Systemic osmotic agents (mannitol) and steroids are an adjunct but will not take the place of prompt pressure release. Ophthalmic Plast Reconstr Surg. Another outcome noted by patients is asymmetry of lateral hooding reduction. May be administered in the operating room or preoperative holding area. Hard palate mucosa is commonly utilized for the graft [1419]. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. 1997;13:849. Plast Reconstr Surg 1971; 47: 246. Juniat, V., Joshi, S., Hersh, D. et al. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. It forms a c shape and makes my eyes asymmetrical. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Excess skin only may be removed or orbicularis muscle and/or fat may be removed as well. R. A. Goldberg, M. F. Marmor, N. Shorr, and J. D. Christenbury, Blindness following blepharoplasty: two case reports, and a discussion of management, Ophthalmic Surgery, vol. 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. 11, pp. CT scan is important, but only after initial decompression treatment has been carried out. 2013;29:20814. Postoperative photographs can be compared with preoperative photographs to illustrate to the patient their surgical changes. 5, pp. Brown, The use of tarsus as a free autogenous graft in eyelid surgery, Ophthalmic Plastic and Reconstructive Surgery, vol. 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. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. 1c). 2, pp. Incisions should be at least 4 to 5mm above the punctum to avoid the canaliculus. Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. Head elevation and limiting activity may reduce edema. Lower eyelid of the same patient shown in Figures. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. Similarly, when using the CO2 laser to cut fat lobules free, one needs a back stop (usually a Q-tip) to absorb the transmitted laser energy and avoid damage to the structures that lie beneath (levator, Mullers muscle, conjunctiva and globe). The amount of lagophthalmos must be such that lower lid elevation would eliminate it. J Allergy Clin Immunol 1986; 78:417. Up and down gaze photographs document levator excursion. 99, no. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. h Flap is marked. Can J Ophthalmol 2003; 38:223. 2, pp. The skin taken has made a hollow that makes the overhang look worse. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Anticoagulants may increase the risk of postoperative bleeding. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. 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 (. 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. Swelling and bruising you may have will be virtually gone by day 10. The procedure can be carried out under local anaesthesia only or in combination with sedation. Septum must be opened if fat is to be removed, but not the levator. In Caucasian men, the crease is usually 69mm above the eyelid margin. 20, no. This fast and predictable approach avoids opening the anterior wound and also avoids overcorrection and scar abnormalities. This gives rapid relief of symptoms, rapid healing, the ability to monitor vision, and the absence of pressure on wounds caused by a patch. If canthotomies have not restored vision, spreading bluntly posteriorly into the orbit along the lateral wall to access deep hematomas and release them, may be helpful. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. Photographs of frontal plane and oblique view. 20292041, 1999. Due to the complexity and intricate nature of eyelid anatomy, complications do exist. However, certain caution should be taken to avoid and manage postoperative ptosis. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. Moistened gauze may be placed over the closed eyelids. 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. 5, pp. If a definite levator laceration is observed, it should be repaired if it is causing ptosis. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. Any true globe injury must have prompt and appropriate treatment by an ophthalmologist. 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! Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. Google Scholar. 2, pp. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. 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. Scars dont run past outside of eye. 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. 1f). For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. Fat removal will help the first two causes, and laser skin resurfacing can aid the third if the pigment is relatively superficial. Eye 36, 564567 (2022). An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. 90, no. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. Antibiotic ointment may be placed over incision. Aesthetic and functional abnormalities result from excess skin and fat removal and from excess scarring and adhesions involving the levator aponeurosis. 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. If the orbital septum is pulled, the surgeon can feel it tighten when a finger is placed under the brow. There was one recurrence of rounding, which was noted at the first post-operative review at 2 weeks following surgery. Meticulous preoperative planning, including precise measurements and noting any asymmetry in facial features, should be a routine for every surgeon. 107, no. Figure 10 shows corneal scarring due to severe lagophthalmos. Occasionally, incision lines may look hypertrophied, particularly in keloid-forming patients. 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. Institutional Review Board/Ethics Committee approval was obtained. 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. 417425, 1993. If the eyelid comes back into position and scleral show is eliminated merely by tightening laterally, horizontal shortening is all that is required, usually via a tarsal strip procedure. A thorough understanding of the upper eyelid anatomy is essential when evaluating patients for possible upper blepharoplasty. The surgeon should spread bluntly posteriorly into the orbit down the lateral wall and through the wounds to access deep hematomas and release them. 9, pp. 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. Unfortunately, even with careful patient selection and surgical planning, and an uneventful perioperative period, some patients may be dissatisfied with their results. R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. 3, article 3, 1995. 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 most common complication when performing the Asian blepharoplasty is asymmetry. People notice this scar within minutes of meeting me and I am very self-conscious about it. 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. Is there help out there? Globe injury can occur with the CO2 laser, with a steel scalpel, or with local anaesthetic injection. Our patients reported excellent outcomes post-operatively without any significant scarring. 767771, 1990. Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. 49, no. 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. One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. Relative . The rounding can have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for patients. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. Invest Ophthalmol Vis Sci 2007; 48:4445. 87, no. Lagophthalmos secondary to upper lid overcorrection. Recognizing that orbital haemorrhage with vision loss is a possible although rare complication from blepharoplasty surgery is important. He said he would try to fix it with skin grafting if I like but, is this very successful? Asian eyelid includes a pretarsal fat pad and may include more volume in the preaponeurotic fat pads. The surgery involves removing redundant skin, fat, and muscle. Cicatricial canthal webs. Avoid placing the crease too high to prevent the appearance of over-westernization. To avoid this, use a Q-tip backstop immediately behind the fat incision made by the CO2 laser. 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. Fortunately, diplopia after blepharoplasty is extremely rare but is still a known complication. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. 1d and 1e). It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. There is no consistently effective treatment of hypopigmentation. 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. Emerg Med Clin North Am 1998; 16:689. 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. The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. 11, pp. A lateral canthal web is a known complication of blepharoplasty. 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. 18, no. Dissection in the lateral canthal area may result in altered lymphatic drainage. 20, no. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. Do I have any good options? Lowers were performed with transcutaneous approach. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. In New York city, I would say it ranges Good evening and thank you for your question .Complications of blepharoplasty can be minor or serious. If essential, a lower incision is made and fat is teased forward between the skin and levator to prevent readhesion of these structures. Prevent by planning an incision that extends to the medial commissure; May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures; Ptosis. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Body dysmorphic disorder. 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. The skin incision should still be kept low, perhaps at 5 to 6mm at the most. 107, no. 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. Filling in the hollowed areas can be problematic. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. May be due to incision extended too far medially. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. If a second finger is required in the central eyelid pushing upward, usually a posterior-lamellar graft is required. 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.
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