Recognition is key, as is a rapid response. 366368, 1969. Im losing faith in him though and am looking elsewhere for revision. The solution to a problem is not always more cutting, however intuitively appealing the anticipated result might sound. If noted, however, it should be treated with bleaching creams. Topical and systemic antibiotics are given due to the open wounds. 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. Finally, management of complications is just as important as surgical technique. If the surgeon thought to preserve the excised skin in moist gauze, this can be utilized up to one week postoperatively. 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. 2003;111:44150. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. I am 13 days post op. e The posterior flap is folded into its new position. The area of canthal rounding is assessed and the new eyelid margin is marked (Fig. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. When preparing for lower lid blepharoplasty, important features to note are the amount of excess skin and the presence of fine rhytids (wrinkles), prolapsed fat (quantity and location), malar bags or festoons, lid laxity, scleral show and pigmentary characteristics. Measurement and precision are key to avoiding overcorrection. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. The use of a suitable sized hand mirror also helps a patient explain his or her coveted appearance. Persistent cases are treated by a V- to-Y plasty procedure. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Absorbable sutures vary in rate of absorption and degree of inflammation often they are removed as well. Depth of excision depends on the preoperative plan. There was one recurrence of rounding, which was noted at the first post-operative review at 2 weeks following surgery. 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. Assess degree of lacrimal gland prolapse. Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. This interferes with the tear pump mechanism. Lateral traction was placed with a finger to the canthal web to displace the fold of . Unfortunately, even with careful patient selection and surgical planning, and an uneventful perioperative period, some patients may be dissatisfied with their results. In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. In addition, placement of an upper lid traction suture is important or the skin graft will be ineffective [79]. Minimizing wound dehiscence involves appropriate suture choice and suture placement. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. 10361040, 1999. In one patient there was rounding recurrence. Article Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. Orbital hematoma, ectropion, and scleral show. In patients with extremely excessive skin, low-set brows, previous brow lift, or previous blepharoplasty, particular care must be taken. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . 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. Plast Reconstr Surg 1978; 61:347. Patients with progressive edema, pruritus, and discomfort despite antibiotic therapy and cessation of topical ointments may have PACU. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. If early cicatrix formation is detected, local nondepot steroid injection can occasionally eliminate the need for more involved surgery. 11, pp. Thank you. Lower eyelid of the same patient shown in Figures. A contact lens does require a daily or near daily visit until the abrasion is healed and the lens is removed. The surgery involves removing redundant skin, fat, and muscle. I had an upper bleph three weeks ago (22 days out). Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Am J Ophthalmol 1996;121:677. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. Yaremchuk MJ. Because of the complexities in modifying the overcorrected upper lid, a more mild degree of symptomatic lagophthalmos can be addressed via lower lid elevation with lower lid posterior lamellar grafting, as detailed in the next section. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. I have had a lower and upper blepharoplasty about 15 years ago, then I had my uppers done again about 4 years ago, but I had my lowers done again about 1year ago and because I had had them done previous the surgeon insisted on a hammock stitch at the outer corners of my eye, which has caused webbing! What is the standard eyelid surgery recovery time? Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. Relative . Ophthalmic Plast Reconstr Surg. Restoring palpebral fissure shape after previous lower blepharoplasty. Lagophthalmos secondary to upper lid overcorrection. Post-treatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, and intravenous steroids until 24 hours of stable vision have been noted. The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. As the surgeon, it is important to be aware of the potential complications of surgery. Cautery to achieve hemostasis may affect nerve or muscle. 125, article 1017, 2010. Our patients reported excellent outcomes post-operatively without any significant scarring. 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. Prospective analysis of changes in corneal topography after upper eyelid surgery. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. When needed, lid crease fixation method depends on surgeon's preferences and experience (. lateral hooding looks worse than before.The right side has raised lumpy scarring which runs a little too far in, probably why I have the web? This is due to more rapid and wider diffusion of the local anaesthetic agent, affecting other structures such as cranial nerves. Control of obvious bleeding points, if present is important. This can also lead to corneal dellen formation, or a dry cornea can break down de novo. 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. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. This area near the nose is called the medial canthus and the same area on the outer eyelids is called the lateral canthus. 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. CT scanning the orbits is important, but only after treatment has been carried out. Some surgeons prefer to place a corneal protector in each eye. This fast and predictable approach avoids opening the anterior wound and also avoids overcorrection and scar abnormalities. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. Septum must be opened if fat is to be removed, but not the levator. 372376, 1998. 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. 8589, 1990. Degree of swelling is related to surgical factors such as ecchymosis, cauterization, tissue manipulation, and patient response to surgery. 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. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. 24, no. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. Postlaser-resurfacing erythema is universal and expected. The skin incision should still be kept low, perhaps at 5 to 6mm at the most. 1h) then split into its anterior and posterior lamellae as described earlier. One of the signs of imminent damage to the muscle is excess bleeding. A partial improvement may be achieved with a posterior lamellar graft and horizontal tightening alone. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. Allergies and a list of medications should be noted. What complications can come from a blepharoplasty? G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. Black EH, Gladstone GJ, Nesi FA. 49, no. These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. 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. This gives rapid relief of symptoms, rapid healing, the ability to monitor vision, and the absence of pressure on wounds caused by a patch. The surgery involves removing redundant skin, fat, and muscle. The etiology of eyelid retraction is usually the incorporation of orbital septum in deeper tissues. Nonsedating antihistamines may help control cold-induced symptoms. 20292041, 1999. Valerie Juniat. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. To obtain Want to know what treatments can help me look like I use to look. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. Blink dysfunction is common postblepharoplasty because of postoperative swelling of the eyelid tissues. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). Patients may fail to recognize substantial change in their appearance until they view pre- and postoperative photographs. Antibiotic ointment may be placed over incision. Gentle cautery applied to the orbital fat may contour and replace the remaining fat posteriorly into the orbit, providing needed volume and fullness. Twelve patients with post-surgical canthal rounding were included. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. I had an upper eyelid surgery six months ago and it has been a disaster. Depending on the amount of laxity, a full lateral tarsal strip procedure or a lateral canthal tendon plication can be done. Canthal rounding can be cosmetically-unacceptable to patients. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). Body dysmorphic disorder. 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. Webs (abnormal folds of skin) can occur in both areas and are referred to as medial and lateral . In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. Levator function is assessed to identify myogenic ptosis. Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. The conjunctival incision made in a transconjunctival lower lid blepharoplasty never requires sutures. Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. Most patients only need to take 7 days off work. h Flap is marked. 2, pp. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. Federici TJ, Meyer DR, Lininger LL. 710, 2010. Holds, R. L. Anderson, and S. M. Thiese, Lower eyelid retraction: a minimal incision surgical approach to retractor lysis, Ophthalmic Surgery, vol. It is rare that true bony decompression either at bedside through the inferomedial floor or more fully in the operating room is required. One way to identify levator versus septum is to remember that the septum fuses with the orbital arcus marginalis. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. 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). In Asians, the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border, Preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border. 90, no. Dupuis C, Rees TD: Historical notes on blepharoplasty. ISSN 1476-5454 (online) B. Plast Reconstr Surg. In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Unfortunately, treatment beyond 1 to 6 hours of total or near-total vision loss is unlikely to be effective. I am devastated. The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. 417425, 1993. 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. I feel too much skin was taken medially and not enough at the outer side. By asking the patient to pull against the levator with the traction suture will help modulate the eyelid height and achieve a more desired height. 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