A Simpler Solution Aesthetics 36

AESTHETICS

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2017 AUGUST The one aesthetic–unit approach to periorbital reju periorbital to approach aesthetic–unit one The Performing only upper blepharoplasty surgery in the pres the in surgery blepharoplasty upper only Performing haveeyelids upper her or his concerned is patient the When unitaesthetic one as area periorbital the addressing By Surgery of the periorbital aesthetic unit is perhaps one ofone perhaps is unit aesthetic periorbital the of Surgery Therefore, the patient acceptance rate is much higher thanhigher much is rate acceptance patient the Therefore, mul require that procedures midface or eyebrow other with lower excess has patient the that event the In incisions. tiple lowerexcess and deformity, trough tear prolapse, fat eyelid andremoval fat transconjunctival wrinkles, and skin eyelid per be easily can peel acid trichloro-acetic and repositioning setting. same the in formed minoroutpatient an in performed be also can venation the periorbital area is not treated as one aesthetic unit,aesthetic one as treated not is area periorbital the eyelidupper example, For follow. often results unfavorable remov the through cosmesis improves often blepharoplasty pre- worsen also can it but skin, eyelid upper redundant of al fissure. palpebral vertical the increasing by eye dry existing retractionand laxity improve to eyelid lower the Tightening problem.this avoid to help can patient’sthe worsen actually will eyebrow ptotic a of ence anddownward eyebrow the pulling by ptosiseyebrow eye the raise to muscle frontalis the of ability the decreasing eyebrowor eyelid upper the raising Similarly, eyelids. and brow droopcanthal lateral and retraction eyelid lower make can orcanthus, lateral eyelid, lower the Raising apparent. more ofptosis make can eyelid upper the raising without midface apparent.more eyebrow and eyelid upper the asso more be may it appearance, angry-looking droopy, sad, a andcorrugator the by caused furrowing eyebrow with ciated muscles.supraciliaris depressor ONE UNIT APPROACH andfunctional excellent achieve to able are we 1), (Figure minimizeto able are we approach, thisWith results. cosmetic incisions.of number the and complications, expense, surgical PERIORBITAL AESTHETIC UNIT PERIORBITAL AESTHETIC improvingas surgery, aesthetic in areas challenging most the mayeyelids lower and upper the of height and cosmesis the When cornea. the of protection and coverage compromise -

GLANCE AT A

When the periorbital area is not treated as oneWhen Addressing the area as one unit minimizes expense, As cosmetic periorbital surgery has evolved, the line As cosmetic periorbital surgery has evolved, aesthetic unit, unfavorable results often follow. aesthetic unit, and the number of incisions. complications, between functional and cosmetic surgery has blurred, with insurance covering less and patients expecting more.

• • • In our practice, we conceptualize two separate aestheticseparate two conceptualize we practice, our In When patients have cosmetic concerns, they may opt foropt may they concerns, cosmetic have patients When Eyelid surgery is one of the most gratifying areas in aestheticin areas gratifying most the of one is surgery Eyelid jowls, and neck.and jowls, is pivotal in creating a natural, happy, and youthful appear youthful and happy, natural, a creating in pivotal is considerWe surgery. periorbital aesthetic-unit one in ance chin,lips, cheek, lower the of composed be to unit lower the made up of the eyebrow, upper eyelid, lateral canthus, lower canthus, lateral eyelid, upper eyebrow, the of up made canthuslateral The area. midface and cheek, upper eyelid, andunit this of point anchoring critical and keystone the is surgical setting with reduced morbidity and expense. and morbidity reduced with setting surgical theconsider We area. neck and face entire the treat to units beto unit, periorbital the as to refer we which half, upper more likely to opt for elective surgery that addresses theiraddresses that surgery elective for opt to likely more both procedures, all perform can we if concerns cosmetic onein incision same the through cosmetic, and functional contribute to functional concerns such as tearing and dry eye.dry and tearing as such concerns functional to contribute arepatients experience, our In surgery. elective additional upper eyelid dermatochalasis and ptosis both cause loss of theof loss cause both ptosis and dermatochalasis eyelid upper lowerpopulation, patient elderly the In field. visual superior mayand common are ectropion and retraction, laxity, eyelid surgery for both patients and physicians, because it addressesit because physicians, and patients both for surgery patientsour of Many concerns. cosmetic and functional both ascomplaint, chief their as problems functional presentwith BY THOMAS J. OBERG, MD; GRANT H. MOORE, MD; KIAN EFTEKHARI, MD; MD; H. MOORE, MD; KIAN EFTEKHARI, THOMAS J. OBERG, MD; GRANT BY MD MD; AND RICHARD L. ANDERSON, MICHAEL W. WORLEY, the periorbital aesthetic unit. unit. aesthetic the periorbital Single-incision rejuvenation of of rejuvenation Single-incision A SIMPLER SOLUTION AESTHETICS 36

CATARACT & REFRACTIVE SURGERY TODAY CATARACT &REFRACTIVE SURGERY nasolacrimal system irrigation in the office. Many older patients nasolacrimal system irrigation in the office. Many older patients drainage system. This distinction can be made by a dye test and eye. Some patients may also have a true obstruction of the tear of reflex lacrimation from the lacrimal gland in response to a dry uate the lacrimal system. Often, patients have tearing because the time of surgery so that the patient will retain more tears. tal occlusion with electrocautery or dissolvable collagen plugs at In these cases, we may also consider performing bilateral punc that will raise and tighten the lateral canthus and lower eyelids. blepharoplasty surgery unless we also plan to perform surgery bral fissure, we are more careful about recommending ptosis or preclude the performance of surgery that may widen the palpe to evaluate the severity of their dry eye. While this does not and cornea at a slit-amp examination with fluorescein staining that he or she has dry eye, it is important to assess the tear film the patient has dry eye or uses artificial tears. If a patient says DRY EYECONSIDERATIONS the functional surgery as well as the cosmesis. covered by insurance but certainly improve the outcome of other concerns, some of which may be cosmetic and not tion. This is a starting point for discussion about all of their such as dermatochalasis, true ptosis, or lower eyelid retrac unit. Many of our patients present with functional concerns forming a surgical approach within the periorbital aesthetic individual functional and cosmetic concerns is critical to PATIENT SELECTION risks associated with anesthesia. procedure room, which can further decrease expenses and If a patient presents with tearing, then the surgeon must eval The first, and perhaps most important, question is whether Proper patient selection and analysis of each patient’s

AUGUST 2017 - - - - “ eyebrow blocking the visual axis, to get insurance approval. eyebrow blocking the visual axis, to get insurance approval. sis. prior functional treatment of dermatochalasis and/or pto satisfied and may aesthetically look worse despite successful appearance. This is likely the main reason patients are dis eyelashes decreases, the face assumes a more sad and angry brow ptosis. the incision below the brow, both of which may lead to more frontalis muscle and potentially some inferior traction from Elevating a droopy eyelid leads to less stimulation of the muscle must work harder to elevate this displaced tissue. decrease preoperative brow height by 2 mm. brow. Performing blepharoplasty alone has been shown to dard blepharoplasty correction will further drag down the to remember that any tissue removed as part of a stan eyebrow warranting surgical correction, it is imperative eyebrow ptosis and a scowl-like appearance. and depressor superciliaris muscles, which also contribute to At the same time, the surgeon should evaluate the corrugator appearance that was the patient’s initial presenting complaint. ther drop eyebrow height and, in doing so, worsen the angry surgeon that performing upper blepharoplasty alone will fur rim in men. The presence of eyebrow ptosis should alert the superior orbital rim in women and at or just above the orbital sis. Normal eyebrow height is at least 1 to 2 mm above the PTOSIS lateral canthus at surgery can improve such tearing. pooling of tears. Tightening the lower eyelids and elevating the with lax lower eyelids also suffer from pump failure and lateral tearing and dry eye.” tearing and dry concernsto such a functional common and may contribute retraction, are and ectropion population, lower eyelid laxity, patientIn the elderly As the brow descends inferiorly with time, the frontalis As the brow descends inferiorly with time, the frontalis When considering whether a patient has ptosis of the The surgeon should evaluate all patients for eyebrow pto Unfortunately, eyebrow ptosis must be severe, with the Unfortunately, eyebrow ptosis must be severe, with the 1,2,3 As the distance between the eyebrow and the As the distance between the eyebrow and the 1,2

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CATARACT & REFRACTIVE SURGERY TODAY CATARACT &REFRACTIVE SURGERY dermatochalasis or upper eyelid ptosis about the potential need for additional incisions. increased morbidity and complications secondary to the tain hairlines, increase surgical costs for the patient, and have approaches create additional scars, are not suitable for cer usually require deeper sedation or general anesthesia. The direct brow lifts also create temporal lift, those techniques superciliaris muscles. While endoscopic, pretrichial, and by performing removal of the corrugator and depressor sion. brow-pexy technique through an upper eyelid crease inci a 1.74 ± 0.05 mm temporal brow lift using our internal We counsel all patients who present for evaluation of We have previously reported our findings of obtaining 4

This works in concert with raising the medial brow This works in concert with raising the medial brow superciliaris muscles through the same incision to eliminate glabellar furrows and raise superciliaris muscles through the same incision to eliminate glabellar furrows and raise the medial brow, both of which often have the added benefit of headache relief. Figure 1. The one-unit approach can also remove the corrugator and depressor Figure 1. The one-unit approach can also remove the corrugator and depressor EYELID ELEVATION WITH LOWER MIDFACE LIFT OCULI FAT (SOOF)/ SUB-ORBICULARIS

AUGUST RESUSPENSION CANTHAL LATERAL 2017 IMPROVEMENT WRINKLE THE PUZZLE THE addresses multipleprocedures PIECES OF PIECES through asingleincision. The one - - - unit approach more laterally. ally flatter horizontally, and female eyebrows tend to arch aspect is overelevated, be left with a more feminine appearance if the temporal a quizzical expression. Additionally, male patients may the central and lateral aspects, a patient may be left with the medial aspect of the eyebrow is elevated higher than effectively creating a “permanent neurotoxin” effect. If approach also relieves furrowing between the eyebrows, much as other more aggressive forehead techniques. superciliaris muscle removal raises the medial brow as elevation and sculpting with corrugator and depressor do not address the eyebrows as well. Internal eyebrow for worsening of any preexisting eyebrow ptosis if we PTOSIS REPAIR UPPER EYELID ELEVATION EYEBROW INTERNAL BLEPHAROPLASTY UPPER EYELID 4 as typical male eyebrows are usu 5 This - AESTHETICS 40

CATARACT & REFRACTIVE SURGERY TODAY CATARACT &REFRACTIVE SURGERY and hypoesthesia in the forehead and between the brows, and hypoesthesia in the forehead and between the brows, informed of the high likelihood for postoperative numbness cles. removal of the corrugator and depressor superciliaris mus achieved complete resolution of their pain following surgical a decrease in the severity of their headaches, and almost 60% previously demonstrated that more than 90% of patients had the corrugator and depressor superciliaris muscles. We have or tension-type central headaches, we encourage removal of ing or depression on exam, or if they complain of migraine HEADACHE REDUCTION nerves running vertically in the fascia overlying the corrugator nerves running verticallyin thefascia overlyingthecorrugator it superiorlytoexposethefurrowmuscles.Wecan thensee laris oculimuscle.We bluntlydissecttheorbicularis andretract and depressorsuperciliarismusclesfromtheoverlyingorbicu roplasty incisionwithStevensscissorstoseparate thecorrugator blunt dissectiontowardthesuperomedialedgeofblepha the corrugatoranddepressorsuperciliarismuscles.Weperform of thefrontalismuscle. important, as itallowstheeyebrowtoelevatewithcontracture Suturing totheposteriorgalea,rather thantheperiosteum,is to correctanyasymmetrythat waspresentpreoperatively. of theposteriorgaleawith4–0polyglactinsutureandattempt taking carenottooverskeletonizetheeyebrow. position. Wesculpttheinferiorportionofeyebrowfatpad, the eyebrowinternally byremovingtissuestetheringitin alower the distanceacrosseyebrow,isreleased.Thisallowsustolift edge oftheblepharoplastyincisionextending three-quartersof en bloc.Theanterior leafoftheposteriorgalea,fromlateral blepharoplasty incisionandexcisetheorbitalretainingligament ing ligamentwithPaufiqueforcepsatthelateraledgeofupper which toraise thelateralcanthusandmidface. for browsculptingand release.Italso providesanatural spacein rotoxin under thetemporalbrow,and itprovidesdirectaccess removal ofthetemporalorbicularisissimilar topermanentneu to elevatetheeyebrow,lateralcanthalarea, andmidface.The provides lateraleyelidcrease formation, butitisalso important lar cauteryifnecessary.Theskinand muscleremoval notonly debulk theuppereyelidfatpadswithStevens scissorsandbipo it withoneortwointerrupted5–0polyglactin sutures.We visualize alevatoraponeurosisdehiscenceatthistime,werepair “open sky”viewofallthestructuresuppereyelid.Ifwe using Stevens scissorsandPaufiqueforceps.Thiscreatesan remove aflapofskin andunderlying orbicularis oculimuscle sis. We useaNo.15bladetomaketheskinincision andthen with skinand muscleremovaltocorrectanydermatochala THE SURGICALTECHNIQUE If patients demonstrate aggressive medial brow furrow 6 To achieve even greater medial brow lift, we can resection To achieve evengreater medialbrowlift,wecanresection Next, weresuspendtheeyebrowfatpadstoposteriorleaf To performaninternaleyebrowlift,wegrasptheorbitalretain Our techniquebeginswithan uppereyelidblepharoplasty When discussing this surgery, patients must always be When discussing this surgery, patients must always be

AUGUST 2017 ------thal tendon. We then use a 4–0 polyglactin suture on the inferior thal tendon. Wethenusea4–0polyglactinsutureontheinferior cheek area.Bluntdissectionallowsdirectaccesstothelateralcan underlying periosteuminthelateralcanthal region,midface,and Stevens scissorstoseparatetheorbicularis oculimusclefromthe suborbicularis oculifatelevation.Weusebluntdissectionwith sion toperformbothlateralcanthalresuspensionandmidface/ and headaches—ifpresent—areoften greatlyimproved. thesia areexpectedformonthsafterremoval.However,furrowing ther raisingthemedialbrow.Supraorbitalanesthesiaand hypoes in thiswell-vascularized areaoftheface. and reducesintraoperativebleeding andpostoperativebruising instead ofpiecemealensurescompleteremovalthemuscle bipolar cauteryforhemostasis. Removingthemusclesenbloc scissors alongwiththedepressorsuperciliarismuscle.We use with Adson-Brownforcepsandremoveiten bloc withStevens muscles. Wegraspthelateral edgeofthecorrugatormuscle ment atbedtime. topical, preservative-freeartificial tearsandartificial tearoint for 2weeks.Weplaceallpatientsundergoingeyelidsurgeryon patient appliessteroid/antibiotic ointment toincisions daily hours forthefirst2daystoencourageegressofanyblood.The encourage gentlepressureovertheeyelidsandbrowevery2 72 hoursand thenwarmcompressestoreducebruising.We into theorbit.Postoperatively,wesuggesticecompressesfor erative residualbleedingthroughtheskinasopposedtoback ning 6–0 plaingutsuturestoallowfor egress ofanypostop the skinusing acombination ofsingle,interrupted,andrun and usebipolarcauteryasneeded forhemostasis.We close rhytids. mid-face andcheekwhilealsoimprovinglateral lowereyelid using 4–0polyglactinsutureonaP-2needle.Thiselevatesthe adjacent totheloweredgeofblepharoplastyincision,also cutaneous flap andsutureittothelateralorbitalrimperiosteum the lateralcanthus.Wethenadvancepreviouslycreatedmyo orbital rimperiosteumadjacenttoWhitnalltubercle.Thiselevates crus ofthelateralcanthaltendonsuperiorlytointernal ing inferior scleral show, inferior conjunctival injection, ing inferior scleral show, inferior conjunctival injection, of lower eyelid retraction, entropion, and ectropion, includ of lagophthalmos and dry eye. after upper eyelid blepharoplasty surgery to reduce the risk to leave more than 22 mm of anterior lamellar skin behind lids, including the length of the anterior lamella. We prefer UPPER EYELIDS alternative that we discuss with patients. which may last for months. Neurotoxin use in this area is an Next, weusethelateralextentofupperblepharoplastyinci We bluntlyundermine themusclesatrootofnose,fur We inspect all edges of the upper blepharoplasty incision We inspectalledgesoftheupperblepharoplastyincision In evaluating the lower eyelids, one should look for signs In evaluating the lower eyelids, one should look for signs After evaluating the eyebrows, we assess the upper eye ------AESTHETICS

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2017 unit surgery in the periorbital area andarea periorbital the in surgery unit – E C AUGUST Midface lift can be conveniently performed in ain performed conveniently be can lift Midface For many years, the lateral tarsal strip was the mainstay ofmainstay the was strip tarsal lateral the years, many For our treatment for lower eyelid laxity and involutional ectro involutional and laxity eyelid lower for treatment our functionalsevere in technique excellent an still is This pion. in However, laxity. marked with cases cosmetic in and cases frombenefit would who those and patients aesthetic our andresuspension canthal lateral prefer we elevation, midface lift. midface blepharo a of aspect lateral the through manner sequential effectivealso is resuspension canthal Lateral incision. plasty LOWER EYELIDS unit surgery in the periorbital area. E) A 79-year-old male patient shown at post at shown patient male 79-year-old A E) area. periorbital the in surgery unit – B unit surgery in the periorbital area and corrugators removal. He still has more upper eyelidupper more has still He removal. corrugators and area periorbital the in surgery unit – unit surgery in the periorbital area and transconjunctival lower eyelid blepharoplasty with fatwith blepharoplasty eyelid lower transconjunctival and area periorbital the in surgery unit – punctal occlusion in thein occlusion punctal

If conservative medical therapy for dry eye or tearing hastearing or eye dry for therapy medical conservative If

also be considered. be also must be more conservative, and conservative, more be must worseningfurther preventing in helpful be can eyelids upper shouldeyelids lower the raising and Tightening eye. dry of been unsuccessful, it is important to discuss surgical options,surgical discuss to important is it unsuccessful, been because upper eyelid surgery can significantly worsen corneal tissue excisionexposure and dry eye. In patients with dry eye, corneal staining with fluorescein, or pooling of fluorescein influorescein of pooling or fluorescein, stainingwith corneal film.tear the operative month 4.5, following one aesthetic one following 4.5, month operative repositioning. and removal postoperative month 2 following one aesthetic one following 2 month postoperative aesthetic one following 4, month postoperative at shown patient female 65-year-old A C) left. the than right the on swelling patientfemale 66-year-old A D) repositioning. and removal fat with blepharoplasty eyelid lower transconjunctival and area periorbital the aesthetic one following 3, month postoperative at shown Figure 2. A) An 82-year-old male patient shown at postoperative month 1, following one aesthetic one following 1, month postoperative at shown patient male 82-year-old An A) 2. Figure atshown patient male 58-year-old A B) eyelids. upper bilateral the of edema mild residual, some has still patient This removal. corrugators

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CATARACT & REFRACTIVE SURGERY TODAY CATARACT &REFRACTIVE SURGERY sues. The lower eyelid and midface are a continuum with the sues. The lower eyelid and midface are a continuum with the its sharpness without disrupting the natural supporting tis raise the lateral canthal angle while simultaneously increasing canthal resuspension allows us to effectively lengthen and rejuvenated appearance to the lateral canthal angle. herein provides an effective method of restoring a natural, cessful surgery. The combined surgical approach described surgical placement of the lateral canthus is paramount to suc anchor point in the periorbital aesthetic unit and thus proper performed. indicated, transconjunctival lower lid blepharoplasty was not obtained with one aesthetic unit surgery, and except where aesthetic gratifying results in more than 2,000 procedures using this one for our patients. The senior author (R.L.A.) has experienced has greatly enhanced both functional and cosmetic results able to treat the entire periorbital aesthetic unit in one setting all performed through this one aesthetic dermatochalasis, lower eyelid laxity, and midface laxity are now of eyebrow ptosis, glabellar furrows, eyelid ptosis, upper eyelid performing the majority of surgeries in our practice. Treatment DISCUSSION the typical or enhanced lateral tarsal strip procedure. entropion, or those with lamellar deficiencies, we still perform crease incision. be performed through the lateral portion of the upper eyelid This elevation improves both function and cosmesis and can a midface/SOOF lift in addition to lateral canthal resuspension. patients with mild to moderate lower eyelid laxity to consider sues both superiorly and laterally as one aesthetic unit. and orbital ligament to move the entire lateral periorbital tis sculpting with release of the anterior leaf of the posterior galea skin and orbicularis muscle removal, as well as internal eyebrow elevate the midface. Also key to the procedure is upper eyelid when present. Limited supraperiosteal dissection is required to fat pads superiorly, and can also improve tear trough deformity rhytids in the lower lids, moves the descended SOOF and cheek interior, superolateral aspect of the orbital rim. by fixating a lateral orbicularis pedicle flap to periosteum in the unit. Midface and suborbicularis oculi fat (SOOF) lift is obtained brow, upper eyelid, lateral canthus, and midface as one aesthetic in periorbital cosmetic surgery and paramount in treating the also leaves aesthetic patients unhappy. shortening of the eyelid with full-thickness excisions often may develop a small or round eye appearance. izontal length of the lower eyelid diminishes, and patients With aging, as the lateral canthal ligament stretches, the hor for mild to moderate ectropion without midface elevation. We believe the lateral canthal angle is the keystone and We believe the lateral canthal angle is the keystone and The upper eyelid crease incision has become the gateway to Based on our long-term results, we routinely encourage Lateral canthal tightening and suspension are the keystone – unit technique. Figure 2 represents results we have unit technique. Figure 2 represents results we have For patients with severe laxity, ectropion or For patients with severe laxity, ectropion or

AUGUST 2017 – unit incision. Being unit incision. Being This improves This improves 8,9 Further Further 8,10,11 Lateral Lateral

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- is also more aware that overly aggressive cosmetic surgery is also more aware that overly aggressive cosmetic surgery further aggravate cosmetic problems. The modern patient fied in this belief, as correction of functional problems may correction of a functional deficit. We believe they are justi more. Most patients are no longer satisfied by the simple blurred, with insurance covering less and patients expecting between functional and cosmetic surgery has become more plications, and cost than other procedures in our experience. cosmetic incision site with less swelling, pain, morbidity, com one session also requires only one recovery period and a single and costs. and leads to decreased surgery, along with its associated risks tages. Use of a single incision increases our efficiency in the OR appearance of the midface. simultaneously also improve lower eyelid rhytids and the lateral canthus, and thus elevating and tightening the canthus 3. BurroghsJR,BeardenWH,AndersonRL,etal.Internalbrowelevationatblepharoplasty. 2. KnizeDM.Ananatomicallybasedstudyofthemechanismeyebrowptosis. 1. LemkeBN,StasiorOG.Theanatomyofeyebrowptosis. provides a powerful yet natural outcome. for the patient. Treating the entire periorbital aesthetic unit recreates the most natural and youthful appearance possible and discussion with the patient, we recommend surgery that leads to an unnatural appearance. Based on our examination 11. VagefiMR,AndersonRL.Thelateraltarsalstripmini-tarsorrhaphyprocedure. 10. OlverJM.Surgicaltipsonthelateraltarsalstrip.Eye(Lond).1998;12:1007-1012. 9. TabanM,NakraT,HwangC,etal. Aestheticlateralcanthoplasty. 8. JordanDR,AndersonRL.Thelateraltarsalstriprevisited.enhancedstrip. 375. 7.Georgescu D,AndersonRL,McCannJD.Lateralcanthalresuspensionsinecanthotomy. Surg. 6. BeardenWH,AndersonRL.Corrugatorsuperciliarismuscleexcisionfortensionandmigraineheadaches. 5. HarsteinM,MassryG,HoldsJ.PearlsandPitfallsinCosmeticOculoplasticSurgery.NewYork:Springer.2015. 192. 4. GeorgescuD,AndersonRL,McCannJD.Browptosiscorrection:acomparisonoffivetechniques. As cosmetic periorbital surgery has evolved, the line As cosmetic periorbital surgery has evolved, the line The one aesthetic 2005;21:418-422. n n Michael W. Worley, MD n n Thomas J. Oberg, MD n n Grant H. Moore, MD n n Kian Eftekhari, MD n n Richard L. Anderson, MD financialinterest:noneacknowledged financialinterest:noneacknowledged financialinterest:noneacknowledged financialinterest:noneacknowledged financialinterest:noneacknowledged Carolina atChapelHill surgeon, EyelidandFacialConsultants, NewOrleans eyelid andfacialsurgeon,AOSurgical Arts,SaltLakeCity,Utah eyelid andfacialsurgeon,AOSurgicalArts,SaltLakeCity,Utah assistant professorofophthalmologyatTheUniversityNorth eyelid andfacialsurgeon,AOSurgicalArts,SaltLakeCity,Utah Rehabilitating the entire periorbital aesthetic unit in Rehabilitating the entire periorbital aesthetic unit in – unit approach has numerous advan Arch Ophthalmol. Ophthal PlastRecontrSurg. 1982;100(6):981-986. Plast ReconstrSurg Arch FacialPlastSurg. Arch Ophthalmol. OphthalPlastRecontrSurg. Arch FacialPlastSurg n 2010;26(3):190-194.

Facial PlastSurg .1996;97(7):1321-1333. 1989;107:604-606. 2009;11(2):136-139. Ophthal Plast Reconstr Ophthal PlastReconstr . 2006;8:36-41. . 2010(26);186- 2011;27:371- - - -