- Facial Surgery
Blepharolasty is a surgical procedure in which redundant tissue (skin, muscle, fat) are excised from the eyelid. Blepharoplasty can be performed on the upper lids or lower lids or on both. Upper lid blepharoplasty is approached from the anterior (transcutaneous). Lower blepharoplasty is best by transconjunctival approach. Blepharoplasty like other aesthetic facial procedures are practiced by many specialists including otolaryngologist, plastic surgeon, ophthalmologist, dermatologist and maxillo-facial surgeon. The universal opinion is that the practice of facial plastic surgery by these varied communities, despite diverse experience and training has very much attributed for the advances of the surgical techniques and upgraded the experience and practice of facial plastic surgeons.
UPPER EYELID BLEPHAROPLASTY
TRANSCUNJUNCTIVAL BLEPHAROPLASTYThe transconjunctival approach was first described in 1924 in France by Bourguet.
- Improve eyelid skin redundancy.
- Improve eyebags – sagging.
- Revision blepharoplasty.
- The incision is marked accurately while the patient is in a sitting position. The marking is performed with a fine marking pen, aided by right angle forceps grasping the redundant skin and muscles. (Figs. 18 – 23 & 24)
- Local anaesthesia 2% Xylocaine with 1:200,000 Adrenaline. Infiltrated twenty minutes before surgery.
- The inferior incision is sited about ten mm above the lash line. Medially the incision extends slightly near to the lash line. Laterally it sweeps upwards toward the brow.
- The superior incision is according to the skin redundancy and runs elliptical with the inferior incision.
- The elliptical redundant skin is excised by using a C02 laser or sharp scissors.
- The muscle is incised superiorly until the fat starts to herniate. If redundant orbicularis muscle exists, a horizontal strip of five to six mm is excised by laser to avoid bleeding.
- The central longitudinal fat pad starts to herniate, it is dissected gently with cotton-tipped applicator, the appropriate amount excised by cross-clamping to fat pedicle, then the excess above the clamp, is excised by laser which achieves the sealing of vessels.
- The medial round fat pad is gently dissected out and excised. Gentle pressure from the surgeon’s assistant on the eyeball facilitates the dissection of the fat pad.
- Any bleeding vessels should be sealed by laser or bipolar cautery.
- Skin is closed meticolously by subcuticular 5/0 Prolene or nylon. M-plaster medically may be necessary.
- Antibiotic ointment, Op-site spray or strips are applied and an ice pack is applied on the eye for a few hours postoperative to avoid oedema. Sutures are removed in three to five days.
- Improve the eyebags, sagginess.
- Improve the redundant skin and tissue prolapse.
- Reduce the lower eyelid fullness due to prominent fat.
- No external scar. This is of particular importance in skin types IV, V, VI (p. 450).
- Preserve the integrity of the muscle.
- Most appropriate for young people with eyebags and good elastic skin.
- Complications of the trancutaneous approach are reduced or avoided such as: lower eyelid retraction, ectropion, entropion or inferior oblique palsy and less postoperative bruising.
- Patient can apply make-up to lower lid next day, continuing with everyday life.
- The use of laser serves to produce more lasting cosmetic results by scoring the orbicularis muscle.
- Marking of the lower eyelid fat pads performed while the patient is in the upright sitting position. Then, the patient is placed in the supine position and given intravenous sedation. The local anaesthetic is 1% Xylocaine plus. (Figs. 18 – 23,24)
- Epinephrine 1:100,000. This is administered into three quadrants of the lower lid (medial, central, lateral) through the conjunctiva, down to the level of the bony occular rim. First the central sector is injected, followed by the medial and lateral, respectively. The anaesthetic is allowed to take effect for fifteen to twenty minutes before proceeding, in order to obtain maximum benefit of anaesthesia and haemostasis. Both eyes are injected at this time.
- A Pyrex eye shield is used to protect the globe and a Desmarres retractor is used to retract the lower lid. The lower ocular rim position is palpated, and the conjunctiva is exposed. A C02 laser (power 4Watts) is used with a sheath around the shaft for increased protection. The incision is made with the C02 laser several millimeters below the tarsal plate and orbital rim and extends about six mm in length. Next, an iris scissors and a cotton tip applicator for retraction are used to dissect out the fat pads. (Fig. 18 – 23)
- The incision is extended medially to just lateral of the punctum. When dissecting medially, the incision should be kept about five mm from the cul-de-sac to avoid the punctum. It should be noted that the punctum extends two mm inferiorly before it turns medially at this point. The five mm margin will give an adequate boundary of safety. If the incision needs to be enlarged, it should always be laterally. Then, the incision may extend to the lateral rim of the orbit, just below the canthus.
- Next, the conjunctival flap is elevated, (6/0) silk suture is placed into the conjunctival flap. A clamp is placed on the suture, which is then draped over the brow and forehead. The Pyrex shield may be removed at this point. This allows the flap to be retracted in a superior position, by the weight of the clamp, to cover the globe. This self-retracting suture acts as a `silent assistant` to retract the tissues in a
- superior direction, protect the globe, alleviate multi-instrument use in the field, and gives the surgeon better access to the surgical field.
- Now, gently with help of the laser (2Watts) or cotton tipped applicator, the fat from the medial and lateral compartments are dissected out, first to expose the valley of the inferior oblique muscle and then the inferior oblique muscle (IOM). The fat pad of the medial and central lower lid fat compartments are partially separated by the IOM. This fat pad is covered by fascia, which is the accurate expansion of the IOM. Cutting this fascia makes the central and lateral fat pad sectors continuous. The majority of the medial fat pad is gradually removed, and care is taken to keep the dissection planes smooth for a better cosmetic result. Once the fat has been removed from all three areas, the upper lid is palpated for any remaining bulges and asymmetry. The amount of fat should be compared between the two eyes in order to evaluate the distribution of the fat removal of the three compartments. Relatively equal amounts of fat should be removed from the respective compartments of each eye to keep a natural appearance, we do not recommend excising more than 50% of the fat pads.
- Tightening of the orbicularis muscle will enhance the results of patients who suffer from excessive bagginess of the lower lids. This may be performed by using the C02 laser to score the muscle in several areas and planes. The effect is to tighten the muscle and draw the excess tissues upward. The scored areas will become fibrosed with time, in order to hold the tissues in place and eliminate the need for removal of excessive skin.
- During and at the end of the procedure, the patients vision and movement of the extra-ocular muscles are examined for deficits. Meticulous haemostasis is obtained using laser or electrocautery. The silent assistant stitch is removed, and the wound edges are repositioned. We do not suture the conjunctiva. Both lids are examined for symmetry. Ice compresses are applied during the immediate postoperative period.
- If a fold of redundant skin remains, it can be excised by the Pinch technique. The incision is 1.5mm below the lash line, medially it stops two to three mm away from the inferior punctum. Laterally, it extends just slightly beyond the lateral canthus. In lateal canthus tightening the incision extended horizontally into skin creases and swept slightly superiorly parallel to the upper lid incision. An intact eight mm should be preserved between the upper and lower lid incisions.
- Haematoma, bruises: Prevented by meticulous technique and the use of ice compresses. Preseptal haematoma present with normal globe retropulsion, no proptosis and no restricted ocular mobility, the vision should not be affected. A postseptal haematoma is characterized by pain, proptosis, decreased vision and ophthalmoplagia. Preseptal haematoma generally clears spontaneously. Evacuation, if necessary should be performed at least seven to nine days postoperative to allow liquifaction. Persistent postseptal haematoma or bleeding is an emergency which calls for exploration and evacuation.
- Overcorrection: One should not excise more than 50% of the fat to keep the natural appearance. Aggressive fat removal can lead to inferior lid concavity or frank enophthalmos and enhancing underlying structures. Patients at risk includes those with deep set eyes and prominent intraorbital rims.
- Undercorrection: Due to poor exposure. Treated by revision.
- Pigmentation: Immediate postoperative darkening due to deposition of haemosiderin, this is self- limited. However, the skin concavity after fat excision tends to absorb rather than reflect light. Furthermore, sun exposure during the immediate postoperative may lead to permanent pigmentation. These patients may benefit from a course of Hydroquinone 4% for three to six months.
- Visual loss: Due to ischaemic retinal or optic nerve damage which is caused by increased intraorbital pressure resulting from bleeding, or due to central retinal artery occlusion. More than seventy five cases have been reported in the medical literature (0.04%). Emergency treatments include conservative, exploration, evacuation, occular hypotensive agents, lateral canthotomy and cantholysis.
- Lacrimal gland prolapse: Lacrimal gland prolapse should be considered in all patients undergoing blepharoplasty. Careful preoperative examination is required, failure to recognize the gland may result during operation in lacrimal lobectomy with hemorrhage and later dry eye. Full examination includes palpation, lid eversion and globe retropulsion. The gland can be identified by its position, pink colour and its discrete shape.
- Keratoconjunctivitis sicca (dry eye): Corneal lubrications are applied. Patient with preoperative dry eye symptoms, should be informed that blepharoplasty is likely to increase their symptoms.
- Lower lid malposition: Retraction, lagophthalmos, ectropion and lateral canthal deformity. Particularly in transcutaneous approach. This adds to the advantages of the transconjunctival approach.
- Diplopia: Caused by injury to inferior oblique muscle (IOM) or other ocular muscles which can be temporary or permanent. IOM should be identified before fat excision.
- Ptosis: Due to injury to the levator aponeurosis. Direct levator repair is the procedure of choice. If the injury is recognized at the operation, immediate repair may be performed. However, if ptosis becomes apparent more than two weeks postoperative it is better observed for at least three months. Ophthalmic consultation is mandatory. Myasthenia gravis should be excluded.
- Lagophthalmos: Failure of the lid to close causes keratitis and discomfort. It usually resolves within one to two weeks. Measures such as lubrication, ointments, night cover should be considered.
- Canthal webbing: In the upper eyelid, resulting from excessive medial skin excision. M-plasty should be considered to avoid medial extension of the incision.
- Occulo cardiac reflex: 25% of patients demonstrated bradycardia and arrythmia during fat pad dissection. Patient should be fully monitored.
- Numbness: Usually disappears in six months.
- Epiphoria: Tearing usually resolves spontaneously.
- Incision irregularities: Cyst, granulomas, keloid.
- Eyelid crease abnormalities: Careful upper eyelid incision marking should be ensured. Early asymmetry best managed with massage. If remains, supratarsal fixation may be indicated.
- Infection: Acute dacrocystitis and or orbital cellulitis. Fungal infection is very rare only one case has been reported by Guyuron. Managed by appropriate antibiotics or antifungal agents.