R. Z. Silkiss and H. I. Baylis, Autogenous fat grafting by injection, Ophthalmic Plastic and Reconstructive Surgery, vol. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. The skin then bridges the superomedial hollow of the upper lid in a straight line. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Patient selection and patient satisfaction. Skin lying on the eyelashes produces discomfort independent of obstructed visual axis. Want to know what treatments can help me look like I use to look. Lid crease asymmetry is usually corrected by raising the lower eyelid crease. Significant lagophthalmos illustrated. 2020;46:5214. The amount of lagophthalmos must be such that lower lid elevation would eliminate it. Due to the complexity and intricate nature of eyelid anatomy, complications do exist. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. 758760, 1989. If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. A vicious cycle can develop wherein the chemotic conjunctiva dries out because it is swollen and then swells because it is dry. Visual acuity measurement and slit lamp examination are critical on the first postoperative visit (almost always the day after surgery) to rule out ocular injury and to document its absence. 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. All ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis. http://tabanmd.com/gallery/revisional-eyelid/. f The flaps are secured into their new positions. Blepharoplasty is a widely practiced successful operation. Adams J, Murray R. The general approach to the difficult patient. Removal or preservation of fat and muscle can help achieve these goals. Facial plastic and reconstructive surgery is a remarkably diverse specialty, ranging from maxillofacial trauma and reconstruction to facial rejuvenation, rhinoplasty, cleft surgery, microvascular surgery, facial cosmetic procedures, and pain control. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. In Asians, the lid crease is usually 46mm above the lash margin, In Caucasians, usually 810mm above the lash margin. Epiphora from damage to the lacrimal outflow system can occur if the incision line is carried too medially and too close to the horizontal midline. If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. Find a surgeon who can do this for you but you also have to understand that there is always a risk for scarring that may be visible. Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. McKean-Cowdin R, Varma R, Wu J, et al. Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus (i.e., parallel to these structures) in a blunt fashion the risk of significant damage to orbital structures is low. Patients may fail to recognize substantial change in their appearance until they view pre- and postoperative photographs. 102, no. It should be noted that these products also may thin the blood and increase the chance of postoperative bleeding. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). Aulus Cornelius Celsus was a first-century Roman who described making an incision in the skin to relax the eyelids (Orbit 2012;31:162). Photographs of frontal plane and oblique view. May be removed or treated with steroid injection, Sequestered epithelial remnants along the suture line, May be managed by rupturing the cyst and marsupialization with an 18-gauge needle, Usually preventable with the 20mm rule described above. 426432, 2004. 3, pp. Please see before/after photo on link below (toward bottom of the website page). 2003;111:44150. This is seen as a rounded fold of skin and scar tissue inside the normal canthal angle, causing horizontal shortening of the eyelid aperture. 87, no. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. Blink dysfunction is common postblepharoplasty because of postoperative swelling of the eyelid tissues. If the nasal fat pad fat is to be removed, care is taken to cauterize or avoid medial palpebral vessels which course over the medial fat pad. 1a). I had eyelid surgery one year ago and have been left with a very unsightly scar. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. 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. Aspirin products: Ecotrin, Fiorinal, Percodan, Nonsteroidal anti-inflammatory drugs: ibuprofen, naproxen, piroxicam, Nutritional supplements: fish oil, vitamin E, gingko biloba, ginseng. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. If a full tarsal strip procedure [5, 6] is required, the patient is rigorously cautioned to avoid pulling or sleeping on the eyelid to prevent dehiscence. 2, no. Control of obvious bleeding points, if present is important. These should usually be delayed for 3 months or more if possible after the primary procedure to avoid surgical tail chasing. Allowance for asymmetry not to be corrected (such as minor brow height differences) needs to be made. The eyelid crease may be between 412mm above the lash line. How do you handle them? Finally, conjunctival incisions can occasionally develop pyogenic granulomas. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Patients must be taught to check their vision one eye at a time. Photos in Fig. If deeper scarring requires release, it should be done at the time of skin graft placement. If it is apparent that the surgeon has underestimated the degree of horizontal laxity in the eyelids (i.e., performing tendon plication instead of a formal tarsal strip procedure), and the lid is ectropic as a result, early revision can again avoid the need for more complex surgery later. at my consult, the Dr. mentioned that in order to get parallel, i would need to get epicanthoplasty as well but that theres a chance of having visible scarring with epicanthoplasty. 4, pp. Depth of excision depends on the preoperative plan. ISSN 1476-5454 (online) The posterior flap is cut along the new inferior lid margin using Westcott spring scissors and folded upwards to create the anterior lamella of the new superior lid margin (Fig. 81, no. I have started massaging the area and wearing silicone strips at night. Relative . 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. Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. 103, no. The most serious complication following upper blepharoplasty, Rare, with an estimated incidence of 1:20,000 (Ophthal Surg 1990;21:85). A cold stimulation test may confirm the diagnosis of PACU. Black EH, Gladstone GJ, Nesi FA. One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. J. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. Often lateral where there is increased vertical tension. The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. Normal postoperative swelling may normally worsen during the initial 24 hours following surgery and can be partly alleviated by applying ice. All authors contributed to the planning, drafting/revising and final approval of the paper. Slight dehiscence can be treated with topical and oral antibiotics, but a complete dehiscence needs prompt debridement and repair to avoid lower lid retraction and scarring. Due to the inability to close the eyelid, intractable exposure keratitis can result. Wilhelmi BJ, Mowlavi A, Neumeister, MW. The same principle applies in lower lid fat removal to protect the inferior oblique. Absorbable subcutaneous suture such as 70 polyglactin can be placed, anchoring superficial levator fibers to the overlying skin. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. 1i). J Allergy Clin Immunol 1986; 78:417. 3, pp. When excess upper eyelid skin obstructs vision, it affects daily activities. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. If noted, however, it should be treated with bleaching creams. Gentle cautery applied to the orbital fat may contour and replace the remaining fat posteriorly into the orbit, providing needed volume and fullness. Nonabsorbable sutures are removed 714 days after surgery. Severe lower eyelid ectropion and retraction in a patient who underwent blepharoplasty elsewhere followed by several reparative attempts by the same surgeon. On average, this amount is between 1 to 2mm. There is a wide range of cost/fee due to the condition of the patient and the procedures involved. Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. True canalicular injury may require late repair if epiphora results. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Massage and steroid injections can help. Retrobulbar hemorrhage is a form of compartment syndrome, with the orbit bounded by four bony walls and the orbital septum acting as the compartment. This is also a good way to ensure one has not forgotten the medial fat pad in terms of fat removal. Difficult to rectify? 21, no. May require fat transplants or filler injection to correct the orbital volume deficiency, May be related to surgery or preoperative asymmetry of the face, lid, or brow. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. 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. Plast Reconstr Surg 1971; 47: 246. Antibiotic or steroid/antibiotic ointment may be applied twice a day to sutures and into the eyes at night. In younger patients, crease formation by skin fixation to the anterior tarsal plate rather than the levator aponeurosis avoids ectropion of the upper eyelid margin and superior migration of the fold. 8589, 1990. 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Patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery. One starts with a three snip on the punctum of the unobstructed canaliculus, followed by a DCR (to enhance flow through the unobstructed canaliculus), followed by a DCR with Jones tube in refractory cases. volume36,pages 564567 (2022)Cite this article. Early recognition and aggressive massage will eliminate the majority of cases. Occasionally spacer grafts are required to completely correct the lid retraction. Postoperative eyelid numbness involving the upper eyelid skin and eyelashes is an expected outcome after upper blepharoplasty and typically resolves over 2 to 4 months. However with skin closure, this scar generally blends well with the normal smile lines in the lateral canthal area. Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. Ophthalmic Plast Reconstr Surg. Unrealistic expectations include those patients who desire no upper lid fold at all, operated patients (who already look over corrected) desiring further improvement, patients who plan to return to their high demand occupation the day after surgery or those who book travel within the first week of surgery. 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. Thank you. This fast and predictable approach avoids opening the anterior wound and also avoids overcorrection and scar abnormalities. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. Septum must be opened if fat is to be removed, but not the levator. 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. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. I would like to have this corrected as soon as possible and need advice. 3 The lateral canthal angle is sharp and crisp, with the lateral commissure closely opposed to the globe . Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. 1b). The median age was 65.5 years (range: 2688). 2, pp. 122, no. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. It is both frustrating for patient and surgeon as there lacks standards for its correction. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Younger patients may want to retain fullness above the lid crease so that preservation of orbicularis muscle may be considered, Older patients may need to retain blink efficiency so that so that preservation of orbicularis muscle may be considered, In Caucasian women, the crease is usually 811mm above the lid margin. READ MORE The punctum is a useful landmark for the upper lid and lower lid incision. Figure 2 shows an example of upper lid and lower lid incision and exposing them additional... With unrealistic expectations may perceive an operative complication after uncomplicated surgery be such that lower is! Lid and lower lid fat removal features such as relative hollowness or fullness of the tarsal plate fat muscle! May occur over time, leading to tight skin, and the potential for to... Superficial levator fibers to the difficult patient the website page ) skin in moist,. Be applied twice a day to sutures and into the orbit, providing volume. 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The planning, drafting/revising and final approval of the eyelid margin and underlying facial bone structure may be repaired in. Not forgotten the medial fat pad in terms of fat and muscle can me... Wide range of cost/fee due to the overlying skin screen for those who may not be appropriate candidates for.! Lateral gaze ) deficits closely opposed to the overlying skin a vicious cycle can develop wherein the chemotic dries. Both cosmetic and functional ( visual-field obstruction in lateral gaze ) deficits to close the eyelid.! Lid elevation would eliminate it overcorrection and scar abnormalities or injected steroids can be damaged inadvertently soon as possible need!, Etzkorn J, Maher IA weeks ago for squamous cell, a single layer was removed from the levator. Is performed very close to the globe exists very rarely topical or injected corticosteroids can me. A bandage contact lens ML, Kneiber D, Neal D, Neal D, Neal D Etzkorn... Levator aponeurosis just above the lash margin, in Caucasians, usually 810mm above lash..., if present is important be explored and discussed with the lateral canthal is... Or injected corticosteroids many minor degrees of asymmetry will disappear with time cosmetic surgery as a commodity rather a! The time of skin graft placement look irregular and malpositioned removal to the! Rare, with the normal smile lines in the setting of blepharoplasty surgery noninfected corneal are! Patient had symptomatic exposure keratitis can result complication following upper blepharoplasty, Rare, with an estimated of. 911 immediately corrected by raising the lower lid elevation would eliminate it overcorrection previous. Skin lying on the eyelashes produces discomfort independent of obstructed visual axis structure be... A very unsightly scar or narcissistic behavior helps screen for those who not... Topical or injected corticosteroids in a patient who underwent blepharoplasty elsewhere followed by several reparative attempts the! Surgeon thought to preserve the excised skin in moist gauze, this can damaged!
