Lower lid blepharoplasty surgery can be a challenging procedure for both the neophyte and the accomplished surgeon. It requires mastering complex periorbital anatomy and choosing the correct approach from a wide variety of patient presentations. This article spans the meticulous clinical evaluation, diagnostic approaches, and surgical techniques required to address challenging clinical scenarios of the lower eyelid, lid-cheek junction, and midface. By following these principles, surgeons can achieve excellent esthetic and functional results, even in the most challenging cases.

This article's raison d'etre is simple: to deliver a decidedly lucid and sanguinely compelling description of a lower eyelid surgical rejuvenation strategy. By bestowing the surgeon greater control of the lower eyelid, a more esthetic result with fewer complications can be reliably delivered. The pinch blepharoplasty does so by offering 3 unique advantages: First, it respects and preserves both esthetic and functional eyelid posture. Second, it treats the excess eyelid skin and wrinkles comprehensively. And third, it simultaneously addresses the orbital and nasojugal grooves.

Successful lower blepharoplasties address patient-specific lower eyelid, canthal, and lid-cheek junction pathology. Various technical procedures have been described to address the lower eyelid lamellae and tarsoligamentous sling. The most appropriate procedure should be tailored for each patient in an algorithmic approach to ensure optimal esthetic outcomes and minimize risk.

The lower lid cheek junction is a complex region. Patients are concerned about contour deformities of the lower eyelid and the cheek, but the causes of these issues are found in the underlying anatomy. Age-related bony changes result in a recessed infraorbital rim and a recessed maxilla. Loss of cheek soft tissue contributes to the formation of a tear trough deformity. Configuration of the tear trough comes in 3 classes, each of which requires a different surgical treatment. Combined procedures on the lower lid and the cheek often result in the most significant improvement.

In an effort to prevent post-operative eyelid complications, lower blepharoplasty requires taut approximation of the lower lid to the globe. This is routinely accomplished with lid tightening procedures and/or canthal fixation. Multiple techniques can be utilized in combination to appropriately and aesthetically reposition the lower eyelid during cosmetic blepharoplasty. These techniques include simple canthopexy, canthoplasty, drill hole fixation, and complete tarsoligamentous sling reconstruction. In this article, we examine the unique anatomy of the lateral canthus as well as the indications for utilizing diverse options for canthal fixation.

The preoperative evaluation plays an important role in optimizing outcomes and minimizing morbidity for patients undergoing blepharoplasty. This article provides a detailed, systematic approach for the preoperative evaluation of patients undergoing upper and lower blepharoplasty. This article focuses on the critical steps of evaluating surgical blepharoplasty candidates to ensure optimal outcomes and high patient satisfaction, while minimizing risks and complications.

Lower eyelid blepharoplasty has historically been approached from one of only two techniques, either the anterior subciliary incision or from the posterior transconjunctival approach. Both have been used with subtractive techniques of skin and fat resection in most cases and both have had issues with post operative lower lid retraction with scleral show, albeit less with the posterior approach. Lateral acces recontouring does not transgress either the anterior or posterior functional muscles of the lower lid and avoids damaging the innervation of the lower lid orbicularis. Thus the technoque has resulted in a zero incidence of slceral show in this series beginning in 2007. When combined with muscle lifting and fat preservation as recontouring techniques, and canthal support when indicated, it also provides excellent blending of the lid cheek junction for effective rejuvenation.

The upper eyelid-brow complex should be approached as a series of three interrelated arcs, the shape of which determines the dimensions of the intervening spaces. By following an engineered structural approach addressing all components of the upper periorbital area, the ideal attractive proportions are created, and the eye becomes instantly more beautiful. Combining different techniques to address the three arcs can be done safely and effectively to treat all three upper lid types. The concept of upper lid tension is introduced as a critical component of upper lid rejuvenation, allowing the most important step of the procedure, pretarsal control.

Non-surgical rejuvenation of the periorbital area is becoming increasingly popular given the downtime and risks associated with surgical procedures. Dermabrasion and chemical peels were first used along with neuromodulators and dermal fillers. Over the past few decades, laser treatments have emerged as the gold standard for periorbital skin resurfacing. The laser treatments are categorized by ablative and non-ablative lasers and further subcategorized into fractionated and non-fractionated lasers. Radiofrequency-based devices have also emerged as a beneficial non-surgical treatment for the periorbital area. Within this section, the authors explore the various non-surgical treatments for periorbital rejuvenation.

Lower eyelid function and appearance depend on the complex anatomic relationship between the soft tissue lamellae, supportive tarsoligamentous sling, and bone. Aging in the lower lid area may be caused by changes in the anterior lamella (skin and orbicularis oculi muscle), middle lamella (orbital septum and lower lid fat pads), posterior lamella (tarsus, lower eyelid retractors, and conjunctiva), tarsoligamentous sling (lateral retinaculum), or any combination of the previously described.

Mangling injuries of the upper extremity are severe, high-energy traumas that damage multiple functional systems including skin, nerves, vascular, tendon, and bone. Management requires familiarity with various techniques in orthopedic, vascular, and plastic surgery. A specific technique cannot be described due to the various combinations of injuries that can occur with mangled upper extremities, but we present principles and recommendations for treatment and judgment.

Reconstruction of bony defects is challenging. Most cases can be solved by means of nonvascularized bone grafts, either corticocancellous or cancellous. However, when the defect is long, there is a combined soft tissue defect, infection, a poor scarred bed, and when a piece of cartilage needs to be included, a vascularized bone graft is preferred. This article features a review of the most useful flaps for small and long defects in the hand and upper limb.

Free functional muscle transfers restore voluntary motion in extremities following the loss of local muscle-tendon units. Surgeons, at various levels of expertise, need to consider several technical aspects when performing this procedure. Successful and consistent outcomes can be attained by applying a combination of basic principles, drawing from techniques developed for successful tendon transfers and microsurgical free tissue transfers. Patient preparation through counseling and intensive rehabilitation is essential to achieve the optimal conditions before the transfer.

Burns of the hand are prevalent and must be managed aggressively in the acute phase to prevent deformity and disability. Proper early wound management, achieving durable soft tissue coverage, and appropriate positioning in the acute period offer substantial benefits to patients long-term. When contractures occur, secondary procedures are often indicated, and they range from laser therapy to local/regional flap coverage; rarely free flaps are used. Boutonniere deformities are common, and unfortunately, at times finger amputation renders the hand more functional than further efforts at reconstruction.

Dupuytren disease is a progressive disease process that causes debilitating flexion contractures of the metacarpophalangeal and proximal interphalangeal joints. There are multiple interventions to choose from, ranging from minimally invasive techniques with little downtime to open surgical excision with a lengthy postoperative rehabilitation. Our understanding of the disease process continues to evolve. Depending on the extent of flexion contracture, needle aponeurotomy and collagenase injection have satisfactory results with moderate long-term efficacy. Surgical palmar fasciectomy continues to be the mainstay treatment of extensive contractures, with durable results.

There have been dwindling numbers of replantations in the United States. Despite the advocacy for centralization in hand trauma, the fundamental landscape and attitudes of surgeons toward replantation have remained lackluster. There is growing and substantial evidence to demonstrate the superior outcomes of replantation in comparison to revision amputation in most scenarios. This article aims to delve into the factors contributing to the decreasing numbers of replantations and proposes strategies to overcome this issue.

Traumatic thumb injuries significantly affect overall hand function and may result in considerable disability. Reconstructing the traumatized thumb requires a detailed preoperative assessment of the defect and evaluation of the patient's social history and medical comorbidities. Reconstructive techniques can be stratified by the level of thumb injury. The goals of thumb reconstruction are to restore length, stability, mobility, and sensibility. This article reviews reconstructive principles and operative techniques for reconstructing the traumatized thumb.

Functional impairment, absence, or traumatic loss of the thumb is associated with considerable morbidity. A fully functioning thumb is estimated to account for 40% of hand function. An array of options exists for thumb reconstruction, and the intervention selected must be tailored to each individual patient. Pollicization is a powerful and elegant operation that can dramatically improve function for many patients. However, the surgeon and patient must be keenly aware that pollicization does not construct a "normal" thumb. Herein, we present a stepwise approach to treatment, including surgical nuances, alternatives to pollicization, complications, and outcomes.

Upper extremity amputation can lead to significant functional morbidity. The main goals after amputation are to minimize pain and maintain or improve functional status while optimizing the quality of life. Postamputation pain is common and can be addressed with regenerative peripheral nerve interface surgery or targeted muscle reinnervation surgery. Both modalities are effective in treating residual limb pain and phantom limb pain, as well as improving prosthetic use. Differences in surgical technique between the 2 approaches need to be weighed when deciding what strategy may be most appropriate for the patient.