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-Aesthetic Plastic Surgery- 1993
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André Camirand, MD
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Montréal (Quebec) Canada
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Abstract
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A classification of crow's feet and its pathophysiology are discussed. The author demonstrates a technique of removing a portion of the overactive orbicularis muscle, the underlying cause of crow's feet, while performing the blepharoplasty. The procedure is effective, safe, and simple.
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Key words: Blepharoplasty, Crow's feet, Orbicularis oculi, Muscle resection.
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W hen discussing crow's feet, we talk of an excessive contracture of the lateral fibers of the orbital part of the orbicularis oculi muscle. This occurs mostly when laughing, crying, or before sneezing. Because of congenital reasons or because of excessive use, the lateral fibers of the orbital orbicularis may hyper trophy and exaggerate crow's feet. This same unde sired trait may be aggravated by dermachalasis and actinic wrinkles.
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History
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In 1962 Ulloa [1] resected a wedge of skin and the underlying orbicularis when performing a blepharo plasty. In 1977 Hinderer [3] was probably the first surgeon to promote the separation of the orbicularis from the overlying skin in order to improve crow's feet (temporarily). Skoog [4] and Aston [1] have manipulated the orbicularis muscle but through a facelift approach.
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| Fig. 1. Artist's conception of wedge resection of the or bicularis |
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Anatomy and Physiology
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The orbicularis oculi is divided in the palpebral part and the orbital part. The former is used when tightly closing the lids, reflexively closing the lids, and keeping the eyes closed during sleep. The orbital part, which includes the corrugator, the frontalis, and the zyzomatic muscles, is a muscle used in facial expression, an expression that can be exaggerated and become undesirable. The innervation of this muscle comes mainly from the temporal and zyzo matic branches of the facial nerve. There is a multitude of nerve branches located in the submuscular areolar layer. If there is a partial interruption of the innervations of the orbital fibers, the innervation of the palpebral fibers cannot be interrupted in the technique described by the author (Fig. 1) .
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The authors' classification scheme for crow's feet is as follows:
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- Static
- Senile
- Actinic
- Dynamic
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-Total ("complete") (opposite both eyelids and lateral canthus)
-Partial ("incomplete'') (no wrinkle opposite lat eral canthus) (Fig. 2)
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| Fig. 2. Classification of dynamic crow's feet |
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| Fig. 3. (A) Artist's conception of subcutaneous and submuscular tunnel; (B) surgical demonstration |
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Technique
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To correct exaggerated crow's feet, while performing a blepharoplasty the surgeon creates a subcutaneous tunnel lateral to the skin incision. After pene trating the orbital orbicularis he creates another tunnel in the submuscular areolar space (deep and opposite the subcutaneous tunnel).
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| Fig. 4. (A) Preoperative view of male patient; (B) postoperative view shows the reduction of dynamic crow's feet |
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At both extremities he clamps the muscle with two hemostats and (Fig. 3) resects the wedge of muscle between the ends. Before removing the hemostat he cauterizes the muscle edges and then closes the skin. The muscle is left as is (no stitching). Another method used consists of extending the skin incision and removing the muscle fibers under direct vision. The author prefers the wider undermining of the skin and ensuing wider muscle resection done without prolongation of the skin incision and scar as described here. Next, the surgeon electrocoagulates the vertical fibers of the orbicularis to make it a static mass of fibrosis; this makes the incision bloodless. After electrocoagulation, the incision may not be necessary and there are no risks of depression. |
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Fate
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The excised wedge of vertical fibers is replaced by a coagulum and the muscular edges previously cauterized retract with contracture. This coagulum is eventually replaced by fibrosis; this is why one does not observe a depression opposite the resection. In the author's experience, however, there were a few patients in whom there was a depression necessitating surgery for correction (plication of subcutaneous scar). This can be prevented by beveling the incision as the muscle is resected. If properly resected there is no way these muscle fibers can regenerate.
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Discussion
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In dynamic crow's feet the only reasonable treatment is to eliminate the underlying cause: the over active lateral or vertical fibers of the orbital part of the orbicularis oculi muscle. For dermachalasis, a browlift is indicated. For actinic wrinkles or static crow's feet, a chemical peel or a dermabrasion is indicated. Even for static crow's feet or dermachalasis, resecting the vertical fibers of the orbicularis muscle, if possible, delays their recurrence.
Although this technique improves crow's feet, it does not eliminate entirely one's facial expression (Figs. 4, 5) . There is still some orbicularis left and the zygomatic and frontal muscles remain intact |
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| Fig. 5. (A) Preoperative view of female patient; (B) post operative view shows absence of muscle contracture when smiling |
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Conclusion
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To improve dynamic crow's feet, one must radicate the underlying cause: the vertical fibers of the orbicularis oculi. This does not interfere with the other functions of the eyelid. The author describes a technique for accomplishing this safely while performing a blepharoplasty.
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| Fig. 6. (A)Preoperative view and (B)6-month postoperative view |
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| Fig. 7. (A) Preoperative view and (B) 2-year postoperative view of frontal lift inferior blepharoplasty and muscle resection |
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| Fig. 8. (A) Preoperative view and (B) 8-month postoperative view |
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| Fig. 9. (A) Preoperative view, (B) 3 month postoperative view smiling, (C) 5-year postoperative view smiling |
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Fig. 10. (A) Preoperative view smiling, (B) 3-month postoperative view, (C) 3-year postoperative view |
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| Fig. 11. (A) Preoperative view, (B) 5-month postoperative view, (C) 1-year postoperative view smiling |
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| Fig. 12. Comparison of excision on right side with incision only on left side. (A) Eighteen month postopera tive view of resection of muscle on the right side shows an absence of muscle contraction. (B) On the left side the muscle was incised not excised. The result is good but not as ob vious (some muscle contraction) |
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| Fig. 13. Similar comparison of excision (right side of face) with incision only (left side). (A) Preoperative, same resection, one year postoperative. (B) Six years postoperative |
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Addendum
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It was suggested to the author that a wedge of muscle be resected on one side while simply incising the muscle fibers on the opposite side, taking care to provide good preoperative and postoperative photographs with the patient at rest and animating the crow's feet. This was done with a series of 73 patients (Figs. 6-13) . Results from both techniques are good (as well as the electrocoagulation of the muscle alone or in combination with excision or incision). The result from resection is more obvious, but there is slightly more morbidity, i.e., swelling and ecchymosis, and three patients complained of a depression which was easily remedied by simple surgical subcutaneous plication of the scar tissues on both sides of the depression. The author prefers the lateral canthoplasty (with transconjunctival resection of fat pads) to the conventional blepharoplasty. The resulting expression is more youthful and there is no damage to the orbital septum nor to the pretarsal orbicularis muscle. This should eliminate any risks of scleral show. The canthoplasty incision makes it very accessible for manipulating the orbital orbicularis muscle. The transconjunctival lateral can thoplasty [5] (a nonstigmatizing approach) is another good approach to manipulating the orbicularis muscle.
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References
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- Aston S: Orbicularis oculi flaps. Plast Reconstr Surg 65:206, 1980
- Gonzàlez-Ulloa M: An update on blepharoplasty aesthetic plastic surgery. Facial wrinkles, integral elimination. Plast Reconstr Surg 29:658, 1962
- Hinderer U: IXth Instructional Course of ISAPS, Tokyo, Japan, August 1977, p 362, 368. Trans Vllth Plast Reconstr Surg, Brazil, September 1979
- Skoog T: Plastic Surgery. Philadelphia: W.B. Saunders, 1974, p 317
- Patterson R. Munro 1, Farkas L: Transconjunctival lateral canthoplasty in Down's syndrome patients: a nonstigmatizing approach. Plast Reconstr Surg 79(5):714, 1987
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Suggested Reading for Canthopexy
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- Whitaker L: Selective alteration of palpebral fissure form by lateral canthopexy. Plast Reconstr Surg 1984, 1974(5):611-619, 1984
- Ortiz-Monasterio F: Lateral canthoplasty to change the eye slant. Plast Reconstr Surg 75(1):1-9, 1985
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