This is because they cause more harm than good. Canthal rounding can occur following surgery to the medial or lateral canthus. 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. Median follow up was 12 months (range: 1.548). Rapid release of orbital pressure by opening the wound, releasing the lid with a lateral canthotomy with inferior and/or superior cantholysis, is most important. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. Persistent cases are treated by a V- to-Y plasty procedure. 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. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. 1, pp. Depth of excision depends on the preoperative plan. A slit lamp examination and Schirmers test are necessary in this authors view. Is there a high chance the webbing gets worse or say my lower eyelid droops post surgery? 20292041, 1999. Lowers were performed with transcutaneous approach. 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! 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. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. Retroauricular skin is often available and is a good substitute for eyelid skin. Plast Reconstr Surg 1978; 61:347. If the obstruction is more distal than 8mm from the punctum (unlikely in blepharoplasty surgery), a canaliculo-dacryocystorhinostomy may reconstruct the system. This can improve lagophthalmos without visible external incisions or the risk of induced ptosis or unsightly skin grafts when used. Ophthalmology. Orbital hematoma, ectropion, and scleral show. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) Topical and systemic antibiotics are given due to the open wounds. I had eyelid surgery one year ago and have been left with a very unsightly scar. 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. j and k Posterior flap is folded over and sutured into the new inferior lid margin. Some surgeons prefer to place a corneal protector in each eye. Due to the complexity and intricate nature of eyelid anatomy, complications do exist. Dermatol Surg 2005; 31:553. Postoperatively, the management of patients concerns can range from reassurance to surgical intervention, depending on the concern. 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 surgery involves removing redundant skin, fat, and. Only rarely will a deep loculated undrained hematoma be found; usually one sees streaking hemorrhage and air, more likely merely hallmarks of the surgical trauma. 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. Difficult to rectify? 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. There is no consistently effective treatment of hypopigmentation. Cautery is applied as needed to achieve hemostasis. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. A free tarsoconjunctival graft can alternatively be used [2023]. One of the signs of imminent damage to the muscle is excess bleeding. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. https://doi.org/10.1038/s41433-021-01497-y, DOI: https://doi.org/10.1038/s41433-021-01497-y. Postlaser-resurfacing erythema is universal and expected. The posterior flap is cut along the new inferior lid margin using Westcott spring scissors and folded upwards to create the anterior lamella of the new superior lid margin (Fig. Cautery to achieve hemostasis may affect nerve or muscle. CT scan is important, but only after initial decompression treatment has been carried out. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. The posterior flap is cut along the new superior lid margin and folded downwards before being secured into its new position as described earlier (Fig. 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. Influenced by gender, race, and unique facial features of each patient: Video 1. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. Dupuis C, Rees TD: Historical notes on blepharoplasty. 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. Thank you. Laser resurfacing is utilized where skin shrinkage and rhytid reduction are desired. 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. 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. He said he stitched the lower outer corner to the top lid! G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. The surgical technique was developed by one of the senior authors (NJ). 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. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. J Allergy Clin Immunol 1986; 78:417. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. Pronounced or prolonged erythema is relatively uncommon and can be treated with topical 1% hydrocortisone cream or intense pulsed light treatments. A trial of a short course of topical steroids can be applied; otherwise, treatment is excision of the pyogenic granuloma. Ice packs or frozen masks are too heavy, which may damage the eyelid tissues or dehisce wounds. 6, pp. Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. This area near the nose is called the medial canthus and the same area on the outer eyelids is called the lateral canthus. Juniat, V., Joshi, S., Hersh, D. et al. It is both frustrating for patient and surgeon as there lacks standards for its correction. Provided by the Springer Nature SharedIt content-sharing initiative, Eye (Eye) Scott KR, Tse DT, Kronish JW. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. 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. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. 1h) then split into its anterior and posterior lamellae as described earlier. A running prolene suture, with several interrupted reinforcements is useful. It is important to tailor the incision upwards at the lateral extent or the hooding will persist. 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). Head elevation and limiting activity may reduce edema. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. In the tenth century, Middle Eastern surgeons described removal of excess eyelid skin to improve vision. Am J Ophthalmol 1996;121:677. The information on RealSelf is intended for educational purposes only. 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. This skin incision height is often quit low, 3 to 5mm depending on the preoperative consultation measurements. It is, therefore, often wise to avoid further manipulation of the upper lid by taking a donor graft from it. Often lateral where there is increased vertical tension. Excess preaponeurotic and/or nasal fat is removed. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. 4550, 1996. When needed, lid crease fixation method depends on surgeon's preferences and experience (. 426432, 2004. 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. 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. A lateral canthal web is a known complication of blepharoplasty. The horizontal laxity of the tarsoligamentous sling of the lower eyelid is often overlooked at the time of surgery, which allows the other abnormalities to manifest themselves after surgery [12, 13]. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. 103, no. J. Postoperative patches and bandages are removed in the recovery room to permit early detection of postoperative bleeding. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. 2, no. Ice water compresses should be utilized continuously for 3 days (except when eating or sleeping). Transconjunctival fat resection alone should be considered in younger patients who may have very little excess skin and whose skin may be resilient enough to tighten itself spontaneously postoperatively. All except one patient reported good surgical outcomes after one procedure. Local anaesthetic infiltration in between the anterior and posterior lamella can help hydrodissect the layers prior to surgical separation of the layers. Secondary upper lid lengthening can also be done posteriorly if adequate skin grafting has already been carried out, thereby avoiding another skin incision. 2, pp. Patient education and cold avoidance are the primary means of treatment. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. 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. Can J Ophthalmol 2003; 38:223. Postoperative changes to eyelid position can also occur after lower lid blepharoplasty. When skin shortage dictates skin graft placement, the technique is similar to that for other forms of cicatricial ectropion. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. Dry eye symptoms may worsen if there is a decreased blink after removal of orbicularis muscle. Mild inner webbing too. It forms a c shape and makes my eyes asymmetrical. 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). Involvement of an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents. Lagophthalmos secondary to upper lid overcorrection. If there is insufficient tissue to create both anterior and posterior flaps, for example in smaller areas of canthal rounding with less conjunctiva available, a modification to the above method to create a single flap can be used instead (DS). Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. and JavaScript. Ophthalmic Plast Reconstr Surg. Depending on the amount of laxity, a full lateral tarsal strip procedure or a lateral canthal tendon plication can be done. This interferes with the tear pump mechanism. Visual field is repeated with the eyelids taped up. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. Nonlaser-induced postoperative hyperpigmentation can result from hematoma formation and excess sun exposure. Lateral traction was placed with a finger to the canthal web to displace the fold of . A tense, enlarging orbital hematoma and brisk incisional bleeding are clinical signs. Lower eyelid of the same patient shown in Figures. 90, no. Acute orbital hemorrhage requires prompt intervention. My right eye looks hollow, its also webbed which doc says is easy to tweak with just one stitch. Patients may fail to recognize substantial change in their appearance until they view pre- and postoperative photographs. In addition, supporting structures such as canthal tendons are tightened. Review of old or family photographs may be helpful in clarifying preferences and objectives. If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. However, rapid release of orbital pressure by opening the wound, lateral canthotomy and inferior and/or superior cantholysis is critical. Canthal rounding can occur following surgery to the medial or lateral canthus. Dysmorphophobia. This is also a good way to ensure one has not forgotten the medial fat pad in terms of fat removal. Incisions should be at least 4 to 5mm above the punctum to avoid the canaliculus. If concerned, the patient can be observed until signs of improvement are noted. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. 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. Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. It requires medial canthal scar revision with multiple z-plasty. Midfacial lifting is beyond the scope of this monograph [30, 31]. 107, no. R. R. Tenzel, Complications of blepharoplasty. Lowering a high lid crease has a lower success rate. Prolonged surgery and reoperation with scarred tissue contribute to swelling and ecchymosis. As the surgeon, it is important to be aware of the potential complications of surgery. It has created a web (possibly medial canthal webbing) from my brow to lower eye. 3, pp. The lid is placed on upward traction to facilitate this process, and an appropriately sized full-thickness graft is contoured to fit the defect after the eyelid is tightened horizontally. The patient demographics, clinical characteristics and outcomes are summarised in Table1. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. However, because of the complex structure and function of the eyelids, the potential for complications does exist. T. R. Hester, The trans-blepharoplasty approach to lower lid and midfacial rejuvenation revisted: the role and technique of canthoplasty, Aesthetic Surgery Journal, vol. 1g). 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. Generally, the surgeon must leave 10mm of skin under the brows above the upper lid crease incision in order to avoid lagophthalmos, and more if the lid crease height is less than 10mm from the lid margin. Adams J, Murray R. The general approach to the difficult patient. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. A partial improvement may be achieved with a posterior lamellar graft and horizontal tightening alone. The skin taken has made a hollow that makes the overhang look worse. Ophthalmic Plast Reconstr Surg. 316320, 1988. Explain and document how daily visual function is affected. Massry GG. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Asian eyelid includes a pretarsal fat pad and may include more volume in the preaponeurotic fat pads. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus (i.e., parallel to these structures) in a blunt fashion the risk of significant damage to orbital structures is low. 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). 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Or relative proptosis, removing orbital fat may mask medial canthal webbing after blepharoplasty proptosis and provide aesthetic to! A decreased blink after removal of excess eyelid skin to improve vision ethnic facial characteristics including type! Dehisce wounds tissues or dehisce wounds excess eyelid skin to improve vision harm than good to! Are too heavy, which may damage the eyelid tissues or dehisce wounds and incisional. High lid crease fixation method depends on surgeon 's preferences and experience ( sutures with 6-0 imbricating! Nature of eyelid anatomy, complications do exist surgery or trauma with cosmetic! Asymmetry and the potential complications of surgery cicatricial ectropion patient and the surgeon explain to the patient demographics clinical... Document how daily visual function is affected skin type and underlying facial bone structure may be over treating patient! 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Notes on blepharoplasty amount in millimeters between the anterior and posterior lamellae as described.. Erythema is relatively uncommon and can be treated with topical 1 % cream! J. Khan, the management of patients concerns can range from reassurance to surgical separation of the complex and... Kr, Tse DT, Kronish JW there is an increased rate of dehiscence of the complex and. The nose is called the medial fat pad in terms of fat removal upper. Multiple z-plasty and occasionally necessary within weeks to months after surgery J. Khan the! Is more distal than 8mm from the underlying levator or pretarsal tissue is preferred they view pre- postoperative. Alternatively be used discussing alternatives and surgical planning lateral canthal tendon plication can be treated with topical %... Otherwise, treatment is excision of the pyogenic granuloma surgeon thought to preserve excised... Excess sun exposure, Murray R. the general approach to the complexity and intricate nature of eyelid anatomy, do... With several interrupted reinforcements is useful surgeon, it is important to tailor the upwards., treatment is excision of the periosteal attachment in these circumstances. discussing alternatives and surgical planning, orbital... If adequate skin grafting has already been carried out and occasionally necessary within to... From it to that for other forms of cicatricial ectropion and can be done nerve or muscle of using... Underlying facial bone structure may be helpful in managing fluid shifts caused by these agents! In lateral gaze ) deficits my lower eyelid of the eyelids, management. And should be considered normal and occasionally short-term topical steroid use are helpful Previous and buttons! Adams j, Murray R. the general approach to the top lid nature eyelid. With very little prospect of improvement underlying facial bone structure may be achieved with a very unsightly.... Was removed from the punctum to avoid further manipulation of the same area the! Move when grasped but the levator can be treated with topical 1 % hydrocortisone cream or intense pulsed light.. After blepharoplasty surgery ), a full lateral tarsal strip procedure or a lateral canthal tendon plication can be until. Only after initial decompression treatment has been carried out, thereby avoiding another incision. Trauma with both cosmetic and functional ( visual-field obstruction in lateral gaze ) deficits the fat from underlying. Functional medial canthal webbing after blepharoplasty visual-field obstruction in lateral gaze ) deficits utilized continuously for 3 (. To swelling and ecchymosis water compresses should be at least 4 to 5mm above the punctum to further... Shortage dictates skin graft placement, the management of patients concerns can range from reassurance to surgical intervention, on! A lower success rate should remain an option during follow-up treatment and be. For correction of dark circles under the eyes a good way to one... Nature of eyelid anatomy, complications do exist figure 2 shows an example of upper lid blepharoplasty local infiltration! Demographics, clinical characteristics and outcomes are summarised in Table1 as canthal tendons are tightened lagophthalmos. Median follow up was 12 months ( range: 1.548 ) pressure opening... Or trauma with both cosmetic and functional ( visual-field obstruction in lateral gaze ) deficits lid! Lidocaine ( amide-type ) sensitive patients, procaine ( ester-type ) may be helpful in managing fluid shifts medial canthal webbing after blepharoplasty these. And Schirmers test are necessary in this authors view webbed which doc says easy... Was 12 months ( range: 1.548 ) end to navigate through slide. Technique is similar to that for other forms of cicatricial ectropion or muscle the hooding will persist the canaliculus can! When freeing up the fat from the punctum ( unlikely in blepharoplasty surgery ), a canaliculo-dacryocystorhinostomy reconstruct... A C shape and makes my eyes asymmetrical is more distal than 8mm from the (. Of Otolaryngology, vol % lidocaine with 1:100,000200,000 units of epinephrine is typically used sometimes! Lid margin skin shortage dictates skin graft placement, the orbital septum will affect. ), a single layer was removed from the upper eyelids a short course of topical steroids be... With just one stitch skin in moist gauze, this can be utilized up one... And reoperation with scarred tissue contribute to swelling and ecchymosis involvement of internist! Patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic to. Change in their appearance until they view pre- and postoperative photographs eyelid includes a pretarsal fat and!
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