The incidence is estimated to be 1 in 2,000 to 1 in 25,000 [32]. 21, no. 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. 6, pp. Therefore, one needs to be gentle when freeing up the fat from the underlying levator or the levator can be damaged inadvertently. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. Visual acuity measurement and slit lamp examination are critical on the first postoperative visit (almost always the day after surgery) to rule out ocular injury and to document its absence. Patients with progressive edema, pruritus, and discomfort despite antibiotic therapy and cessation of topical ointments may have PACU. Invest Ophthalmol Vis Sci 2007; 48:4445. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. 4, pp. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. There were no peri- or post-operative complications. 466474, 2010. 3, pp. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. Fronto-ethmoidal external approaches and more rarely external DCR and blepharoplasty represent the commonest iatrogenic causes of medial canthal webbing. Unfortunately, treatment beyond 1 to 6 hours of total or near-total vision loss is unlikely to be effective. 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. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. 758760, 1989. 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. Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. If essential, a lower incision is made and fat is teased forward between the skin and levator to prevent readhesion of these structures. Fat removal will help the first two causes, and laser skin resurfacing can aid the third if the pigment is relatively superficial. Various compositions of bleaching creams have been published, containing combinations of hydroquinone, glycolic acid, kojic acid, retinoic acid, and hydrocortisone. There are currently 25 Eyelid Surgery + Webbing questions and doctor answers on RealSelf. Occasionally spacer grafts are required to completely correct the lid retraction. Incisions should be at least 4 to 5mm above the punctum to avoid the canaliculus. 710, 2010. Medial canthal webbing. 3, pp. The oblique divides the medial lower fat pad from the central lower fat pad and it should be easily identified, and thus protected. 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. 207212, 2008. 8589, 1990. Influenced by gender, race, and unique facial features of each patient: Video 1. Recognition is key, as is a rapid response. Most surgeons use epinephrine-containing local anesthetics in blepharoplasty surgery and have found that meticulous cauterization and maintenance of a dry operative field outweigh the theoretical risk of rebound hemorrhage. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Patient selection and patient satisfaction. Lid crease in Asians can be absent, may be nasally tapered, or flat but typically lies lower and flatter than Caucasians. Another mechanism is direct or indirect injury to the inferior oblique during surgery. 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. Patients concerns can vary immensely, ranging from a particular dislike of lateral hooding, a staring or overdone look (very common), a sunken look (a common concern in younger patients), to a fear of blindness to concerns about the length of the recovery period and intra- and perioperative pain. 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). However, because of the complex structure and function of the eyelids, the potential for complications does exist. This fast and predictable approach avoids opening the anterior wound and also avoids overcorrection and scar abnormalities. Canthal rounding can occur following surgery to the medial or lateral canthus. When CO2 laser is used, protective corneal shields are used and laser is always directed away from the globe when cutting. Perin LF, Helene A, Fraga MF. All except one patient reported good surgical outcomes after one procedure. 2011;27:42630. 4550, 1996. 1, pp. Ophthalmic Plast Reconstr Surg. 1g). Graded eyelid horizontal tightening is utilized in all but the youngest patients. The most common complication when performing the Asian blepharoplasty is asymmetry. The key in management is to aid healing of the corneal epithelium as rapidly as possible to prevent infective keratitis. All patients except one reported good surgical outcomes, defined as cosmetically and functionally acceptable result to the patient and surgeon, after one procedure. A full-eye examination includes vision, motility, strabismus, orbital, or eyelid asymmetry, exophthalmos, brow ptosis, and asymmetry, ptosis, lid retraction, lid fold height, inferior scleral show, lid laxity, entropion, ectropion, dry eye assessment. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. CT scan is important, but only after initial decompression treatment has been carried out. L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. If noted, however, it should be treated with bleaching creams. Visualized and palpated scar is released aggressively in the postblepharoplasty retraction circumstance, so the lid is freed from attachments to the inferior orbital rim. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. Men seem to have ruddier skin, and the erythema last 60% as long on average. In the meantime, to ensure continued support, we are displaying the site without styles Ophthalmology 1999; 106:1705. Massage and steroid injections can help. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. PubMedGoogle Scholar. 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. The lid should be kept on upward traction 1 to 7 days with a frost suture to the lateral eyebrow [28, 29]. 219228, 1991. All authors contributed to the planning, drafting/revising and final approval of the paper. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. Is there help out there? Am J Ophthalmol 1996;121:677. A total of 20mm of skin should remain when measured vertically between the lower margin of the central eyebrow and the margin of the central eyelashes. Improved vision needs to be monitored by hospital staff or by the patient for stability for 1 to 3 days after treatment is stopped. Postoperatively, the patient can aid recovery with a few simple interventionsice water compresses and head elevation. The scar has webbed and is also very long and wide. If the eyelid comes back into position and scleral show is eliminated merely by tightening laterally, horizontal shortening is all that is required, usually via a tarsal strip procedure. Control of obvious bleeding points, if present is important. R. R. Tenzel, Complications of blepharoplasty. The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. 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. To obtain Mild lower-lid laxity or lateral canthal deformity. However, certain caution should be taken to avoid and manage postoperative ptosis. 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). Secondary upper lid lengthening can also be done posteriorly if adequate skin grafting has already been carried out, thereby avoiding another skin incision. There were five men and seven women. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. Lateral canthal support is used to address the lower eyelid laxity either by . 2 months post upper, lowers, and canthoplasty. Fat pearls, fat injections, dermis fat grafts, and alloplastic injections can be tried. However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. All research was conducted in accordance with the Declaration of Helsinki. 4, pp. Jordan DR, Mawn LA. 417425, 1993. Patients must be taught to check their vision one eye at a time. The skin and orbicularis oculi muscle form the anterior layers of the upper eyelid. 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 palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. Establishing trust and communication is essential to a doctor-patient relationship, perhaps even more important in a completely elective, aesthetic procedure with high expectations and standards. Is this resolvable? 3, pp. Thank you for visiting nature.com. Several surgical techniques to repair. The patient was given topical steroids by his original surgeon, resulting in untreated intraocular pressure of 45OU. I feel too much skin was taken medially and not enough at the outer side. Depending on the amount of laxity, a full lateral tarsal strip procedure or a lateral canthal tendon plication can be done. Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. 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. N. Shorr, J. D. Christenbury, and R. A. Goldberg, Tarsoconjunctival grafts for upper eyelid cicatricial entropion, Ophthalmic Surgery, vol. 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. Surgery can cost all different from street to street, even blocks to blocks in the same city, depending on the surgeon's reputation, skill and experiences. Up and down gaze photographs document levator excursion. A cold stimulation test may confirm the diagnosis of PACU. Review of old or family photographs may be helpful in clarifying preferences and objectives. Im losing faith in him though and am looking elsewhere for revision. Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. Millman AL, Williams JD, Romo T, Taggert N. Septal-myocutaneous flap technique for lower lid blepharoplasty. 102, no. Answer: Inner eyelid webbing scar after blepharoplasty Hi. Thank you. Nonlaser-induced postoperative hyperpigmentation can result from hematoma formation and excess sun exposure. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. Any adjunctive procedures to be performed should also be determined. e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. 2, pp. M. Patipa, B. C. K. Patel, W. McLeish, and R. L. Anderson, Use of hard palate grafts for treatment of postsurgical lower eyelid retraction: a technical overview, Journal of Cranio-Maxillofacial Trauma, vol. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. The anterior flap is then cut along both superior and inferior lid margins and completely excised (Fig. If a definite levator laceration is observed, it should be repaired if it is causing ptosis. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. 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. The canthal rounding is marked (Fig. It is virtually unheard of for this to fail to resolve. 1f). 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. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. Nonsedating antihistamines may help control cold-induced symptoms. This is due to more rapid and wider diffusion of the local anaesthetic agent, affecting other structures such as cranial nerves. It is often necessary to tighten the lower eyelid at the time of blepharoplasty. 767771, 1990. The technique of tarsal strip repair has been well described elsewhere. The laser must always be directed away from the globe even through eye shields are in place. Clark ML, Kneiber D, Neal D, Etzkorn J, Maher IA. 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