It may be necessary to lighten the patients sedation to gain an accurate assessment of lid height, and sitting them upright is also useful. I had eyelid surgery one year ago and have been left with a very unsightly scar. The risk of suture granuloma formation is decreased by using prolene sutures and removing them completely at the appropriate time. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. More effect (in terms of lifting skin off the eyelashes) for less skin excision can be achieved by creating a higher lid crease during the blepharoplasty. Dissection in the lateral canthal area may result in altered lymphatic drainage. Upper eyelid spacer grafts such as sclera or tarsus are best avoided, as they are unnecessary and can be unsightly and palpable to the patient. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. 12, no. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. Ophthalmology 1999; 106:1705. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. A posterior lamellar graft is then placed between the cut lower edge of tarsal plate and the recessed cut conjunctival edge. Therefore, careful incision planning and meticulous surgery will minimize this problem. 21962208, 1998. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. The median age was 65.5 years (range: 2688). Minimizing wound dehiscence involves appropriate suture choice and suture placement. 5, pp. Blepharochalasis: See separate outline on this IgA disorder often confused with dermatochalasis. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Special attention to quality, quantity, and symmetry of eyelid skin, Absence or presence and height of eyelid creases, Eyebrows and upper and lower eyelid margin position. 417425, 1993. 2, pp. Laser can be used to expose the superficial fibers of the levator for incorporation into the skin closure. Patients undergo upper blepharoplasty for purely aesthetic reasons. Temporary sutures may approximate the skin before application of the glue. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. One should identify (and preserve) the inferior oblique and levator during surgery, to be confident they have not been injured. The addition of epinephrine to local anesthetic solutions prolongs the duration of action of the anesthetic agent and may reduce intraoperative bleeding. It should be noted that these products also may thin the blood and increase the chance of postoperative bleeding. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. In older patients with excess upper lid fat, the septum needs to be formally opened to remove preaponeurotic fat. Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. READ MORE Please see before/after photo on link below (toward bottom of the website page). This fast and predictable approach avoids opening the anterior wound and also avoids overcorrection and scar abnormalities. Lewis CM, Lavell S, Simpson MF. Relative merits and disadvantages of addressing concurrent blepharoptosis, eyebrow ptosis, eyelid retraction, and other sources of eyelid, eyebrow and orbital asymmetry can be included in the discussion on proposed blepharoplasty. Systemic osmotic agents and corticosteroids may be given but do not take the place of prompt pressure release. There was one recurrence of rounding, which was noted at the first post-operative review at 2 weeks following surgery. Similarly, when using the CO2 laser to cut fat lobules free, one needs a back stop (usually a Q-tip) to absorb the transmitted laser energy and avoid damage to the structures that lie beneath (levator, Mullers muscle, conjunctiva and globe). The risks are significant and include brief effect, scarring and tissue irregularities, uneven contours, and ptosis and lid retraction. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. Invest Ophthalmol Vis Sci 2007; 48:4445. Retrobulbar hemorrhage is a form of compartment syndrome, with pressure rising abruptly within the fixed 4 walls of the orbit. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. An alternative approach is the "pinch method" where eyelid skin is grasped and gathered until the skin is tight and the lashes begin to evert. lateral hooding looks worse than before.The right side has raised lumpy scarring which runs a little too far in, probably why I have the web? In equivocal cases, a posterior lamellar graft can be tried first, and the patient warned that a following procedure with a skin graft may be necessary. The commonest form is caused when local anaesthetic is supplemented intraoperatively by direct fat injection once the conjunctiva (lower lid) or skin (upper lid) is open. 4350, 1985. I feel too much skin was taken medially and not enough at the outer side. I am 13 days post op. Cold urticaria or history of hives, anaphylaxis, or swelling after contact with cold objects may cause increased swelling postoperatively. The surgeon should spread bluntly posteriorly into the orbit down the lateral wall and through the wounds to access deep hematomas and release them. Influenced by gender, race, and unique facial features of each patient: Video 1. Hard palate mucosa is commonly utilized for the graft [1419]. Millman AL, Williams JD, Romo T, Taggert N. Septal-myocutaneous flap technique for lower lid blepharoplasty. As the surgeon, it is important to be aware of the potential complications of surgery. The scars usually occur when the incisions are carried too medially and the skin bridges the supero-medial hollow of the upper lid in a straight line. Also, avoid excess cautery to the levator. CAS Ophthalmic Plast Reconstr Surg. The risk is failure, with reemphasis, doubling, or other scarring of the existing low crease. The patient will also have asymmetrical pain and decreased vision. Federici TJ, Meyer DR, Lininger LL. In Caucasian men, the crease is usually 69mm above the eyelid margin. However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. If the obstruction is more distal than 8mm from the punctum (unlikely in blepharoplasty surgery), a canaliculo-dacryocystorhinostomy may reconstruct the system. Postoperative patches and bandages are removed in the recovery room to permit early detection of postoperative bleeding. Lowers were performed with transcutaneous approach. 125, no. Correspondence to The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. If essential, a lower incision is made and fat is teased forward between the skin and levator to prevent readhesion of these structures. Thank you for visiting nature.com. Rapid treatment is critical. Heinze JB, Hueston JT. 5, pp. Explain and document how daily visual function is affected. 4, pp. Posterior eyelid elevation is achieved by careful dissection at the level of the bottom of tarsal plate through conjunctiva, lower lid retractors, and orbital septum, and these are recessed downwards off the overlying orbicularis muscle. The swelling can also cause the puncta to turn inwards or evert by swelling or tissue contraction caused by incision lines or laser resurfacing, which also causes epiphora. Understanding the differences in anatomy in the occidental and oriental eyelid is essential when performing blepharoplasty surgery in this population. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. Excessive bruising can lead to a prolonged recovery, infection, cicatrisation, and skin pigmentation. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. In the meantime, to ensure continued support, we are displaying the site without styles I would like to have this corrected as soon as possible and need advice. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. Prevent by planning an incision that extends to the medial commissure, May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures, May be due to inadvertent trauma to the levator complex, including postsurgical edema and dehiscence, May be due to unrecognized preoperative levator dehiscence, May be related to lagophthalmos and dry eye, Usually corrected with lubrication regimen, May require corrective lid surgery to reduce palpebral aperture, May be related to corneal irritation and/or dryness. CO2 laser incisions need 7 days to heal, so sutures are removed on day 7 or 8. Your stitches will be removed 4 days after your procedure. Valerie Juniat. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. Antibiotic ointment may be placed over incision. do you think epicanthoplasty would be a good option? Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). The lower lateral marking is extended to the orbital rim or end of the eyebrow and may course superiorly or follow existing creases to meet the upper mark. However, certain caution should be taken to avoid and manage postoperative ptosis. Patients who experience severe itching, erythema, and progressive conjunctival injection should be advised to discontinue topical ointment due to possible allergy. Twelve patients with post-surgical canthal rounding were included. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. Lazzeri D, Agostini T, Figus M et al: The contribution of Aulus Cornelius Celsus (25 B.C.-50 A.D.) to eyelid surgery. However, rapid release of orbital pressure by opening the wound, lateral canthotomy and inferior and/or superior cantholysis is critical. C. D. McCord Jr. and J. W. Shore, Avoidance of complications in lower lid blepharoplasty, Ophthalmology, vol. The surgery involves removing redundant skin, fat, and muscle. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. Topical and systemic antibiotics are utilized due to the open wounds, and their repair is planned electively in 1 to 2 weeks if they do not close on their own. 1h) then split into its anterior and posterior lamellae as described earlier. Measurement and precision are key to avoiding overcorrection. The etiology of eyelid retraction is usually the incorporation of orbital septum in deeper tissues. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. Hi. Medial canthal webbing. Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty surgery. B. C. K. Patel, M. Patipa, R. L. Anderson, and W. McLeish, Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip, Plastic and Reconstructive Surgery, vol. However, another approach to management to postoperative ptosis is to wait the 3 months and then perform a posterior Fasanella-Servat procedure. Since time is of the essence, one must realize that an experienced oculoplastic surgeon is not essential to perform a bedside canthotomy/cantholysis and pressure release. The incidence is estimated to be 1 in 2,000 to 1 in 25,000 [32]. Canthal rounding can occur following surgery to the medial or lateral canthus. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. However, this was not encountered in our patient group. Cautery to achieve hemostasis may affect nerve or muscle. N. Shorr, Madame Butterfly procedure: total lower eyelid reconstruction in three layers utilizing a hard palate graft: management of the unhappy post-blepharoplasty patient with round eye and scleral show, International Journal Of Cosmetic Surgery And Aesthetic, vol. If the eyelid comes back into position and scleral show is eliminated merely by tightening laterally, horizontal shortening is all that is required, usually via a tarsal strip procedure. Before discharge, wounds are checked for bleeding and dehiscence. CT scanning the orbits is important, but only after treatment has been carried out. Medially, this often results from the incision nearing the lid margin too closely or if the incision is extended to far medially or inappropriately angled inferiorly. Remove granulation tissue and freshen wound edges. Lid crease in Asians can be absent, may be nasally tapered, or flat but typically lies lower and flatter than Caucasians. It is both frustrating for patient and surgeon as there lacks standards for its correction. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. When skin shortage dictates skin graft placement, the technique is similar to that for other forms of cicatricial ectropion. C. M. Stephenson and B. Our patients reported excellent outcomes post-operatively without any significant scarring. M. J. Hawes and G. A. Jamell, Complications of tarsoconjunctival grafts, Ophthalmic Plastic and Reconstructive Surgery, vol. 122, no. If the patient continues to have difficulty describing or demonstrating what he or she desires changed, and into what, it obligates the surgeon to promote discussion or present alternatives until clear agreement occursotherwise, surgery should not be done. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. Webs abnormal folds of skin can occur in both areas and are referred to as medial and lateral canthal webs. 438440, 2000. Another outcome noted by patients is asymmetry of lateral hooding reduction. Filling in the hollowed areas can be problematic. 6, pp. C. R. Leone and J. V. Van Gemert, Lower lid reconstruction using tarsoconjunctival grafts and bipedicle skin-muscle flap, Archives of Ophthalmology, vol. Ophthal Plast Reconstr Surg 2004; 20:426. The patient must be a resurfacing candidate to consider this treatment modality (Fitzpatrick skin type, I, II, or III), and the risks of hypopigmentation and hyperpigmentation stressed. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. Lid crease asymmetry is usually corrected by raising the lower eyelid crease. Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. In patients (especially males) with prominent skin and orbicularis excess who are not laser candidates, fat is still removed transconjunctivally, the eyelid is tightened horizontally and a conservative skin muscle pinch excision is utilized. Often lateral where there is increased vertical tension. Asian eyelid includes a pretarsal fat pad and may include more volume in the preaponeurotic fat pads. Photos in Fig. Article Patients may inadvertently rub their eyes in the hours after surgery when their lids are numb or while sleeping. Artificial tears may also be recommended. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. Adams J, Murray R. The general approach to the difficult patient. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. The rhomboid flap is an effective quick and simple technique for medial canthal reconstruction. A slit lamp examination and Schirmers test are necessary in this authors view. Relative . Lastly, there are occasional patients who develop unrelated cranial nerve palsies some weeks or months after surgery by chance alone. A good understanding of anatomy and careful preoperative counseling of the patient is crucial for success. Dry eye symptoms may worsen if there is a decreased blink after removal of orbicularis muscle. Blink dysfunction is common postblepharoplasty because of postoperative swelling of the eyelid tissues. In addition, supporting structures such as canthal tendons are tightened. Secondary revision surgery should remain an option during follow-up treatment and should be considered normal and occasionally necessary within weeks to months after surgery. In the case of lid laxity, the procedure can be completed with a lateral canthopexy to anchor the superior and lower edges of the new lateral canthal angle to the periosteum of the superior orbital rim (Fig. Will I need an eventual revision? What is the standard eyelid surgery recovery time? Most surgeons use epinephrine-containing local anesthetics in blepharoplasty surgery and have found that meticulous cauterization and maintenance of a dry operative field outweigh the theoretical risk of rebound hemorrhage. How do you handle them? Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. If suspicious that an orbital hemorrhage has occurred, laser eye protectors (metallic scleral contact lenses) block vision and must be removed to assess the visual acuity. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. ISSN 0950-222X (print), https://doi.org/10.1038/s41433-021-01497-y, Medial canthoplasty for the management of exposure keratopathy, The kissing puncta: an under-reported and stubborn cause of epiphora, Anterior lamellar deficit ectropion management, Skin redraping for correction of lower eyelid epiblepharon combined with medial epicanthal fold: a retrospective analysis of 286 Asian children, A novel technique for the measurement of eyelid contour to compare outcomes following Mullers muscle-conjunctival resection and external levator resection surgery, The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations, Comparison of three surgical techniques for internal angular dermoid cysts: a randomized controlled trial, Causes and management of persistent septal deviation after septoplasty, Strategies for ear elevation and the treatment of relevant complications in autologous cartilage microtia reconstruction. 2 were supplied by DS and NJ. Remember that the levator aponeurosis is the stage on which the fat removal of upper blepharoplasty is played; and it is natural for early postoperative dysfunction to occasionally be seen. Patient selection and patient satisfaction. Aspirin products: Ecotrin, Fiorinal, Percodan, Nonsteroidal anti-inflammatory drugs: ibuprofen, naproxen, piroxicam, Nutritional supplements: fish oil, vitamin E, gingko biloba, ginseng. Ophthalmic Plast Reconstr Surg. Partial removal of orbicularis muscle over the medial eyelid area with grafting of medial fat into the lateral sub-brow area has been proposed to restore youthful contours (Fezza J, OPRS 2012;28:446). 1b). 29, no. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Lower eyelid skin excision or laser resurfacing (or neither) is another key decision. 366368, 1969. 1j and 1k). It is difficult to lower a crease which is too high. There is no consistently effective treatment of hypopigmentation. 466474, 2010. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. Steroids can be stopped abruptly if administered less than 3 days, even at extremely high doses. Post-treatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, and intravenous steroids until 24 hours of stable vision have been noted. However, it will always be less cosmetic than a primary blepharoplasty done conservatively, and it may take up to one year to blend in. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. This is because most patients will initially experience small amounts of lagophthalmos from ongoing local anaesthetic effect on the orbicularis, swelling, and stiffness of the eyelids. 90, no. 1992; 99:222. In Caucasians, the orbital septum attaches to the levator aponeurosis at or slightly above the superior tarsal border or over the anterior surface of the tarsus. Pers Soc Psychol Bull 2003; 29:885. Prompt decompression of the orbit alone can restore vision. There were five men and seven women. The canthal rounding is split into its anterior and posterior lamellae using a 15-blade followed by Westcott spring scissors (Fig. Ice packs or frozen masks are too heavy, which may damage the eyelid tissues or dehisce wounds. Canthal rounding can be cosmetically-unacceptable to patients. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. Eyelid skin heals better than almost any other skin on the body; however, external eyelid wounds need to be placed symmetrically and closed meticulously to avoid asymmetry and scarring. Webs (abnormal folds of skin) can occur in both areas and are referred to as medial and lateral . If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. Assess degree of lacrimal gland prolapse. If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus, in a blunt fashion, the risk of significant damage to orbital structures is low. In addition, supporting structures such as canthal tendons are tightened. Gentle cautery applied to the orbital fat may contour and replace the remaining fat posteriorly into the orbit, providing needed volume and fullness. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. In Asians, the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border, Preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border. Am J Ophthalmol 1996;121:677. For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. 4, pp. Pronounced or prolonged erythema is relatively uncommon and can be treated with topical 1% hydrocortisone cream or intense pulsed light treatments. Cautery is applied as needed to achieve hemostasis. The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Blindness following blepharoplasty: two case reports, and a discussion of management. i Anterior flap is completely excised. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. 1, no. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. Dermatol Surg. 21, no. Lid crease fixation is not always necessary. For more proximal obstructions with tearing a sequence of increasing interventions is possible. Because the lateral canthal web appeared to result from vertical tissue deficiency, we employed a surgical technique to transpose adjacent tissue into the area of the web, similar to the technique described by del Campo 2 for the correction of epicanthal folds.

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