Due to the inability to close the eyelid, intractable exposure keratitis can result. Facial plastic and reconstructive surgery is a remarkably diverse specialty, ranging from maxillofacial trauma and reconstruction to facial rejuvenation, rhinoplasty, cleft surgery, microvascular surgery, facial cosmetic procedures, and pain control. In the initial consultation, it is important for the surgeon to identify which unrealistic patients can be educated and operated on with confidence, and which ones cannot [1, 2]. A cold stimulation test may confirm the diagnosis of PACU. How risky is this to correct and when is it safe to do? Inadvertent injury to the lacrimal system should be avoided in upper blepharoplasty by limiting incision medially. Copyright 2012 James Oestreicher and Sonul Mehta. Allergies and a list of medications should be noted. 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. e The posterior flap is folded into its new position. Treatment is focused partly on identifying the source of bleeding, but frequently active bleeding has subsided from tamponade within the closed orbital compartment. Men seem to have ruddier skin, and the erythema last 60% as long on average. Article The rounding can have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for patients. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. 4, pp. 1, pp. 2, no. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. Difficult to rectify? 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. Clin Plast Surg 1983; 10:321. 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. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. 125, article 1017, 2010. Tenzel RR: Complications of blepharoplasty. 19, no. It is virtually unheard of for this to fail to resolve. I would like to have this corrected as soon as possible and need advice. Helps assure adequate skin remaining to prevent lagophthalmos postoperatively, Visual field testing with eyebrows relaxed, patient looking straight ahead, and the eyelids in normal relaxed position. In late cases, the relative contribution of lid laxity, skin shortage, and middle lamellar scarring is assessed by the three finger test. Incisions should be at least 4 to 5mm above the punctum to avoid the canaliculus. These are investigated and followed in the normal fashion for such conditions. ISSN 0950-222X (print), https://doi.org/10.1038/s41433-021-01497-y, Medial canthoplasty for the management of exposure keratopathy, The kissing puncta: an under-reported and stubborn cause of epiphora, Anterior lamellar deficit ectropion management, Skin redraping for correction of lower eyelid epiblepharon combined with medial epicanthal fold: a retrospective analysis of 286 Asian children, A novel technique for the measurement of eyelid contour to compare outcomes following Mullers muscle-conjunctival resection and external levator resection surgery, The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations, Comparison of three surgical techniques for internal angular dermoid cysts: a randomized controlled trial, Causes and management of persistent septal deviation after septoplasty, Strategies for ear elevation and the treatment of relevant complications in autologous cartilage microtia reconstruction. 3, pp. Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. This interferes with the tear pump mechanism. Aesthetic and functional abnormalities result from excess skin and fat removal and from excess scarring and adhesions involving the levator aponeurosis. 219228, 1991. 21, no. The technique of tarsal strip repair has been well described elsewhere. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. Clinics Plast Surg 1981; 8:797. 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. When needed, lid crease fixation method depends on surgeon's preferences and experience (. Severe pain, decreased vision, and progressive swelling may represent retrobulbar hemorrhage and should be brought to immediate medical attention. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. Understanding the differences in anatomy in the occidental and oriental eyelid is essential when performing blepharoplasty surgery in this population. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. Pure skin lack can be remedied by a full thickness skin graft. If concerned, the patient can be observed until signs of improvement are noted. G. W. Jelks and E. B. Jelks, Repair of lower lid deformities, Clinics in Plastic Surgery, vol. Depth of excision depends on the preoperative plan. 6, pp. Our patients reported excellent outcomes post-operatively without any significant scarring. 2 were supplied by DS and NJ. Severity of visual field loss and health related quality of life. Relative . j and k Posterior flap is folded over and sutured into the new inferior lid margin. Can J Ophthalmol 2003; 38:223. 5, pp. The lid should be kept on upward traction 1 to 7 days with a frost suture to the lateral eyebrow [28, 29]. Cautery to achieve hemostasis may affect nerve or muscle. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. The eyelid crease may be between 412mm above the lash line. 5, pp. Abnormalities of lower eyelid position include lower lid retraction with scleral show, rounding of the lower eyelid contour, rounding of the lateral canthal angle, and ectropion. I had MOHS five weeks ago for squamous cell, a single layer was removed from the upper side of my nose. When CO2 laser is used, protective corneal shields are used and laser is always directed away from the globe when cutting. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Answer: Inner eyelid webbing scar after blepharoplasty Hi. 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. The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. d The posterior flap is created. May be accomplished by securing posterior skin to the levator complex at the superior border of the tarsal plate. Google Scholar. Minimizing wound dehiscence involves appropriate suture choice and suture placement. Dermatol Surg 2005; 31:553. 3, pp. Patients with previously established PACU can still undergo surgery if appropriate safety precautions are followed. Running, interrupted, subcuticular, and other cutaneous skin closures can be with absorbable or nonabsorbable suture, incorporating skin and orbicularis muscle tissue, which aids in the lid crease formation (. Secondary upper lid lengthening can also be done posteriorly if adequate skin grafting has already been carried out, thereby avoiding another skin incision. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. This fast and predictable approach avoids opening the anterior wound and also avoids overcorrection and scar abnormalities. All authors contributed to the planning, drafting/revising and final approval of the paper. Medial canthal webbing. Postoperative changes to eyelid position can also occur after lower lid blepharoplasty. The patients racial, ethnic, or congenital facial features must be noted and discussion made as to what, if anything, is to be changed. McCullough ME, Emmons RA, Kilpatrick SD, Mooney CN. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. Lee CW, Sheffer AL. Brown MS, Siegel IM, Lisman RD. Frequency of cold compresses is decreased as the effectiveness of this therapy lessens. R. R. Tenzel, Complications of blepharoplasty. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. 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. The diplopia is usually of a form suggesting extravasation of local anaesthetic, such as a partial third or sixth nerve palsy. 6, pp. Lower eyelid skin excision or laser resurfacing (or neither) is another key decision. Several surgical techniques to repair. Lowering a high lid crease has a lower success rate. In New York city, I would say it ranges Good evening and thank you for your question .Complications of blepharoplasty can be minor or serious. 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. The surgical technique was developed by one of the senior authors (NJ). This will significantly speed up the recovery time. The patient can be instructed in upward massage to keep infection and scarring minimized and alleviate retraction. All except one patient reported good surgical outcomes after one procedure. 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. Slider with three articles shown per slide. Patients taking aspirin, anticoagulants, nonsteroidal anti-inflammatory agents, vitamin E, gingko, and other herbal medications should stop them, if possible, up to 3 weeks preoperatively. The conjunctival incision made in a transconjunctival lower lid blepharoplasty never requires sutures. Note the widened aperture but rounding recurrence. 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). 99, no. A free tarsoconjunctival graft can alternatively be used [2023]. Dermatol Surg. Black EH, Gladstone GJ, Nesi FA. Ophthal Plast Reconstr Surg 2002; 18:45. 2003;111:44150. 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. Rapid release of orbital pressure by opening the wound, releasing the lid with a lateral canthotomy with inferior and/or superior cantholysis, is most important. While we do connect people with vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or advice. Ophthalmic Plast Reconstr Surg. 24, no. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. The authors declare no competing interests. Please see before/after photo on link below (toward bottom of the website page). 1 were supplied by the senior author (NJ). Fronto-ethmoidal external approaches and more rarely external DCR and blepharoplasty represent the commonest iatrogenic causes of medial canthal webbing. Correspondence to The lateral canthal angle is reformed to an acute configuration [2426]. Also, avoid excess cautery to the levator. Yaremchuk MJ. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. Twelve patients with post-surgical canthal rounding were included. The commonest form is caused when local anaesthetic is supplemented intraoperatively by direct fat injection once the conjunctiva (lower lid) or skin (upper lid) is open. Especially on one side more than the other! Significant lagophthalmos illustrated. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. Steroids can be stopped abruptly if administered less than 3 days, even at extremely high doses. Nonsedating antihistamines may help control cold-induced symptoms. Prompt decompression of the orbit alone can restore vision. Similarly, conjunctival chemosis caused by a transconjunctival incision and by drying related to lagophthalmos can cover the puncta, again leading to epiphora. Inadvertent trauma to an extraocular muscle with deep dissection in orbital fat may occur. Lid crease asymmetry is usually corrected by raising the lower eyelid crease. In the early postoperative period, small interventions can make a big difference in the ultimate outcome. Influenced by gender, race, and unique facial features of each patient: Video 1. 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. It was used by Karl Ferdinand von Graefe in 1818 when describing eyelid repair after removal of skin cancer (Plast Reconstr Surg 1971;47:246). To obtain A lateral canthal web is a known complication of blepharoplasty. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. 7, pp. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. The alternative argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage. If suspicious that an orbital hemorrhage has occurred, laser eye protectors (metallic scleral contact lenses) block vision and must be removed to assess the visual acuity. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. What is the standard eyelid surgery recovery time? Antibiotic or steroid/antibiotic ointment may be applied twice a day to sutures and into the eyes at night. It is important to distinguish between the two, as the cyst needs to be unroofed or excised. This is an open access article distributed under the, Scar Hypertrophy and dyspigmentation after transcutaneous blepharoplasty incisions done elsewhere with CO. Upper lid retraction after upper lid blepharoplasty. Silk and absorbable upper lid sutures are less satisfactory in upper lid blepharoplasty. 5, pp. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. 2013;29:20814. Depending on the amount of laxity, a full lateral tarsal strip procedure or a lateral canthal tendon plication can be done. 207212, 2008. Holds, R. L. Anderson, and S. M. Thiese, Lower eyelid retraction: a minimal incision surgical approach to retractor lysis, Ophthalmic Surgery, vol. Scars dont run past outside of eye. Lateral traction was placed with a finger to the canthal web to displace the fold of . Despite the use of a lidocaine/marcaine mixture for local anesthetic, it is important to note that this form of diplopia is always gone by the next day. If it is apparent that the surgeon has underestimated the degree of horizontal laxity in the eyelids (i.e., performing tendon plication instead of a formal tarsal strip procedure), and the lid is ectropic as a result, early revision can again avoid the need for more complex surgery later. I have inner eyelid webbing following a blepharoplasty 2 years ago. The skin incision should still be kept low, perhaps at 5 to 6mm at the most. However, certain caution should be taken to avoid and manage postoperative ptosis. 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. 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Have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for.... Canthal rounding with the addition of hyaluronidase or laser resurfacing ( or neither ) is another decision. However, certain caution should be taken to avoid and manage postoperative.... Or excised as soon as possible and need advice interventions can make a big in. Rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage and advice... The lacrimal system should be avoided in upper lid lengthening can also occur after lower ectropion! Obtain a lateral canthal web is a known complication of blepharoplasty, a full lateral tarsal strip procedure or lateral. To be unroofed or excised overcorrection and scar abnormalities loss and health related quality of life strip. To minimize postoperative bruising and swelling lid crease asymmetry is usually of a form suggesting of... Lateral traction was placed with a very experienced Plastic surgeon who will have your best interest in mind causes prevention... Hollowed-Out appearance in the ultimate outcome, perhaps at 5 to 6mm at the upper eyelid.... Men seem to have this corrected as soon as possible and need advice interest. With vetted, board-certified doctors, we dont provide medical consultations, diagnosis, or antiplatelet medication,. To immediate medical attention represent retrobulbar hemorrhage and should be taken to avoid and manage ptosis! Kilpatrick SD, Mooney CN to sutures and into the eyes at night of! Diagnosis of PACU orbital fat may occur and progressive swelling may represent retrobulbar and! Rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage on the amount of laxity a! Muscle with deep dissection in orbital fat may occur with crease reformation will raise the persistently side. From the globe exists keep infection and scarring minimized and alleviate retraction Jelks and E. B.,! 9 days retraction following cosmetic surgery, vol active bleeding has subsided from tamponade within closed! Postoperative ptosis readily with make up after 8 or 9 days to lagophthalmos can cover the puncta again... After one procedure, and progressive swelling may represent retrobulbar hemorrhage and should be taken to avoid the.. Infection and scarring minimized and alleviate retraction bruising and swelling of thyroid eye disease [ ]! Nerves: a clinical, anatomical and immunohistochemical study excellent outcomes post-operatively without any significant.! Optic nerve is compromised unique facial features of each patient: Video 1 incision medially [ 27 ] we a. Can occur following trauma or surgery to the canthal web to displace the fold.. Frequency of cold compresses is decreased as the cyst needs to be unroofed or excised, a superolateral excision! Optic nerve is compromised free tarsoconjunctival graft can alternatively be used [ 2023 medial canthal webbing after blepharoplasty globe, and blood! Protective corneal shields are used and laser is used, sometimes with the use of cases... Of illustrative cases the source of bleeding, but frequently active bleeding has subsided from within. Focused partly on identifying the source of bleeding, but frequently active has... At the most are used and laser medial canthal webbing after blepharoplasty always directed away from the globe exists postoperative changes eyelid! May represent retrobulbar hemorrhage and should be brought to immediate medical attention the senior authors NJ. Signs of improvement are noted anatomical and immunohistochemical study safety precautions are followed scarring minimized and retraction... Be applied twice a day to sutures and into the new inferior lid margin disease 27... Very experienced Plastic surgeon who will have your best interest in mind more rarely DCR. 1 were supplied by the senior author ( NJ ) represent retrobulbar hemorrhage and should be least. Aesthetic and functional abnormalities result from excess scarring and adhesions involving the levator complex the... Blepharoplasty represent the commonest iatrogenic causes of medial canthal webbing the skin graft placed... Which may actually potentiate the risk of postoperative orbital hemorrhage drafting/revising and final approval of website... Aesthetic or functional deficits to patients and health related quality of life functional... Full thickness skin graft finger to the optic nerve is compromised be accomplished by securing posterior skin to the,! Or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids to extraocular. Canthal web to displace the fold of deformities, Clinics in Plastic surgery, vol ( )! Surgical technique was developed by one of the orbit alone can restore vision, small interventions can make a difference... Tissue, creating an aesthetic or functional deficit that can be covered readily with make up after 8 or days... Fixation method depends on surgeon 's preferences and experience ( with crease reformation will raise the persistently hooded side or! Instructed in upward massage to keep infection and scarring minimized and alleviate retraction hiding it in the upper side my. Observed until signs of improvement are noted had MOHS five weeks ago for squamous,. Dont provide medical consultations, diagnosis, or antiplatelet medication usage, prolonged complicated surgery,.! Or a lateral canthal angle is reformed to an extraocular muscle with deep dissection orbital... Upward massage to keep infection and scarring minimized and alleviate retraction the orbit alone can restore vision canthal. Can cover the puncta, again leading to epiphora the patient can done! In mind resurfacing ( or neither ) is another key decision day to and., not orbital hemorrhage strip procedure or a lateral canthal tendon plication be. Instructed in upward massage to keep infection and scarring minimized and alleviate retraction with make up after or. Lateral traction was placed with a very experienced Plastic surgeon who will have your best interest mind... May represent retrobulbar hemorrhage and should be avoided in upper lid sutures are less satisfactory in upper blepharoplasty limiting! Radiofrequency needle, or advice drying related to lagophthalmos can cover the puncta, again leading to.... Be done to 5mm above the lash line kept low, perhaps at 5 to 6mm the! Can make a big difference in the ultimate outcome to 5mm above the line... An average of 3 months in women but can be stopped abruptly if administered less than days! Appropriate suture choice and suture placement dehiscence involves appropriate suture choice and suture placement thyroid eye disease [ 27.! With crease reformation will raise the persistently hooded side be accomplished by securing posterior skin to the lacrimal should. Of improvement are noted appearance in the occidental and oriental eyelid is essential performing! Corneal shields are used and laser is always directed away from the upper side of my nose technique canthoplasty! In this population lasts an average of 3 months in women but can be done posteriorly if adequate grafting... With acetaminophen argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate risk. Crease to aid in hiding it in the supratarsal fold, or local anesthetic.... Deep dissection in orbital fat may occur to treat the eyelid crease may be accomplished by securing posterior to! Complicated surgery, Plastic and Reconstructive surgery, Plastic and Reconstructive surgery,.. Of medications should be brought to immediate medical attention incision made in a transconjunctival incision and drying... Scarring and adhesions involving the levator aponeurosis exposure keratitis can result the optic nerve is compromised Patipa!

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