4, pp. True canalicular injury may require late repair if epiphora results. 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. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. However, rapid release of orbital pressure by opening the wound, lateral canthotomy and inferior and/or superior cantholysis is critical. 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). T. R. Hester, The trans-blepharoplasty approach to lower lid and midfacial rejuvenation revisted: the role and technique of canthoplasty, Aesthetic Surgery Journal, vol. Similarly, conjunctival chemosis caused by a transconjunctival incision and by drying related to lagophthalmos can cover the puncta, again leading to epiphora. Swelling and bruising you may have will be virtually gone by day 10. Despite the use of a lidocaine/marcaine mixture for local anesthetic, it is important to note that this form of diplopia is always gone by the next day. Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Lagophthalmos secondary to upper lid overcorrection. Arch Ophthalmol 1999; 117:907. 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. 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. D. R. Jordan and R. L. Anderson, The lateral tarsal strip revisited: the enhanced tarsal strip, Archives of Ophthalmology, vol. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. 2. a Patient 2: Right lateral canthal rounding following tumour excision and reconstructionsingle flap technique. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. Copyright 2012 James Oestreicher and Sonul Mehta. c The anterior flap is created and folded into its new position. 1f). Lid crease fixation is not always necessary. Z. In the Asian upper eyelid, there is a lower fusion point between the orbital septum and the levator aponeurosis, which allows orbital fat to descend further down in addition to the increased fat in the preseptal fibroadipose layer. Canthal rounding can occur following surgery to the medial or lateral canthus. The eyelid crease may be between 412mm above the lash line. 4, 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. 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. If noted, however, it should be treated with bleaching creams. There were no peri- or post-operative complications. Please see before/after photo on link below (toward bottom of the website page). I am 13 days post op. 3, pp. 4550, 1996. such as yours can be softened with a z-plasty in the crease itself. The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. Multiple repairs may be required for the optimum result to be achieved. Patients with vitiligo may have an increased risk of hypopigmentation. 19, no. However, another approach to management to postoperative ptosis is to wait the 3 months and then perform a posterior Fasanella-Servat procedure. A good understanding of anatomy and careful preoperative counseling of the patient is crucial for success. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. A vicious cycle can develop wherein the chemotic conjunctiva dries out because it is swollen and then swells because it is dry. 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. 99, no. Midfacial lifting is beyond the scope of this monograph [30, 31]. 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. 1g). Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. 1h) then split into its anterior and posterior lamellae as described earlier. Google Scholar. Lelli GJ, Lisman RD: Blepharoplasty complications. Severity of visual field loss and health related quality of life. 10391046, 1983. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. It is difficult to lower a crease which is too high. Gentle cautery applied to the orbital fat may contour and replace the remaining fat posteriorly into the orbit, providing needed volume and fullness. This will significantly speed up the recovery time. Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. In the tenth century, Middle Eastern surgeons described removal of excess eyelid skin to improve vision. A slit lamp examination and Schirmers test are necessary in this authors view. 125, no. Juniat, V., Joshi, S., Hersh, D. et al. Cicatricial canthal webs. Consult with a doctor virtually or in person. Institutional Review Board/Ethics Committee approval was obtained. Clin Plast Surg 1983; 10:321. Levator function is assessed to identify myogenic ptosis. Allergy Asthma Proc 2003; 24:9. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. 1j and 1k). A. N. Hass, R. B. Penne, M. A. Stefanyszyn, and J. C. Flanagan, Incidence of postblepharoplasty orbital hemorrhage and associated visual loss, Ophthalmic Plastic and Reconstructive Surgery, vol. f The flaps are secured into their new positions. It is both frustrating for patient and surgeon as there lacks standards for its correction. Allergies and a list of medications should be noted. I would like to have this corrected as soon as possible and need advice. The punctum is a useful landmark for the upper lid and lower lid incision. Postoperatively, the patient can aid recovery with a few simple interventionsice water compresses and head elevation. 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. Antibiotic or steroid/antibiotic ointment may be applied twice a day to sutures and into the eyes at night. Restoring palpebral fissure shape after previous lower blepharoplasty. Care is taken not to remove too much of this volume producing tissue, particularly in the pupillary meridian where inadequate fat will often cause an Aframe deformity. Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, Australia, Chelsea and Westminster NHS trust, London, UK, You can also search for this author in Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. 5, pp. 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. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. Lower blepharoplasty is one of the most common facial plastic surgery. Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. 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. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. 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. For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. 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. The same principle applies in lower lid fat removal to protect the inferior oblique. 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). 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). 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. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. C. D. McCord Jr., The correction of lower lid malposition following lower lid blepharoplasty, Plastic and Reconstructive Surgery, vol. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. 20292041, 1999. If the obstruction is more distal than 8mm from the punctum (unlikely in blepharoplasty surgery), a canaliculo-dacryocystorhinostomy may reconstruct the system. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. Ophthal Plast Reconstr Surg 2004; 20:426. Men seem to have ruddier skin, and the erythema last 60% as long on average. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. 107, no. 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. 758760, 1989. One approach to assuring that sufficient skin remains for complete closure of the eyelid is the 20mm rule. 1a). This is particularly important if incisions are made with the CO2 laser. Those who recover fastest compress through most of the first night as well. Webs (abnormal folds of skin) can occur in both areas and are referred to as medial and lateral . The patient demographics, clinical characteristics and outcomes are summarised in Table1. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. 5155, 1996. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. 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. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. I have started massaging the area and wearing silicone strips at night. There is a wide range of cost/fee due to the condition of the patient and the procedures involved. People notice this scar within minutes of meeting me and I am very self-conscious about it. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. Article Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . Explain and document how daily visual function is affected. Dermatol Surg. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. Thank you for visiting nature.com. Excess hollowing from aggressive fat removal can be treated by the same enhancement techniques as detailed for the upper eyelids and are subject to the same risks and limitations. In the initial assessment, patients are encouraged to voice their desires and concerns regarding the aesthetic appearance and functional features of their eyelids. The alternative argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage. Heinze JB, Hueston JT. This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. In addition, supporting structures such as canthal tendons are tightened. 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). 11, pp. 1, pp. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. 1b). 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]. Medial canthal webbing occurs when incisions are carried too medially as seen in Figure 9. Assess nasal fat pad and preaponeurotic fat pad protrusion. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. The patient will also have asymmetrical pain and decreased vision. Excessive bruising can lead to a prolonged recovery, infection, cicatrisation, and skin pigmentation. C. D. McCord Jr. and J. W. Shore, Avoidance of complications in lower lid blepharoplasty, Ophthalmology, vol. Absorbable subcutaneous suture such as 70 polyglactin can be placed, anchoring superficial levator fibers to the overlying skin. Lastly, there are occasional patients who develop unrelated cranial nerve palsies some weeks or months after surgery by chance alone. Pure skin lack can be remedied by a full thickness skin graft. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Correspondence to The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. 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