Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty surgery. The anterior flap is cut along the new superior lid margin using Westcott spring scissors and folded downwards to create the anterior lamella of the new inferior lid margin (Fig. CO2 laser incisions need 7 days to heal, so sutures are removed on day 7 or 8. 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. 2. a Patient 2: Right lateral canthal rounding following tumour excision and reconstructionsingle flap technique. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. 21, no. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. Am J Ophthalmol 2007;143:1013. 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. Black EH, Gladstone GJ, Nesi FA. If persistent, intense pulse light is a useful adjuvant treatment. Battu VK, Meyer DR, Wobig JL. Cicatricial canthal webs. 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. The surgeon must know his or her patients anatomy and distinguish septum from levator. 4, pp. 5, pp. 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. Levator function is assessed to identify myogenic ptosis. Safety of Periocular Mohs Reconstruction: a Two-Center Retrospective Study. 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 alternative argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). 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. In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A and bleaching creams can be utilized. Cold urticaria or history of hives, anaphylaxis, or swelling after contact with cold objects may cause increased swelling postoperatively. 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. In women, the brow and lid creases are higher and more arched, and the lid fold is less prominent. Visual field is repeated with the eyelids taped up. Medial canthal webbing. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. 3, article 3, 1995. Patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery. Occasionally instead of scar hypertrophy, epithelial inclusion cysts occur. It is often necessary to tighten the lower eyelid at the time of blepharoplasty. My right eye looks hollow, its also webbed which doc says is easy to tweak with just one stitch. Retrobulbar hemorrhage is a form of compartment syndrome, with the orbit bounded by four bony walls and the orbital septum acting as the compartment. In one patient there was rounding recurrence. 21, no. Artificial tears may also be recommended. Twelve patients with post-surgical canthal rounding were included. 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. CO2 skin resurfacing is useful to address skin redundancy and festoons (in patients with appropriate skin types). 2, pp. The previous scar is opened up, internal adhesions are widely released (and perfect hemostasis obtained). A posterior lamellar graft is then placed between the cut lower edge of tarsal plate and the recessed cut conjunctival edge. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. A good understanding of anatomy and careful preoperative counseling of the patient is crucial for success. Canthal web revision (Canthoplasty, Revision Canthoplasty) The area where the upper and lower lids meet is called the canthus. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. Depth of excision depends on the preoperative plan. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. 19, no. In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. 11, pp. Primary acquired cold urticaria. Filling in the hollowed areas can be problematic. 1828, 1996. 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]. 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. Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. May be administered in the operating room or preoperative holding area. However, because of the complex structure and function of the eyelids, the potential for complications does exist. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. Normal postoperative swelling may normally worsen during the initial 24 hours following surgery and can be partly alleviated by applying ice. 2, pp. When needed, lid crease fixation method depends on surgeon's preferences and experience (. Freeman EE, Muoz B, Rubin G, West SK. Aesthet Surg J 2009; 29:87. N. Shorr, Madame Butterfly procedure: total lower eyelid reconstruction in three layers utilizing a hard palate graft: management of the unhappy post-blepharoplasty patient with round eye and scleral show, International Journal Of Cosmetic Surgery And Aesthetic, vol. For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. c The anterior flap is created and folded into its new position. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. 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. Retrobulbar hemorrhage is a form of compartment syndrome, with pressure rising abruptly within the fixed 4 walls of the orbit. Provided by the Springer Nature SharedIt content-sharing initiative, Eye (Eye) May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. Secondary upper lid lengthening can also be done posteriorly if adequate skin grafting has already been carried out, thereby avoiding another skin incision. Once patients concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. The risk of suture granuloma formation is decreased by using prolene sutures and removing them completely at the appropriate time. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). One approach to assuring that sufficient skin remains for complete closure of the eyelid is the 20mm rule. Men seem to have ruddier skin, and the erythema last 60% as long on average. Pure skin lack can be remedied by a full thickness skin graft. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. On examination of the patient, the surgeon must look for ophthalmic and periocular disease by history and a full-eye examination. Ice water compresses should be utilized continuously for 3 days (except when eating or sleeping). I have started massaging the area and wearing silicone strips at night. Interrupted sutures are used to reapproximate the wound edges. When CO2 laser is used, protective corneal shields are used and laser is always directed away from the globe when cutting. Antibiotic ointment may be placed over incision. It is virtually unheard of for this to fail to resolve. 5155, 1996. Thank you. 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. He said he stitched the lower outer corner to the top lid! Moistened gauze may be placed over the closed eyelids. Canthal rounding has been reported following periocular tumour or trauma reconstruction [4, 5]. Several surgical techniques to repair. 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. When planning to perform an upper lid blepharoplasty, determining the amount of excess skin in the upper lids, the amount of excess or prolapsed fat, the position of the lacrimal glands, and the extent of lateral hooding and medial bulging are important. R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. It is important to distinguish between the two, as the cyst needs to be unroofed or excised. This skin incision height is often quit low, 3 to 5mm depending on the preoperative consultation measurements. 4, pp. Postoperative eyelid numbness involving the upper eyelid skin and eyelashes is an expected outcome after upper blepharoplasty and typically resolves over 2 to 4 months. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. and JavaScript. N. Shorr, J. D. Christenbury, and R. A. Goldberg, Tarsoconjunctival grafts for upper eyelid cicatricial entropion, Ophthalmic Surgery, vol. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. Holds, R. L. Anderson, and S. M. Thiese, Lower eyelid retraction: a minimal incision surgical approach to retractor lysis, Ophthalmic Surgery, vol. 20, no. However, certain caution should be taken to avoid and manage postoperative ptosis. 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. at my consult, the Dr. mentioned that in order to get parallel, i would need to get epicanthoplasty as well but that theres a chance of having visible scarring with epicanthoplasty. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. Bruising and swelling typically lasts 1014 days after surgery. Scars dont run past outside of eye. The rounding can have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for patients. 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. Lateral canthal support is used to address the lower eyelid laxity either by . If a second finger is required in the central eyelid pushing upward, usually a posterior-lamellar graft is required. 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. The rhomboid flap is an effective quick and simple technique for medial canthal reconstruction. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. The tissue to be excised is grasped with a forceps and meticulously dissected along the intended plane. The patient will also have asymmetrical pain and decreased vision. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. Adams J, Murray R. The general approach to the difficult patient. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. Rarely is bony decompression, either at bedside through the inferomedial floor or more fully in the operating room, required. Assess degree of lacrimal gland prolapse. Lateral skin often takes longer to soften and smooth because it is thicker compared to eyelid skin. Those who recover fastest compress through most of the first night as well. Excessive skin removal may require free full-thickness skin grafting. Proper repair is an art in itself. These should usually be delayed for 3 months or more if possible after the primary procedure to avoid surgical tail chasing. Allowance for asymmetry not to be corrected (such as minor brow height differences) needs to be made. Most patients only need to take 7 days off work. Injury to the inferior oblique or less commonly other extraocular muscles, is rare. As the surgeon, it is important to be aware of the potential complications of surgery. Canthoplasty repair for canthal rounding. 604606, 1989. 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. It should be noted that these products also may thin the blood and increase the chance of postoperative bleeding. It requires medial canthal scar revision with multiple z-plasty. This interferes with the tear pump mechanism. 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. In the tenth century, Middle Eastern surgeons described removal of excess eyelid skin to improve vision. Intravenous mannitol 20% (12g/kg over 3060minutes). 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. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. 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. 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. Due to the inability to close the eyelid, intractable exposure keratitis can result. 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