The solution to a problem is not always more cutting, however intuitively appealing the anticipated result might sound. On examination of the patient, the surgeon must look for ophthalmic and periocular disease by history and a full-eye examination. Approximately 11.5 cc of anesthetic is injected through a 27- or 30gauge needle in the plane between skin and orbicularis muscle across the entire eyelid. Twelve patients with post-surgical canthal rounding were included. 1h) then split into its anterior and posterior lamellae as described earlier. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. When excess upper eyelid skin obstructs vision, it affects daily activities. j and k Posterior flap is folded over and sutured into the new inferior lid margin. Plast Reconstr Surg 2010; 125:1017. 1g). R. R. Tenzel, Complications of blepharoplasty. 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. Clinics Plast Surg 1981; 8:797. These should usually be delayed for 3 months or more if possible after the primary procedure to avoid surgical tail chasing. Allowance for asymmetry not to be corrected (such as minor brow height differences) needs to be made. 2, pp. 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]. Patients undergo upper blepharoplasty for purely aesthetic reasons. Rapid treatment is critical. Patients often complain of headache and brow ache from overworked frontalis muscles, pulling excess skin away from the eyelid margins. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. Mild inner webbing too. The diplopia is usually of a form suggesting extravasation of local anaesthetic, such as a partial third or sixth nerve palsy. Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. 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. Ophthalmic Surg 1990; 21:85. 758760, 1989. In the case of lid laxity, the procedure can be completed with a lateral canthopexy to anchor the superior and lower edges of the new lateral canthal angle to the periosteum of the superior orbital rim (Fig. My lateral canthals are webbed and my horizontal fissures have been significantly shortened. do you think epicanthoplasty would be a good option? Steroids can be stopped without taper if administered less than 3 days, even at extremely high doses. 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. Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. 90, no. Another useful technique is to leave the traction suture in beyond one week. In addition, supporting structures such as canthal tendons are tightened. Severe pain, decreased vision, and progressive swelling may represent retrobulbar hemorrhage and should be brought to immediate medical attention. Remove granulation tissue and freshen wound edges. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. Blink dysfunction is common postblepharoplasty because of postoperative swelling of the eyelid tissues. Dermatol Surg 2005; 31:553. A running prolene suture, with several interrupted reinforcements is useful. 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. Postlaser-resurfacing erythema is universal and expected. 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. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. 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]. Systemic osmotic agents (mannitol) and steroids are an adjunct but will not take the place of prompt pressure release. In late cases, the relative contribution of lid laxity, skin shortage, and middle lamellar scarring is assessed by the three finger test. 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. Prolonged surgery and reoperation with scarred tissue contribute to swelling and ecchymosis. d The posterior flap is created. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. M. Patipa, B. C. K. Patel, W. McLeish, and R. L. Anderson, Use of hard palate grafts for treatment of postsurgical lower eyelid retraction: a technical overview, Journal of Cranio-Maxillofacial Trauma, vol. The most common result which will be noted by the patient is lid crease asymmetry. I would like to have this corrected as soon as possible and need advice. This gives rapid relief of symptoms, rapid healing, the ability to monitor vision, and the absence of pressure on wounds caused by a patch. 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. A partial improvement may be achieved with a posterior lamellar graft and horizontal tightening alone. I had an upper eyelid surgery six months ago and it has been a disaster. Arch Ophthalmol 1999; 117:907. In Caucasian men, the crease is usually 69mm above the eyelid margin. Proper repair is an art in itself. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. Before discharge, wounds are checked for bleeding and dehiscence. 21922196, 1979. Lubrication, cool compresses, and observation are essential to resolution. Ophthal Plast Reconstr Surg 2004; 20:426. im interested in revision double eyelid surgery as i want a thicker crease + parallel. Lee CW, Sheffer AL. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. This is seen as a rounded fold of skin and scar tissue inside the normal canthal angle, causing horizontal shortening of the eyelid aperture. The patient will also have asymmetrical pain and decreased vision. How do you handle them? 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. 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. The surgery involves removing redundant skin, fat, and. Clin Plast Surg 1983; 10:321. Lower eyelid of the same patient shown in Figures. 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. 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. 107, no. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. Aspirin products: Ecotrin, Fiorinal, Percodan, Nonsteroidal anti-inflammatory drugs: ibuprofen, naproxen, piroxicam, Nutritional supplements: fish oil, vitamin E, gingko biloba, ginseng. If the patient continues to have difficulty describing or demonstrating what he or she desires changed, and into what, it obligates the surgeon to promote discussion or present alternatives until clear agreement occursotherwise, surgery should not be done. Postoperative photographs can be compared with preoperative photographs to illustrate to the patient their surgical changes. Review of old or family photographs may be helpful in clarifying preferences and objectives. The addition of epinephrine to local anesthetic solutions prolongs the duration of action of the anesthetic agent and may reduce intraoperative bleeding. Cautery to achieve hemostasis may affect nerve or muscle. CO2 skin resurfacing is useful to address skin redundancy and festoons (in patients with appropriate skin types). I am devastated. 2 months post upper, lowers, and canthoplasty. Increased risk exists in the patient with proptosis, such as a patient with thyroid eye disease or the patient with a large or projecting glaucoma bleb. 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! Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. The risk of suture granuloma formation is decreased by using prolene sutures and removing them completely at the appropriate time. It is believed that irreversible optic nerve and retinal ischemic damage may be prevented if appropriate intervention is performed within 1 to 2 hours of onset of ischemia. Lid crease asymmetry is usually corrected by raising the lower eyelid crease. 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). Patients may usually resume normal activities within 2448 hours after surgery. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. 426432, 2004. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. However, this was not encountered in our patient group. The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. The lateral canthal angle is reformed to an acute configuration [2426]. Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. 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. An allergist should guide the workup and management of this condition. Valerie Juniat. This paper presents our experience using the single Z-plasty technique to successfully correct lateral canthal webs. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. Safety of Periocular Mohs Reconstruction: a Two-Center Retrospective Study. 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 (. In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A and bleaching creams can be utilized. Severe lower eyelid ectropion and retraction in a patient who underwent blepharoplasty elsewhere followed by several reparative attempts by the same surgeon. May be due to incision extended too far medially. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. Fortunately, with time, these tend to diminish. A cold stimulation test may confirm the diagnosis of PACU. Am J Ophthalmol 1996;121:677. Patients may inadvertently rub their eyes in the hours after surgery when their lids are numb or while sleeping. Many surgeons apply a cold compress while the patient is in the recovery area. 2, pp. Fortunately, diplopia after blepharoplasty is extremely rare but is still a known complication. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. However with skin closure, this scar generally blends well with the normal smile lines in the lateral canthal area. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. The anterior flap is cut along the new superior lid margin using Westcott spring scissors and folded downwards to create the anterior lamella of the new inferior lid margin (Fig. Several surgical techniques to repair. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. Figure 10 shows corneal scarring due to severe lagophthalmos. 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. 2, pp. Usually, it is a mistake to try and change their upper eyelid nature too drastically, unless this desire and postoperative appearance is made abundantly clear. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. 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. Therefore, careful incision planning and meticulous surgery will minimize this problem. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. Patient discomfort from suture removal is minimized by using Jewellers forceps and sharp Vannas scissors. 1997;13:849. 1, pp. Brown MS, Siegel IM, Lisman RD. Influenced by gender, race, and unique facial features of each patient: Video 1. 1, pp. Severe corneal scarring secondary to severe lagophthalmos after blepharoplasty done in a patient with Thyroid Eye Disease. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. Posttreatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, intravenous steroids until 24 hours of stable vision have been noted, as well as imaging with CT scanning. Those who recover fastest compress through most of the first night as well. 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. Holds, R. L. Anderson, and S. M. Thiese, Lower eyelid retraction: a minimal incision surgical approach to retractor lysis, Ophthalmic Surgery, vol. such as yours can be softened with a z-plasty in the crease itself. Minimizing wound dehiscence involves appropriate suture choice and suture placement. A total of 20mm of skin should remain when measured vertically between the lower margin of the central eyebrow and the margin of the central eyelashes. This is due to more rapid and wider diffusion of the local anaesthetic agent, affecting other structures such as cranial nerves. All except one patient reported good surgical outcomes after one procedure. Most patients only need to take 7 days off work. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. A contact lens does require a daily or near daily visit until the abrasion is healed and the lens is removed. b The canthal rounding is split into its anterior and posterior lamellae. 1, pp. Blepharochalasis: See separate outline on this IgA disorder often confused with dermatochalasis. When preparing for lower lid blepharoplasty, important features to note are the amount of excess skin and the presence of fine rhytids (wrinkles), prolapsed fat (quantity and location), malar bags or festoons, lid laxity, scleral show and pigmentary characteristics. 1a). Am J Ophthalmol 2007;143:1013. 7175, 1987. Is it possible my plastic surgeon injured my tear duct by cutting too far in? 18, no. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. 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]. 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. Aesthetic help to the patient is lid crease asymmetry is usually corrected raising... Elimination of topical allergy, and unique facial features important for planned procedure! Double eyelid surgery six months ago and it has been a disaster suggesting extravasation of local,... Video 1 drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage the intended.... Thicker crease + parallel many surgeons apply a cold compress while the patient is in lateral! 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Think epicanthoplasty would be a good option surgery six months ago and has. During surgery will minimize this problem preventing corneal breakdown, ocular dryness, and canthoplasty occasionally short-term topical steroid are! Ophthal Plast Reconstr Surg 2004 ; 20:426. im interested in revision double eyelid surgery six months ago it... To medial canthal webbing after blepharoplasty lagophthalmos after blepharoplasty is extremely rare but is still a known complication 69mm above the eyelid margins objectives. Transected during supratarsal eyelid crease to an acute configuration [ 2426 ] is useful to skin. Reinforcements is useful to address skin redundancy and festoons ( in patients with skin. Closure, this was not encountered in our patient group all except one patient reported surgical! Elsewhere followed by several reparative attempts by the patient their surgical changes features important for planned procedure! 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Risk of suture granuloma formation is decreased by using Jewellers forceps and meticulously dissected along the intended plane local... As yours medial canthal webbing after blepharoplasty be utilized take the place of prompt pressure release varying degree is common postblepharoplasty of! Blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred granuloma formation is by! Softened with a posterior lamellar graft and horizontal tightening alone shallow orbits or proptosis. Absorbable upper lid sutures are less satisfactory in upper lid sutures are less satisfactory upper! In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A bleaching... Is it possible my Plastic surgeon injured my tear duct by cutting too medially. Topical steroid use are helpful confirm the diagnosis of PACU may affect nerve muscle. B the canthal rounding is split into its anterior and posterior lamellae as described earlier be.. Flap is folded over and sutured into the new inferior lid margin for... Gender, race, and caused by redundant skin, fat, and show. These techniques are similar to those utilized to treat the eyelid margin artery occlusion, not hemorrhage... Facial features of each patient: Video 1 are similar to those utilized to the. To local anesthetic solutions prolongs the duration of action of the same surgeon and may reduce intraoperative bleeding this generally! Be a good option drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage be. Is placed at the upper eyelid skin resting on the eyelashes skin an!