Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. 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. The surgeon needs to stop the bleeding but at the same time avoid excess cautery or other trauma to the muscle. Ophthalmology. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. 11, pp. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). Do I have any good options? 438440, 2000. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. Lagophthalmos due to internal scarring requires surgical exploration and lysis of the scar tissue. It seems my canthoplasty has failed. Significant lagophthalmos illustrated. 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. The diplopia is usually of a form suggesting extravasation of local anaesthetic, such as a partial third or sixth nerve palsy. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. 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. The incidence is estimated to be 1 in 2,000 to 1 in 25,000 [32]. The exception can be the patient who has had a combined blepharoplasty and levator advancement ptosis repair and is obviously under corrected at about a weektheir wound can be readily opened and the slipped levator suture replaced fairly easily. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Scott KR, Tse DT, Kronish JW. Hard palate mucosa is commonly utilized for the graft [1419]. Head elevation and limiting activity may reduce edema. Difficult to rectify? One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. A vicious cycle can develop wherein the chemotic conjunctiva dries out because it is swollen and then swells because it is dry. Due to the inability to close the eyelid, intractable exposure keratitis can result. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. 29, no. Wilhelmi BJ, Mowlavi A, Neumeister, MW. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. Lower eyelid of this patient shows cicatricial ectropion with middle lamellar scarring causing lid retraction as well after blepharoplasty elsewhere. If early cicatrix formation is detected, local nondepot steroid injection can occasionally eliminate the need for more involved surgery. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Blindness after blepharoplasty: mechanism and early reversal. One approach to assuring that sufficient skin remains for complete closure of the eyelid is the 20mm rule. In late cases, the relative contribution of lid laxity, skin shortage, and middle lamellar scarring is assessed by the three finger test. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. 4, pp. 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. Fat removal will help the first two causes, and laser skin resurfacing can aid the third if the pigment is relatively superficial. It requires medial canthal scar revision with multiple z-plasty. 367373, 1972. All research was conducted in accordance with the Declaration of Helsinki. May be administered in the operating room or preoperative holding area. However, because of the complex structure and function of the eyelids, the potential for complications does exist. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Avoid placing the crease too high to prevent the appearance of over-westernization. Fortunately, diplopia after blepharoplasty is extremely rare but is still a known complication. 2, pp. 9, pp. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. Involvement of an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents. 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. 316320, 1988. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Is there help out there? Webs abnormal folds of skin can occur in both areas and are referred to as medial and lateral canthal webs. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl-2-cyanoacrylate. 1b). 99, no. Multiple repairs may be required for the optimum result to be achieved. Patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery. Mild lower-lid laxity or lateral canthal deformity. Postoperative patches and bandages are removed in the recovery room to permit early detection of postoperative bleeding. Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. The patient must be a resurfacing candidate to consider this treatment modality (Fitzpatrick skin type, I, II, or III), and the risks of hypopigmentation and hyperpigmentation stressed. 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. However, this was not encountered in our patient group. Will I need an eventual revision? The skin then bridges the superomedial hollow of the upper lid in a straight line. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. 1c). M. Ferri and J. H. Oestreicher, Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting, Orbit, vol. Canthal rounding can be cosmetically-unacceptable to patients. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. 2013;29:20814. Cautery is applied as needed to achieve hemostasis. To minimize bruising, the patient should avoid using anticoagulative drugs, control his or her hypertension if present, and avoid postoperative trauma, bending, and straining [4]. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Men seem to have ruddier skin, and the erythema last 60% as long on average. Due to the complexity and intricate nature of eyelid anatomy, complications do exist. 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. Frequency of cold compresses is decreased as the effectiveness of this therapy lessens. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. Lateral skin often takes longer to soften and smooth because it is thicker compared to eyelid skin. Skin lying on the eyelashes produces discomfort independent of obstructed visual axis. 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. 107, no. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. Filling in the hollowed areas can be problematic. 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. Internet Explorer). Patient education and cold avoidance are the primary means of treatment. Patients may usually resume normal activities within 2448 hours after surgery. In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. 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. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. He had severe chemosis and discomfort due to significant lagophthalmos. 34, no. 20, no. 21, no. Excessive skin removal may require free full-thickness skin grafting. Dry eye symptoms may worsen if there is a decreased blink after removal of orbicularis muscle. Allergies and a list of medications should be noted. How do you handle them? In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. 4, pp. Clin Plast Surg 1983; 10:321. All except one patient reported good surgical outcomes after one procedure. The punctum is a useful landmark for the upper lid and lower lid incision. Nonlaser-induced postoperative hyperpigmentation can result from hematoma formation and excess sun exposure. This is an open access article distributed under the, Scar Hypertrophy and dyspigmentation after transcutaneous blepharoplasty incisions done elsewhere with CO. Upper lid retraction after upper lid blepharoplasty. Juniat, V., Joshi, S., Hersh, D. et al. One must be careful to note patients with poorly developed midfacial bony structure where the lower lids already sit low, and where the potential for postoperative retraction is much higher. In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A and bleaching creams can be utilized. It is often necessary to tighten the lower eyelid at the time of blepharoplasty. volume36,pages 564567 (2022)Cite this article. One starts with a three snip on the punctum of the unobstructed canaliculus, followed by a DCR (to enhance flow through the unobstructed canaliculus), followed by a DCR with Jones tube in refractory cases. Lelli GJ, Lisman RD: Blepharoplasty complications. He said he would try to fix it with skin grafting if I like but, is this very successful? Steroids can be stopped without taper if administered less than 3 days, even at extremely high doses. Occasionally spacer grafts are required to completely correct the lid retraction. What is the standard eyelid surgery recovery time? 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. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. 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. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Alternatively, removing anterior fat may unmask the underlying proptosis, and care should be exercised. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. Black EH, Gladstone GJ, Nesi FA. All authors contributed to the planning, drafting/revising and final approval of the paper. Postoperatively, the management of patients concerns can range from reassurance to surgical intervention, depending on the concern. Control of obvious bleeding points, if present is important. Eyelid sensation after supratarsal lid crease incision. Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Institutional Review Board/Ethics Committee approval was obtained. Antibiotic ointment may be placed over incision. 107, no. Secondary upper lid lengthening can also be done posteriorly if adequate skin grafting has already been carried out, thereby avoiding another skin incision. Depth of excision depends on the preoperative plan. 207212, 2008. b. Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. 1f). 24, no. CAS 20, no. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. Google Scholar. 11, pp. I had eyelid surgery one year ago and have been left with a very unsightly scar. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. Since time is of the essence, one must realize that an experienced oculoplastic surgeon is not essential to perform a bedside canthotomy/cantholysis and pressure release. My lateral canthals are webbed and my horizontal fissures have been significantly shortened. An unsightly complication following blepharoplasty is webbing of the tissue at the medial or lateral canthus. 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. Copyright 2012 James Oestreicher and Sonul Mehta. Prolene is inert and ties cleanly, which is useful in closing a wound precisely. Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. A posterior lamellar graft is then placed between the cut lower edge of tarsal plate and the recessed cut conjunctival edge. The canthal rounding is split into its anterior and posterior lamellae using a 15-blade followed by Westcott spring scissors (Fig. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. 767771, 1990. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. Ophthalmic Plast Reconstr Surg. g Lateral canthopexy. 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). 122, no. The scar has webbed and is also very long and wide. Laser eye protectors are essential if the CO2 laser is utilized, but there must be enough ocular lubrication present to avoid a corneal abrasion when they are inserted or removed. 3 The lateral canthal angle is sharp and crisp, with the lateral commissure closely opposed to the globe . Midfacial lifting is beyond the scope of this monograph [30, 31]. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). In Caucasian men, the crease is usually 69mm above the eyelid margin. Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. Plast Reconstr Surg. Occasionally instead of scar hypertrophy, epithelial inclusion cysts occur. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. 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. There were no peri- or post-operative complications. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. Please see before/after photo on link below (toward bottom of the website page). 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. What complications can come from a blepharoplasty? I am also very wary of risk. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. Nonabsorbable sutures are removed 714 days after surgery. 281288, 2002. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. Pure skin lack can be remedied by a full thickness skin graft. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. 125, article 1017, 2010. When needed, lid crease fixation method depends on surgeon's preferences and experience (. Federici TJ, Meyer DR, Lininger LL. Similarly, conjunctival chemosis caused by a transconjunctival incision and by drying related to lagophthalmos can cover the puncta, again leading to epiphora. 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. The new superior lid margin is left to heal by granulation. This will significantly speed up the recovery time. Ophthalmic Surg 1990; 21:85. In the meantime, to ensure continued support, we are displaying the site without styles I had strange eyes that if tired could look so puffy/saggy but if not they were near perfect (a little excess always present left side). If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. The incision, which is made along the previously marked lines, can be made with a 15Bard Parker blade, an incisional CO2 laser, a diamond blade, or a needle-tipped Bovie or radiofrequency instrument. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. ISSN 1476-5454 (online) 366368, 1969. May be accomplished by securing posterior skin to the levator complex at the superior border of the tarsal plate. The use of the CO2 laser and maintaining a dry surgical field with bipolar cautery or by defocusing the CO2 laser will minimize the occurrence of postoperative ecchymosis. If brow ptosis is present, straight-ahead photograph with eyebrows elevated by the patient demonstrates compensation. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. Any true globe injury must have prompt and appropriate treatment by an ophthalmologist. R. R. Tenzel, Complications of blepharoplasty. 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. Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. The surgery involves removing redundant skin, fat, and muscle. Abnormalities of lower eyelid position include lower lid retraction with scleral show, rounding of the lower eyelid contour, rounding of the lateral canthal angle, and ectropion. 7175, 1987. Patients should rest with their head up at least 45 to 60 degrees. Asian eyelid includes a pretarsal fat pad and may include more volume in the preaponeurotic fat pads. He said he stitched the lower outer corner to the top lid! Aesthetic and functional abnormalities result from excess skin and fat removal and from excess scarring and adhesions involving the levator aponeurosis. This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). Another outcome noted by patients is asymmetry of lateral hooding reduction. The information on RealSelf is intended for educational purposes only. I am 13 days post op. ISSN 0950-222X (print), https://doi.org/10.1038/s41433-021-01497-y, Medial canthoplasty for the management of exposure keratopathy, The kissing puncta: an under-reported and stubborn cause of epiphora, Anterior lamellar deficit ectropion management, Skin redraping for correction of lower eyelid epiblepharon combined with medial epicanthal fold: a retrospective analysis of 286 Asian children, A novel technique for the measurement of eyelid contour to compare outcomes following Mullers muscle-conjunctival resection and external levator resection surgery, The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations, Comparison of three surgical techniques for internal angular dermoid cysts: a randomized controlled trial, Causes and management of persistent septal deviation after septoplasty, Strategies for ear elevation and the treatment of relevant complications in autologous cartilage microtia reconstruction. at my consult, the Dr. mentioned that in order to get parallel, i would need to get epicanthoplasty as well but that theres a chance of having visible scarring with epicanthoplasty.