R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. Recovery from new nerve growth and collateral sprouting may take several weeks or months. Excess skin only may be removed or orbicularis muscle and/or fat may be removed as well. 5155, 1996. In more severe cases, the rounding can cause functional deficit with visual obstruction on lateral gaze. Clin Plast Surg 1983; 10:321. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Measurement and precision are key to avoiding overcorrection. Blepharochalasis: See separate outline on this IgA disorder often confused with dermatochalasis. Unfortunately, treatment beyond 1 to 6 hours of total or near-total vision loss is unlikely to be effective. Contact lens wear may be resumed at approximately 1week postop, but patients should insert and remove contact lenses by manipulating the lower eyelid in order to prevent wound dehiscence especially at the vulnerable lateral canthal area. Heinze JB, Hueston JT. Plast Reconstr Surg. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. Blood supply to critical structures including the optic nerve become compromised. This is particularly important if incisions are made with the CO2 laser. Patients undergo upper blepharoplasty for purely aesthetic reasons. Difficult to rectify? 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. If the patient continues to have difficulty describing or demonstrating what he or she desires changed, and into what, it obligates the surgeon to promote discussion or present alternatives until clear agreement occursotherwise, surgery should not be done. Lateral canthal support is used to address the lower eyelid laxity either by . Tenzel RR: Complications of blepharoplasty. In addition, supporting structures such as canthal tendons are tightened. 3 The lateral canthal angle is sharp and crisp, with the lateral commissure closely opposed to the globe . Arch Ophthalmol 1999; 117:907. This is because they cause more harm than good. Other conditions such as ptosis, brow ptosis, entropion, ectropion, or eyelid retraction may also need to be corrected at the time a blepharoplasty is performed to ensure the best functional and aesthetic result. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). Similarly, conjunctival chemosis caused by a transconjunctival incision and by drying related to lagophthalmos can cover the puncta, again leading to epiphora. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. A partial improvement may be achieved with a posterior lamellar graft and horizontal tightening alone. CAS The patient was given topical steroids by his original surgeon, resulting in untreated intraocular pressure of 45OU. Meticulous preoperative planning, including precise measurements and noting any asymmetry in facial features, should be a routine for every surgeon. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. The surgery involves removing redundant skin, fat, and muscle. 2011;27:42630. 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. This fast and predictable approach avoids opening the anterior wound and also avoids overcorrection and scar abnormalities. Relative merits and disadvantages of addressing concurrent blepharoptosis, eyebrow ptosis, eyelid retraction, and other sources of eyelid, eyebrow and orbital asymmetry can be included in the discussion on proposed blepharoplasty. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. 1g). 426432, 2004. 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. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. Google Scholar. 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. Postlaser-resurfacing erythema is universal and expected. Early injection takes advantage of the time required to move, position, prep, and drape the patient, during which time the anesthetic will take effect. 1, no. Am J Ophthalmol 1996;121:677. Millman AL, Williams JD, Romo T, Taggert N. Septal-myocutaneous flap technique for lower lid blepharoplasty. The eyelid crease may be between 412mm above the lash line. Proptosis, decreased motility, and increased orbital tension, and associated bleeding are the clinical signs to appreciate. Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty surgery. e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. Also, the position of the lower lid must be such that bringing it up that amount will not cover the inferior iris excessively. 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. The median age was 65.5 years (range: 2688). In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. Adams J, Murray R. The general approach to the difficult patient. The patient will also have asymmetrical pain and decreased vision. d. Patient 9: Left lateral canthal rounding following blepharoplastydouble flap technique (right side not shown). Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. 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. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Pronounced or prolonged erythema is relatively uncommon and can be treated with topical 1% hydrocortisone cream or intense pulsed light treatments. Canthal rounding can cause cosmetic or functional deficit with visual obstruction on lateral gaze. The lower lateral marking is extended to the orbital rim or end of the eyebrow and may course superiorly or follow existing creases to meet the upper mark. I had an upper bleph three weeks ago (22 days out). 1c). Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. Once patients concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. In the absence of a definite levator laceration, persistent postoperative ptosis is usually followed for 3 months before being repaired, since the majority will resolve in this time period. Patients with vitiligo may have an increased risk of hypopigmentation. Photographs of frontal plane and oblique view. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. Intravenous mannitol 20% (12g/kg over 3060minutes). A slit lamp examination and Schirmers test are necessary in this authors view. 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. Primary acquired cold urticaria. Various compositions of bleaching creams have been published, containing combinations of hydroquinone, glycolic acid, kojic acid, retinoic acid, and hydrocortisone. Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. This can also lead to corneal dellen formation, or a dry cornea can break down de novo. Allergies and a list of medications should be noted. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Wilhelmi BJ, Mowlavi A, Neumeister, MW. You are using a browser version with limited support for CSS. 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. 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. N. Shorr, J. D. Christenbury, and R. A. Goldberg, Tarsoconjunctival grafts for upper eyelid cicatricial entropion, Ophthalmic Surgery, vol. 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. im interested in revision double eyelid surgery as i want a thicker crease + parallel. Open or closed lateral canthoplasty often performed in conjunction with various facial rejuvenation procedures (Taban, OPRS 2010) (e.g., upper- and/or lower-lid blepharoplasty, midface lift) Contraindications. Google Scholar. Graded eyelid horizontal tightening is utilized in all but the youngest patients. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. 99, no. Scars dont run past outside of eye. 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. Review of old or family photographs may be helpful in clarifying preferences and objectives. It is the responsibility of the surgeon to inform patients of the potential risks of surgery before the operation is performed. Artificial tears may also be recommended. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. 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. In the face of frank orbital hemorrhage with proptosis, a frozen globe, and vision loss, bold measures are called for. Slight dehiscence can be treated with topical and oral antibiotics, but a complete dehiscence needs prompt debridement and repair to avoid lower lid retraction and scarring. Laser resurfacing is utilized where skin shrinkage and rhytid reduction are desired. 19, no. Dissection in the lateral canthal area may result in altered lymphatic drainage. Scott KR, Tse DT, Kronish JW. However with skin closure, this scar generally blends well with the normal smile lines in the lateral canthal area. Topical and systemic antibiotics are given due to the open wounds. Assess nasal fat pad and preaponeurotic fat pad protrusion. 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. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. 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. All research was conducted in accordance with the Declaration of Helsinki. 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. Laser eye protectors are essential if the CO2 laser is utilized, but there must be enough ocular lubrication present to avoid a corneal abrasion when they are inserted or removed. 604606, 1989. 710, 2010. The surgeon must know his or her patients anatomy and distinguish septum from levator. Safety of Periocular Mohs Reconstruction: a Two-Center Retrospective Study. Blindness following blepharoplasty: two case reports, and a discussion of management. https://doi.org/10.1038/s41433-021-01497-y, DOI: https://doi.org/10.1038/s41433-021-01497-y. Proptosis, severe pain, decreased visual acuity, relative afferent pupillary defect, and elevated intraocular pressure confirm the diagnosis. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. 8589, 1990. Excessive bruising can lead to a prolonged recovery, infection, cicatrisation, and skin pigmentation. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. May require fat transplants or filler injection to correct the orbital volume deficiency, May be related to surgery or preoperative asymmetry of the face, lid, or brow. 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. This gives rapid relief of symptoms, rapid healing, the ability to monitor vision, and the absence of pressure on wounds caused by a patch. 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 4550, 1996. volume36,pages 564567 (2022)Cite this article. The lateral canthal angle is reformed to an acute configuration [2426]. 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. With appropriate case selection, thorough discussion with surgical candidates, and careful surgical technique, most of these can be avoided. Ice water compresses should be utilized continuously for 3 days (except when eating or sleeping). CO2 laser incisions need 7 days to heal, so sutures are removed on day 7 or 8. Multiple repairs may be required for the optimum result to be achieved. Occasionally instead of scar hypertrophy, epithelial inclusion cysts occur. 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. If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. PubMedGoogle Scholar. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. 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). Dermatol Surg 2005; 31:553. Also, avoid excess cautery to the levator. If a second finger is required in the central eyelid pushing upward, usually a posterior-lamellar graft is required. G. J. Leilli and R. D. Lieman, Blepharoplasty complications, Plastic and Reconstructive Surgery, vol. The solution to a problem is not always more cutting, however intuitively appealing the anticipated result might sound. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. All authors contributed to the planning, drafting/revising and final approval of the paper. Cicatricial canthal webs. Orbital hematoma, ectropion, and scleral show. Answer: Inner eyelid webbing scar after blepharoplasty Hi. 1b). Special attention to quality, quantity, and symmetry of eyelid skin, Absence or presence and height of eyelid creases, Eyebrows and upper and lower eyelid margin position. 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. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. Aesthet Surg J 2009; 29:87. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. 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. 367373, 1972. Pre- and post-operative photographs of selected cases are shown in Fig. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. Ophthalmology. There were no peri- or post-operative complications. An allergist should guide the workup and management of this condition. In Asians, the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border, Preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border. The surgery involves removing redundant skin, fat, and muscle. Besides webbing and incisions up to my eye brows I have this sagging in my left eye. In addition, placement of an upper lid traction suture is important or the skin graft will be ineffective [79]. D. R. Jordan and R. L. Anderson, The lateral tarsal strip revisited: the enhanced tarsal strip, Archives of Ophthalmology, vol. Note the widened aperture but rounding recurrence. Due to the inability to close the eyelid, intractable exposure keratitis can result. True canalicular injury may require late repair if epiphora results. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. I have scar webbing from a previous lower bleph. Ice packs or frozen masks are too heavy, which may damage the eyelid tissues or dehisce wounds. Interrupted sutures are used to reapproximate the wound edges. 87, no. If a definite levator laceration is observed, it should be repaired if it is causing ptosis. Another mechanism is direct or indirect injury to the inferior oblique during surgery. Severe lower eyelid ectropion and retraction in a patient who underwent blepharoplasty elsewhere followed by several reparative attempts by the same surgeon. Perin LF, Helene A, Fraga MF. Patients must be taught to check their vision one eye at a time. Ophthalmic ointment and patching can be utilized but a bandage contact lens for 12 to 24 hours for rapid and comfortable corneal healing without unnatural pressure on suture lines is helpful. Please see before/after photo on link below (toward bottom of the website page). May be accomplished by securing posterior skin to the levator complex at the superior border of the tarsal plate. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. Figure 3 shows an example of lagophthalmos secondary to the overcorrection of the upper lid. Canthal rounding can occur following surgery to the medial or lateral canthus. When skin shortage dictates skin graft placement, the technique is similar to that for other forms of cicatricial ectropion. http://tabanmd.com/gallery/revisional-eyelid/. 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. 1, pp. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. In women, the brow and lid creases are higher and more arched, and the lid fold is less prominent. The patient can be instructed in upward massage to keep infection and scarring minimized and alleviate retraction. 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. Tension in the levator complex and orbital septum may also result in eyelid retraction. Another possible issue is post-operative conjunctival thickening and persistent redness in the operated area. Slider with three articles shown per slide. 3, pp. Postoperative eyelid numbness involving the upper eyelid skin and eyelashes is an expected outcome after upper blepharoplasty and typically resolves over 2 to 4 months. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. This will significantly speed up the recovery time. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. 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. The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. Copyright 2012 James Oestreicher and Sonul Mehta. 107, no. My case seems quite complex compared to other cases of rounding I have seen: there appears to be a split between the lower eyelid and the webbing as opposed to the whole angle being blunted. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. R. R. Tenzel, Complications of blepharoplasty. Patients should plan to not drive for a week, due to the blurriness caused by the ointment use. h Flap is marked. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. Prevent by planning an incision that extends to the medial commissure; May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures; Ptosis. It is both frustrating for patient and surgeon as there lacks standards for its correction. The wound may be left open or closed loosely. 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. 7175, 1987. I would like to have this corrected as soon as possible and need advice. Head elevation and limiting activity may reduce edema. Z. Article Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Brown, The use of tarsus as a free autogenous graft in eyelid surgery, Ophthalmic Plastic and Reconstructive Surgery, vol. Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies, Patient-Reported Outcomes with LASIK Symptoms and Satisfaction, Oculofacial Plastic Surgery Education Center, Patient management: treatment and follow-up, Preventing and managing treatment complications, Common treatment responses, follow-up strategies, International Society of Refractive Surgery, Restoration of normal function and appearance of the upper eyelids, Repair changes occur secondary to aging, hereditary features, inflammation, growth of abnormal tissue, trauma, Improve visual function related to obstruction of the visual axis, Improve appearance that can make patient feel more youthful, Avoid unrealistic expectations about change in appearance may limit patient acceptance of surgical result, Avoid unrealistic expectations that may also extend to anticipated improvement in quality of life, Help patient cope with difficult adjustments to change in appearance that may lead to anger, stress, anxiety, and depression. 2013;29:20814. 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. The most common result which will be noted by the patient is lid crease asymmetry. 4350, 1985. The punctum is a useful landmark for the upper lid and lower lid incision. 107, no. Severity of visual field loss and health related quality of life. 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. Patient discomfort from suture removal is minimized by using Jewellers forceps and sharp Vannas scissors. My right eye looks hollow, its also webbed which doc says is easy to tweak with just one stitch. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. 34, no. Lagophthalmos due to internal scarring requires surgical exploration and lysis of the scar tissue. 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]. Prospective analysis of changes in corneal topography after upper eyelid surgery. The conjunctival incision made in a transconjunctival lower lid blepharoplasty never requires sutures. Institutional Review Board/Ethics Committee approval was obtained. Narcissists as 'victims': the role of narcissism in the perception of transgressions. Mild inner webbing too. This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). Inadvertent trauma to an extraocular muscle with deep dissection in orbital fat may occur. Nonsedating antihistamines may help control cold-induced symptoms. Mild lower-lid laxity or lateral canthal deformity. 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. Degree of swelling is related to surgical factors such as ecchymosis, cauterization, tissue manipulation, and patient response to surgery. Medially, this often results from the incision nearing the lid margin too closely or if the incision is extended to far medially or inappropriately angled inferiorly. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Globe injury can occur with the CO2 laser, with a steel scalpel, or with local anaesthetic injection. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position.