The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. 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. Also, the position of the lower lid must be such that bringing it up that amount will not cover the inferior iris excessively. 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. g Lateral canthopexy. Assess degree of lacrimal gland prolapse. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. 281288, 2002. A cold stimulation test may confirm the diagnosis of PACU. Ophthalmic Plast Reconstr Surg. 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 Antibiotic ointment may be placed over incision. 1c). However with skin closure, this scar generally blends well with the normal smile lines in the lateral canthal area. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Remember also that when the preaponeurotic fat is grasped and the septal attachments divided, it is possible to pull the superficial levator aponeurosis up with it. However, because of the complex structure and function of the eyelids, the potential for complications does exist. 106, no. Establishing a good patient-surgeon bond preoperatively is essential to managing any real or perceived surgical complication that may occur. 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). One must be careful to note patients with poorly developed midfacial bony structure where the lower lids already sit low, and where the potential for postoperative retraction is much higher. The eyelid crease may be between 412mm above the lash line. 604606, 1989. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. Besides webbing and incisions up to my eye brows I have this sagging in my left eye. Will I need an eventual revision? 20, no. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. http://tabanmd.com/gallery/revisional-eyelid/. Younger patients may want to retain fullness above the lid crease so that preservation of orbicularis muscle may be considered, Older patients may need to retain blink efficiency so that so that preservation of orbicularis muscle may be considered, In Caucasian women, the crease is usually 811mm above the lid margin. The authors favor CO2 laser blepharoplasty with a trans-conjunctival lower lid approach. 219228, 1991. Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Therefore, it is critical to release the septum from these deeper tissues. The information on RealSelf is intended for educational purposes only. He said he stitched the lower outer corner to the top lid! Blindness following blepharoplasty: two case reports, and a discussion of management. Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. Ophthal Plast Reconstr Surg 2002; 18:45. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. Head elevation and limiting activity may reduce edema. 4, pp. http://tabanmd.com/gallery/revisional-eyelid/ Helpful Mehryar (Ray) Taban, MD, FACS Oculoplastic Surgeon, Board Certified in Ophthalmology ( 302) If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. Interrupted sutures are used to reapproximate the wound edges. Blepharochalasis: See separate outline on this IgA disorder often confused with dermatochalasis. Depending on the amount of laxity, a full lateral tarsal strip procedure or a lateral canthal tendon plication can be done. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. 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. Rapid treatment is critical. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. Early recognition and aggressive massage will eliminate the majority of cases. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. Most patients only need to take 7 days off work. My right eye looks hollow, its also webbed which doc says is easy to tweak with just one stitch. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. 5155, 1996. Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. Medially, this often results from the incision nearing the lid margin too closely or if the incision is extended to far medially or inappropriately angled inferiorly. Increased risk exists in the patient with proptosis, such as a patient with thyroid eye disease or the patient with a large or projecting glaucoma bleb. My lateral canthals are webbed and my horizontal fissures have been significantly shortened. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). 6, pp. Postlaser-resurfacing erythema is universal and expected. 4, pp. The alternative argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage. As the surgeon, it is important to be aware of the potential complications of surgery. If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. 3, pp. This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. 29, no. 21, no. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty surgery. The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. Lateral canthal support is used to address the lower eyelid laxity either by . R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. Am J Ophthalmol 2007;143:1013. A thorough understanding of the upper eyelid anatomy is essential when evaluating patients for possible upper blepharoplasty. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. This can improve lagophthalmos without visible external incisions or the risk of induced ptosis or unsightly skin grafts when used. CT scanning the orbits is important, but only after treatment has been carried out. Nonlaser-induced postoperative hyperpigmentation can result from hematoma formation and excess sun exposure. Prevent by planning an incision that extends to the medial commissure; May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures; Ptosis. I have scar webbing from a previous lower bleph. Ophthalmic Plast Reconstr Surg. Understanding the differences in anatomy in the occidental and oriental eyelid is essential when performing blepharoplasty surgery in this population. Hard palate mucosa is commonly utilized for the graft [1419]. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. The risks are significant and include brief effect, scarring and tissue irregularities, uneven contours, and ptosis and lid retraction. Midfacial lifting is beyond the scope of this monograph [30, 31]. 12, no. Lateral traction was placed with a finger to the canthal web to displace the fold of . Ophthalmology. Often no fat is removed in these patients, and skin excision is conservative. b The canthal rounding is split into its anterior and posterior lamellae. Lagophthalmos secondary to upper lid overcorrection. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. 5, pp. Lid crease asymmetry is usually corrected by raising the lower eyelid crease. I was given antibiotic drops but havent seen any improvement in two weeks.I also appear to have webbing forming in both eyes but more so on the right (which also looks smaller). f The flaps are secured into their new positions. Visual field is repeated with the eyelids taped up. 107, no. In addition, placement of an upper lid traction suture is important or the skin graft will be ineffective [79]. Ophthal Plast Reconstr Surg 1999;15:378. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. Medial canthal webbing. Plast Reconstr Surg 1978; 61:347. 90, no. Allergy Asthma Proc 2003; 24:9. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. Ophthalmic Surg 1990; 21:85. Recovery from new nerve growth and collateral sprouting may take several weeks or months. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. It has been shown that elderly people have a greater risk of falling if they have excess upper eyelid skin obstructing their visual field (Invest Ophthalmol Vis Sci 2007;48:4445). Ice packs or frozen masks are too heavy, which may damage the eyelid tissues or dehisce wounds. 2013;29:20814. 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). Mackley CL. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . 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. Patients must be taught to check their vision one eye at a time. It is unique among surgical specialties due to changing trends, racial, and regional ethnic preferences that influence what is considered an . Dry eye symptoms may worsen if there is a decreased blink after removal of orbicularis muscle. This can also lead to corneal dellen formation, or a dry cornea can break down de novo. 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. 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. Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. 4, pp. Explain and document how daily visual function is affected. Steroids can be stopped without taper if administered less than 3 days, even at extremely high doses. Ophthalmology 1999; 106:1705. Dermatol Surg. 767771, 1990. c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. 1f). Transconjunctival fat resection alone should be considered in younger patients who may have very little excess skin and whose skin may be resilient enough to tighten itself spontaneously postoperatively. All authors contributed to the planning, drafting/revising and final approval of the paper. Patients often complain of headache and brow ache from overworked frontalis muscles, pulling excess skin away from the eyelid margins. Correspondence to The surgeon should spread bluntly posteriorly into the orbit down the lateral wall and through the wounds to access deep hematomas and release them. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. The surgeon must know his or her patients anatomy and distinguish septum from levator. Copyright 2012 James Oestreicher and Sonul Mehta. There was one recurrence of rounding, which was noted at the first post-operative review at 2 weeks following surgery. I had eyelid surgery one year ago and have been left with a very unsightly scar. 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. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. Dissection in the lateral canthal area may result in altered lymphatic drainage. Laser resurfacing in appropriate patients combined with transconjunctival blepharoplasty and appropriate lid tightening gives a far superior result to conventional exterior blepharoplasty, in terms of scar avoidance, avoidance of eyelid retraction, and a more natural and complete resolution of skin redundancy and rhytids.