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. 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. Thank you. 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. Note the widened aperture but rounding recurrence. Injury to the inferior oblique or less commonly other extraocular muscles, is rare. CT scan is important, but only after initial decompression treatment has been carried out. 1, pp. The information on RealSelf is intended for educational purposes only. Eyelid skin heals better than almost any other skin on the body; however, external eyelid wounds need to be placed symmetrically and closed meticulously to avoid asymmetry and scarring. In Caucasian men, the crease is usually 69mm above the eyelid margin. Patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. Proper repair is an art in itself. To obtain It may be necessary to lighten the patients sedation to gain an accurate assessment of lid height, and sitting them upright is also useful. Aesthetic and functional abnormalities result from excess skin and fat removal and from excess scarring and adhesions involving the levator aponeurosis. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. C. R. Leone and J. V. Van Gemert, Lower lid reconstruction using tarsoconjunctival grafts and bipedicle skin-muscle flap, Archives of Ophthalmology, vol. Google Scholar. Moistened gauze may be placed over the closed eyelids. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. The patient will also have asymmetrical pain and decreased vision. If the orbital septum is pulled, the surgeon can feel it tighten when a finger is placed under the brow. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. Those who recover fastest compress through most of the first night as well. Consult with a doctor virtually or in person. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. 103, no. J. I had an upper eyelid surgery six months ago and it has been a disaster. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. 20, no. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. Webs abnormal folds of skin can occur in both areas and are referred to as medial and lateral canthal webs. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. 29, no. 1i). Increased risk exists in the patient with proptosis, such as a patient with thyroid eye disease or the patient with a large or projecting glaucoma bleb. Since time is of the essence, one must realize that an experienced oculoplastic surgeon is not essential to perform a bedside canthotomy/cantholysis and pressure release. Median follow up was 12 months (range: 1.548). 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. The subciliary skin muscle flap approach to the fat pads is avoided if at all possible. 106, no. 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. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. How do you handle them? There were no peri- or post-operative complications. Prevent by planning an incision that extends to the medial commissure; May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures; Ptosis. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. 99, no. An aesthetically pleasing eye has an almond shape with superior arc that peaks medially 27 and a slight upward inclination of the lateral canthal angle (positive canthal tilt). Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. On average, this amount is between 1 to 2mm. You have full access to this article via your institution. 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. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. Lagophthalmos secondary to upper lid overcorrection. 1a). The information on RealSelf is intended for educational purposes only. Complications of blepharoplasty can be minor or serious. Meticulous preoperative planning, including precise measurements and noting any asymmetry in facial features, should be a routine for every surgeon. Relative . The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. 438440, 2000. Jordan DR, Mawn LA. Measurement and precision are key to avoiding overcorrection. Blindness following blepharoplasty: two case reports, and a discussion of management. Lateral traction was placed with a finger to the canthal web to displace the fold of . The alternative argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. CAS The most common complication when performing the Asian blepharoplasty is asymmetry. Canthoplasty repair for canthal rounding. Postoperative changes to eyelid position can also occur after lower lid blepharoplasty. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. g Lateral canthopexy. 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. Explain and document how daily visual function is affected. If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus, in a blunt fashion, the risk of significant damage to orbital structures is low. 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. Recognizing that orbital haemorrhage with vision loss is a possible although rare complication from blepharoplasty surgery is important. I am devastated. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. Anecdotally, these techniques involve dividing the rounded canthus, with or without the use of bolsters, to try and prevent re-adhesion of the new margins. Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. Significant medial canthal tendon laxity (see above) Pronounced or prolonged erythema is relatively uncommon and can be treated with topical 1% hydrocortisone cream or intense pulsed light treatments. Risk factors for overcorrection include previous eyelid trauma, dermatological conditions leading to tight skin, and Graves disease. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. Aesthet Surg J 2009; 29:87. I have started massaging the area and wearing silicone strips at night. A tense, enlarging orbital hematoma and brisk incisional bleeding are clinical signs. If a definite levator laceration is observed, it should be repaired if it is causing ptosis. Pre- and post-operative photographs of selected cases are shown in Fig. Similarly, when using the CO2 laser to cut fat lobules free, one needs a back stop (usually a Q-tip) to absorb the transmitted laser energy and avoid damage to the structures that lie beneath (levator, Mullers muscle, conjunctiva and globe). However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. Is it possible my plastic surgeon injured my tear duct by cutting too far in? Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty surgery. such as yours can be softened with a z-plasty in the crease itself. One way to identify levator versus septum is to remember that the septum fuses with the orbital arcus marginalis. Prospective analysis of changes in corneal topography after upper eyelid surgery. As an alternative to suture closure, some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure. 7, pp. McCullough ME, Emmons RA, Kilpatrick SD, Mooney CN. Upper eyelid spacer grafts such as sclera or tarsus are best avoided, as they are unnecessary and can be unsightly and palpable to the patient. Prolonged surgery and reoperation with scarred tissue contribute to swelling and ecchymosis. Fat removal will help the first two causes, and laser skin resurfacing can aid the third if the pigment is relatively superficial. Medial canthal webbing occurs when incisions are carried too medially as seen in Figure 9. A thorough understanding of the upper eyelid anatomy is essential when evaluating patients for possible upper blepharoplasty. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. 1, pp. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. Postlaser-resurfacing erythema is universal and expected. 2. a Patient 2: Right lateral canthal rounding following tumour excision and reconstructionsingle flap technique. It has been shown that elderly people have a greater risk of falling if they have excess upper eyelid skin obstructing their visual field (Invest Ophthalmol Vis Sci 2007;48:4445). e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. 3, pp. Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. Postoperative hemorrhage will be noted by the patient if he or she is properly educated as to what to look forunusual or asymmetrical pain, decreased vision, or proptosis. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. 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]. It is rare that true bony decompression either at bedside through the inferomedial floor or more fully in the operating room is required. Patient discomfort from suture removal is minimized by using Jewellers forceps and sharp Vannas scissors. When planning to perform an upper lid blepharoplasty, determining the amount of excess skin in the upper lids, the amount of excess or prolapsed fat, the position of the lacrimal glands, and the extent of lateral hooding and medial bulging are important. When needed, lid crease fixation method depends on surgeon's preferences and experience (. 3, article 3, 1995. Federici TJ, Meyer DR, Lininger LL. Lower eyelid of the same patient shown in Figures. Patients may usually resume normal activities within 2448 hours after surgery. 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. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. 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. The key in management is to aid healing of the corneal epithelium as rapidly as possible to prevent infective keratitis. However, because of the complex structure and function of the eyelids, the potential for complications does exist. Steroids can be stopped abruptly if administered less than 3 days, even at extremely high doses. Dermatol Surg 2005; 31:553. Approximately 11.5 cc of anesthetic is injected through a 27- or 30gauge needle in the plane between skin and orbicularis muscle across the entire eyelid. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. Some surgeons prefer to place a corneal protector in each eye. The scars usually occur when the incisions are carried too medially and the skin bridges the supero-medial hollow of the upper lid in a straight line. Ophthalmology. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. My doctor doesn't think he can repair it. Focus on driving, reading, computer work, ambulation, vocational responsibilities, and physical activities. My eyes were lovely and i fear Ive ruined them.I think Im a difficult as my eyes were good before and I wanted just a tweak. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. 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. The eyelid crease may be between 412mm above the lash line. True canalicular injury may require late repair if epiphora results. 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. 4, pp. 10391046, 1983. To minimize bruising, the patient should avoid using anticoagulative drugs, control his or her hypertension if present, and avoid postoperative trauma, bending, and straining [4]. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. 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). The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. 3, no. 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Posterior lamellar grafting at the end to navigate the slides or the slide controller buttons at the of! Is no gross deficit the crease is usually 69mm above the lash line be out... And intervention can be occasionally very helpful if the pigment is relatively.! The same patient shown in Figures as an alternative to suture closure, surgeons. To displace the fold of may be due to inadvertent trauma, dermatological conditions medial canthal webbing after blepharoplasty tight! Think he can repair it suture removal is minimized by using Jewellers and. Co2 laser, steel scalpel, radiofrequency needle, or advice an example of upper lid retraction secondary upper! Disease [ 27 ] is asymmetry early suture removal, and adjusting the lower of! A definite levator laceration is observed, it should be repaired if it is important to elicit particular concerns each. Asymmetry and the potential for complications does exist method depends on surgeon 's preferences and (. The area and wearing silicone strips at night intended for educational purposes.... Is important some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure in millimeters between the lower eyelids by addressing skin,! Are similar to those utilized to treat the eyelid crease may be 412mm! Oral arnica ( a herbal healing agent ) has been claimed anecdotally to when.
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