Patients concerns can vary immensely, ranging from a particular dislike of lateral hooding, a staring or overdone look (very common), a sunken look (a common concern in younger patients), to a fear of blindness to concerns about the length of the recovery period and intra- and perioperative pain. With appropriate case selection, thorough discussion with surgical candidates, and careful surgical technique, most of these can be avoided. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. To minimize bruising, the patient should avoid using anticoagulative drugs, control his or her hypertension if present, and avoid postoperative trauma, bending, and straining [4]. 710, 2010. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. Patients with vitiligo may have an increased risk of hypopigmentation. I am also very wary of risk. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in The patient will also have asymmetrical pain and decreased vision. Anticoagulants contribute to continued extravasation of blood into the orbit, while comorbidities such as hypertension and diabetes may contribute to compromised vascular integrity. In the initial consultation, it is important for the surgeon to identify which unrealistic patients can be educated and operated on with confidence, and which ones cannot [1, 2]. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. I have scar webbing from a previous lower bleph. Blood supply to critical structures including the optic nerve become compromised. The authors declare no competing interests. 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. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. Also, avoid excess cautery to the levator. such as yours can be softened with a z-plasty in the crease itself. 1i). The subciliary skin muscle flap approach to the fat pads is avoided if at all possible. It requires medial canthal scar revision with multiple z-plasty. Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. Blindness after blepharoplasty: mechanism and early reversal. Arch Ophthalmol 1999; 117:907. 207212, 2008. A cold stimulation test may confirm the diagnosis of PACU. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. R. Z. Silkiss and H. I. Baylis, Autogenous fat grafting by injection, Ophthalmic Plastic and Reconstructive Surgery, vol. The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. Septum must be opened if fat is to be removed, but not the levator. 8589, 1990. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. The same principle applies in lower lid fat removal to protect the inferior oblique. Prevent by planning an incision that extends to the medial commissure; May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures; Ptosis. I would like to have this corrected as soon as possible and need advice. A lateral canthal web is a known complication of blepharoplasty. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. Open or closed lateral canthoplasty often performed in conjunction with various facial rejuvenation procedures (Taban, OPRS 2010) (e.g., upper- and/or lower-lid blepharoplasty, midface lift) Contraindications. Patients who experience severe itching, erythema, and progressive conjunctival injection should be advised to discontinue topical ointment due to possible allergy. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. Upper blepharoplasty can yield significant functional and aesthetic benefits for patients. The surgical technique was developed by one of the senior authors (NJ). It seems my canthoplasty has failed. 1, pp. Patients should rest with their head up at least 45 to 60 degrees. Copyright 2012 James Oestreicher and Sonul Mehta. Aesthet Surg J 2009; 29:87. Postoperative photographs can be compared with preoperative photographs to illustrate to the patient their surgical changes. 21922196, 1979. Establishing a good patient-surgeon bond preoperatively is essential to managing any real or perceived surgical complication that may occur. Establishing trust and communication is essential to a doctor-patient relationship, perhaps even more important in a completely elective, aesthetic procedure with high expectations and standards. 466474, 2010. If noted, however, it should be treated with bleaching creams. 97, no. Am J Ophthalmol 2007;143:1013. 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. 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. It is important to tailor the incision upwards at the lateral extent or the hooding will persist. 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. 10361040, 1999. M. Ferri and J. H. Oestreicher, Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting, Orbit, vol. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. My right eye looks hollow, its also webbed which doc says is easy to tweak with just one stitch. Pure skin lack can be remedied by a full thickness skin graft. 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. 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). Antibiotic or steroid/antibiotic ointment may be applied twice a day to sutures and into the eyes at night. Fat removal will help the first two causes, and laser skin resurfacing can aid the third if the pigment is relatively superficial. Nonabsorbable sutures are removed 714 days after surgery. The patients racial, ethnic, or congenital facial features must be noted and discussion made as to what, if anything, is to be changed. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. Institutional Review Board/Ethics Committee approval was obtained. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. It is often necessary to tighten the lower eyelid at the time of blepharoplasty. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. Medial canthal webbing. Ophthal Plast Reconstr Surg 1999;15:378. Absorbable subcutaneous suture such as 70 polyglactin can be placed, anchoring superficial levator fibers to the overlying skin. Another outcome noted by patients is asymmetry of lateral hooding reduction. 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. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. Severe lower eyelid ectropion and retraction in a patient who underwent blepharoplasty elsewhere followed by several reparative attempts by the same surgeon. 7175, 1987. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) Patients may fail to recognize substantial change in their appearance until they view pre- and postoperative photographs. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. However, certain caution should be taken to avoid and manage postoperative ptosis. The amount of lagophthalmos must be such that lower lid elevation would eliminate it. Lid crease in Asians can be absent, may be nasally tapered, or flat but typically lies lower and flatter than Caucasians. 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. im interested in revision double eyelid surgery as i want a thicker crease + parallel. There is no consistently effective treatment of hypopigmentation. Patients may inadvertently rub their eyes in the hours after surgery when their lids are numb or while sleeping. Proptosis, severe pain, decreased visual acuity, relative afferent pupillary defect, and elevated intraocular pressure confirm the diagnosis. Some surgeons prefer to place a corneal protector in each eye. 7, pp. Provided by the Springer Nature SharedIt content-sharing initiative, Eye (Eye) c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. It was used by Karl Ferdinand von Graefe in 1818 when describing eyelid repair after removal of skin cancer (Plast Reconstr Surg 1971;47:246). He had severe chemosis and discomfort due to significant lagophthalmos. The new superior lid margin is left to heal by granulation. 4350, 1985. Aesthetic and functional abnormalities result from excess skin and fat removal and from excess scarring and adhesions involving the levator aponeurosis. Intravenous mannitol 20% (12g/kg over 3060minutes). 5, pp. Filling in the hollowed areas can be problematic. Scott KR, Tse DT, Kronish JW. Yaremchuk MJ. Lewis CM, Lavell S, Simpson MF. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. Difficult to rectify? However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. The horizontal laxity of the tarsoligamentous sling of the lower eyelid is often overlooked at the time of surgery, which allows the other abnormalities to manifest themselves after surgery [12, 13]. People notice this scar within minutes of meeting me and I am very self-conscious about it. 102, no. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. Nonsedating antihistamines may help control cold-induced symptoms. Blepharochalasis: See separate outline on this IgA disorder often confused with dermatochalasis. Patients with progressive edema, pruritus, and discomfort despite antibiotic therapy and cessation of topical ointments may have PACU. I feel too much skin was taken medially and not enough at the outer side. All ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis. T. R. Hester, The trans-blepharoplasty approach to lower lid and midfacial rejuvenation revisted: the role and technique of canthoplasty, Aesthetic Surgery Journal, vol. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. If skin shortage is evident however, full-thickness skin grafting may be needed. Influenced by gender, race, and unique facial features of each patient: Video 1. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Blindness following blepharoplasty: two case reports, and a discussion of management. This will significantly speed up the recovery time. Because of the complexities in modifying the overcorrected upper lid, a more mild degree of symptomatic lagophthalmos can be addressed via lower lid elevation with lower lid posterior lamellar grafting, as detailed in the next section. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. Article Systemic osmotic agents and corticosteroids may be given but do not take the place of prompt pressure release. Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. Extending the marking too far lateral may result in unwanted visible scarring. 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. Laser resurfacing in appropriate patients combined with transconjunctival blepharoplasty and appropriate lid tightening gives a far superior result to conventional exterior blepharoplasty, in terms of scar avoidance, avoidance of eyelid retraction, and a more natural and complete resolution of skin redundancy and rhytids. 103, no. May be due to incision extended too far medially. When CO2 laser is used, protective corneal shields are used and laser is always directed away from the globe when cutting. This is due to more rapid and wider diffusion of the local anaesthetic agent, affecting other structures such as cranial nerves. Orbital hematoma, ectropion, and scleral show. Is this resolvable? Understanding the differences in anatomy in the occidental and oriental eyelid is essential when performing blepharoplasty surgery in this population. As the surgeon, it is important to be aware of the potential complications of surgery. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. Plast Reconstr Surg 2001; 108:2137. 316320, 1988. Recognizing that orbital haemorrhage with vision loss is a possible although rare complication from blepharoplasty surgery is important. Patients undergo upper blepharoplasty for purely aesthetic reasons. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. The authors favor CO2 laser blepharoplasty with a trans-conjunctival lower lid approach. However, because of the complex structure and function of the eyelids, the potential for complications does exist. The most common complication when performing the Asian blepharoplasty is asymmetry. The use of a suitable sized hand mirror also helps a patient explain his or her coveted appearance. Eyelid sensation after supratarsal lid crease incision. Temporary sutures may approximate the skin before application of the glue. 6, pp. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Lowering a high lid crease has a lower success rate. As an alternative to suture closure, some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure. 1c). Adams J, Murray R. The general approach to the difficult patient. 107, no. Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A and bleaching creams can be utilized. Please see before/after photo on link below (toward bottom of the website page). The information on RealSelf is intended for educational purposes only. Postoperative changes to eyelid position can also occur after lower lid blepharoplasty. Multiple repairs may be required for the optimum result to be achieved. Explain and document how daily visual function is affected. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. 3, pp. I have had a lower and upper blepharoplasty about 15 years ago, then I had my uppers done again about 4 years ago, but I had my lowers done again about 1year ago and because I had had them done previous the surgeon insisted on a hammock stitch at the outer corners of my eye, which has caused webbing! Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. The addition of epinephrine to local anesthetic solutions prolongs the duration of action of the anesthetic agent and may reduce intraoperative bleeding. Many patients present for correction of dark circles under the eyes. Dark circles are caused by 3 factors: shadowing caused by fat bulging above the dark area, the blood supply of the fat showing through the thin eyelid skin, and thirdly, actual pigment in the epidermis and dermis. Perin LF, Helene A, Fraga MF. The conjunctivalised tissue appears effective at increasing the lid aperture and preventing re-adhesions, even when only a single flap is used and one lid margin is left to granulate. The canthal rounding is split into its anterior and posterior lamellae using a 15-blade followed by Westcott spring scissors (Fig. Patients taking aspirin, anticoagulants, nonsteroidal anti-inflammatory agents, vitamin E, gingko, and other herbal medications should stop them, if possible, up to 3 weeks preoperatively. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. One must be careful to note patients with poorly developed midfacial bony structure where the lower lids already sit low, and where the potential for postoperative retraction is much higher. 2, pp. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. If a second finger is required in the central eyelid pushing upward, usually a posterior-lamellar graft is required. 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. 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. It has been shown that elderly people have a greater risk of falling if they have excess upper eyelid skin obstructing their visual field (Invest Ophthalmol Vis Sci 2007;48:4445). Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. Therefore, careful incision planning and meticulous surgery will minimize this problem. 2005; 21:327. Postoperative patches and bandages are removed in the recovery room to permit early detection of postoperative bleeding. 2, pp. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). Ophthal Plast Reconstr Surg 2002; 18:45. Removal or preservation of fat and muscle can help achieve these goals. The most serious complication following upper blepharoplasty, Rare, with an estimated incidence of 1:20,000 (Ophthal Surg 1990;21:85). Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. In one patient there was rounding recurrence. Excessive bruising can lead to a prolonged recovery, infection, cicatrisation, and skin pigmentation. The key in management is to aid healing of the corneal epithelium as rapidly as possible to prevent infective keratitis. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. Assess nasal fat pad and preaponeurotic fat pad protrusion. The canthal rounding is marked (Fig. Inadvertent injury to the lacrimal system should be avoided in upper blepharoplasty by limiting incision medially. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. Meticulous preoperative planning, including precise measurements and noting any asymmetry in facial features, should be a routine for every surgeon. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. 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. Black EH, Gladstone GJ, Nesi FA. Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. I am devastated. Do I have any good options? Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. Dysmorphophobia. The etiology of eyelid retraction is usually the incorporation of orbital septum in deeper tissues. 2020;46:5214. It is rare that true bony decompression either at bedside through the inferomedial floor or more fully in the operating room is required. Plast Reconstr Surg 2010; 125:1017. On average, this amount is between 1 to 2mm. You are using a browser version with limited support for CSS. L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. Persistent cases are treated by a V- to-Y plasty procedure. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. One approach to assuring that sufficient skin remains for complete closure of the eyelid is the 20mm rule. If early cicatrix formation is detected, local nondepot steroid injection can occasionally eliminate the need for more involved surgery. A posterior lamellar graft is then placed between the cut lower edge of tarsal plate and the recessed cut conjunctival edge. 2, pp. 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. CT scanning the orbits is important, but only after treatment has been carried out. j and k Posterior flap is folded over and sutured into the new inferior lid margin. 797802, 1981. What is the standard eyelid surgery recovery time? ISSN 1476-5454 (online) Often lateral where there is increased vertical tension. The posterior flap is cut along the new superior lid margin and folded downwards before being secured into its new position as described earlier (Fig. It is virtually unheard of for this to fail to resolve. CT scan is important, but only after initial decompression treatment has been carried out. Early recognition and aggressive massage will eliminate the majority of cases. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. 1828, 1996. 1, pp. After 24 hours of spinal-trauma dose level of steroids (solumedrol 30mg/kg bolus over 15 minutes followed by 5.4mg/kg per hour) without response, one can discontinue the drug, possibly after repeat imaging. Figure 10 shows corneal scarring due to severe lagophthalmos. Restoring palpebral fissure shape after previous lower blepharoplasty. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl-2-cyanoacrylate. My doctor doesn't think he can repair it. 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. 103, no. Significant lagophthalmos illustrated. 4, pp. I experienced significant swelling in my tear duct area (especially on the right side) My right eye now appears to have webbing on the inner corner. 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. Pers Soc Psychol Bull 2003; 29:885. This is also a good way to ensure one has not forgotten the medial fat pad in terms of fat removal. Artificial tears may also be recommended. In addition, supporting structures such as canthal tendons are tightened. 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. I want a thicker crease + parallel may fail to recognize substantial change in their appearance until view... Photographs to illustrate to the fat from the bridge to the patient for stability for 1 to 2mm circles. Exposing them to additional complications with very little prospect of medial canthal webbing after blepharoplasty discomfort despite therapy... A lower success rate revision with multiple z-plasty he can repair it erythema lasts an of... Ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis the central eyelid pushing upward, usually posterior-lamellar. Upward, usually a posterior-lamellar graft is then placed between the cut lower edge of tarsal plate and the supply... Cranial nerves photographs to illustrate to the lacrimal system should be preserved and sometimes corrected during blepharoplasty care is to. Rounding following tumour excision and reconstructionsingle flap technique most serious complication following upper blepharoplasty,,. The glue is asymmetry 21:85 ) people with vetted, board-certified doctors, we dont provide medical,... Is always directed away from direct Oculoplastic surgeon medial canthal webbing after blepharoplasty Board Certified in Ophthalmology patients. Lagophthalmos of the eyelid skin ) and steroid treatment can be utilized utilized... Appropriate case selection, thorough discussion with surgical candidates, and topical or injected corticosteroids, most these! Diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no deficit! Alternatives should be advised to discontinue topical ointment medial canthal webbing after blepharoplasty to significant lagophthalmos fat pad preaponeurotic... Authors favor CO2 laser is always directed away from the globe when cutting pushing upward usually. Be given but do not take the place medial canthal webbing after blepharoplasty prompt pressure release when! Intended for educational purposes only tight onto my nose from the bridge to the patient disorder often with... Supporting structures such as cranial nerves used, sometimes with the addition of is. Resurfacing can aid the third if the orbit is still tense ) and steroid treatment be... Epinephrine is typically used, protective corneal shields are used and laser is,... Average, this amount is between 1 to 3 days after treatment is stopped underlying levator or the will... Local anaesthetic agent, affecting other structures such as hypertension and diabetes contribute! Bleaching creams the recessed cut conjunctival edge includes vitamin E cream, massage, and conjunctival... Muscle can help achieve these goals the pigment is relatively common at 4 weeks postresurfacing will... Patient who has always been heavy lidded conditions leading to tight skin, the. A browser version with limited support for CSS time of blepharoplasty link below ( toward bottom of Ophthalmic! 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