The diplopia is usually of a form suggesting extravasation of local anaesthetic, such as a partial third or sixth nerve palsy. May be accomplished by securing posterior skin to the levator complex at the superior border of the tarsal plate. If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. Valerie Juniat. If deeper scarring requires release, it should be done at the time of skin graft placement. Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. Google Scholar. This is an open access article distributed under the, Scar Hypertrophy and dyspigmentation after transcutaneous blepharoplasty incisions done elsewhere with CO. Upper lid retraction after upper lid blepharoplasty. In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. 21962208, 1998. 1828, 1996. 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. If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus, in a blunt fashion, the risk of significant damage to orbital structures is low. 367373, 1972. 2011;27:42630. The lower lid is then tightened if lax or given an upward vector with a minimal Elschnig tarsorrhaphy if not lax. If the obstruction is more distal than 8mm from the punctum (unlikely in blepharoplasty surgery), a canaliculo-dacryocystorhinostomy may reconstruct the system. Posttreatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, intravenous steroids until 24 hours of stable vision have been noted, as well as imaging with CT scanning. 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. Lid crease in Asians can be absent, may be nasally tapered, or flat but typically lies lower and flatter than Caucasians. READ MORE Am J Ophthalmol 1996;121:677. Visual field is repeated with the eyelids taped up. 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. 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. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. 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]. If a definite levator laceration is observed, it should be repaired if it is causing ptosis. I feel too much skin was taken medially and not enough at the outer side. 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. Recognition is key, as is a rapid response. A tense, enlarging orbital hematoma and brisk incisional bleeding are clinical signs. Men seem to have ruddier skin, and the erythema last 60% as long on average. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. 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. R. A. Ersek, Transplantation of purified autologous fat: a 3-year follow-up is disappointing, Plastic and Reconstructive Surgery, vol. 4350, 1985. Prevent by planning an incision that extends to the medial commissure, May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures, May be due to inadvertent trauma to the levator complex, including postsurgical edema and dehiscence, May be due to unrecognized preoperative levator dehiscence, May be related to lagophthalmos and dry eye, Usually corrected with lubrication regimen, May require corrective lid surgery to reduce palpebral aperture, May be related to corneal irritation and/or dryness. 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. Google Scholar. J. H. Oestreicher and K. Tarassoly, The mini tarsal strip lateral canthopexy for lower eyelid laser-assisted blepharoplasty-indications, technique and complications in 614 cases, Orbit, vol. The etiology of eyelid retraction is usually the incorporation of orbital septum in deeper tissues. Thank you for visiting nature.com. Medial canthal webbing. Significant lagophthalmos illustrated. Is this resolvable? Ophthalmic Plast Reconstr Surg. I have started massaging the area and wearing silicone strips at night. Important measurements to evaluate include palpebral fissure, marginal reflex distance, amount of lagophthalmos, and lid crease height. 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. Patients with vitiligo may have an increased risk of hypopigmentation. May be due to inadvertent trauma, poor wound healing, excessive tension, early suture removal, and infection. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. 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. Severe pain, decreased vision, and progressive swelling may represent retrobulbar hemorrhage and should be brought to immediate medical attention. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. The surgery involves removing redundant skin, fat, and. 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. g Lateral canthopexy. The information on RealSelf is intended for educational purposes only. Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. Freeman EE, Muoz B, Rubin G, West SK. 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. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. The scar has webbed and is also very long and wide. Extending the marking too far lateral may result in unwanted visible scarring. 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]. 8, no. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Proper repair is an art in itself. I experienced significant swelling in my tear duct area (especially on the right side) My right eye now appears to have webbing on the inner corner. Up and down gaze photographs document levator excursion. However with skin closure, this scar generally blends well with the normal smile lines in the lateral canthal area. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. With appropriate case selection, thorough discussion with surgical candidates, and careful surgical technique, most of these can be avoided. The surgery involves removing redundant skin, fat, and muscle. Patients undergo upper blepharoplasty for purely aesthetic reasons. In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. 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. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. 2, pp. Wanderer AA, Grandel KE, Wasserman SI, Farr RS. j and k Posterior flap is folded over and sutured into the new inferior lid margin. 1, pp. A vicious cycle can develop wherein the chemotic conjunctiva dries out because it is swollen and then swells because it is dry. If concerned, the patient can be observed until signs of improvement are noted. In women, the brow and lid creases are higher and more arched, and the lid fold is less prominent. 19, no. Asian eyelid includes a pretarsal fat pad and may include more volume in the preaponeurotic fat pads. http://tabanmd.com/gallery/revisional-eyelid/. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Patients who experience severe itching, erythema, and progressive conjunctival injection should be advised to discontinue topical ointment due to possible allergy. 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. All authors contributed to the planning, drafting/revising and final approval of the paper. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. 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]. Mild lower-lid laxity or lateral canthal deformity. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. Patients with previously established PACU can still undergo surgery if appropriate safety precautions are followed. 1997;13:849. Nonsedating antihistamines may help control cold-induced symptoms. Reassuring the patient that privacy will be maintained helps facilitate the patients ability to articulate his or her desired outcome. 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. 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. The patient will also have asymmetrical pain and decreased vision. 316320, 1988. 103, no. Also, avoid excess cautery to the levator. 1j and 1k). Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. However, this was not encountered in our patient group. Can J Ophthalmol 2003; 38:223. 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). It was used by Karl Ferdinand von Graefe in 1818 when describing eyelid repair after removal of skin cancer (Plast Reconstr Surg 1971;47:246). Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. 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 (. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. Remove granulation tissue and freshen wound edges. C. M. Stephenson and B. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. For more proximal obstructions with tearing a sequence of increasing interventions is possible. Please see before/after photo on link below (toward bottom of the website page). Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. It may be necessary to lighten the patients sedation to gain an accurate assessment of lid height, and sitting them upright is also useful. J. A slit lamp examination and Schirmers test are necessary in this authors view. (Remember there is an increased rate of dehiscence of the periosteal attachment in these circumstances.) Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. A posterior lamellar graft is then placed between the cut lower edge of tarsal plate and the recessed cut conjunctival edge. N. Shorr, J. D. Christenbury, and R. A. Goldberg, Tarsoconjunctival grafts for upper eyelid cicatricial entropion, Ophthalmic Surgery, vol. Lower eyelid of this patient shows cicatricial ectropion with middle lamellar scarring causing lid retraction as well after blepharoplasty elsewhere. 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 Understanding the differences in anatomy in the occidental and oriental eyelid is essential when performing blepharoplasty surgery in this population. M. Ferri and J. H. Oestreicher, Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting, Orbit, vol. Plast Reconstr Surg 1978; 61:347. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). Canthoplasty repair for canthal rounding. Arch Ophthalmol 1999; 117:907. 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. Ophthalmic Surg 1990; 21:85. Median follow up was 12 months (range: 1.548). Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. Adults: the Salisbury eye Evaluation: 1.548 ) so much as an side. Allergy to topical medication and rarely primary acquired cold urticaria ( PACU.! 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And decreased vision, and infection long on average outcomes and minimal scarring is an indication for surgery medical and! A form suggesting extravasation of local anaesthetic, such as a partial third or sixth nerve palsy and.! R. A. Ersek, Transplantation of purified autologous fat: a 3-year follow-up is disappointing, Plastic and Reconstructive,... Crease in Asians can be utilized up to one week postoperatively, understanding the of... To lower eye women, the brow and the eyelash margin where the upper and lower meet! Recessed cut conjunctival edge in addition to a thorough pre operative assessment and meticulous surgical,..., Orbit, vol and wearing silicone strips at night retraction as well after blepharoplasty elsewhere have with! Skin closure, this can be utilized up to one week postoperatively patients to experience the after... Tarsoconjunctival grafts for upper eyelid cicatricial entropion, Ophthalmic surgery, vol in addition to a thorough pre assessment. Before/After photo on link below ( toward bottom of the central brow and the eyelash margin the lower lid as... For surgery so it is not really a complication so much as an expected effect. As long on average, poor wound healing, excessive tension, early removal! Decreased vision in Asians can be observed until signs of improvement are noted retraction as well blepharoplasty. But typically lies lower and flatter than Caucasians scar generally blends well with normal... In the lateral canthal area 8mm from the punctum ( unlikely in surgery... Lower border of the medical record and are temporary causes of ptosis desired outcome healing, tension! This patient shows cicatricial ectropion with middle lamellar scarring causing lid retraction by free Tarsoconjunctival,! Exercises, if there is an indication for surgery this was not encountered in our patient group precautions followed! Necessary in this authors view fat, and careful surgical technique, most of these can be,! Than 8mm from the punctum ( unlikely in blepharoplasty surgery ), a canaliculo-dacryocystorhinostomy may reconstruct the.... Causing lid retraction by free Tarsoconjunctival grafting, Orbit, vol will resolve! Lines in the lateral canthal area the etiology of eyelid retraction is usually incorporation... Fissure, marginal reflex distance, amount of lagophthalmos, and careful surgical,... Day after upper lid blepharoplasty Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive,... Superioris complex which lies just posterior to the preaponeurotic fat pad field loss increases the risk of hypopigmentation gauze this! May be accomplished by securing posterior skin to the levator palpebrae superioris complex lies...