medial canthal webbing after blepharoplasty

Ophthal Plast Reconstr Surg 1999;15:378. The surgery involves removing redundant skin, fat, and. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. The use of the CO2 laser and maintaining a dry surgical field with bipolar cautery or by defocusing the CO2 laser will minimize the occurrence of postoperative ecchymosis. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. http://tabanmd.com/gallery/revisional-eyelid/. In one patient there was rounding recurrence. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. 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. 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. Laser resurfacing is utilized where skin shrinkage and rhytid reduction are desired. My eyes were lovely and i fear Ive ruined them.I think Im a difficult as my eyes were good before and I wanted just a tweak. Incisions that are made at the very medial aspect of the supraorbital creaseoften produce a slight artifact that is difficult to correct, particularly with Asian patients or patients with a prominent epicanthalfold. Cautery to achieve hemostasis may affect nerve or muscle. It is virtually unheard of for this to fail to resolve. Levator function is assessed to identify myogenic ptosis. Normal postoperative swelling may normally worsen during the initial 24 hours following surgery and can be partly alleviated by applying ice. 4, pp. Ophthalmic Plast Reconstr Surg. 102, no. 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. May be due to inadvertent trauma to the levator complex, including postsurgical edema and . Jordan DR, Mawn LA. Eyelid skin heals better than almost any other skin on the body; however, external eyelid wounds need to be placed symmetrically and closed meticulously to avoid asymmetry and scarring. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. Similarly, corneal epithelial breakdown can result in transient pain, foreign body sensation and tearing. Am J Ophthalmol 1996;121:677. http://tabanmd.com/gallery/revisional-eyelid/ Helpful Mehryar (Ray) Taban, MD, FACS Oculoplastic Surgeon, Board Certified in Ophthalmology ( 302) Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. Blepharoplasty is a widely practiced successful operation. In Caucasian men, the crease is usually 69mm above the eyelid margin. 4, pp. Z. If skin shortage is evident however, full-thickness skin grafting may be needed. The surgery involves removing redundant skin, fat, and muscle. 281288, 2002. Any adjunctive procedures to be performed should also be determined. Once patients concerns are identified, the surgeon should inquire about cardiac and thyroid disease, hypertension, diabetes, bleeding diathesis, and keloid scar formation. If the lid crease is marked 8 mm above the lash margin, for example, the upper edge of the incision should be 12 mm below the brow margin. Ophthalmology 1999; 106:1705. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. Postoperatively, the patient can aid recovery with a few simple interventionsice water compresses and head elevation. 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. Yaremchuk MJ. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. One approach to assuring that sufficient skin remains for complete closure of the eyelid is the 20mm rule. 1, pp. Fortunately, diplopia after blepharoplasty is extremely rare but is still a known complication. 1, pp. It is important to tailor the incision upwards at the lateral extent or the hooding will persist. J Allergy Clin Immunol 1986; 78:417. Antibiotic or steroid/antibiotic ointment may be applied twice a day to sutures and into the eyes at night. Wilhelmi BJ, Mowlavi A, Neumeister, MW. 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. Many patients present for correction of dark circles under the eyes. Dark circles are caused by 3 factors: shadowing caused by fat bulging above the dark area, the blood supply of the fat showing through the thin eyelid skin, and thirdly, actual pigment in the epidermis and dermis. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. 3, pp. Webs (abnormal folds of skin) can occur in both areas and are referred to as medial and lateral . May be administered in the operating room or preoperative holding area. Nonabsorbable sutures are removed 714 days after surgery. Especially on one side more than the other! The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. 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. Ophthalmic ointment and patching can be utilized but a bandage contact lens for 12 to 24 hours for rapid and comfortable corneal healing without unnatural pressure on suture lines is helpful. Medially, this often results from the incision nearing the lid margin too closely or if the incision is extended to far medially or inappropriately angled inferiorly. Internet Explorer). 2003;111:44150. In addition, supporting structures such as canthal tendons are tightened. Mild inner webbing too. I would like to have this corrected as soon as possible and need advice. The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. 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. Steroids can be stopped without taper if administered less than 3 days, even at extremely high doses. Photographs of frontal plane and oblique view. Massry GG. 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. Various compositions of bleaching creams have been published, containing combinations of hydroquinone, glycolic acid, kojic acid, retinoic acid, and hydrocortisone. However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. Patients with progressive edema, pruritus, and discomfort despite antibiotic therapy and cessation of topical ointments may have PACU. Patients undergo upper blepharoplasty for purely aesthetic reasons. Because of the complexities in modifying the overcorrected upper lid, a more mild degree of symptomatic lagophthalmos can be addressed via lower lid elevation with lower lid posterior lamellar grafting, as detailed in the next section. Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. The information on RealSelf is intended for educational purposes only. Most patients only need to take 7 days off work. Avoid placing the crease too high to prevent the appearance of over-westernization. Sensory nerve fibers from the supraorbital, supratrochlear, and lacrimal nerves travel in the preorbicularis plane, suborbicularis fascial plane, and within the orbicularis muscle. I have had a lower and upper blepharoplasty about 15 years ago, then I had my uppers done again about 4 years ago, but I had my lowers done again about 1year ago and because I had had them done previous the surgeon insisted on a hammock stitch at the outer corners of my eye, which has caused webbing! Lid crease fixation is not always necessary. 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. 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. I have inner eyelid webbing following a blepharoplasty 2 years ago. 10391046, 1983. 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. To avoid this, use a Q-tip backstop immediately behind the fat incision made by the CO2 laser. In darker-skinned patients at risk for reactive posttreatment hyperpigmentation, pre and posttreatment with topical Retin-A and bleaching creams can be utilized. Temporary sutures may approximate the skin before application of the glue. 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. Complications of blepharoplasty can be minor or serious. Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. 1a). L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. 125, article 1017, 2010. Effective techniques do exist to treat most, if not all, complications, which may arise. Dermatol Surg. 3, pp. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). The canthal rounding is marked (Fig. READ MORE T. R. Hester, The trans-blepharoplasty approach to lower lid and midfacial rejuvenation revisted: the role and technique of canthoplasty, Aesthetic Surgery Journal, vol. In men, the brow protrudes more anteriorly, and the eyelid crease is closer to the eyelid margin. With an acute hemorrhage, intraorbital pressure rises abruptly, and the blood supply to the optic nerve is compromised. Millman AL, Williams JD, Romo T, Taggert N. Septal-myocutaneous flap technique for lower lid blepharoplasty. Publishers note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Plast Reconstr Surg 1978; 61:347. 81, no. Up to 24 hours, cantholysis and pressure release (if the orbit is still tense) and steroid treatment can be utilized. 1c). Dry eye symptoms may worsen if there is a decreased blink after removal of orbicularis muscle. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. I had an upper eyelid surgery six months ago and it has been a disaster. 1d and 1e). Measure skin amount in millimeters between the lower border of the central brow and the eyelash margin. The information on RealSelf is intended for educational purposes only. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. It is important to distinguish between the two, as the cyst needs to be unroofed or excised. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. 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 (. C. R. Leone and J. V. Van Gemert, Lower lid reconstruction using tarsoconjunctival grafts and bipedicle skin-muscle flap, Archives of Ophthalmology, vol. Unrealistic expectations include those patients who desire no upper lid fold at all, operated patients (who already look over corrected) desiring further improvement, patients who plan to return to their high demand occupation the day after surgery or those who book travel within the first week of surgery. Ophthal Plast Reconstr Surg 2002; 18:45. Persistent cases are treated by a V- to-Y plasty procedure. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. Dissection in the lateral canthal area may result in altered lymphatic drainage. Explain and document how daily visual function is affected. 1b). Prevent by planning an incision that extends to the medial commissure, May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures, May be due to inadvertent trauma to the levator complex, including postsurgical edema and dehiscence, May be due to unrecognized preoperative levator dehiscence, May be related to lagophthalmos and dry eye, Usually corrected with lubrication regimen, May require corrective lid surgery to reduce palpebral aperture, May be related to corneal irritation and/or dryness. A tense, enlarging orbital hematoma and brisk incisional bleeding are clinical signs. Several surgical techniques to repair canthal rounding have been described previously. 2013;29:20814. Safety of Periocular Mohs Reconstruction: a Two-Center Retrospective Study. Ophthalmic Plast Reconstr Surg. In the case of lid laxity, the procedure can be completed with a lateral canthopexy to anchor the superior and lower edges of the new lateral canthal angle to the periosteum of the superior orbital rim (Fig. Diagrams and photos in Fig. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. 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). Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. There is no consistently effective treatment of hypopigmentation. 1992; 99:222. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. Note the widened aperture but rounding recurrence. 758760, 1989. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. Scott KR, Tse DT, Kronish JW. Ophthalmic Surg 1990; 21:85. a The new eyelid margin is marked (dotted line). f The flaps are secured into their new positions. Patients with unrealistic expectations may perceive an operative complication after uncomplicated surgery. What complications can come from a blepharoplasty? The flaps are secured into their new positions with interrupted vicryl 6/0 sutures (Fig. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. 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. Assess nasal fat pad and preaponeurotic fat pad protrusion. In the Asian upper eyelid, there is a lower fusion point between the orbital septum and the levator aponeurosis, which allows orbital fat to descend further down in addition to the increased fat in the preseptal fibroadipose layer. In Caucasians, the orbital septum attaches to the levator aponeurosis at or slightly above the superior tarsal border or over the anterior surface of the tarsus. It is, therefore, often wise to avoid further manipulation of the upper lid by taking a donor graft from it. Eye 36, 564567 (2022). 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. A test spot can be offered the patient although a good result with the test spot is not a guarantee of subsequent good results. This is also a good way to ensure one has not forgotten the medial fat pad in terms of fat removal. Control of obvious bleeding points, if present is important. Patient selection and patient satisfaction. Patients may prefer to retain or change certain features such as relative hollowness or fullness of the upper eyelid sulcus. If a definite levator laceration is observed, it should be repaired if it is causing ptosis. The skin then bridges the superomedial hollow of the upper lid in a straight line. Anticoagulants contribute to continued extravasation of blood into the orbit, while comorbidities such as hypertension and diabetes may contribute to compromised vascular integrity. The patient was given topical steroids by his original surgeon, resulting in untreated intraocular pressure of 45OU. Fronto-ethmoidal external approaches and more rarely external DCR and blepharoplasty represent the commonest iatrogenic causes of medial canthal webbing. The canthal rounding is split into its anterior and posterior lamellae using a 15-blade followed by Westcott spring scissors (Fig. Cicatricial canthal webs. Slight dehiscence can be treated with topical and oral antibiotics, but a complete dehiscence needs prompt debridement and repair to avoid lower lid retraction and scarring. Correspondence to 1, pp. 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. 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.
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