Systemic osmotic agents and corticosteroids may be given but do not take the place of prompt pressure release. The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. 1b). 5, pp. 2, no. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. These can result from skin shortage, middle-lamellar (orbital septum) scarring, and posterior lamellar (retractors and conjunctiva) cicatrisation as seen in Figures 4, 5, 6, 7, and 8. 4350, 1985. B. C. K. Patel, M. Patipa, R. L. Anderson, and W. McLeish, Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip, Plastic and Reconstructive Surgery, vol. Do I have any good options? Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. Primary acquired cold urticaria. 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. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. It is difficult to lower a crease which is too high. 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. 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. The most serious complication following upper blepharoplasty, Rare, with an estimated incidence of 1:20,000 (Ophthal Surg 1990;21:85). Measurement and precision are key to avoiding overcorrection. 3, pp. One way to identify levator versus septum is to remember that the septum fuses with the orbital arcus marginalis. Moistened gauze may be placed over the closed eyelids. 1828, 1996. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. Control of obvious bleeding points, if present is important. 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. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. do you think epicanthoplasty would be a good option? Any adjunctive procedures to be performed should also be determined. Battu VK, Meyer DR, Wobig JL. 11, pp. Federici TJ, Meyer DR, Lininger LL. Clinics Plast Surg 1981; 8:797. Thank you for visiting nature.com. Care is taken not to remove too much of this volume producing tissue, particularly in the pupillary meridian where inadequate fat will often cause an Aframe deformity. 767771, 1990. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. 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. Another useful technique is to leave the traction suture in beyond one week. If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. Will I need an eventual revision? Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. 90, no. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Mild lower-lid laxity or lateral canthal deformity. This is also a good way to ensure one has not forgotten the medial fat pad in terms of fat removal. I have started massaging the area and wearing silicone strips at night. Dysmorphophobia. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. Occasionally, incision lines may look hypertrophied, particularly in keloid-forming patients. Levator function is assessed to identify myogenic ptosis. 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. 5155, 1996. Canthoplasty repair for canthal rounding. Fat removal will help the first two causes, and laser skin resurfacing can aid the third if the pigment is relatively superficial. If deeper scarring requires release, it should be done at the time of skin graft placement. Head elevation and limiting activity may reduce edema. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. This will significantly speed up the recovery time. Visualized and palpated scar is released aggressively in the postblepharoplasty retraction circumstance, so the lid is freed from attachments to the inferior orbital rim. Safety of Periocular Mohs Reconstruction: a Two-Center Retrospective Study. The technique of tarsal strip repair has been well described elsewhere. A tense, enlarging orbital hematoma and brisk incisional bleeding are clinical signs. An aesthetically pleasing eye has an almond shape with superior arc that peaks medially 27 and a slight upward inclination of the lateral canthal angle (positive canthal tilt). Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. The lower lid is then tightened if lax or given an upward vector with a minimal Elschnig tarsorrhaphy if not lax. Visual field is repeated with the eyelids taped up. In addition, supporting structures such as canthal tendons are tightened. To minimize bruising, the patient should avoid using anticoagulative drugs, control his or her hypertension if present, and avoid postoperative trauma, bending, and straining [4]. 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. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). 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. 87, no. Massage and steroid injections can help. Filling in the hollowed areas can be problematic. Our patients reported excellent outcomes post-operatively without any significant scarring. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. I feel too much skin was taken medially and not enough at the outer side. This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). 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. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. 6, pp. Internet Explorer). Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. The canthal rounding is marked (Fig. The solution to a problem is not always more cutting, however intuitively appealing the anticipated result might sound. Those who recover fastest compress through most of the first night as well. McKean-Cowdin R, Varma R, Wu J, et al. Plast Reconstr Surg 1971; 47: 246. What complications can come from a blepharoplasty? 1992; 99:222. Several surgical techniques to repair canthal rounding have been described previously. Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. Ophthal Plast Reconstr Surg 2002; 18:45. Photos in Fig. Wilhelmi BJ, Mowlavi A, Neumeister, MW. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. Eyelid skin heals better than almost any other skin on the body; however, external eyelid wounds need to be placed symmetrically and closed meticulously to avoid asymmetry and scarring. Great care is taken to point the needle away from the globe, to avoid inadvertent penetration with sudden patient movement. Severity of visual field loss and health related quality of life. 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. 103, no. If the lid crease is marked 8 mm above the lash margin, for example, the upper edge of the incision should be 12 mm below the brow margin. The wound may be left open or closed loosely. A slit lamp examination and Schirmers test are necessary in this authors view. 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. If persistent, intense pulse light is a useful adjuvant treatment. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. One starts with a three snip on the punctum of the unobstructed canaliculus, followed by a DCR (to enhance flow through the unobstructed canaliculus), followed by a DCR with Jones tube in refractory cases. Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery. Canthal rounding can be cosmetically-unacceptable to patients. If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus (i.e., parallel to these structures) in a blunt fashion the risk of significant damage to orbital structures is low. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. Aspirin products: Ecotrin, Fiorinal, Percodan, Nonsteroidal anti-inflammatory drugs: ibuprofen, naproxen, piroxicam, Nutritional supplements: fish oil, vitamin E, gingko biloba, ginseng. People notice this scar within minutes of meeting me and I am very self-conscious about it. 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. Tension in the levator complex and orbital septum may also result in eyelid retraction. 12, no. Steroids can be stopped without taper if administered less than 3 days, even at extremely high doses. Degree of swelling is related to surgical factors such as ecchymosis, cauterization, tissue manipulation, and patient response to surgery. Upper eyelid spacer grafts such as sclera or tarsus are best avoided, as they are unnecessary and can be unsightly and palpable to the patient. The subciliary skin muscle flap approach to the fat pads is avoided if at all possible. 3, pp. In the face of frank orbital hemorrhage with proptosis, a frozen globe, and vision loss, bold measures are called for. The conjunctival incision made in a transconjunctival lower lid blepharoplasty never requires sutures. 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. Patients undergo upper blepharoplasty for purely aesthetic reasons. May be due to incision extended too far medially. 4, pp. Google Scholar. The information on RealSelf is intended for educational purposes only. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. 21, no. 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. 9, pp. Alternatively, removing anterior fat may unmask the underlying proptosis, and care should be exercised. PubMedGoogle Scholar. Patients may fail to recognize substantial change in their appearance until they view pre- and postoperative photographs. What is the standard eyelid surgery recovery time? 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.
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