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. It is important to distinguish between the two, as the cyst needs to be unroofed or excised. D. R. Jordan and R. L. Anderson, The lateral tarsal strip revisited: the enhanced tarsal strip, Archives of Ophthalmology, vol. Plast Reconstr Surg. One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. 21922196, 1979. 20, no. The same principle applies in lower lid fat removal to protect the inferior oblique. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Review of old or family photographs may be helpful in clarifying preferences and objectives. All ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis. The lateral canthal angle is reformed to an acute configuration [2426]. 466474, 2010. 97, no. 3, article 3, 1995. Excessive bruising can lead to a prolonged recovery, infection, cicatrisation, and skin pigmentation. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. 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. Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. A good understanding of anatomy and careful preoperative counseling of the patient is crucial for success. The risks are significant and include brief effect, scarring and tissue irregularities, uneven contours, and ptosis and lid retraction. In Caucasian men, the crease is usually 69mm above the eyelid margin. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. 12, no. Many surgeons apply a cold compress while the patient is in the recovery area. Severe pain, decreased vision, and progressive swelling may represent retrobulbar hemorrhage and should be brought to immediate medical attention. A. N. Hass, R. B. Penne, M. A. Stefanyszyn, and J. C. Flanagan, Incidence of postblepharoplasty orbital hemorrhage and associated visual loss, Ophthalmic Plastic and Reconstructive Surgery, vol. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in 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]. 438440, 2000. 797802, 1981. My doctor doesn't think he can repair it. Antibiotic ointment may be placed over incision. Anticoagulants contribute to continued extravasation of blood into the orbit, while comorbidities such as hypertension and diabetes may contribute to compromised vascular integrity. Besides webbing and incisions up to my eye brows I have this sagging in my left eye. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. In equivocal cases, a posterior lamellar graft can be tried first, and the patient warned that a following procedure with a skin graft may be necessary. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. Dermatol Surg. 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. Valerie Juniat. These are investigated and followed in the normal fashion for such conditions. The surgery involves removing redundant skin, fat, and muscle. Massage and steroid injections can help. Lee CW, Sheffer AL. ISSN 0950-222X (print), https://doi.org/10.1038/s41433-021-01497-y, Medial canthoplasty for the management of exposure keratopathy, The kissing puncta: an under-reported and stubborn cause of epiphora, Anterior lamellar deficit ectropion management, Skin redraping for correction of lower eyelid epiblepharon combined with medial epicanthal fold: a retrospective analysis of 286 Asian children, A novel technique for the measurement of eyelid contour to compare outcomes following Mullers muscle-conjunctival resection and external levator resection surgery, The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations, Comparison of three surgical techniques for internal angular dermoid cysts: a randomized controlled trial, Causes and management of persistent septal deviation after septoplasty, Strategies for ear elevation and the treatment of relevant complications in autologous cartilage microtia reconstruction. Ice packs or frozen masks are too heavy, which may damage the eyelid tissues or dehisce wounds. If persistent, intense pulse light is a useful adjuvant treatment. It may be necessary to lighten the patients sedation to gain an accurate assessment of lid height, and sitting them upright is also useful. 21, no. 3, no. 4350, 1985. In the initial assessment, patients are encouraged to voice their desires and concerns regarding the aesthetic appearance and functional features of their eyelids. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. Lagophthalmos secondary to upper lid overcorrection. Recognizing that orbital haemorrhage with vision loss is a possible although rare complication from blepharoplasty surgery is important. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. As the surgeon, it is important to be aware of the potential complications of surgery. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. 2003;111:44150. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. Mild inner webbing too. It is unique among surgical specialties due to changing trends, racial, and regional ethnic preferences that influence what is considered an . 1, pp. In addition, supporting structures such as canthal tendons are tightened. If the orbital septum is pulled, the surgeon can feel it tighten when a finger is placed under the brow. 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]. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. Severity of visual field loss and health related quality of life. PubMedGoogle Scholar. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. 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). 103, no. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Measurement and precision are key to avoiding overcorrection. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. 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. Abnormalities of lower eyelid position include lower lid retraction with scleral show, rounding of the lower eyelid contour, rounding of the lateral canthal angle, and ectropion. Retrobulbar hemorrhage is a form of compartment syndrome, with the orbit bounded by four bony walls and the orbital septum acting as the compartment. In addition, supporting structures such as canthal tendons are tightened. 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. The anterior flap is cut along the new superior lid margin using Westcott spring scissors and folded downwards to create the anterior lamella of the new inferior lid margin (Fig. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. The information on RealSelf is intended for educational purposes only. The skin taken has made a hollow that makes the overhang look worse. Meticulous preoperative planning, including precise measurements and noting any asymmetry in facial features, should be a routine for every surgeon. 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. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. The key in management is to aid healing of the corneal epithelium as rapidly as possible to prevent infective keratitis. Retrobulbar hemorrhage is a form of compartment syndrome, with pressure rising abruptly within the fixed 4 walls of the orbit. 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. 372376, 1998. 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. 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. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. Due to the inability to close the eyelid, intractable exposure keratitis can result. L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. The flaps are secured into their new positions with interrupted vicryl 6/0 sutures (Fig. Fronto-ethmoidal external approaches and more rarely external DCR and blepharoplasty represent the commonest iatrogenic causes of medial canthal webbing. Superior oblique muscle and trochlea can be vulnerable to surgical trauma because of their anterior position in the orbit (Plast Reconstr Surg 2001;108:2137). im interested in revision double eyelid surgery as i want a thicker crease + parallel. Normal postoperative swelling may normally worsen during the initial 24 hours following surgery and can be partly alleviated by applying ice. Inadvertent trauma to an extraocular muscle with deep dissection in orbital fat may occur. 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. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. Google Scholar. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). Postlaser-resurfacing erythema is universal and expected. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. 10361040, 1999. Complications of blepharoplasty can be minor or serious. I have started massaging the area and wearing silicone strips at night. In older patients with excess upper lid fat, the septum needs to be formally opened to remove preaponeurotic fat. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. The risk of suture granuloma formation is decreased by using prolene sutures and removing them completely at the appropriate time. Minimizing wound dehiscence involves appropriate suture choice and suture placement. 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. A lateral canthal web is a known complication of blepharoplasty. 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. In patients (especially males) with prominent skin and orbicularis excess who are not laser candidates, fat is still removed transconjunctivally, the eyelid is tightened horizontally and a conservative skin muscle pinch excision is utilized. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. C. M. Stephenson and B. Nonabsorbable sutures are removed 714 days after surgery. 1997;13:849. B. One approach to assuring that sufficient skin remains for complete closure of the eyelid is the 20mm rule. The surgery involves removing redundant skin, fat, and muscle. 11, pp. Excessive skin removal may require free full-thickness skin grafting. A running prolene suture, with several interrupted reinforcements is useful. 366368, 1969. 1992; 99:222. 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. Canthal webbing can be associated with scleral show laterally due to inferior lid retraction, and is a known complication of blepharoplasty or reconstruction following trauma or tumour excision [1,2,3]. 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. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). 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. Medial canthal webbing occurs when incisions are carried too medially as seen in Figure 9. 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. He had severe chemosis and discomfort due to significant lagophthalmos. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. C. R. Leone and J. V. Van Gemert, Lower lid reconstruction using tarsoconjunctival grafts and bipedicle skin-muscle flap, Archives of Ophthalmology, vol. This area near the nose is called the medial canthus and the same area on the outer eyelids is called the lateral canthus. If noted, however, it should be treated with bleaching creams. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. 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. If concerned, the patient can be observed until signs of improvement are noted. Patients may inadvertently rub their eyes in the hours after surgery when their lids are numb or while sleeping. 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. In the meantime, to ensure continued support, we are displaying the site without styles Care is taken not to remove too much of this volume producing tissue, particularly in the pupillary meridian where inadequate fat will often cause an Aframe deformity. Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. Do I have any good options? Heinze JB, Hueston JT. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. Median follow up was 12 months (range: 1.548). 2013;29:20814. In Asians, the lid crease is usually 46mm above the lash margin, In Caucasians, usually 810mm above the lash margin. McKean-Cowdin R, Varma R, Wu J, et al. do you think epicanthoplasty would be a good option? If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus (i.e., parallel to these structures) in a blunt fashion the risk of significant damage to orbital structures is low. Consult with a doctor virtually or in person. 7, pp. Internet Explorer). Publishers note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The use of a suitable sized hand mirror also helps a patient explain his or her coveted appearance. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. Lid crease in Asians can be absent, may be nasally tapered, or flat but typically lies lower and flatter than Caucasians. Patients often complain of headache and brow ache from overworked frontalis muscles, pulling excess skin away from the eyelid margins. 6, pp. Occasionally, incision lines may look hypertrophied, particularly in keloid-forming patients. The surgeon should spread bluntly posteriorly into the orbit down the lateral wall and through the wounds to access deep hematomas and release them. 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. Lateral canthal support is used to address the lower eyelid laxity either by . Slider with three articles shown per slide. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. 49, no. Any adjunctive procedures to be performed should also be determined. 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. 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. May be accomplished by securing posterior skin to the levator complex at the superior border of the tarsal plate. In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. Ophthalmology 1999; 106:1705. A contact lens does require a daily or near daily visit until the abrasion is healed and the lens is removed. 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. 5, pp. 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. Patients with vitiligo may have an increased risk of hypopigmentation. 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. If the obstruction is more distal than 8mm from the punctum (unlikely in blepharoplasty surgery), a canaliculo-dacryocystorhinostomy may reconstruct the system. Institutional Review Board/Ethics Committee approval was obtained. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. 12511260, 1997. 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. 122, no. You are using a browser version with limited support for CSS. 21, no. Department of Ophthalmology and Visual Sciences, University of Adelaide, Adelaide, Australia, Chelsea and Westminster NHS trust, London, UK, You can also search for this author in The lower lid is then tightened if lax or given an upward vector with a minimal Elschnig tarsorrhaphy if not lax. 1j and 1k). Aesthet Surg J 2009; 29:87. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. It is, therefore, often wise to avoid further manipulation of the upper lid by taking a donor graft from it. 125, article 1017, 2010. 5155, 1996. If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. Lubrication, cool compresses, and observation are essential to resolution. How risky is this to correct and when is it safe to do? Rarely is bony decompression, either at bedside through the inferomedial floor or more fully in the operating room, required. Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. Im losing faith in him though and am looking elsewhere for revision. 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.

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