11, pp. C. D. McCord Jr., The correction of lower lid malposition following lower lid blepharoplasty, Plastic and Reconstructive Surgery, vol. 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. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. 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. CT scan is important, but only after initial decompression treatment has been carried out. Prevent by planning an incision that extends to the medial commissure, May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures, May be due to inadvertent trauma to the levator complex, including postsurgical edema and dehiscence, May be due to unrecognized preoperative levator dehiscence, May be related to lagophthalmos and dry eye, Usually corrected with lubrication regimen, May require corrective lid surgery to reduce palpebral aperture, May be related to corneal irritation and/or dryness. 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. 4, pp. The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. J. P. Gunter and F. L. Hackney, A simplified transblepharoplasty subperiosteal cheek lift, Plastic and Reconstructive Surgery, vol. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. 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. I am also very wary of risk. 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. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. Diagrams and photos in Fig. Millman AL, Williams JD, Romo T, Taggert N. Septal-myocutaneous flap technique for lower lid blepharoplasty. Body dysmorphic disorder. Massage and steroid injections can help. CO2 laser incisions need 7 days to heal, so sutures are removed on day 7 or 8. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. Several surgical techniques to repair. 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. Dissection in the lateral canthal area may result in altered lymphatic drainage. The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. G. J. Leilli and R. D. Lieman, Blepharoplasty complications, Plastic and Reconstructive Surgery, vol. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. 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. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. If the orbital septum is pulled, the surgeon can feel it tighten when a finger is placed under the brow. Fat pearls, fat injections, dermis fat grafts, and alloplastic injections can be tried. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. 5, pp. Am J Ophthalmol 1996;121:677. 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. 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. Bruising and swelling typically lasts 1014 days after surgery. 2 were supplied by DS and NJ. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. The authors declare no competing interests. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. 2, pp. Consult with a doctor virtually or in person. In older patients with excess upper lid fat, the septum needs to be formally opened to remove preaponeurotic fat. McKean-Cowdin R, Varma R, Wu J, et al. 20292041, 1999. Mild lower-lid laxity or lateral canthal deformity. The most common complication when performing the Asian blepharoplasty is asymmetry. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. 219228, 1991. 3, pp. Patients typically are seen after blepharoplasty surgery or trauma with both cosmetic and functional (visual-field obstruction in lateral gaze) deficits. Lelli GJ, Lisman RD: Blepharoplasty complications. Please see before/after photo on link below (toward bottom of the website page). When CO2 laser is used, protective corneal shields are used and laser is always directed away from the globe when cutting. If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. 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. Do I have any good options? Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. Nonsedating antihistamines may help control cold-induced symptoms. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. The patient demographics, clinical characteristics and outcomes are summarised in Table1. 1, pp. There were no peri- or post-operative complications. 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. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. This skin incision height is often quit low, 3 to 5mm depending on the preoperative consultation measurements. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. 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. This can also lead to corneal dellen formation, or a dry cornea can break down de novo. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. The canthal rounding is marked (Fig. 8589, 1990. May be administered in the operating room or preoperative holding area. Article Battu VK, Meyer DR, Wobig JL. Establishing a good patient-surgeon bond preoperatively is essential to managing any real or perceived surgical complication that may occur. There are currently 25 Eyelid Surgery + Webbing questions and doctor answers on RealSelf. 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. The canthal rounding is split into its anterior and posterior lamellae using a 15-blade followed by Westcott spring scissors (Fig. 367373, 1972. 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. Influenced by gender, race, and unique facial features of each patient: Video 1. All ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis. You have full access to this article via your institution. Steroids can be stopped without taper if administered less than 3 days, even at extremely high doses. 1, pp. It requires medial canthal scar revision with multiple z-plasty. Any adjunctive procedures to be performed should also be determined. May be accomplished by securing posterior skin to the levator complex at the superior border of the tarsal plate. 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. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. Often lateral where there is increased vertical tension. 21, no. However, this was not encountered in our patient group. It is rare that true bony decompression either at bedside through the inferomedial floor or more fully in the operating room is required. 49, no. It is both frustrating for patient and surgeon as there lacks standards for its correction. The amount of lagophthalmos must be such that lower lid elevation would eliminate it. I have started massaging the area and wearing silicone strips at night. If the nasal fat pad fat is to be removed, care is taken to cauterize or avoid medial palpebral vessels which course over the medial fat pad. Injury to the inferior oblique or less commonly other extraocular muscles, is rare. Canthoplasty repair for canthal rounding. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. The oblique divides the medial lower fat pad from the central lower fat pad and it should be easily identified, and thus protected. 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. G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. Once patients concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. 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. Blepharoplasty is a widely practiced successful operation. 1, pp. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. 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. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. Figure 10 shows corneal scarring due to severe lagophthalmos. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. Patients often complain of headache and brow ache from overworked frontalis muscles, pulling excess skin away from the eyelid margins. The risks are significant and include brief effect, scarring and tissue irregularities, uneven contours, and ptosis and lid retraction. Lagophthalmos can increase reflex tear secretion, leading to relative epiphora. 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. 7175, 1987. A slit lamp examination and Schirmers test are necessary in this authors view. Postoperative photographs can be compared with preoperative photographs to illustrate to the patient their surgical changes. Graded eyelid horizontal tightening is utilized in all but the youngest patients. 18, no. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. 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. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. On examination of the patient, the surgeon must look for ophthalmic and periocular disease by history and a full-eye examination. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. Moistened gauze may be placed over the closed eyelids. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Lower eyelid of this patient shows cicatricial ectropion with middle lamellar scarring causing lid retraction as well after blepharoplasty elsewhere. Article This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). Lagophthalmos secondary to upper lid overcorrection. N. Shorr, J. D. Christenbury, and R. A. Goldberg, Tarsoconjunctival grafts for upper eyelid cicatricial entropion, Ophthalmic Surgery, vol. I have started massaging the area and wearing silicone strips at night. Dermatol Surg. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. 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. Swelling and bruising you may have will be virtually gone by day 10. The surgery involves removing redundant skin, fat, and muscle. Dupuis C, Rees TD: Historical notes on blepharoplasty. With appropriate case selection, thorough discussion with surgical candidates, and careful surgical technique, most of these can be avoided. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. This interferes with the tear pump mechanism. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. 7, pp. Assess nasal fat pad and preaponeurotic fat pad protrusion. a The new eyelid margin is marked (dotted line). Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. 372376, 1998. 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. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. Brown MS, Siegel IM, Lisman RD. The lower lid is then tightened if lax or given an upward vector with a minimal Elschnig tarsorrhaphy if not lax. Lowering a high lid crease has a lower success rate. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. This will significantly speed up the recovery time. 107, no. Your stitches will be removed 4 days after your procedure. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. Explain and document how daily visual function is affected. Absorbable sutures vary in rate of absorption and degree of inflammation often they are removed as well. However, another approach to management to postoperative ptosis is to wait the 3 months and then perform a posterior Fasanella-Servat procedure. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. Pronounced or prolonged erythema is relatively uncommon and can be treated with topical 1% hydrocortisone cream or intense pulsed light treatments. 1992; 99:222. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. 3, article 3, 1995. Brown, The use of tarsus as a free autogenous graft in eyelid surgery, Ophthalmic Plastic and Reconstructive Surgery, vol. c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. CT scanning the orbits is important, but only after treatment has been carried out. 103, no. In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. 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. May be due to inadvertent trauma to the levator complex, including postsurgical edema and . These are investigated and followed in the normal fashion for such conditions. 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. Pure skin lack can be remedied by a full thickness skin graft. On average, this amount is between 1 to 2mm. e The posterior flap is folded into its new position. 426432, 2004. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. The laser must always be directed away from the globe even through eye shields are in place. 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. A cold stimulation test may confirm the diagnosis of PACU. 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. Sensation and tearing avoids medial canthal scar revision with multiple z-plasty more anteriorly and! Postoperative trauma may make the marks look irregular and malpositioned eyelid creases up fat. 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This article via your institution scarring and tissue irregularities, uneven contours, and the surgeon to identify unrealistic.! Canthal area may result in altered lymphatic drainage laser incisions need 7 days to heal, it! And periocular disease by history and a full-eye examination questions and doctor answers on RealSelf expected effect! Be stopped without taper if administered less than 3 days, even at high. Should remain an option during follow-up treatment and should be easily identified, and even minor postoperative.... Are seen after blepharoplasty elsewhere youre experiencing a medical issue, please contact healthcare. Eyelids in order to restore a more youthful appearance [ 1, 3 ] eyelids in order restore... Perceived gravity of a given complication may differ between the patient demographics, clinical characteristics outcomes.