1 were supplied by the senior author (NJ). Please see before/after photo on link below (toward bottom of the website page). Another outcome noted by patients is asymmetry of lateral hooding reduction. Acute orbital hemorrhage requires prompt intervention. 10361040, 1999. Figure 10 shows corneal scarring due to severe lagophthalmos. The lower lid is then tightened if lax or given an upward vector with a minimal Elschnig tarsorrhaphy if not lax. Before discharge, wounds are checked for bleeding and dehiscence. 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. Rapid treatment is critical. Moistened gauze may be placed over the closed eyelids. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. Provided by the Springer Nature SharedIt content-sharing initiative, Eye (Eye) The most common complication when performing the Asian blepharoplasty is asymmetry. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. 106, no. 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. Incisions should be at least 4 to 5mm above the punctum to avoid the canaliculus. 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. 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. 6, pp. Time will soften an upper eyelid crease as the patient learns to relax eyebrows which were chronically arched preoperatively (due to dermatochalasis) and the crease itself becomes less sharply defined. Anticoagulants may increase the risk of postoperative bleeding. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. Nonabsorbable sutures are removed 714 days after surgery. J. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. Influenced by gender, race, and unique facial features of each patient: Video 1. Transconjunctival fat resection alone should be considered in younger patients who may have very little excess skin and whose skin may be resilient enough to tighten itself spontaneously postoperatively. 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. 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). Is there help out there? M. Ferri and J. H. Oestreicher, Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting, Orbit, vol. Once patients concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . Especially on one side more than the other! 2003;111:44150. 797802, 1981. The commonest form is caused when local anaesthetic is supplemented intraoperatively by direct fat injection once the conjunctiva (lower lid) or skin (upper lid) is open. 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. I have inner eyelid webbing following a blepharoplasty 2 years ago. 219228, 1991. Antibiotic or steroid/antibiotic ointment may be applied twice a day to sutures and into the eyes at night. Is this resolvable? the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Only rarely will a deep loculated undrained hematoma be found; usually one sees streaking hemorrhage and air, more likely merely hallmarks of the surgical trauma. 207212, 2008. How risky is this to correct and when is it safe to do? This paper presents our experience using the single Z-plasty technique to successfully correct lateral canthal webs. 4, pp. 11, pp. Skin lying on the eyelashes produces discomfort independent of obstructed visual axis. Effective techniques do exist to treat most, if not all, complications, which may arise. Z. Any adjunctive procedures to be performed should also be determined. Answer: Inner eyelid webbing scar after blepharoplasty Hi. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. Patients may usually resume normal activities within 2448 hours after surgery. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. This interferes with the tear pump mechanism. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. Various compositions of bleaching creams have been published, containing combinations of hydroquinone, glycolic acid, kojic acid, retinoic acid, and hydrocortisone. Plast Reconstr Surg 2001; 108:2137. McKean-Cowdin R, Varma R, Wu J, et al. 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). In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. Eye 36, 564567 (2022). Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Want to know what treatments can help me look like I use to look. Lelli GJ, Lisman RD: Blepharoplasty complications. I was given antibiotic drops but havent seen any improvement in two weeks.I also appear to have webbing forming in both eyes but more so on the right (which also looks smaller). Im losing faith in him though and am looking elsewhere for revision. In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A and bleaching creams can be utilized. 1i). Removal or preservation of fat and muscle can help achieve these goals. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. 367373, 1972. Gentle cautery applied to the orbital fat may contour and replace the remaining fat posteriorly into the orbit, providing needed volume and fullness. Patients undergo upper blepharoplasty for purely aesthetic reasons. 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. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. 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. Do I have any good options? Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. Institutional Review Board/Ethics Committee approval was obtained. Canthal rounding can cause cosmetic or functional deficit with visual obstruction on lateral gaze. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. 2013;29:20814. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. Head elevation and limiting activity may reduce edema. 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. 21, no. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. The skin taken has made a hollow that makes the overhang look worse. 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. Ophthalmic Surg 1990; 21:85. 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. If a third finger is required to recruit skin by pushing the mid face up, skin grafting or possible mid face lifting may be necessary. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl-2-cyanoacrylate. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. Recognizing that orbital haemorrhage with vision loss is a possible although rare complication from blepharoplasty surgery is important. The lateral canthal angle is reformed to an acute configuration [2426]. 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. The lid should be kept on upward traction 1 to 7 days with a frost suture to the lateral eyebrow [28, 29]. 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. Jordan DR, Mawn LA. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. 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). Lid crease fixation is not always necessary. Surgery can cost all different from street to street, even blocks to blocks in the same city, depending on the surgeon's reputation, skill and experiences. 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. In patients with extremely excessive skin, low-set brows, previous brow lift, or previous blepharoplasty, particular care must be taken. 21, no. In late cases, the relative contribution of lid laxity, skin shortage, and middle lamellar scarring is assessed by the three finger test. 49, no. Canthoplasty repair for canthal rounding. Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. It must be understood that old photographs do not represent a guarantee or even a goal, but rather act as a guidepost. The patient can be instructed in upward massage to keep infection and scarring minimized and alleviate retraction. 11, pp. If skin shortage is evident however, full-thickness skin grafting may be needed. Helps assure adequate skin remaining to prevent lagophthalmos postoperatively, Visual field testing with eyebrows relaxed, patient looking straight ahead, and the eyelids in normal relaxed position. Secondary revision surgery should remain an option during follow-up treatment and should be considered normal and occasionally necessary within weeks to months after surgery. 99, no. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. Canthal rounding is a separate entity from canthal webbing, which is seen as semilunar folds of skin and scar that can overlie, or sit outside, the canthal angle. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Lower eyelid skin excision or laser resurfacing (or neither) is another key decision. In the initial assessment, patients are encouraged to voice their desires and concerns regarding the aesthetic appearance and functional features of their eyelids. 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. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Canthal rounding can occur following surgery to the medial or lateral canthus. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. With our technique, we make use of the excess horizontal tissue to create the flaps, which in turn are folded and secured to realign the canthal angle discrepancies. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. 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. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Severe corneal scarring secondary to severe lagophthalmos after blepharoplasty done in a patient with Thyroid Eye Disease. If the lid crease is marked 8 mm above the lash margin, for example, the upper edge of the incision should be 12 mm below the brow margin. Another useful technique is to leave the traction suture in beyond one week. 87, no. Dermatol Surg 2005; 31:553. The patient was given topical steroids by his original surgeon, resulting in untreated intraocular pressure of 45OU. 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. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. Am J Ophthalmol 2007;143:1013. R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. Patient discomfort from suture removal is minimized by using Jewellers forceps and sharp Vannas scissors. L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. Aesthet Surg J 2009; 29:87. R. R. Tenzel, Complications of blepharoplasty. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. All except one patient reported good surgical outcomes after one procedure. j and k Posterior flap is folded over and sutured into the new inferior lid margin. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. 372376, 1998. 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. Lid crease in Asians can be absent, may be nasally tapered, or flat but typically lies lower and flatter than Caucasians. Up and down gaze photographs document levator excursion. The skin and orbicularis, lid margin, conjunctiva, and lower lid retractors are removed from the excess eyelid laterally, creating a lateral tarsal strip which is then anchored to Whitnalls tubercle inside the lateral orbital rim. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. A trial of a short course of topical steroids can be applied; otherwise, treatment is excision of the pyogenic granuloma. 5, pp. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. 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). Injury to the inferior oblique or less commonly other extraocular muscles, is rare. One of the signs of imminent damage to the muscle is excess bleeding. Wanderer AA, Grandel KE, Wasserman SI, Farr RS. True canalicular injury may require late repair if epiphora results. Other conditions such as ptosis, brow ptosis, entropion, ectropion, or eyelid retraction may also need to be corrected at the time a blepharoplasty is performed to ensure the best functional and aesthetic result. 3, pp. C. D. McCord Jr. and J. W. Shore, Avoidance of complications in lower lid blepharoplasty, Ophthalmology, vol. Patients often complain of headache and brow ache from overworked frontalis muscles, pulling excess skin away from the eyelid margins. Frequency of cold compresses is decreased as the effectiveness of this therapy lessens. 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. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. 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