The surgery involves removing redundant skin, fat, and muscle. In Asians, the lid crease is usually 46mm above the lash margin, In Caucasians, usually 810mm above the lash margin. 2, pp. The conjunctival incision made in a transconjunctival lower lid blepharoplasty never requires sutures. Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. 21, no. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. 604606, 1989. Patient education and cold avoidance are the primary means of treatment. 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. The rhomboid flap is an effective quick and simple technique for medial canthal reconstruction. He had severe chemosis and discomfort due to significant lagophthalmos. Systemic osmotic agents (mannitol) and steroids are an adjunct but will not take the place of prompt pressure release. 2, pp. 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. 5, pp. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. The conjunctivalised tissue appears effective at increasing the lid aperture and preventing re-adhesions, even when only a single flap is used and one lid margin is left to granulate. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. Alternatively, removing anterior fat may unmask the underlying proptosis, and care should be exercised. 19, no. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. Canthal rounding can cause cosmetic or functional deficit with visual obstruction on lateral gaze. Severe lower eyelid ectropion and retraction in a patient who underwent blepharoplasty elsewhere followed by several reparative attempts by the same surgeon. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. Plast Reconstr Surg. The swelling can also cause the puncta to turn inwards or evert by swelling or tissue contraction caused by incision lines or laser resurfacing, which also causes epiphora. Milder eyelid laxity is treated by a form of lateral canthal tendon plication at the time of lower lid blepharoplasty, and dehiscence here is less common and of milder extent, and hence can usually be managed supportively [7]. PubMedGoogle Scholar. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. 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. CAS The punctum is a useful landmark for the upper lid and lower lid incision. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. 20, no. 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. The use of the CO2 laser and maintaining a dry surgical field with bipolar cautery or by defocusing the CO2 laser will minimize the occurrence of postoperative ecchymosis. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Is it possible my plastic surgeon injured my tear duct by cutting too far in? Dermatol Surg 2005; 31:553. I would like to have this corrected as soon as possible and need advice. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. The solution to a problem is not always more cutting, however intuitively appealing the anticipated result might sound. Laser can be used to expose the superficial fibers of the levator for incorporation into the skin closure. This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). May be due to inadvertent trauma to the levator complex, including postsurgical edema and . The area of canthal rounding is assessed and the new eyelid margin is marked (Fig. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. Pers Soc Psychol Bull 2003; 29:885. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. 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. Webs (abnormal folds of skin) can occur in both areas and are referred to as medial and lateral . Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. 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. This area near the nose is called the medial canthus and the same area on the outer eyelids is called the lateral canthus. Ophthal Plast Reconstr Surg 1999;15:378. It is virtually unheard of for this to fail to resolve. 2020;46:5214. However, this was not encountered in our patient group. True canalicular injury may require late repair if epiphora results. More effect (in terms of lifting skin off the eyelashes) for less skin excision can be achieved by creating a higher lid crease during the blepharoplasty. 4, pp. Severity of visual field loss and health related quality of life. The information on RealSelf is intended for educational purposes only. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. He said he would try to fix it with skin grafting if I like but, is this very successful? If skin shortage is evident however, full-thickness skin grafting may be needed. Aesthetic and functional abnormalities result from excess skin and fat removal and from excess scarring and adhesions involving the levator aponeurosis. Complications of blepharoplasty can be minor or serious. After 24 hours of spinal-trauma dose level of steroids (solumedrol 30mg/kg bolus over 15 minutes followed by 5.4mg/kg per hour) without response, one can discontinue the drug, possibly after repeat imaging. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. Lateral canthal support is used to address the lower eyelid laxity either by . All except one patient reported good surgical outcomes after one procedure. I have started massaging the area and wearing silicone strips at night. If there is insufficient tissue to create both anterior and posterior flaps, for example in smaller areas of canthal rounding with less conjunctiva available, a modification to the above method to create a single flap can be used instead (DS). Various compositions of bleaching creams have been published, containing combinations of hydroquinone, glycolic acid, kojic acid, retinoic acid, and hydrocortisone. Dissection in the lateral canthal area may result in altered lymphatic drainage. 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. Lewis CM, Lavell S, Simpson MF. Pre- and post-operative photographs of selected cases are shown in Fig. If brow ptosis is present, straight-ahead photograph with eyebrows elevated by the patient demonstrates compensation. Federici TJ, Meyer DR, Lininger LL. Patients must be taught to check their vision one eye at a time. 372376, 1998. 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. Patient selection and patient satisfaction. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. 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. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. On average, this amount is between 1 to 2mm. The surgery involves removing redundant skin, fat, and muscle. Despite the use of a lidocaine/marcaine mixture for local anesthetic, it is important to note that this form of diplopia is always gone by the next day. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. The most common result which will be noted by the patient is lid crease asymmetry. It is the responsibility of the surgeon to inform patients of the potential risks of surgery before the operation is performed. Note any resistance to passive lid movement. Cicatricial canthal webs. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. CT scan is important, but only after initial decompression treatment has been carried out. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Am J Ophthalmol 2007;143:1013. I have scar webbing from a previous lower bleph. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. Lower eyelid of the same patient shown in Figures. Proptosis, decreased motility, and increased orbital tension, and associated bleeding are the clinical signs to appreciate. Measurement and precision are key to avoiding overcorrection. 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. 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