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. 7175, 1987. 2, no. 107, no. 2020;46:5214. 366368, 1969. Also, avoid excess cautery to the levator. 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. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. 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. 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. 367373, 1972. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. Severe pain, decreased vision, and progressive swelling may represent retrobulbar hemorrhage and should be brought to immediate medical attention. 1g). 1f). Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. 21, no. 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. Aesthet Surg J 2009; 29:87. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. 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. Orbital hematoma, ectropion, and scleral show. Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. The incision, which is made along the previously marked lines, can be made with a 15Bard Parker blade, an incisional CO2 laser, a diamond blade, or a needle-tipped Bovie or radiofrequency instrument. 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. Juniat, V., Joshi, S., Hersh, D. et al. 10361040, 1999. A cold stimulation test may confirm the diagnosis of PACU. d. Patient 9: Left lateral canthal rounding following blepharoplastydouble flap technique (right side not shown). The wound may be left open or closed loosely. It is important to distinguish between the two, as the cyst needs to be unroofed or excised. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. In younger patients, crease formation by skin fixation to the anterior tarsal plate rather than the levator aponeurosis avoids ectropion of the upper eyelid margin and superior migration of the fold. Primary acquired cold urticaria. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. The surgical technique was developed by one of the senior authors (NJ). This interferes with the tear pump mechanism. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl-2-cyanoacrylate. 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). 8, no. Article We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Finally, management of complications is just as important as surgical technique. 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. The risk is failure, with reemphasis, doubling, or other scarring of the existing low crease. Patient education and cold avoidance are the primary means of treatment. Frequency of cold compresses is decreased as the effectiveness of this therapy lessens. 5, pp. Lower eyelid skin excision or laser resurfacing (or neither) is another key decision. Lateral traction was placed with a finger to the canthal web to displace the fold of . 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. It requires medial canthal scar revision with multiple z-plasty. Prevent by planning an incision that extends to the medial commissure; May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures; Ptosis. http://tabanmd.com/gallery/revisional-eyelid/ Helpful Mehryar (Ray) Taban, MD, FACS Oculoplastic Surgeon, Board Certified in Ophthalmology ( 302) It has created a web (possibly medial canthal webbing) from my brow to lower eye. Ophthalmic Surg 1990; 21:85. 87, no. He said he would try to fix it with skin grafting if I like but, is this very successful? Blink dysfunction is common postblepharoplasty because of postoperative swelling of the eyelid tissues. 97, no. It is difficult to lower a crease which is too high. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). Copyright 2012 James Oestreicher and Sonul Mehta. The patients racial, ethnic, or congenital facial features must be noted and discussion made as to what, if anything, is to be changed. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) Arch Ophthalmol 1999; 117:907. Especially on one side more than the other! Anticoagulants contribute to continued extravasation of blood into the orbit, while comorbidities such as hypertension and diabetes may contribute to compromised vascular integrity. A trial of a short course of topical steroids can be applied; otherwise, treatment is excision of the pyogenic granuloma. 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. The patient will also have asymmetrical pain and decreased vision. 6, pp. It is often necessary to tighten the lower eyelid at the time of blepharoplasty. Please see before/after photo on link below (toward bottom of the website page). 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. Photos in Fig. Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. 12511260, 1997. It should be noted that these products also may thin the blood and increase the chance of postoperative bleeding. Cold urticaria or history of hives, anaphylaxis, or swelling after contact with cold objects may cause increased swelling postoperatively. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. It is virtually unheard of for this to fail to resolve. 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. Plast Reconstr Surg 2001; 108:2137. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. When needed, lid crease fixation method depends on surgeon's preferences and experience (. Antibiotic ointment may be placed over incision. 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. CT scan is important, but only after initial decompression treatment has been carried out. Recognition is key, as is a rapid response. 9, pp. 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. 6, pp. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. 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 changes to eyelid position can also occur after lower lid blepharoplasty. R. Z. Silkiss and H. I. Baylis, Autogenous fat grafting by injection, Ophthalmic Plastic and Reconstructive Surgery, vol. The canthal rounding is split into its anterior and posterior lamellae using a 15-blade followed by Westcott spring scissors (Fig. The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. 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. Old photographs are useful to determine the patients youthful upper eyelid fold configuration. 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. Once patients concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. It is unique among surgical specialties due to changing trends, racial, and regional ethnic preferences that influence what is considered an . 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. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. The authors favor CO2 laser blepharoplasty with a trans-conjunctival lower lid approach. Early injection takes advantage of the time required to move, position, prep, and drape the patient, during which time the anesthetic will take effect. J. H. Oestreicher, N. K. Pang, and W. Liao, Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients, Ophthalmic Plastic and Reconstructive Surgery, vol. Nonabsorbable sutures are removed 714 days after surgery. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. Slider with three articles shown per slide. 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. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. McKean-Cowdin R, Varma R, Wu J, et al. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. 1h) then split into its anterior and posterior lamellae as described earlier. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. Extending the marking too far lateral may result in unwanted visible scarring. 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. 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. 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. 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Experienced by every blepharoplasty patient, so it is often necessary to tighten the lower eyelid at the time blepharoplasty.
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