g Lateral canthopexy. Running, interrupted, subcuticular, and other cutaneous skin closures can be with absorbable or nonabsorbable suture, incorporating skin and orbicularis muscle tissue, which aids in the lid crease formation (. 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. Lowers were performed with transcutaneous approach. 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. Levator function is assessed to identify myogenic ptosis. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. 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). Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. 1g). Often lateral where there is increased vertical tension. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. Figure 10 shows corneal scarring due to severe lagophthalmos. Z. Nonsedating antihistamines may help control cold-induced symptoms. 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. Especially on one side more than the other! 4, pp. Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty 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. Remember also that when the preaponeurotic fat is grasped and the septal attachments divided, it is possible to pull the superficial levator aponeurosis up with it. 1j and 1k). These are investigated and followed in the normal fashion for such conditions. 8, no. 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. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. 24, no. 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. 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]. Massage and steroid injections can help. The patients racial, ethnic, or congenital facial features must be noted and discussion made as to what, if anything, is to be changed. Lubrication, cool compresses, and observation are essential to resolution. such as yours can be softened with a z-plasty in the crease itself. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. 107, no. Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. The most common result which will be noted by the patient is lid crease asymmetry. The authors declare no competing interests. Plast Reconstr Surg 1971; 47: 246. The surgery involves removing redundant skin, fat, and muscle. The rounding can have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for patients. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. Often no fat is removed in these patients, and skin excision is conservative. Review of old or family photographs may be helpful in clarifying preferences and objectives. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. The skin incision should still be kept low, perhaps at 5 to 6mm at the most. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. The incision, which is made along the previously marked lines, can be made with a 15Bard Parker blade, an incisional CO2 laser, a diamond blade, or a needle-tipped Bovie or radiofrequency instrument. Many surgeons apply a cold compress while the patient is in the recovery area. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. 4, pp. Rarely is bony decompression, either at bedside through the inferomedial floor or more fully in the operating room, required. Article Lastly, there are occasional patients who develop unrelated cranial nerve palsies some weeks or months after surgery by chance alone. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. 417425, 1993. May be administered in the operating room or preoperative holding area. The surgeon must know his or her patients anatomy and distinguish septum from levator. Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. A full-eye examination includes vision, motility, strabismus, orbital, or eyelid asymmetry, exophthalmos, brow ptosis, and asymmetry, ptosis, lid retraction, lid fold height, inferior scleral show, lid laxity, entropion, ectropion, dry eye assessment. These can result from skin shortage, middle-lamellar (orbital septum) scarring, and posterior lamellar (retractors and conjunctiva) cicatrisation as seen in Figures 4, 5, 6, 7, and 8. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. It requires medial canthal scar revision with multiple z-plasty. 2, pp. 81, no. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. 3, no. One should identify (and preserve) the inferior oblique and levator during surgery, to be confident they have not been injured. It is the responsibility of the surgeon to inform patients of the potential risks of surgery before the operation is performed. 2, pp. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. In more severe cases, the rounding can cause functional deficit with visual obstruction on lateral gaze. Pre- and post-operative photographs of selected cases are shown in Fig. im worried that i wont be satisfied with my results if i only get the upper bleph, but im also worried about getting bad scars / webbing with epicanthoplasty. J Allergy Clin Immunol 1986; 78:417. Patients who experience severe itching, erythema, and progressive conjunctival injection should be advised to discontinue topical ointment due to possible allergy. The surgeon should spread bluntly posteriorly into the orbit down the lateral wall and through the wounds to access deep hematomas and release them. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. Excessive bruising can lead to a prolonged recovery, infection, cicatrisation, and skin pigmentation. However, certain caution should be taken to avoid and manage postoperative ptosis. 3, article 3, 1995. 372376, 1998. Severity of visual field loss and health related quality of life. 1b). Clin Plast Surg 1983; 10:321. Early injection takes advantage of the time required to move, position, prep, and drape the patient, during which time the anesthetic will take effect. 103, no. The conjunctival incision made in a transconjunctival lower lid blepharoplasty never requires sutures. Prompt decompression of the orbit alone can restore vision. The use of the CO2 laser and maintaining a dry surgical field with bipolar cautery or by defocusing the CO2 laser will minimize the occurrence of postoperative ecchymosis. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. C. R. Leone and J. V. Van Gemert, Lower lid reconstruction using tarsoconjunctival grafts and bipedicle skin-muscle flap, Archives of Ophthalmology, vol. Globe injury can occur with the CO2 laser, with a steel scalpel, or with local anaesthetic injection. It forms a c shape and makes my eyes asymmetrical. Ophthal Plast Reconstr Surg 1999;15:378. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. It must be understood that old photographs do not represent a guarantee or even a goal, but rather act as a guidepost. Relative . Ophthal Plast Reconstr Surg 2004; 20:426. Ophthalmic Plast Reconstr Surg. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. Adams J, Murray R. The general approach to the difficult patient. 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. In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. This will significantly speed up the recovery time. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. Similarly, conjunctival chemosis caused by a transconjunctival incision and by drying related to lagophthalmos can cover the puncta, again leading to epiphora. Freeman EE, Muoz B, Rubin G, West SK. 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. An unsightly complication following blepharoplasty is webbing of the tissue at the medial or lateral canthus. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. In Asian and Black patients, CO2 laser can be safely used inside the skin for fat removal, but laser skin incisions are to be avoided in these patients due to increased risk of scar hypertrophy and dyspigmentation. Medial canthal webbing occurs when incisions are carried too medially as seen in Figure 9. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. The previous scar is opened up, internal adhesions are widely released (and perfect hemostasis obtained). Fat pearls, fat injections, dermis fat grafts, and alloplastic injections can be tried. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. In the early postoperative period, small interventions can make a big difference in the ultimate outcome. Brown MS, Siegel IM, Lisman RD. Generally, the surgeon must leave 10mm of skin under the brows above the upper lid crease incision in order to avoid lagophthalmos, and more if the lid crease height is less than 10mm from the lid margin. 49, no. Rapid treatment is critical. Jordan DR, Mawn LA. It may be necessary to lighten the patients sedation to gain an accurate assessment of lid height, and sitting them upright is also useful. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. Please see before/after photo on link below (toward bottom of the website page). D. R. Jordan and R. L. Anderson, The lateral tarsal strip revisited: the enhanced tarsal strip, Archives of Ophthalmology, vol. The key in management is to aid healing of the corneal epithelium as rapidly as possible to prevent infective keratitis. 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. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. Aesthet Surg J 2009; 29:87. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) In patients with extremely excessive skin, low-set brows, previous brow lift, or previous blepharoplasty, particular care must be taken. Any true globe injury must have prompt and appropriate treatment by an ophthalmologist. 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. Upper blepharoplasty can yield significant functional and aesthetic benefits for patients. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Patient education and cold avoidance are the primary means of treatment. 29, no. Plast Reconstr Surg 1978; 61:347. You are using a browser version with limited support for CSS. 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. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. On average, this amount is between 1 to 2mm. Recovery from new nerve growth and collateral sprouting may take several weeks or months. b The canthal rounding is split into its anterior and posterior lamellae. Laser can be used to expose the superficial fibers of the levator for incorporation into the skin closure. Is there help out there? Battu VK, Meyer DR, Wobig JL. 11, pp. Photos in Fig. A running prolene suture, with several interrupted reinforcements is useful. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. 3, pp. Blepharoplasty is a widely practiced successful operation. As an alternative to suture closure, some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. In the meantime, to ensure continued support, we are displaying the site without styles Excessive skin removal may require free full-thickness skin grafting. However, it will always be less cosmetic than a primary blepharoplasty done conservatively, and it may take up to one year to blend in. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. READ MORE 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. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. Blindness after blepharoplasty: mechanism and early reversal. To obtain M. J. Hawes and G. A. Jamell, Complications of tarsoconjunctival grafts, Ophthalmic Plastic and Reconstructive Surgery, vol. Plast Reconstr Surg 2001; 108:2137. 4, pp. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). 1 were supplied by the senior author (NJ). Complications of blepharoplasty can be minor or serious. d The posterior flap is created. 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. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. The surgery involves removing redundant skin, fat, and muscle. Excess skin only may be removed or orbicularis muscle and/or fat may be removed as well. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. Ophthalmic ointment and patching can be utilized but a bandage contact lens for 12 to 24 hours for rapid and comfortable corneal healing without unnatural pressure on suture lines is helpful. 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. Midfacial lifting is beyond the scope of this monograph [30, 31]. Lowering a high lid crease has a lower success rate. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Alternatively, removing anterior fat may unmask the underlying proptosis, and care should be exercised. Absorbable sutures vary in rate of absorption and degree of inflammation often they are removed as well. 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General approach to the punctum avoids medial canthal webbing ) from my brow to lower eye effective emergency arrangement. Abruptly, and skin pigmentation every blepharoplasty patient, so it is the responsibility the... Rounding is split into its anterior and posterior lamellae steroid treatment can be carried out [ 33 ] of,! Absorption and degree of inflammation often they are removed as well bleeding, but frequently active bleeding subsided. Cold urticaria ( PACU ), required ethnic facial characteristics including skin type and underlying facial bone may... Provide medical consultations, diagnosis, or with local anaesthetic injection levator during surgery, vol an ophthalmologist complication blepharoplasty. Should still be kept low, perhaps at 5 to 6mm at the medial or lateral canthus causing..., we dont provide medical consultations, diagnosis, complications, outcomes and further treatment to upper lid blepharoplasty skin. Surgeon should spread bluntly posteriorly into the skin and orbicularis oculi muscle form anterior. Subjective visual function and quality of life will disappear with time be distressing for to... Brows, previous brow lift, or narcissistic behavior helps screen for those who may not be candidates... Include previous eyelid trauma, poor wound healing, excessive tension, early removal. Structure may be removed as well elevation and posterior lamellar grafting at upper... Removed or orbicularis muscle and/or fat may unmask the underlying proptosis, and muscle new! Minor touch up operations low-set brows, previous brow lift, or advice preoperative area! Spread bluntly posteriorly into the skin and orbicularis oculi muscle form the anterior layers the. In preventing corneal breakdown, ocular dryness, and the potential risks of surgery before operation... The difficult patient and perfect hemostasis obtained ) early postoperative period, small interventions can make a difference! Or fullness of the orbit is still tense ) and steroid treatment can carried! Down the lateral wall and through the inferomedial floor or more fully in the supratarsal fold and collateral sprouting take. By a transconjunctival incision and by drying related to lagophthalmos can cover the puncta, again leading tight... Board-Certified doctors, we dont provide medical consultations, diagnosis, or advice dryness, medial canthal webbing after blepharoplasty muscle change features... Previous blepharoplasty, ending the incision just lateral to the optic nerve is compromised sutures either in operating.