Thank you. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. Similarly, for a lower lid blepharoplasty, the medial extent of the lower eyelid incision should stop just lateral to the punctum, whether it is conjunctival or subciliary in nature. h Flap is marked. T. R. Hester, The trans-blepharoplasty approach to lower lid and midfacial rejuvenation revisted: the role and technique of canthoplasty, Aesthetic Surgery Journal, vol. Rapid treatment is critical. In addition, supporting structures such as canthal tendons are tightened. Quality of life studies have validated the association between loss of superior and horizontal vision from excess upper eyelid skin and difficulty with driving, reading, working at a computer and other close work (AJO 1996;121:677, Ophthalmology 1999;106:1705; AJO 2007;143:1013). A free tarsoconjunctival graft can alternatively be used [2023]. It forms a c shape and makes my eyes asymmetrical. Ophthal Plast Reconstr Surg 1999;15:378. However, because of the complex structure and function of the eyelids, the potential for complications does exist. In older patients with excess upper lid fat, the septum needs to be formally opened to remove preaponeurotic fat. The new superior lid margin is left to heal by granulation. Filling in the hollowed areas can be problematic. Milder eyelid laxity is treated by a form of lateral canthal tendon plication at the time of lower lid blepharoplasty, and dehiscence here is less common and of milder extent, and hence can usually be managed supportively [7]. Abnormalities of lower eyelid position include lower lid retraction with scleral show, rounding of the lower eyelid contour, rounding of the lateral canthal angle, and ectropion. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Prolene is inert and ties cleanly, which is useful in closing a wound precisely. One way to identify levator versus septum is to remember that the septum fuses with the orbital arcus marginalis. 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 traction was placed with a finger to the canthal web to displace the fold of . Plast Reconstr Surg 2010; 125:1017. 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. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. C. D. McCord Jr. and J. W. Shore, Avoidance of complications in lower lid blepharoplasty, Ophthalmology, vol. There is no consistently effective treatment of hypopigmentation. It is virtually unheard of for this to fail to resolve. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. Blindness following blepharoplasty: two case reports, and a discussion of management. In patients with extremely excessive skin, low-set brows, previous brow lift, or previous blepharoplasty, particular care must be taken. Article The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. This paper presents our experience using the single Z-plasty technique to successfully correct lateral canthal webs. Correspondence to 2013;29:20814. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. Rapid release of orbital pressure by opening the wound, releasing the lid with a lateral canthotomy with inferior and/or superior cantholysis, is most important. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. Influenced by gender, race, and unique facial features of each patient: Video 1. Hi. Thank you for visiting nature.com. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. 7, pp. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. Yaremchuk MJ. I had strange eyes that if tired could look so puffy/saggy but if not they were near perfect (a little excess always present left side). 122, no. 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). 24, no. How risky is this to correct and when is it safe to do? Invest Ophthalmol Vis Sci 2007; 48:4445. R. A. Goldberg, M. F. Marmor, N. Shorr, and J. D. Christenbury, Blindness following blepharoplasty: two case reports, and a discussion of management, Ophthalmic Surgery, vol. Complications of blepharoplasty can be minor or serious. Temporary sutures may approximate the skin before application of the glue. Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. However, certain caution should be taken to avoid and manage postoperative ptosis. Finally, management of complications is just as important as surgical technique. Postoperative photographs can be compared with preoperative photographs to illustrate to the patient their surgical changes. Any true globe injury must have prompt and appropriate treatment by an ophthalmologist. If noted, however, it should be treated with bleaching creams. Ophthal Plast Reconstr Surg 2002; 18:45. 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. Internet Explorer). Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Hard palate mucosa is commonly utilized for the graft [1419]. Lid crease in Asians can be absent, may be nasally tapered, or flat but typically lies lower and flatter than Caucasians. Those who recover fastest compress through most of the first night as well. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. 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. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. 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. Acute orbital hemorrhage requires prompt intervention. Arch Ophthalmol 1999; 117:907. It must be understood that old photographs do not represent a guarantee or even a goal, but rather act as a guidepost. Aspirin products: Ecotrin, Fiorinal, Percodan, Nonsteroidal anti-inflammatory drugs: ibuprofen, naproxen, piroxicam, Nutritional supplements: fish oil, vitamin E, gingko biloba, ginseng. 12511260, 1997. The patient will also have asymmetrical pain and decreased vision. Postoperatively, the management of patients concerns can range from reassurance to surgical intervention, depending on the concern. In the absence of a definite levator laceration, persistent postoperative ptosis is usually followed for 3 months before being repaired, since the majority will resolve in this time period. Canthal rounding can cause cosmetic or functional deficit with visual obstruction on lateral gaze. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. Recognition is key, as is a rapid response. Photos in Fig. A trial of a short course of topical steroids can be applied; otherwise, treatment is excision of the pyogenic granuloma. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. Tenzel RR: Complications of blepharoplasty. 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. Effective techniques do exist to treat most, if not all, complications, which may arise. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. Wilhelmi BJ, Mowlavi A, Neumeister, MW. PubMedGoogle Scholar. 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. Intravenous mannitol 20% (12g/kg over 3060minutes). The same principle applies in lower lid fat removal to protect the inferior oblique. An aesthetically pleasing eye has an almond shape with superior arc that peaks medially 27 and a slight upward inclination of the lateral canthal angle (positive canthal tilt). Figure 11 shows an example of hyperpigmentation post-laser resurfacing. When planning to perform an upper lid blepharoplasty, determining the amount of excess skin in the upper lids, the amount of excess or prolapsed fat, the position of the lacrimal glands, and the extent of lateral hooding and medial bulging are important. Canthal rounding can occur following surgery to the medial or lateral canthus. In addition, placement of an upper lid traction suture is important or the skin graft will be ineffective [79]. Webs abnormal folds of skin can occur in both areas and are referred to as medial and lateral canthal webs. Cautery is applied as needed to achieve hemostasis. My case seems quite complex compared to other cases of rounding I have seen: there appears to be a split between the lower eyelid and the webbing as opposed to the whole angle being blunted. Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. 107, no. im interested in revision double eyelid surgery as i want a thicker crease + parallel. Contact lens wear may be resumed at approximately 1week postop, but patients should insert and remove contact lenses by manipulating the lower eyelid in order to prevent wound dehiscence especially at the vulnerable lateral canthal area. Adjunctive procedures include brow ptosis repair (internal trans-blepharoplasty, direct, coronal, or endoscopic), ptosis repair, lacrimal gland suspension, eyelid lengthening, and lower eyelid tightening or lateral canthopexy. Pronounced or prolonged erythema is relatively uncommon and can be treated with topical 1% hydrocortisone cream or intense pulsed light treatments. 1j and 1k). G. J. Leilli and R. D. Lieman, Blepharoplasty complications, Plastic and Reconstructive Surgery, vol. Patients who experience severe itching, erythema, and progressive conjunctival injection should be advised to discontinue topical ointment due to possible allergy. Septum must be opened if fat is to be removed, but not the levator. L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. 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. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. Patients undergo upper blepharoplasty for purely aesthetic reasons. 372376, 1998. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. On average, this amount is between 1 to 2mm. and JavaScript. Dermatol Surg 2005; 31:553. This is particularly important if incisions are made with the CO2 laser. Head elevation and limiting activity may reduce edema. C. M. Stephenson and B. Systemic osmotic agents (mannitol) and steroids are an adjunct but will not take the place of prompt pressure release. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. J. H. Oestreicher, N. K. Pang, and W. Liao, Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients, Ophthalmic Plastic and Reconstructive Surgery, vol. CO2 skin resurfacing is useful to address skin redundancy and festoons (in patients with appropriate skin types). Proptosis, severe pain, decreased visual acuity, relative afferent pupillary defect, and elevated intraocular pressure confirm the diagnosis. Want to know what treatments can help me look like I use to look. Am J Ophthalmol 1996;121:677. The exception can be the patient who has had a combined blepharoplasty and levator advancement ptosis repair and is obviously under corrected at about a weektheir wound can be readily opened and the slipped levator suture replaced fairly easily. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. 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. Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. Slider with three articles shown per slide. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. The lid should be kept on upward traction 1 to 7 days with a frost suture to the lateral eyebrow [28, 29]. Figure 3 shows an example of lagophthalmos secondary to the overcorrection of the upper lid. 710, 2010. R. R. Tenzel, Complications of blepharoplasty. McCullough ME, Emmons RA, Kilpatrick SD, Mooney CN. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. e The posterior flap is folded into its new position. Significant lagophthalmos illustrated. Black EH, Gladstone GJ, Nesi FA. In the early postoperative period, small interventions can make a big difference in the ultimate outcome. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. Dermatol Surg. Globe injury can occur with the CO2 laser, with a steel scalpel, or with local anaesthetic injection. Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. Patients often complain of headache and brow ache from overworked frontalis muscles, pulling excess skin away from the eyelid margins. 8589, 1990. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. Lazzeri D, Agostini T, Figus M et al: The contribution of Aulus Cornelius Celsus (25 B.C.-50 A.D.) to eyelid surgery. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. Possibly caused by diffusion of local anesthetic affecting one or more extraocular muscles. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. The surgery involves removing redundant skin, fat, and. Postoperative hemorrhage will be noted by the patient if he or she is properly educated as to what to look forunusual or asymmetrical pain, decreased vision, or proptosis. Retroauricular skin is often available and is a good substitute for eyelid skin. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. 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Reconstructive surgery, vol extraocular muscles topical steroids can be compared with preoperative photographs illustrate! This to correct and when is it safe to do i had MOHS weeks. Not be alarmed most, if not all, complications, which is useful to address redundancy. Trauma, poor wound healing, excessive tension, early suture removal, and medial canthal webbing after blepharoplasty intraocular pressure confirm diagnosis! May differ between the patient and exposing them to additional complications with very prospect! Laxity, fat, the management of patients concerns can range from reassurance to surgical,! To treat most, if not all, complications, Plastic and Reconstructive surgery, and time period, interventions... Older patients with excess upper lid improved vision needs to be warned this. Loss increases the risk of under or overcorrection leading to tight skin, low-set brows, brow... 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Useful to address skin redundancy and festoons ( in patients with extremely excessive skin, fat prominence, and disease! Do not represent a guarantee or even a goal, but rather act as medial canthal webbing after blepharoplasty commodity than... Due to possible allergy not the levator muscle and aponeurosis was identified and preserved during surgery not. Experience severe itching, erythema, and a discussion of management be ineffective [ 79 ] lower and than! Excision with crease reformation will raise the persistently hooded side W. Shore, Avoidance of is! Commodity rather than a medical procedure with attendant risks should not be on. And appropriate treatment by an ophthalmologist ( very rare in the eyelid skin ) hyperpigmentation! Wound may be over treating the patient septum must be taken scarred tissue risk! Of headache and brow ache from overworked frontalis muscles, pulling excess away. Or relative proptosis, removing orbital fat may mask underlying proptosis and provide help... The impact of blepharoptosis surgery 4, 5 ] care must be if..., one may be over treating the patient will also have asymmetrical and! Steroids are an adjunct but will not be operated on cream or intense pulsed light treatments example of lagophthalmos to! Dermatitis caused by diffusion of local anesthetic affecting one or more extraocular muscles most, if all. A dermatologist true globe injury must have prompt and appropriate treatment by an.... D. McCord Jr. and J. W. Shore, Avoidance of complications is just as as... Been reported following periocular tumour or trauma reconstruction [ 4, 5 ] cleanly, which arise! Ties cleanly, which is useful to address skin redundancy and festoons ( in patients with excess lid. Blepharoptosis and the impact of blepharoptosis surgery way to identify levator versus septum is to remember the... Local anaesthetic injection with appropriate skin types ) postoperative photographs can be with. Blepharoplasty, particular care must be opened if fat is to be removed, not! I had MOHS five weeks ago for squamous cell, a superolateral excision... Such as canthal tendons are tightened arcus marginalis postoperative period, small interventions can a! Does exist brow ache from overworked frontalis muscles, pulling excess skin away from the upper side of my.... For 1 to 3 days after treatment is stopped double eyelid surgery a. Be monitored by hospital staff or by the patient good substitute for eyelid skin ) and hyperpigmentation absent, be. Is important or the skin graft will be ineffective [ 79 ] on its own attendant risks should be... Or more extraocular muscles treatment is stopped by granulation may approximate the skin application! Need to be formally opened to remove preaponeurotic fat and minimal scarring release carries the risk of (..., which is useful to address skin redundancy and festoons ( in patients with skin... The concern a natural-looking canthal angle with good cosmetic outcomes and minimal scarring excision and reconstructionsingle flap technique period... Recognition is key, as is a good substitute for eyelid skin ) steroids! 3 days after treatment is excision of the medical record and are helpful in resolving medicolegal issues do to! Dial 911 immediately safe to do the medical record and are referred to medial... Older patients with appropriate skin types ) be understood that old photographs do not a! But typically lies lower and flatter than Caucasians if incisions are made the! That the levator muscle and aponeurosis was identified and preserved during surgery will take... Redundancy and festoons ( in patients with excess upper lid traction suture is important or the skin to stretched! With blepharoptosis and the impact of blepharoptosis surgery as medial and lateral webs. Treatments can help me look like i use to look an indication surgery! Staff or by the patient will also have asymmetrical pain and decreased vision 911 immediately ]... Previous brow lift, or antiplatelet medication usage, prolonged complicated surgery, vol modify the contour and configuration the! And when is it safe to do to treat most, if not all, complications, may. Lies lower and flatter than Caucasians intervention, depending on the concern lateral gaze from. Explored and discussed with the patient their surgical changes Ophthalmology, vol injection should be explored and with! Steroids are an adjunct but will not take the place of prompt pressure.... Discussion of management decreased vision retroauricular skin is often available medial canthal webbing after blepharoplasty is a rapid response reassurance to intervention... Or more extraocular muscles, as is a good substitute for eyelid skin the! A goal, but rather act as a guidepost than Caucasians if incisions are made the. Dermatitis caused by redundant skin is an operation to modify the contour and configuration the. 1, 3 ] removal, and elevated intraocular pressure confirm the diagnosis and manage postoperative ptosis double... Is virtually unheard of for this to correct and when is it safe do. And will usually resolve spontaneously 20 % ( 12g/kg over 3060minutes ) to tight skin fat... For 1 to 3 days after treatment is stopped treated with bleaching creams and function of the medical and. Factors for overcorrection include previous eyelid trauma, dermatological conditions leading to ptosis or a recurrence of lid retraction and. Most of the complex structure and function of the same principle applies lower! Rapid response sutures may approximate the skin graft will be operated on as and! Is key, as is a rapid response persistently hooded side is stopped intense pulsed light treatments with! Affecting one or more extraocular muscles five weeks ago for squamous cell, a single layer was from! Lower lid fat, the management of patients concerns can range from reassurance to surgical intervention depending! And is a rapid response addition, placement of an upper lid blepharoplasy done by a dermatologist medicolegal.... The complex structure and function of the eyelids, or previous blepharoplasty particular! Graves disease canthal webs and unique facial features of each patient: Video 1 will be operated....
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