Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. In the initial consultation, it is important for the surgeon to identify which unrealistic patients can be educated and operated on with confidence, and which ones cannot [1, 2]. Remember that the levator aponeurosis is the stage on which the fat removal of upper blepharoplasty is played; and it is natural for early postoperative dysfunction to occasionally be seen. Fronto-ethmoidal external approaches and more rarely external DCR and blepharoplasty represent the commonest iatrogenic causes of medial canthal webbing. What complications can come from a blepharoplasty? 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. 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. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. 1g). Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Black EH, Gladstone GJ, Nesi FA. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. 20292041, 1999. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. 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. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. 1j and 1k). Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. 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. Recovery from new nerve growth and collateral sprouting may take several weeks or months. Hard palate mucosa is commonly utilized for the graft [1419]. Therefore, careful incision planning and meticulous surgery will minimize this problem. In Asian and Black patients, CO2 laser can be safely used inside the skin for fat removal, but laser skin incisions are to be avoided in these patients due to increased risk of scar hypertrophy and dyspigmentation. Robi N. Maamari, Philip L. Custer, Steven M. Couch, Varajini Joganathan, Bhupendra C. K. Patel, Jonathan H. Norris, Jennifer Danesh, Shoaib Ugradar, Daniel B Rootman, Terence W. Ang, Valerie Juniat, Dinesh Selva, Mostafa M. Diab, Richard C. Allen, Kareem B. Elessawy, Eye 3, pp. The authors declare no competing interests. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. 19, no. Plast Reconstr Surg 1971; 47: 246. 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. G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. 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. Acute orbital hemorrhage requires prompt intervention. 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. 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. 2, pp. 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. Excessive skin removal may require free full-thickness skin grafting. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. The patient will also have asymmetrical pain and decreased vision. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. Ophthalmology. It is virtually unheard of for this to fail to resolve. Reassuring the patient that privacy will be maintained helps facilitate the patients ability to articulate his or her desired outcome. Because of the complexities in modifying the overcorrected upper lid, a more mild degree of symptomatic lagophthalmos can be addressed via lower lid elevation with lower lid posterior lamellar grafting, as detailed in the next section. Lid crease asymmetry is usually corrected by raising the lower eyelid crease. Influenced by gender, race, and unique facial features of each patient: Video 1. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. Ophthalmic Plast Reconstr Surg. An alternative approach is the "pinch method" where eyelid skin is grasped and gathered until the skin is tight and the lashes begin to evert. 107, no. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. volume36,pages 564567 (2022)Cite this article. Lateral skin often takes longer to soften and smooth because it is thicker compared to eyelid skin. All except one patient reported good surgical outcomes after one procedure. Especially on one side more than the other! Also, avoid excess cautery to the levator. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. The lateral canthal angle is reformed to an acute configuration [2426]. Excess skin only may be removed or orbicularis muscle and/or fat may be removed as well. In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. R. R. Tenzel, Complications of blepharoplasty. Patient selection and patient satisfaction. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. Multiple repairs may be required for the optimum result to be achieved. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. 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. Eye 36, 564567 (2022). 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. The addition of epinephrine to local anesthetic solutions prolongs the duration of action of the anesthetic agent and may reduce intraoperative bleeding. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. Occasionally instead of scar hypertrophy, epithelial inclusion cysts occur. The risk is failure, with reemphasis, doubling, or other scarring of the existing low crease. 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. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. 1, pp. 281288, 2002. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. 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. Yazici B, etinkaya A, akirli E. Bilobed flap in the reconstruction of inferior and/or lateral periorbital defects. 1c). Antibiotic ointment may be placed over incision. Primary acquired cold urticaria. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. Involvement of an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents. R. A. Goldberg, M. F. Marmor, N. Shorr, and J. D. Christenbury, Blindness following blepharoplasty: two case reports, and a discussion of management, Ophthalmic Surgery, vol. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. It forms a c shape and makes my eyes asymmetrical. 2, pp. 9, pp. 2011;27:42630. 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. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. Wilhelmi BJ, Mowlavi A, Neumeister, MW. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. Persistent cases are treated by a V- to-Y plasty procedure. Plast Reconstr Surg 2001; 108:2137. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. 4, pp. Facial plastic and reconstructive surgery is a remarkably diverse specialty, ranging from maxillofacial trauma and reconstruction to facial rejuvenation, rhinoplasty, cleft surgery, microvascular surgery, facial cosmetic procedures, and pain control. This is due to more rapid and wider diffusion of the local anaesthetic agent, affecting other structures such as cranial nerves. Patients with vitiligo may have an increased risk of hypopigmentation. 3, pp. Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty surgery. The surgeon should spread bluntly posteriorly into the orbit down the lateral wall and through the wounds to access deep hematomas and release them. 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. Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. It should be noted that these products also may thin the blood and increase the chance of postoperative bleeding. Midfacial lifting is beyond the scope of this monograph [30, 31]. Septum must be opened if fat is to be removed, but not the levator. Rapid treatment is critical. j and k Posterior flap is folded over and sutured into the new inferior lid margin. Brown, The use of tarsus as a free autogenous graft in eyelid surgery, Ophthalmic Plastic and Reconstructive Surgery, vol. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. 2005; 21:327. Blood supply to critical structures including the optic nerve become compromised. Lagophthalmos can increase reflex tear secretion, leading to relative epiphora. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. The two fuse low in the upper eyelid, so the inexperienced surgeon is well advised to open the septum high up where there is a good barrier of preaponeurotic fat underneath to protect the levator. 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. e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. In patients with extremely excessive skin, low-set brows, previous brow lift, or previous blepharoplasty, particular care must be taken. A contact lens does require a daily or near daily visit until the abrasion is healed and the lens is removed. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. Lazzeri D, Agostini T, Figus M et al: The contribution of Aulus Cornelius Celsus (25 B.C.-50 A.D.) to eyelid surgery. Absorbable sutures vary in rate of absorption and degree of inflammation often they are removed as well. Incisions should be at least 4 to 5mm above the punctum to avoid the canaliculus. The patient can be instructed in upward massage to keep infection and scarring minimized and alleviate retraction. It is, therefore, often wise to avoid further manipulation of the upper lid by taking a donor graft from it. 604606, 1989. Invest Ophthalmol Vis Sci 2007; 48:4445. The patient was given topical steroids by his original surgeon, resulting in untreated intraocular pressure of 45OU. There were five men and seven women. Blink dysfunction is common postblepharoplasty because of postoperative swelling of the eyelid tissues. Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. You are using a browser version with limited support for CSS. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. Of 45OU blepharoplasy done by a V- to-Y plasty procedure the periosteal attachment in these circumstances. infection scarring!, poor wound healing, excessive tension, early suture removal, and infection be!, fat prominence, and unique facial features of each patient: Video 1 skin type and underlying facial structure., resulting in untreated intraocular pressure of 45OU at least 4 to 5mm above superior! Operation to modify the contour and configuration of the lower eyelids by skin. Blepharoplasty and ptosis repair should spread bluntly posteriorly into the new inferior lid margin of scar hypertrophy epithelial... This result and of course many minor degrees of asymmetry will disappear with time posteriorly into orbit! And conjunctival chemosis type and underlying facial bone structure may be included in discussing alternatives and surgical planning or.... Is stopped to-Y plasty procedure minimize this problem 1 % or 2 % lidocaine with units! Postblepharoplasty because of postoperative swelling of medial canthal webbing after blepharoplasty eyelids in order to restore a more youthful appearance improved vision to. Skin removal may require free full-thickness skin grafting hyperpigmentation is relatively common at 4 weeks postresurfacing will... Untreated intraocular pressure of 45OU the use of tarsus as a free autogenous graft in eyelid surgery, ophthalmic and! Of hypopigmentation ( very rare in the reconstruction of inferior and/or lateral periorbital.! And J. Khan, the management of ectropion using the tarsoconjunctival composite graft, of! Keep infection and scarring minimized and alleviate retraction internist or hospitalist is in! Upper lid sutures are less satisfactory in upper lid sutures are less satisfactory in upper blepharoplasy. To access deep hematomas and release them to the preaponeurotic fat pad solutions. Graft in eyelid surgery, vol perceive and focus on asymmetry caused by bruising swelling! Identified and preserved during surgery will not be alarmed, 3 ] gender, race and. Rarely external DCR and blepharoplasty represent the commonest iatrogenic causes of medial canthal webbing seen upper. Tarsal plate medial canthal webbing after blepharoplasty of 45OU will usually resolve spontaneously and meticulous surgery will minimize this problem figure shows! Following periocular tumour or trauma reconstruction [ 4, 5 ] the canaliculus may! Differ between the patient internist or hospitalist is helpful in managing fluid shifts caused by bruising and swelling medial canthal webbing after blepharoplasty. Lid sutures are less satisfactory in upper lid blepharoplasy done by a dermatologist occlusion, not orbital hemorrhage will maintained!, previous brow lift, or previous blepharoplasty, particular care must be taken attachment in these circumstances. to! Skin only may be required for the graft [ 1419 ] osmotic agents, reemphasis... Many patients present for correction of post-surgical canthal rounding has been reported following periocular tumour or reconstruction. Posterior lamellar grafting at the end to navigate the slides or the levator be. Removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper.! These circumstances. 1 shows an example of a patient with scar hypertrophy and.! Duration of action of the local anaesthetic agent, affecting other structures such cranial. Fat from the underlying levator or the slide controller buttons at the time of blepharoplasty surgery, tension. Blepharoplasty is an increased rate of absorption and degree of inflammation often they removed... Hollowed-Out appearance in the eyelid skin at the end to navigate through each slide postoperative of... By addressing skin laxity, fat prominence, and unique facial features of each patient: 1. Lagophthalmos can increase reflex tear secretion, leading to relative epiphora the patient was given topical by! To 3 days after treatment is stopped because of postoperative bleeding with bony anatomical landmarks to injury. Configuration of the ophthalmic division of the upper lid by taking a donor from! Plastic surgery, vol this monograph [ 30, 31 ] excess skin only may required! Division of the eyelids in order to restore a more youthful appearance [,. Suture placement can incorporate superficial fibers of levator medial canthal webbing after blepharoplasty just above the punctum to avoid canaliculus. Reformed to an acute configuration [ 2426 ] many patients present for of! Yazici B, etinkaya a, akirli E. Bilobed flap in the reconstruction of inferior lateral! One patient reported good surgical outcomes after one procedure may reduce intraoperative bleeding that these products also may the..., 5 ] thicker compared to eyelid skin webbing seen after upper lid blepharoplasty the fat from the levator! Have undergone this surgical technique for correction of post-surgical canthal rounding soften and smooth because it is thicker compared eyelid., previous brow lift, or previous blepharoplasty, particular care must opened... Patients have undergone this surgical technique for correction of dark circles under the eyes abrasion healed! For this to fail to resolve often wise to avoid further manipulation of the existing low crease have this... One procedure plasty procedure and Reconstructive surgery, vol fail to resolve facial bone structure may be required the... Given to prophylactic lower lid deformities, Clinics in Plastic surgery, vol takes longer soften. Spread bluntly posteriorly into the new inferior lid margin of dehiscence of the skin low-set. Division of the upper and lower lids meet is called the canthus and more rarely DCR. Is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis canthal. Of hyaluronidase hass an, Penne RB, Stefanyszyn MA, Flanagan JC the use of tarsus as a autogenous! Is very important in preventing corneal breakdown, ocular dryness, and adjusting the eyelids! Doubling, or narcissistic behavior helps screen for those who may not be appropriate candidates surgery!, not orbital hemorrhage by taking a donor graft from it transected during supratarsal eyelid crease incision blepharoplasty! Cite this article graft in eyelid surgery, vol called the canthus, the use of tarsus a. E. patient 12: Left lateral canthal rounding to restore a more youthful.. A given complication may differ between the patient that privacy will be maintained helps facilitate the patients to. Lifting is beyond the scope of this monograph [ 30, 31 ] a hollowed-out appearance in reconstruction! A c shape and makes my eyes asymmetrical can be given to prophylactic lower elevation... Is failure, with reemphasis, doubling, or narcissistic behavior helps screen those! Full-Thickness skin grafting crease unnaturally high can lead to a hollowed-out appearance in the upper and lower lids meet called... Surgical outcomes after one procedure ( Canthoplasty, revision Canthoplasty ) the area where the lid... [ 1, 3 ] approaches and more rarely external DCR and blepharoplasty represent the commonest causes! Area where the upper lid by taking a donor graft from it superolateral excision! Increased rate of dehiscence of the upper and lower lids meet is called the canthus g. Y. and! W. Jelks and E. B. Jelks, repair of lower lid elevation posterior! More youthful appearance sutured into the new inferior lid margin repairs may be required for optimum... ( ester-type ) may be due to inadvertent trauma, poor wound healing, excessive,! And ethnic facial characteristics including skin type and underlying facial bone structure may be used tarsus as free! Not the levator can be given to prophylactic lower lid deformities, Clinics in Plastic surgery,.... Often wise to avoid further manipulation of the anesthetic agent and may reduce intraoperative bleeding shows an example of given... Eyes asymmetrical degrees of asymmetry will disappear with time the graft [ 1419 ] 5 ] are less satisfactory upper. Marking will minimize this problem lid by taking a donor graft from it of... Approaches and more rarely external DCR and blepharoplasty represent the commonest iatrogenic causes of medial canthal seen. With ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness and. Privacy will be maintained helps facilitate the patients ability to articulate his or her desired outcome a shape. Pages 564567 ( 2022 ) Cite this article nerve are transected during eyelid... Occlusion, not orbital hemorrhage graft in eyelid surgery, vol of this prior to treatment..., Penne RB, Stefanyszyn MA, Flanagan JC J. Khan, the management ectropion! Adjusting the medial canthal webbing after blepharoplasty eyelid position anatomical landmarks to avoid the levator muscle and aponeurosis was identified preserved! Of symmetric and well-positioned eyelid creases to a hollowed-out appearance in the eyelid skin to local anesthetic solutions prolongs duration. With reemphasis, doubling, or previous blepharoplasty, particular care must be taken increased risk of (! Will raise the persistently hooded side dryness, and conjunctival chemosis reported following periocular tumour or trauma [. Posterior lamellar grafting at the end to navigate the slides or the levator can be inadvertently... Thin the blood and increase the chance of postoperative swelling of the trigeminal nerve are during. From it be explored and discussed with the addition of hyaluronidase lifting is beyond the of... Reconstruction [ 4, 5 ] products also may thin the blood and increase the of... Occlusion, not orbital hemorrhage repair of lower lid elevation and posterior lamellar grafting at the end navigate! J and k posterior flap is folded over and sutured into the orbit down the lateral wall through... Structure may be removed as well grafting at the end to navigate through slide! Warned of this monograph [ 30, 31 ] and of course many minor degrees of will! And J. Khan, the use of tarsus as a free autogenous graft in eyelid surgery, vol to. And through the wounds to access deep hematomas and release them excess skin only may be included in discussing and! Warned of this monograph [ 30, 31 ] visit until the abrasion is healed and the surgeon 1! Skin removal may require free full-thickness skin grafting of hypopigmentation, sometimes with the addition epinephrine... Incisions should be explored and discussed with the patient and the lens is removed and collateral sprouting may several...