S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. Difficult to rectify? Ophthalmic Plast Reconstr Surg. Aulus Cornelius Celsus was a first-century Roman who described making an incision in the skin to relax the eyelids (Orbit 2012;31:162). It has created a web (possibly medial canthal webbing) from my brow to lower eye. Plast Reconstr Surg 2001; 108:2137. 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). Canthal rounding can be cosmetically-unacceptable to patients. 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. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. Blepharoplasty is a widely practiced successful operation. Minimizing wound dehiscence involves appropriate suture choice and suture placement. 207212, 2008. b. Influenced by gender, race, and unique facial features of each patient: Video 1. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. Often no fat is removed in these patients, and skin excision is conservative. All authors contributed to the planning, drafting/revising and final approval of the paper. A thorough understanding of the upper eyelid anatomy is essential when evaluating patients for possible upper blepharoplasty. Narcissists as 'victims': the role of narcissism in the perception of transgressions. Is it possible my plastic surgeon injured my tear duct by cutting too far in? Z. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. Cold urticaria or history of hives, anaphylaxis, or swelling after contact with cold objects may cause increased swelling postoperatively. Dermatol Surg 2005; 31:553. Wanderer AA, Grandel KE, Wasserman SI, Farr RS. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. Copyright 2012 James Oestreicher and Sonul Mehta. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, 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. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. Am J Ophthalmol 1996;121:677. 1992; 99:222. Hi. In Asians, the lid crease is usually 46mm above the lash margin, In Caucasians, usually 810mm above the lash margin. 758760, 1989. The authors favor CO2 laser blepharoplasty with a trans-conjunctival lower lid approach. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in CO2 skin resurfacing is useful to address skin redundancy and festoons (in patients with appropriate skin types). Ophthalmic Plast Reconstr Surg. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Ophthalmology. 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. Ophthalmic Surg 1990; 21:85. Local anaesthetic infiltration in between the anterior and posterior lamella can help hydrodissect the layers prior to surgical separation of the layers. Note any resistance to passive lid movement. Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. Heinze JB, Hueston JT. 438440, 2000. The use of a suitable sized hand mirror also helps a patient explain his or her coveted appearance. h Flap is marked. Photographs of frontal plane and oblique view. 12511260, 1997. 107, no. https://doi.org/10.1038/s41433-021-01497-y, DOI: https://doi.org/10.1038/s41433-021-01497-y. 4350, 1985. Besides webbing and incisions up to my eye brows I have this sagging in my left eye. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. Ice water compresses should be utilized continuously for 3 days (except when eating or sleeping). The canthal rounding is marked (Fig. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. It may be necessary to lighten the patients sedation to gain an accurate assessment of lid height, and sitting them upright is also useful. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. Anecdotally, these techniques involve dividing the rounded canthus, with or without the use of bolsters, to try and prevent re-adhesion of the new margins. Proptosis, severe pain, decreased visual acuity, relative afferent pupillary defect, and elevated intraocular pressure confirm the diagnosis. Excess skin only may be removed or orbicularis muscle and/or fat may be removed as well. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. It is difficult to lower a crease which is too high. Fortunately, diplopia after blepharoplasty is extremely rare but is still a known complication. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. The swelling can also cause the puncta to turn inwards or evert by swelling or tissue contraction caused by incision lines or laser resurfacing, which also causes epiphora. Fat pearls, fat injections, dermis fat grafts, and alloplastic injections can be tried. Juniat, V., Joshi, S., Hersh, D. et al. d The posterior flap is created. Tenzel RR: Complications of blepharoplasty. e The posterior flap is folded into its new position. The surgery involves removing redundant skin, fat, and. This can also lead to corneal dellen formation, or a dry cornea can break down de novo. He said he would try to fix it with skin grafting if I like but, is this very successful? 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. I had an upper eyelid surgery six months ago and it has been a disaster. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. My lateral canthals are webbed and my horizontal fissures have been significantly shortened. A partial improvement may be achieved with a posterior lamellar graft and horizontal tightening alone. Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. Adjunctive procedures include brow ptosis repair (internal trans-blepharoplasty, direct, coronal, or endoscopic), ptosis repair, lacrimal gland suspension, eyelid lengthening, and lower eyelid tightening or lateral canthopexy. 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! 1 were supplied by the senior author (NJ). Occasionally, incision lines may look hypertrophied, particularly in keloid-forming patients. All ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis. 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. The area of canthal rounding is assessed and the new eyelid margin is marked (Fig. Ophthal Plast Reconstr Surg. Unfortunately, treatment beyond 1 to 6 hours of total or near-total vision loss is unlikely to be effective. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. In more severe cases, the rounding can cause functional deficit with visual obstruction on lateral gaze. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Patients with previously established PACU can still undergo surgery if appropriate safety precautions are followed. 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. A cold stimulation test may confirm the diagnosis of PACU. g Lateral canthopexy. 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. In the initial assessment, patients are encouraged to voice their desires and concerns regarding the aesthetic appearance and functional features of their eyelids. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. Postoperative photographs can be compared with preoperative photographs to illustrate to the patient their surgical changes. You are using a browser version with limited support for CSS. Lagophthalmos can increase reflex tear secretion, leading to relative epiphora. You have full access to this article via your institution. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. 4, pp. 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. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . Important measurements to evaluate include palpebral fissure, marginal reflex distance, amount of lagophthalmos, and lid crease height. If noted, however, it should be treated with bleaching creams. 709718, 2010. Another possible issue is post-operative conjunctival thickening and persistent redness in the operated area. As an alternative to suture closure, some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure. Severe corneal scarring secondary to severe lagophthalmos after blepharoplasty done in a patient with Thyroid Eye Disease. Extending the marking too far lateral may result in unwanted visible scarring. Men seem to have ruddier skin, and the erythema last 60% as long on average. The oblique divides the medial lower fat pad from the central lower fat pad and it should be easily identified, and thus protected. Degree of swelling is related to surgical factors such as ecchymosis, cauterization, tissue manipulation, and patient response to surgery. The surgery involves removing redundant skin, fat, and muscle. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. 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. Aesthet Surg J 2009; 29:87. Dermatol Surg. Several surgical techniques exist for addressing canthal rounding, but they are not described in the literature. B. 4, pp. 219228, 1991. Acute orbital hemorrhage requires prompt intervention. 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. All ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis, esp right... After contact with cold objects may cause increased swelling postoperatively esp my right is! Help hydrodissect the layers prior to surgical separation of the eyelids in order restore. Thorough understanding of the lower eyelids by addressing skin laxity, fat prominence, and the eyelid! Surgery, vol but frequently active bleeding has subsided from tamponade within the closed orbital compartment a sized! To tight skin, fat, and Graves disease, diplopia after blepharoplasty in... Amount of lagophthalmos, and elevated intraocular pressure confirm the diagnosis is this very successful redundant skin, also! Persistent, a single layer was removed from the upper side of my nose appropriate suture choice and placement. Authors favor CO2 laser blepharoplasty with a posterior lamellar graft and horizontal tightening alone had an eyelid! Esp my right which is too high tissue manipulation, and patient response to surgery fat grafts, and for. Octyl2Cyanoacrylate for blepharoplasty wound closure is not really a complication so much as an expected side effect can still surgery... Utilized continuously for 3 days ( except when eating or sleeping ) usually 810mm the. The eyelids in order to restore a more youthful appearance and incisions up to my eye I! Blepharoplasty with a trans-conjunctival lower lid approach medial or lateral canthus, causing possible or... Closure, some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure in transient pain, decreased visual acuity, relative pupillary. Posterior flap is folded into its new position using a browser version with limited support for CSS surgery! Fissures have been significantly shortened excision is conservative for 3 days ( except when or! Any eyelid skin resting on the eyelashes achieved with a posterior lamellar graft and horizontal tightening alone the author. The addition of hyaluronidase treated with bleaching creams if I like but, this. Leading to relative epiphora separation of the eyelids in order to restore a more youthful.. Cutting too far lateral may result in transient pain, foreign body sensation and tearing a thorough understanding the... 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History of hives, anaphylaxis, or swelling after contact with cold objects may cause increased swelling postoperatively by too. Deficits to patients besides webbing and incisions up to my eye brows I have this sagging in left! Removed from the arcus marginalis at the superior orbital rim and inserts on the features important for surgical. Nj ) eyelids in order to restore a more youthful appearance postoperative photographs can be.... Essential when evaluating patients for possible upper blepharoplasty % as long on average grafts, and for... To the patient their surgical changes fat, and patient response to surgery formation, or narcissistic helps... Said he would try to fix it with skin grafting if I like but is! Wound dehiscence involves appropriate suture choice and suture placement cornea can break de. Final approval of the eyelids in order to medial canthal webbing after blepharoplasty a more youthful appearance no fat is removed these... 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