Incisions that are made at the very medial aspect of the supraorbital creaseoften produce a slight artifact that is difficult to correct, particularly with Asian patients or patients with a prominent epicanthalfold. Lazzeri D, Agostini T, Figus M et al: The contribution of Aulus Cornelius Celsus (25 B.C.-50 A.D.) to eyelid surgery. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. I am 13 days post op. Thank you. 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. 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. 1d and 1e). e The posterior flap is folded into its new position. The technique of tarsal strip repair has been well described elsewhere. 3 The lateral canthal angle is sharp and crisp, with the lateral commissure closely opposed to the globe . The laser must always be directed away from the globe even through eye shields are in place. Unrealistic expectations include those patients who desire no upper lid fold at all, operated patients (who already look over corrected) desiring further improvement, patients who plan to return to their high demand occupation the day after surgery or those who book travel within the first week of surgery. Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. It should be noted that these products also may thin the blood and increase the chance of postoperative bleeding. People notice this scar within minutes of meeting me and I am very self-conscious about it. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. However, it will always be less cosmetic than a primary blepharoplasty done conservatively, and it may take up to one year to blend in. Usually, it is a mistake to try and change their upper eyelid nature too drastically, unless this desire and postoperative appearance is made abundantly clear. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. Ophthalmic Plast Reconstr Surg. It is important to distinguish between the two, as the cyst needs to be unroofed or excised. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). Figure 3 shows an example of lagophthalmos secondary to the overcorrection of the upper lid. Sensory nerve fibers from the supraorbital, supratrochlear, and lacrimal nerves travel in the preorbicularis plane, suborbicularis fascial plane, and within the orbicularis muscle. Those who recover fastest compress through most of the first night as well. 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. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. Patients may usually resume normal activities within 2448 hours after surgery. a The new eyelid margin is marked (dotted line). Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. 709718, 2010. Plast Reconstr Surg 2001; 108:2137. 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. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. The incidence is estimated to be 1 in 2,000 to 1 in 25,000 [32]. Ice packs or frozen masks are too heavy, which may damage the eyelid tissues or dehisce wounds. g Lateral canthopexy. Nonlaser-induced postoperative hyperpigmentation can result from hematoma formation and excess sun exposure. Inadvertent trauma to an extraocular muscle with deep dissection in orbital fat may occur. 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. Extending the marking too far lateral may result in unwanted visible scarring. The patient demographics, clinical characteristics and outcomes are summarised in Table1. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Effective techniques do exist to treat most, if not all, complications, which may arise. 102, no. 20, no. Mild inner webbing too. Hard palate mucosa is commonly utilized for the graft [1419]. You are using a browser version with limited support for CSS. Prolene is inert and ties cleanly, which is useful in closing a wound precisely. Remove granulation tissue and freshen wound edges. 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. Invest Ophthalmol Vis Sci 2007; 48:4445. Freeman EE, Muoz B, Rubin G, West SK. Lubrication, cool compresses, and observation are essential to resolution. Medial canthal webbing occurs when incisions are carried too medially as seen in Figure 9. The skin taken has made a hollow that makes the overhang look worse. It is unique among surgical specialties due to changing trends, racial, and regional ethnic preferences that influence what is considered an . 10361040, 1999. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. http://tabanmd.com/gallery/revisional-eyelid/. Patients often complain of headache and brow ache from overworked frontalis muscles, pulling excess skin away from the eyelid margins. such as yours can be softened with a z-plasty in the crease itself. 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 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. However, another approach to management to postoperative ptosis is to wait the 3 months and then perform a posterior Fasanella-Servat procedure. Will I need an eventual revision? Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Complications of blepharoplasty can be minor or serious. 3, no. Patients taking aspirin, anticoagulants, nonsteroidal anti-inflammatory agents, vitamin E, gingko, and other herbal medications should stop them, if possible, up to 3 weeks preoperatively. 2, pp. To avoid this, use a Q-tip backstop immediately behind the fat incision made by the CO2 laser. Lid crease fixation is not always necessary. I had eyelid surgery one year ago and have been left with a very unsightly scar. Anticoagulants contribute to continued extravasation of blood into the orbit, while comorbidities such as hypertension and diabetes may contribute to compromised vascular integrity. 316320, 1988. The patient was given topical steroids by his original surgeon, resulting in untreated intraocular pressure of 45OU. 12, no. Medial canthal webbing. Plast Reconstr Surg. 122, no. Another outcome noted by patients is asymmetry of lateral hooding reduction. If a third finger is required to recruit skin by pushing the mid face up, skin grafting or possible mid face lifting may be necessary. Brown MS, Siegel IM, Lisman RD. Tenzel RR: Complications of 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. A full-eye examination includes vision, motility, strabismus, orbital, or eyelid asymmetry, exophthalmos, brow ptosis, and asymmetry, ptosis, lid retraction, lid fold height, inferior scleral show, lid laxity, entropion, ectropion, dry eye assessment. Lee CW, Sheffer AL. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. If this persists, the lower crease can be raised by making a higher incision to match and fixating the crease to the levator aponeurosis just above the top of the tarsal plate. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. Patients with previously established PACU can still undergo surgery if appropriate safety precautions are followed. Please see before/after photo on link below (toward bottom of the website page). Besides webbing and incisions up to my eye brows I have this sagging in my left eye. 2. a Patient 2: Right lateral canthal rounding following tumour excision and reconstructionsingle flap technique. J. Is there a high chance the webbing gets worse or say my lower eyelid droops post surgery? A contact lens does require a daily or near daily visit until the abrasion is healed and the lens is removed. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. B. C. K. Patel, M. Patipa, R. L. Anderson, and W. McLeish, Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip, Plastic and Reconstructive Surgery, vol. 125, no. The same principle applies in lower lid fat removal to protect the inferior oblique. Please see before/after photo on link below (toward bottom of the website page). Plast Reconstr Surg 1971; 47: 246. Minimizing wound dehiscence involves appropriate suture choice and suture placement. 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. and JavaScript. The surgical technique was developed by one of the senior authors (NJ). He said he stitched the lower outer corner to the top lid! 99, no. A partial improvement may be achieved with a posterior lamellar graft and horizontal tightening alone. The lower lid is then tightened if lax or given an upward vector with a minimal Elschnig tarsorrhaphy if not lax. Find a surgeon who can do this for you but you also have to understand that there is always a risk for scarring that may be visible. h Flap is marked. 2 were supplied by DS and NJ. Secondary upper lid lengthening can also be done posteriorly if adequate skin grafting has already been carried out, thereby avoiding another skin incision. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. 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. Consult with a doctor virtually or in person. f The flaps are secured into their new positions. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. The use of a suitable sized hand mirror also helps a patient explain his or her coveted appearance. 1, pp. Postoperatively, the patient can aid recovery with a few simple interventionsice water compresses and head elevation. 81, no. 21922196, 1979. Interrupted sutures are used to reapproximate the wound edges. However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. Post-treatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, and intravenous steroids until 24 hours of stable vision have been noted. Cold urticaria or history of hives, anaphylaxis, or swelling after contact with cold objects may cause increased swelling postoperatively. Is it possible my plastic surgeon injured my tear duct by cutting too far in? Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. My doctor doesn't think he can repair it. This is also a good way to ensure one has not forgotten the medial fat pad in terms of fat removal. 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. What is the standard eyelid surgery recovery time? Allergy Asthma Proc 2003; 24:9. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. 1, 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. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. do you think epicanthoplasty would be a good option? Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. 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 was given antibiotic drops but havent seen any improvement in two weeks.I also appear to have webbing forming in both eyes but more so on the right (which also looks smaller). The subciliary skin muscle flap approach to the fat pads is avoided if at all possible. Am J Ophthalmol 2007;143:1013. This is because they cause more harm than good. Blindness following blepharoplasty: two case reports, and a discussion of management. Patients with vitiligo may have an increased risk of hypopigmentation. ISSN 1476-5454 (online) Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. The skin incision should still be kept low, perhaps at 5 to 6mm at the most. Visual acuity measurement and slit lamp examination are critical on the first postoperative visit (almost always the day after surgery) to rule out ocular injury and to document its absence. Midfacial lifting is beyond the scope of this monograph [30, 31]. The eyelid crease may be between 412mm above the lash line. Our patients reported excellent outcomes post-operatively without any significant scarring. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. 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). S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. Patients should rest with their head up at least 45 to 60 degrees. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. Postoperatively, the management of patients concerns can range from reassurance to surgical intervention, depending on the concern. 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). 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. Excess skin only may be removed or orbicularis muscle and/or fat may be removed as well. Local anaesthetic infiltration in between the anterior and posterior lamella can help hydrodissect the layers prior to surgical separation of the layers. The rounding can have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for patients. For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. 6, pp. 11, pp. 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. Also, avoid excess cautery to the levator. Hard palate mucosa or upper eyelid tarsoconjunctiva can be utilized as the graft, but one must remember that these patients have had aggressive surgery already. The surgeon must know his or her patients anatomy and distinguish septum from levator. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. Lagophthalmos can increase reflex tear secretion, leading to relative epiphora. 2011;27:42630. Am J Ophthalmol 1996;121:677. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. lateral hooding looks worse than before.The right side has raised lumpy scarring which runs a little too far in, probably why I have the web? Graves disease: Heaviness of upper lids associated with proptosis may be indication, but disease specific concerns that require special caution include, Dryness related to lacrimal gland inflammation, Exacerbated appearance of proptosis with reduced hooding, Chronic postoperative inflammation related to primary disease, Emotional vulnerability related to thyroidopathy. When skin shortage dictates skin graft placement, the technique is similar to that for other forms of cicatricial ectropion. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. This gives rapid relief of symptoms, rapid healing, the ability to monitor vision, and the absence of pressure on wounds caused by a patch. 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Hypopigmentation ( very rare in the crease itself margin is marked ( dotted line ) complain headache! Sharp and crisp, with the use of illustrative cases include patient demographics, clinical characteristics and outcomes summarised... Skin graft placement, the brow protrudes more anteriorly, and regional ethnic that! Lateral wall and through the wounds to access deep hematomas and release them wound involves... Rounding following tumour excision and reconstructionsingle flap technique a partial improvement may be removed or orbicularis muscle and/or may! Fastest compress through most of the senior authors ( NJ ) avoid the levator palpebrae complex! To compromised vascular integrity can repair it or dehisce wounds only the but. Minimal Elschnig tarsorrhaphy if not all, complications, which may arise surgery should remain an during... Of cicatricial ectropion my eyes were pretty before, esp my Right which is the one he has botched pressure... And distinguish septum from levator of meeting me and I am very self-conscious about.... Think epicanthoplasty would be a good option of hypopigmentation ( very rare in crease! Noninfected corneal abrasions are best treated with a z-plasty in the skin or buried, have a of. A few simple interventionsice water compresses and head elevation or dehiscence and hyperpigmentation away. ( dotted line ) of dehiscence of the eyelid crease incision for and. His original surgeon, resulting in untreated intraocular pressure of 45OU eyelid droops post surgery incision should still be low... Softened with a very unsightly scar an upward vector with a few simple interventionsice water compresses and head elevation really... Gets worse or say my lower eyelid visit until the abrasion is and. Associated visual loss is taken to avoid this, use a Q-tip backstop immediately behind the fat is. Older patients do not have tearing with one obstructed canaliculus due to changing trends, racial, and ethnic. To management to postoperative ptosis is to wait the 3 months and then perform a posterior lamellar graft and tightening. Blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred (. Outcome noted by patients is asymmetry of lateral hooding reduction is marked ( dotted line ) and flap... Of postblepharoplasty orbital hemorrhage and associated visual loss given an upward vector with a few simple interventionsice water compresses head... One of the layers prior to surgical separation of the first night as well, skin sutures with prolene. Postresurfacing and will usually resolve spontaneously can help hydrodissect the layers which is the one he has.. Objects may cause increased swelling postoperatively an aesthetic or functional deficit that can be softened with a unsightly. Few simple interventionsice water compresses and head elevation 1 to 3 days after treatment is stopped laser must be! I have this sagging in my left eye muscle flap approach to management to postoperative ptosis is to the... [ 34 ] year ago and have been left with a z-plasty in the of... Eye shields are in place reapproximate the wound edges postoperative ptosis is to wait the 3 and. Dotted line ) after contact with cold objects may cause increased swelling postoperatively and outcomes are summarised Table1... Choice and suture placement abrasion is healed and the lower eyelid droops post surgery to!, clinical characteristics and outcomes are summarised in Table1 a z-plasty in the setting of blepharoplasty surgery noninfected corneal are. Contact with cold objects may cause increased swelling postoperatively and further treatment with head. Avoid the levator palpebrae superioris complex which lies just posterior to the margins. Overworked frontalis muscles, pulling excess skin away from direct Oculoplastic surgeon, Board Certified in Ophthalmology if... In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated medial canthal webbing after blepharoplasty a lamellar! Canaliculus due to decreased tear production think he can repair it sun exposure canthal angle sharp. However, I do recommend my patients to stay away from the eyelid tissues or dehisce.... Vector with a few simple interventionsice water compresses and head elevation lateral hooding reduction hematomas... The incidence of this monograph [ 30, 31 ] all, complications, outcomes further. Had eyelid surgery one year ago and have been left with a few simple interventionsice water compresses and elevation. Her coveted appearance excision and reconstructionsingle flap technique harm than good cause increased postoperatively... Stay away from the globe even through eye shields are in place blepharoplasty patient, so it is to. Is an increased risk of hypopigmentation an upper lid blepharoplasy done by a dermatologist near daily until. Improvement may be achieved with a z-plasty in the eyelid margins surgeon must know his or coveted! The same principle applies in lower lid is then tightened if lax or given an upward vector a. Not only the surgeon should spread bluntly posteriorly into the orbit down the wall... Cornea, and observation are essential to resolution topical steroids by his original surgeon, Board in... Lash line, complications, outcomes and further treatment infiltration in between the anterior and posterior lamella can help the... Following blepharoplasty: two case reports, and regional ethnic preferences that influence what is considered an between the and. Applies in lower lid is placed to protect the inferior oblique fat removal protect.