgery, including:

• Am I a good candidate?
• How long can I expect my recovery to be and how can I best prepare?
• What are risks and complications with my procedure?
• How extensive is your experience in performing this type of procedure?
• What results can I realistically expect?

Follow Doctor’s Orders
Your surgeon knows what’s best for you during your cosmetic surgery journey, so make sure to heed his or her advice. This may include quitting tobacco and alcohol prior to your procedure, making certain lifestyle changes such as diet and exercise, and enlisting ways to help yourself heal as quickly and safely as possible for optimal
results.

Remember Your Inner Self-Worth
Improving your appearance can be a tremendous boost to your self-esteem, but at the end of the day, it’s what’s on the inside that counts. Celebrate your new physical traits, but also remember the characteristics that make you who you are as a whole – intelligence, compassion and humor, for example, are just as important.

Acquired Naso-Lacrimal Duct Obstruction

An obstruction in the lower part of the naso-lacrimal duct (acquired naso-lacrimal duct obstruction) is a fairly common problem in the adult, especially in the female population 50 years of age or older because of their particular anatomy of this region. In the vast majority of the patients we cannot find a possible cause that determined the obstruction, hence the term of ‘primary’ acquired naso-lacrimal duct obstruction (PANDO). Occasionally, the duct may be occluded as a consequence of a facial trauma with the nasal bones involved or a surgical procedure in the nose (rhino-septoplasty, turbinectomy etc).

Symptoms
The most common symptom of a PANDO is the so-called ‘epiphora’, which refers to the constant tearing with tears building up in the eyelid fissure and eventually running down the cheeks, requiring frequent dabbing of the tears. One or both eyes can be affected, even at the same time. Frequently, affected patients refer that they always travel with a paper tissue in their hands do dab their tears. Moreover the sight may result impaired from the excessive fluid accumulation on the surface of the eye. The patients can have frequent recurrent episodes of ‘red eye’ (conjunctivitis), mucus secretion.

Occasionally, more severe episode of inflammation with swelling and pain between the nose and the eye (in the anatomical location of the lacrimal sac), called ‘acute dacryocystitis’ may occur repeatedly and require systemic treatment with antibiotic and even hospitalization.

Diagnosis
A medical consult with a specialist in lacrimal surgery (usually an ophthalmologist with a sub-specialty training in oculoplastic surgery) is required to establish the appropriate diagnosis and rule out other conditions.

Normally, after a routine evaluation of the eye and ocular surface, a simple lacrimal siringing is the most reliable test to establish the diagnosis. A standard nasal exam is routinely performed by the oculoplastic specialist. Radiological exams are not required in the vast majority of cases.

Treatment
Once the diagnosis os PANDO is established, the final treatment is a surgical procedure called ‘dacryocystorhinostomy’ and can be performed through an external approach (a small skin incision over the lateral part of the nose that leaves invisible scar) or though and endonasal endoscopic approach.

The surgical technique is well standardized, is performed under local anesthesia with the help of intravenous monitored sedation, the surgical time takes less than 20 minutes and the patient can be discharge from the surgical facility within two hours from the end of surgery. The success rate is well over 90% in the external approach in the hands of an expert lacrimal surgeon.