It requires medial canthal scar revision with multiple z-plasty. The area of canthal rounding is assessed and the new eyelid margin is marked (Fig. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. 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. Prolonged surgery and reoperation with scarred tissue contribute to swelling and ecchymosis. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl-2-cyanoacrylate. 90, no. The wound may be left open or closed loosely. 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. The rhomboid flap is an effective quick and simple technique for medial canthal reconstruction. 207212, 2008. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. There were no peri- or post-operative complications. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. The surgery involves removing redundant skin, fat, and muscle. Reassuring the patient that privacy will be maintained helps facilitate the patients ability to articulate his or her desired outcome. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. Anticoagulants may increase the risk of postoperative bleeding. It is virtually unheard of for this to fail to resolve. do you think epicanthoplasty would be a good option? 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. Note any resistance to passive lid movement. 21, no. The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. 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. 710, 2010. Occasionally, incision lines may look hypertrophied, particularly in keloid-forming patients. A tense, enlarging orbital hematoma and brisk incisional bleeding are clinical signs. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. Surgery can cost all different from street to street, even blocks to blocks in the same city, depending on the surgeon's reputation, skill and experiences. Excess preaponeurotic and/or nasal fat is removed. Lower blepharoplasty is one of the most common facial plastic surgery. Severe pain, decreased vision, and progressive swelling may represent retrobulbar hemorrhage and should be brought to immediate medical attention. 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. im worried that i wont be satisfied with my results if i only get the upper bleph, but im also worried about getting bad scars / webbing with epicanthoplasty. Cautery is applied as needed to achieve hemostasis. In addition, supporting structures such as canthal tendons are tightened. The solution to a problem is not always more cutting, however intuitively appealing the anticipated result might sound. Ophthal Plast Reconstr Surg. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. Running, interrupted, subcuticular, and other cutaneous skin closures can be with absorbable or nonabsorbable suture, incorporating skin and orbicularis muscle tissue, which aids in the lid crease formation (. Prospective analysis of changes in corneal topography after upper eyelid surgery. 219228, 1991. Retroauricular skin is often available and is a good substitute for eyelid skin. Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Steroids can be stopped without taper if administered less than 3 days, even at extremely high doses. Patients may fail to recognize substantial change in their appearance until they view pre- and postoperative photographs. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. Unfortunately, treatment beyond 1 to 6 hours of total or near-total vision loss is unlikely to be effective. Allergies and a list of medications should be noted. M. J. Hawes and G. A. Jamell, Complications of tarsoconjunctival grafts, Ophthalmic Plastic and Reconstructive Surgery, vol. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. 2005; 21:327. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. 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]. h Flap is marked. Plast Reconstr Surg 2001; 108:2137. Ophthalmic Plast Reconstr Surg. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. Lazzeri D, Agostini T, Figus M et al: The contribution of Aulus Cornelius Celsus (25 B.C.-50 A.D.) to eyelid surgery. The posterior flap is cut along the new superior lid margin and folded downwards before being secured into its new position as described earlier (Fig. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. 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. Lateral canthal support is used to address the lower eyelid laxity either by . 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. 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. Injury to the inferior oblique or less commonly other extraocular muscles, is rare. If the obstruction is more distal than 8mm from the punctum (unlikely in blepharoplasty surgery), a canaliculo-dacryocystorhinostomy may reconstruct the system. Plast Reconstr Surg 1971; 47: 246. Important measurements to evaluate include palpebral fissure, marginal reflex distance, amount of lagophthalmos, and lid crease height. I have inner eyelid webbing following a blepharoplasty 2 years ago. Swelling and bruising you may have will be virtually gone by day 10. J. However, because of the complex structure and function of the eyelids, the potential for complications does exist. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. 102, no. Many surgeons apply a cold compress while the patient is in the recovery area. Canthoplasty repair for canthal rounding. If a full tarsal strip procedure [5, 6] is required, the patient is rigorously cautioned to avoid pulling or sleeping on the eyelid to prevent dehiscence. 4, pp. 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. 1d and 1e). c The anterior flap is created and folded into its new position. The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. These are investigated and followed in the normal fashion for such conditions. Prolene is inert and ties cleanly, which is useful in closing a wound precisely. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Blindness following blepharoplasty: two case reports, and a discussion of management. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. The lid is placed on upward traction to facilitate this process, and an appropriately sized full-thickness graft is contoured to fit the defect after the eyelid is tightened horizontally. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. 11, pp. All research was conducted in accordance with the Declaration of Helsinki. g Lateral canthopexy. The same principle applies in lower lid fat removal to protect the inferior oblique. Pre- and post-operative photographs of selected cases are shown in Fig. 87, no. Recognition is key, as is a rapid response. Retrobulbar hemorrhage is a form of compartment syndrome, with pressure rising abruptly within the fixed 4 walls of the orbit. In the meantime, to ensure continued support, we are displaying the site without styles 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. 97, no. 1f). May be due to incision extended too far medially. volume36,pages 564567 (2022)Cite this article. Article Im losing faith in him though and am looking elsewhere for revision. Antibiotic ointment may be placed over incision. 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. Find a surgeon who can do this for you but you also have to understand that there is always a risk for scarring that may be visible. 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. The previous scar is opened up, internal adhesions are widely released (and perfect hemostasis obtained). Also, avoid excess cautery to the levator. Canthal rounding can cause cosmetic or functional deficit with visual obstruction on lateral gaze. Can J Ophthalmol 2003; 38:223. Proptosis, decreased motility, and increased orbital tension, and associated bleeding are the clinical signs to appreciate. One approach to assuring that sufficient skin remains for complete closure of the eyelid is the 20mm rule. There was one recurrence of rounding, which was noted at the first post-operative review at 2 weeks following surgery. It is both frustrating for patient and surgeon as there lacks standards for its correction. Ophthalmology. 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. d. Patient 9: Left lateral canthal rounding following blepharoplastydouble flap technique (right side not shown). 8589, 1990. If noted, however, it should be treated with bleaching creams. 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Excessive skin removal may require free full-thickness skin grafting. 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. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. The amount of lagophthalmos must be such that lower lid elevation would eliminate it. 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. 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. What complications can come from a blepharoplasty? Often no fat is removed in these patients, and skin excision is conservative. Our patients reported excellent outcomes post-operatively without any significant scarring. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. CT scan is important, but only after initial decompression treatment has been carried out. Once patients concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. Brown, The use of tarsus as a free autogenous graft in eyelid surgery, Ophthalmic Plastic and Reconstructive Surgery, vol. Finally, management of complications is just as important as surgical technique. Globe injury can occur with the CO2 laser, with a steel scalpel, or with local anaesthetic injection. 1a). The flaps are secured into their new positions with interrupted vicryl 6/0 sutures (Fig. Any true globe injury must have prompt and appropriate treatment by an ophthalmologist. The use of a suitable sized hand mirror also helps a patient explain his or her coveted appearance. 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. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. 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. However, rapid release of orbital pressure by opening the wound, lateral canthotomy and inferior and/or superior cantholysis is critical. Figure 3 shows an example of lagophthalmos secondary to the overcorrection of the upper lid. The most common complication when performing the Asian blepharoplasty is asymmetry. May be due to incision extended too far medially. 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. 81, no. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . Temporary sutures may approximate the skin before application of the glue. Interrupted sutures are used to reapproximate the wound edges. 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. Establishing a good patient-surgeon bond preoperatively is essential to managing any real or perceived surgical complication that may occur. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Filling in the hollowed areas can be problematic. Septum must be opened if fat is to be removed, but not the levator. 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. Involvement of an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents. 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]. The diplopia is usually of a form suggesting extravasation of local anaesthetic, such as a partial third or sixth nerve palsy. 417425, 1993. 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