Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Blepharoplasty The eyes are the portals of entry to the soul. The eyes, however, represent more than just the globe itself. The anatomic configuration and emotional changes of the eyelids and periorbital region play a pivotal role in maintaining facial harmony through expression of human character, mood, and feelings. The specific roles of the eyelids are both functional and aesthetic. A blepharoplasty can be performed for either purpose. Functional blepharoplasty restores normalcy to an eyelid that has been altered by trauma, infection, inflammation, degeneration, neoplasia, or developmental errors. Cosmetic surgery attempts to improve the appearance of tissues or structures that are histologically and functionally normal. In either case, the goal of blepharoplasty is restoration and rejuvenation of the eyelids. This is accomplished through elimination and correction of laxity and redundancy of skin, removal of pseudoherniated fat, and the correction of abnormal eyelid position. The history of blepharoplasty dates back to the first century AD, when Aulus Cornelius Celsus, a first century Roman, described the excision of skin for "relaxed upper eyelids" in De Re Medica. As early as the tenth century, Arabian surgeons devised ways to excise excess skin folds in the upper eyelid that impaired vision. The term blepharoplasty dates back to 1817, when Von Graefe described a technique for repairing deformities caused by resection of cancer in the eyelids. In 1844, Sichel, provided the first accurate description of herniated orbital fat. In 1907, Conrad Miller wrote Cosmetic Surgery and the Correction of Featural Imperfections, the first book on cosmetic surgery. His 1924 edition contains diagrams of incisions for upper and lower eyelid surgery similar to those used today. In the late 1920s, French surgeons advocated removal of herniated orbital fat for cosmetic reasons. Since the 1940s, fat removal has remained an integral part of blepharoplasty. In 1951, Castenares described in detail the fat compartments of the upper and lower eyelids, although his work has been disputed in the past several years based on dye studies in cadavers. Any discussion about blepharoplasty would be incomplete without a discussion about orbital anatomy. The best way to approach upper eyelid anatomy is to divide the lid into tissue planes. Working posteriorly, there is skin, orbicularis, orbital septum, preaponeurotic fat, levator aponeurosis, and tarsus and conjunctiva. The skin of the upper lid is extremely thin, loose, and mobile over the deeper structures, which is essential for normal lid appearance and function. The skin becomes coarser, thicker, and more sebaceous lateral to the bony margin. The upper lid skin is well vascularized and healing occurs quickly with favorable scar formation. The eye is almond shaped with the lateral canthus slightly more superior than the medial canthus: typical superior elevations at the lateral canthus are 2 mm for men and 4 mm for women. An average palpebral opening is 10-12 mm in height and 28-30mm in width. The distance from the lateral canthus to the orbital rim is about 5 mm. The upper lid fold in Caucasians is approximately 8-11mm. The lower lid crease is about 5-6 mm. The high point of the brow is directed superiorly toward the lateral limbus. The upper eyelid margin normally crosses the cornea 2 mm inferior to the superior limbus. The distance from the supraorbital rim to the inferior aspect of the brow at the lateral limbus is about 10 mm in Caucasian women. Beneath the skin and subcutaneous tissues lies the orbicularis muscle, which is divided into the outer orbital portion and the inner palpebral portion, the latter of which is further subdivided into pretarsal and preseptal portions. The preseptal part overlies the orbital septum, and the pretarsal part overlies the tarsal plate. Lateral and medial segments of the orbicularis participate with the tarsal plate in the formation of the canthal tendons. The orbicularis oculi muscle, which closes the lid, is very strong. It may become hypertrophied and redundant, causing an excess fullness to the upper or lower lid. The orbital septum, which lies deep to the orbicularis, is a key structure and landmark in blepharoplasty. The septum is a thin sheet of fibrous tissue that originates along the superior orbital rim and hangs like a curtain across the lid. It joins the levator aponeurosis by interdigitating fibers at the upper edge of the tarsal plate. The septum keeps the orbital fat in its posterior position. Weakening of the septum with aging, hereditary predisposition, or trauma may cause protrusion of the orbital fat. The orbital fat lies deep to the orbital septum, providing a cushion to the structures of the orbit. The fat separates the orbital septum from the levator aponeurosis. The upper lid had 2 fat compartments, central and nasal. The central compartment is the larger, and its fat is yellower than the light colored more dense fat of the nasal compartment. Laterally, the fat may be associated with the lacrimal gland. However, the gland has a more granular appearance than the fat with a firmer consistency. The lower lid is believed to have three fat compartments: a small medial, small temporal, and a fairly large central compartment. The fat in the medial compartment is classically lighter in color and denser than the fat of the other compartments. Contained in the inferior orbital fat is the inferior oblique muscle, which arises from the anterior medial orbital floor. This muscle separates the medial fat compartment form the central fat compartment as it passes posteriorly and laterally beneath the equator of the globe. This orbital fat does not seem to be related to other fat in the human body. The quantity remains relatively constant regardless of obesity or weight loss. The orbital fat is a static structure, in that once it is removed, it does not regenerate. Although recent studies have disputed Castenares' strict compartment theory, it is still helpful to think of the fat distribution in a compartmentalized fashion. The levator is the primary elevator of the eyelid. The muscle originates from the orbital periosteum and passes forward above the superior rectus muscle, gradually forming a tendon that fans out to form the levator aponeurosis. This extends the full width of the lid at the level of the upper tarsus where the tendon fuses with the orbital septum to insert in the anterior third of the tarsus. Fibers from the aponeurosis blend with those of the orbital septum at the level of the tarsus and insert into the orbicularis muscle, subcutaneous tissue and skin to produce the lid crease. Muller's muscle originates from the belly of the levator aponeurosis and inserts at the retrotarsal margin. It is closely associated with the underlying tarsus and vascular arcade. The contraction of Muller's muscle contributes about 2 mm of lid height. The tarsus is often called the skeleton of the eyelid. It is a fibrous plate that is approximately 10 mm wide in the central upper lid, narrowing medially and laterally. The tarsus of the lower lid is a bit narrower, from 4-5 mm at its center. The tarsal plates extend from the lateral commissure to the punctum, containing numerous meibomian glands that empty into the ciliary border. The tarsus and conjunctiva form the inner linings of the lid. The conjunctiva is the most posterior layer of the lid. It surfaces the most posterior aspect of the eyelids and anterior surface of the globe, reflecting on itself at the inferior and superior fornices. The lower eyelid is often referred to as a bilamellar structure. The anterior lamella is composed of skin, orbicularis muscle, and the orbital septum. The posterior lamella is composed of the tarsus, capsulopalpebral fascia, inferior tarsal muscles, and conjuntiva. Between these two lamellae lies the orbital fat. Of note, there are subtle differences in anatomy across ethnicity. Much has been written about the Asian eyelid and the Asian blepharoplasty. However, this extends beyond the scope of this presentation and will not be addressed today. The pre-operative evaluation begins by determining the specific purpose for the patient's consultation. The patient should describe what they would like corrected and what level of expectation they have toward this aesthetic goal. A review of the past medical history is also important to reveal any contraindications or underlying illnesses that may affect the surgery. The surgeon should always be aware of the possibility of thyroid disease manifesting as orbital disease. Graves' ophthalmopathy can cause globe protrusion, eyelid retraction and symptoms of dry eyes, while hypothyroidism may produce myxedema, which the patient and surgeon may misdiagnose as protruding orbital fat. Previous facial palsy may result in persistent weakness of the periorbital musculature, which may lead to inadequate corneal lubrication and corneal desiccation or ulceration. Allergy may cause intermittent swelling and dermatitis of the eyelid skin and recurrent periorbital edema. Chronic renal disease and diabetes may affect wound healing and increase the risk of infection. Detail should also be paid to the ophthalmologic history. Does the patient wear glasses or contact lenses? Glaucoma patients require ophthalmologic assessment and treatment to avoid an attack of closed angle glaucoma in the perioperative period. Is the superior visual field perceived to be decreased by the upper eyelids? Questions should be asked to determine any chronic eyelid disorders. These include questions on tearing, dryness, frequent blinking, mucous discharge, red eye, eyelid edema, itching, or burning. Numerous systemic diseases are linked with the dry eye syndrome and should alert the physician to possible post-operative problems. Finally, has there been any previous eye surgery? Before we start our evaluation, let's take a moment to define some terms. Blepharochalasis is a commonly misused term that should be reserved for a rare familial condition characterized by chronic, recurrent edema of the eyelids with subsequent breakdown of the tissues within the eyelids, including the orbital septum. This causes prolapse of the orbital fat, resulting in drooping of the lid. Blepharochalasis is a functional indication for a blepharoplasty. Dermatochalasis means relaxation of skin. It is associated with the aging process and variable amounts of fat herniation and prolapse. This is part of the normal aging process and is not a functional indication unless there is dermatochalasis causing "pseudoptosis" with superior visual field defect. Blepharoptosis, or the drooping eyelid is caused by a malfunction of the levator muscles. Levator function is measured by blocking the action of the frontalis muscle and measuring the excursion of the eyelid from downgaze to upgaze. Levator excursion from 15-18 mm is considered normal and 10-14 mm is good function. The examination begins with a careful assessment of the full face. Any asymmetries should be pointed out. If these are not recognized pre-operatively, they may become a focus of concern and dissatisfaction postoperatively. The natural eyelid crease can be found by lifting the patient's eyebrow and asking the patient to first look downward, then slightly upward, then downward again. This crease lies at the upper edge of the tarsal plate, usually 9 to 11 mm from the lash line. When the lid crease is significantly closer to the lash line, the eye takes on a heavy, full, or sleepy appearance. Asymmetric or absent lid creases must be identified, because asymmetry can be accentuated with standard blepharoplasty techniques. The lid fold is the tissue above the lid crease that may protrude and prolapse over the lid crease, obscuring it. This fold may extend the entire horizontal length of the lid or it may be apparent only centrally or laterally. The fold may be composed of excess skin, hypertrophied orbicularis muscle, redundant soft tissue, prolapsed lacrimal gland, herniated orbital fat, or any combination. The excess tissue may result in hooding that is so great that skin lies on or over the edge of the eyelashes. Hooding is usually greatest in the lateral half of the eyelid and can result in limitation of the visual fields in upper and outer gaze. Pseudoptosis occurs when there is excess skin and hooding that depresses the upper lid. Vision obstruction is an indication for a therapeutic blepharoplasty. The successful blepharoplasty is designed to keep the lid fold from prolapsing to obscure the lid crease. Excess fat of the upper lid may be present, but is not always seen with lid open or closed. With the upper lid closed, digital pressure is applied on the globe, causing the fat to bulge forward. As I mentioned earlier, the normal eyelid level covers 2-3 mm of the superior limbus. Ptosis is present if the lid is lower than this position. Ptosis can be classified as congenital or acquired, and is caused by neurogenic, myogenic, aponeurotic, and mechanical mechanisms. Myasthenia gravis should always be considered in the differential diagnosis of acquired ptosis, particularly in the patient with severe ptosis bilaterally. However, the added weight of excessive skin from dermatochalasis may produce a levator aponeurosis dehiscence, which is probably the most common cause of acquired ptosis. Acquired ptosis is also characterized by a high or absent lid crease and thinning of upper eyelid tissue. Levator function is normal. Pseudoptosis can be separated from true ptosis by gently elevating the excess skin. This unweighting of the upper lid will help determine the true lid level. If the upper lid is higher than the superior limbus, lid retraction is present. Some individuals normally have upper lid levels at or above the corneal limbus. The most common cause of pathologic lid retraction is Graves' ophthalmopathy. Whenever the upper eyelid level is above the level of the superior corneal limbus, a thorough evaluation of thyroid function should be considered. The upper eyelid retraction may be unilateral or bilateral. Other findings of thyroid ophthalmopathy include lymphoid infiltration of the orbital fat and extraocular muscles producing ocular motility problems, eyelid fullness, proptosis, prominent scleral blood vessels, and lid lag or inability of the upper eyelids to relax adequately to cover the corneas on down gaze. These patients are often unaware of their endocrine condition at the time of consultation. It is crucial to recognize these patients pre-operatively, because they will require ancillary techniques to the standard blepharoplasty. The lower eyelid is examined in a similar fashion. The changes commonly found in the lower eyelids include excessive skin, excessive or protruding orbital fat, laxity of the eyelid, rhytids, orbicularis muscle hypertrophy, and malar bags or festoons. The extent of the excess lower lid skin can be appreciated by placing light pressure laterally, using an upward and downward motion creating an excursion of excess skin. Laxity of the orbicularis muscle may contribute to the formation of malar mounds and festoons. A festoon is excess skin and orbicularis that cascades below the inferior orbital rim. Fenestrations of the muscle may lead to protrusion of fat between muscle fibers. Gentle pressure on the lid can show protruding fat, which should be differentiated from eyelid edema. Orbital fat is ballottable with digital pressure on the lid, whereas edema will stay constant. Patients with lower lid edema should be warned that this might persist after surgery. The lower lid should have a tangential relationship with the lower limits of the cornea. Seldom does it cover the cornea by more than 0.5 to 1 mm. When the lid margin does not reach the cornea, the white of the sclera is visible. Inferior scleral show of 1-2 mm may be a normal variant. The magnitude of scleral show should be carefully noted and discussed with the patient. Patients with lower lid laxity are prone to develop lower lid malposition as a result of cosmetic blepharoplasty. Significant deformities can result when excess skin and muscle are excised and/or inadequate lateral canthal support is obtained. Ancillary lower eyelid and lateral canthal procedures are best combined with cosmetic blepharoplasty in these patients to obtain optimal results. The most important part of the pre-operative exam is an ophthalmological examination including assessment of visual acuity, extra-ocular muscle movement, fundoscopic exam, intraocular pressure, tear film adequacy, width of palpebral fissures, and visual fields. An intact Bell's phenomenon is a protective outward and upward rotation of the globe with eyelid closure. The Bell's reflex helps protect against corneal injury and exposure keratitis owing to the temporary inability to fully close the eyelids following blepharoplasty. Some advocate a pre-operative screening Schirmer's test. Researchers have found the Schirmer's test to be less important than history in predicting the development of dry eyes after blepharoplasty. The value of a Schirmer's test is to identify an otherwise seemingly normal patient prior to blepharoplasty, but should not be relied on as the sole method of screening. Nevertheless, those patients at risk should either have a conservative resection or a staged upper and lower lid resection. The general consensus in the literature is that these patients should be referred to an ophthalmologist for this exam. This exam serves as a baseline should the patient complain of any visual changes postoperatively. It also alerts the surgeon to any dry-eye problems that may need to be addressed after surgery. Preoperative clinical photography is essential in documenting existing eyelid and periorbital anatomy. The photographs are used for preoperative surgical planning and intraoperative decision making. The recommended standard preoperative photographic views include full face in repose and smiling, close-up views of eyelids and periorbital structures in repose and smiling; close-up view of the eyelids and periorbital structures in upgaze and downgaze: and close up lateral views. Right and left oblique views of the full face and eyelids may be added to complement the evaluation. In this case presentation, AG is a 50-year-old male who complains of excess skin on his upper lids and increasing puffiness of his lower lids. He feels he looks older and tired, but does not feel that way. He is worried that looking older will have an adverse effect on his business. Past medical history is significant for occasional allergic rhinitis. There is no history of thyroid disease or diabetes. Ophthalmologic history reveals no visual complaints, no chronic eyelid disorders, dry eyes, or prior eye surgery. Pre-operative photographs showed some minimal early prow ptosis, slightly worse on the left. There is bilateral dermatochalasis with prominent lateral hooding on the right upper eyelid without significant pseudoptosis. There is no scleral show, retraction, or ectropion. Lid creases are symmetric. On up gaze, we can really appreciate the herniated orbital fat inferiorly. Sclera and conjunctiva are normal in appearance and non-injected. Snap test and retraction tests are normal. The remainder of the head and neck exam is within normal limits. Before going to the operating room, the patient must understand that certain conditions cannot be improved or dramatically changed by blepharoplasty. The surgeon should point these out to the patient. Crow's feet, or laugh lines that are lateral to the lateral canthus can rarely be improved. Immediately after surgery, they may be decreased because of edema, but in a few months they will return. Fine wrinkling of the lower lids cannot be removed by blepharoplasty alone, and occasionally the wrinkling is accentuated. Cheek pads cannot be completely eliminated. These are often caused by edema and fluid retention in the soft tissues anterior to the infraorbital ridge and over the zygoma. Finally, dark circles under the eyes will not be improved by blepharoplasty, although shadowing caused by fat herniation may be improved. Some relative contraindications include proptosis, either congenital or secondary to thyroid disease. A naturally deep-set eye is another relative contraindication. Surgery will further accentuate the hollow look. Also, as I mentioned earlier, patients with dry eyes also are poor surgical candidates. The presence of a general medical cause for eyelid edema or the presence of major ocular pathology are also contraindications for blepharoplasty. I will now briefly go through the steps of an upper lid blepharoplasty, as an in depth discussion is beyond the scope of this presentation. First the patient is marked while sitting upright. The lower incision is drawn first and should follow the natural lid crease. To determine exactly how much skin to excise, the pinch technique is used. The patient is instructed to close the upper lids and then a forceps is used to gently pinch the redundant tissue with the lower arm of the forceps on the lower incision. The object is not to remove as much skin as possible, but to remove that which is redundant and unnecessary for lid closure. When the skin is removed, the fibers of the orbicularis will be seen. Usually a 2-3 mm strip of muscle is removed. An incision is then made in the septum overlying the bulging fat. Only fat that easily protrudes should be removed. Skin is then reapproximated. Before we jump to the lower lid, we need to address two important adjuncts of upper lid blepharoplasty: lid ptosis and brow ptosis. Blepharoplasty of the ptotic lid, without repair of the ptosis, may result in exaggeration of the drooping eyelid postoperatively. Repair of the ptosis, by reapproximating the levator aponeurosis to the upper portion of the tarsus, should be performed at the time of blepharoplasty to produce the best functional and cosmetic result. Most patients focus primarily on the eyelid without recognizing the influence of the ptotic brow. Generally, the eyebrows are slightly above the level of the superior orbital rim. When the eyebrows migrate below the superior orbital rim, the redundancy of the upper eyelid skin is magnified. The normal female brow in its medial aspect is directly over the orbital rim, the central brow is just above the orbital rim, and the lateral brow is about a centimeter above the rim. The male eyebrow is flatter and is generally closer to the level of the superior orbital rim. As the brow descends because of age or heredity, the impression of the upper lid skin redundancy worsens. If the entire brow is below the orbital rim, blepharoplasty alone will not solve the aesthetic problem. In fact, removal of the infrabrow skin in the presence of extreme brow ptosis may precipitate a worsening of the brow ptosis. One explanation is that the excision of skin and soft tissue simply brings the eyebrow closer to the eyelid margin. Another is that the correction of the dermatochalasis alleviates the patient's need to keep the eyebrows elevated and, as a result, the forehead musculature relaxes and the eyebrows descend bilaterally. Correction of eyebrow laxity can be accomplished with a coronal forehead lift either through a transverse midforehead incision, a hairline incision, or a post hairline incision. A suprabrow incision can also be used. Repair can also be done endoscopically. Brow lift techniques should be considered at the time of blepharoplasty because elevating the brows reduces the amount of skin to be removed from the upper lids. Recent literature has focused on a browplasty or browpexy. These procedures can be performed through an upper blepharoplasty incision after the skin and orbicularis have been excised. A browpexy involves brow fixation to the supraorbital rim, while a browplasty involves sculpting or removing the brow fat pad. Approaches to lower blepharoplasty are more numerous than those for upper blepharoplasty. The two major techniques are transcutaneous and transconjunctival. The traditional transcutaneous approach is reliable and leads to acceptable results with an imperceptible scar. Briefly, this involves a subciliary incision that is carried down through the orbicularis muscle down to the orbital rim. This skin muscle flap is elevated off the orbital septum. The septum is then incised and excess fat removed. In contrast, the transconjunctival blepharoplasty involves an incision in the lower lid conjunctiva, thus avoiding disruption of the orbicularis muscle. The dissection then proceeds along one of two routes. The preseptal approach involves placement of the incision high along the inside of the lower lid conjunctiva so that dissection proceeds anterior to the orbital septum and under the orbicularis. Using the retroseptal approach, the incision is placed 5 mm or more behind the tarsal plate. Along this route fat compartments are entered directly after lower retractors are incised, and dissection takes place in the plane behind the orbital septum and orbicularis muscle. Disadvantages of the transcutaneous technique include placement of an incision through the orbicularis muscle, with resultant bleeding, bruising, and ultimately scar contracture. Because of scar contraction in the plane of the orbicularis and septum, there may be additional risk for rounding of the lower eyelid and ectropion resulting from the vertical contracture and vertical shortening of the lower lid. The impetus for pursuing the transconjunctival approach has been the desire to overcome the spectrum of post-operative lower eyelid retraction problems, which progress from scleral show to frank ectropion, the theory being that avoiding dissection through the orbicularis and septum, the risk of rounding and scleral show may be reduced. A transconjunctival blepharoplasty is an ideal procedure for removal of pseudoherniated fat. It does very little, however, to correct skin excess or orbicularis hypertrophy. Skin excess can be dealt with by excision with a pinch technique. Briefly, this involves pinching the lower lid skin 1-2 mm below the lash line. This creates a ridge of skin that extends medially paralleling the lid margin, which should not alter the position or shape of the lower eyelid. The ridge of excess skin is then removed. This does involve an external skin excision, violating one of the main advantages of the transconjunctival approach. In performing the pinch, the orbicularis is not violated and the orbicularis sling retained. Theoretically, the support of the lower lid is maintained, decreasing the risk of scleral show. Here are some basic indications for transconjunctival blepharoplasty: young patient with fat pads without skin excess; people at risk for dyschromic or hypertrophic scar; secondary blepharoplasty, which includes patients with inadequate removal of fat or relapse after a skin flap technique; and patients with pre-existing pseudoproptosis who are at risk for the complications of lower eyelid retraction and further scleral show when transcutaneous approaches are used. Retrospective reviews show that the transconjunctival approach avoids lower lid malposition, one of the common complications associated with transcutaneous blepharoplasty. The most common transconjunctival complication cited is inadequate fat removal. Dr. Netscher et al. here at Baylor performed a limited prospective study on 10 consecutive patients in which a transcutaneous approach was performed on the left and a transconjunctival approach was used on the right. Patients who required an eyelid tightening procedure determined by a poor response to the snap test and distraction test greater than 8 mm were excluded. Their results showed that average fat removed from each side was the same. Three patients developed mild bilateral scleral show post-operatively, and a fourth developed it on the left side. No patients had ectropion. Follow up photographs were graded by four independent observers. In no patient was the external scar ever mentioned as a detraction from the final result or ever even remarked on in the early recovery period. Overall grading on both sides was universally very good with no significant difference between the two sides. Laxity of the lateral canthal tendon, orbicularis muscle and skin may occur individually, or in combination. For patients with eyelid laxity, several eyelid-shortening procedures are available. These range from lateral canthoplasty, orbicularis muscle suspension, Kuhnt -Szymanowski procedure, or even a Gore-Tex sling to correct more significant degrees of laxity or ectropion. The lateral tarsal strip procedure is more in vogue today. It is felt that the primary pathology of eyelid laxity in the older patient is weakening of the lateral canthal tendon, which this procedure directly addresses. After a lateral canthotomy is performed, a free tarsal strip is created by denuding the tarsus of the overlying skin and orbicularis anteriorly, the conjunctiva posteriorly, and the lower eyelid retractors inferiorly. This lateral tarsal strip is then reapproximated to the periosteum to produce the desired amount of lid tightening. Complications of blepharoplasty are rare, and in most circumstances, minor and self-limiting. Often treatment consists of reassuring the patient and following conservative medical management that allows for wound healing to follow its natural course. The most feared complication of blepharoplasty is orbital hemorrhage and blindness. There have been more than 75 cases of partial or complete blindness reported in the English literature. The incidence has been estimated at 0.04%. A widely accepted theory suggests intraorbital bleeding increases introrbital and introcular pressure, compromises the ocular circulation, and results in ischemic retinal, or optic nerve damage. The bleeding is believed to stem from aggressive manipulation of intraorbital fat with inadequate ligation and cautery of fat pad vasculature. Clinically, the signs and symptoms include acute pain, proptosis, chemosis, and opthalmoplegia. The globe and lid may become hard to palpation. Acute orbital hemorrhage is a medical and surgical emergency. An emergency ophthalmology consult should be obtained, but treatment should not be delayed.Treatment includes wound exploration along with lateral canthotomy and cantholysis. Mannitol and steroids are also advocated. Further surgical options include anterior chamber paracentesis and bony orbital decompression. Diplopia in the early post-operative period is not uncommon. It may be caused by edema or anesthesia infiltration of the extra-ocular muscles. Long lasting diplopia is extremely rare and may be caused by damage to the inferior oblique muscle, which is especially vulnerable during the transconjunctival approach. Management is supportive. Post-operative ptosis occasionally occurs secondary to edema and ecchymosis. In these cases the ptosis is temporary and usually resolves after 2-3 weeks. The most frequent cause is the failure to recognize it pre-operatively. Ptosis lasting longer than 3 months requires re-exploration of the eyelid to identify any break in the levator aponeurosis. Lid crease asymmetry is best avoided by a careful pre-operative exam. Early post-operative asymmetry is best managed by time and gentle massage of the higher crease. Post-operative eyebrow ptosis is most commonly caused by failure to recognize the eyebrow ptosis and asymmetry pre-operatively. Patients who decline to have the brow ptosis corrected at the time of blepharoplasty must be informed of the possible aesthetic compromise. Lower lid malposition represents an imbalance of the dynamic forces acting on the lid. Many surgeons suggest the principle cause of lower eyelid malposition is unrecognized laxity in the tarsoligamentous sling. Mild eyelid retraction typically presents as lateral scleral show or rounding of the lateral palpebral fissure. Rounding can result from triangular excision of skin at the lateral canthus and is exaggerated by horizontal laxity. It is important to remember that minimal skin should be excise in a lower blepharoplasty. The round eye appearance may improve slowly with time and gentle upward massage. Lateral canthal resuspension can be done if symptoms persist. Scleral show is reported in up to 15% in large blepharoplasty series. Treatment is again conservative with massage therapy for 2-3 months with a lid tightening procedure if symptoms persist beyond that time. Although ectropion is one of the most commonly discussed complications of lower blepharoplasty, its incidence is estimated to occur in less than 1% of patients. Again the best treatment is prevention by attention to lower lid laxity and minimal skin and orbicularis excision. Conservative treatment with massage therapy is recommended for at least 3 months to obtain resolution. For persistent ectropion tightening procedures or skin grafts can be used. Post-operative wound infections are rare due to the rich vascular supply of the orbit and eyelid. Post operative fat pad asymmetry most often results from poor pre-operative evaluation of fat pad locations and poor visualization and excision intra-operatively. One of the most common mistakes is failure to identify and excise the medial fat pad. For post-operative fat pad asymmetry, it is best to wait 6-8 weeks before attempting correction. Mild dry eye syndrome secondary to lagopthalmos is a common transient problem. However, it can produce corneal ulcerations that may threaten vision. Lagopthalmos occurs at surgery secondary to loss of orbicularis function from the local anesthesia. Lagopthalmos lasting weeks to months requires treatment with eye lubricants to protect the cornea and reduce irritative symptoms. The cause is probably related to the amount of skin excised from the upper lid and not the amount of muscle excised. In most cases lagopthalmos resolves as the wound undergoes scar relaxation. In closing, I add one final complication: the unhappy patient. Blepharoplasty can be one of the most gratifying aesthetic procedures. However, an elective cosmetic procedure combined with the opposite result produces the unhappy patient. The easiest way to avoid this complication is to determine pre-existing conditions that increase the likelihood of unfavorable effects of blepharoplasty as well as adhering to the patient's pre-surgical cosmetic goals. Then the result will be the happy patient. AG is a 50-year-old male who complains of excess skin on his upper lids and increasing puffiness of his lower lids. He feels he looks older and tired, but does not feel that way. He is worried that looking older will have an adverse effect on his business. Past medical history of occ allergic rhinitis, no history of thyroid disease, no diabetes. Past surgical history - none. Ophthalmology history - no history of visual complaints, no chronic eyelid disorders, dry eyes, or prior eye surgery. Meds - none. All - NKDA Physical examination reveals minimal early brow ptosis, slightly worse on the left. There is bilateral dermatochalasis with prominent lateral hooding on the right upper eyelid without significant pseudoptosis. There is no scleral show, retraction, or ectropion. Lid creases are symmetric. Significant herniated orbital fat is easily visible inferiorly with up gaze. Sclera and conjunctiva are normal in appearance and non-injected. Snap and retraction tests are normal. The remainder of the head and neck exam is within normal limits. Functional indications for upper and lower eyelid blepharoplasty. American Academy of Ophthalmology. Ophthalmology 1995;102:693-695. Adamson PA, Tropper GJ, McGraw BL. Extended blepharoplasty. Arch Otolaryngol Head Neck Surg 1991; 117:606-609. Adamson PA, Strecker HD. Transcutaneous lower blepharoplasty. Facial Plast Surg 1996; 12:171-183. Alt TH. Blepharoplasty. Dermatol Clin 1995;13:389-430.
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Browpexy: lateral orbicularis muscle fixation as an adjunct to
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