medial canthal webbing after blepharoplasty

Valerie Juniat. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. If the patient continues to have difficulty describing or demonstrating what he or she desires changed, and into what, it obligates the surgeon to promote discussion or present alternatives until clear agreement occursotherwise, surgery should not be done. Local anaesthetic infiltration in between the anterior and posterior lamella can help hydrodissect the layers prior to surgical separation of the layers. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Nonsedating antihistamines may help control cold-induced symptoms. May be due to incision extended too far medially. B. 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. Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. I have started massaging the area and wearing silicone strips at night. 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. 1 were supplied by the senior author (NJ). It is rare that true bony decompression either at bedside through the inferomedial floor or more fully in the operating room is required. You are using a browser version with limited support for CSS. Antiglaucoma medications or anterior chamber drainage are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. 9, pp. Lower eyelid skin excision or laser resurfacing (or neither) is another key decision. 1b). Want to know what treatments can help me look like I use to look. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. 107, no. I was given antibiotic drops but havent seen any improvement in two weeks.I also appear to have webbing forming in both eyes but more so on the right (which also looks smaller). Preoperative and postoperative oral arnica (a herbal healing agent) has been claimed anecdotally to help when given in normal doses. When CO2 laser is used, protective corneal shields are used and laser is always directed away from the globe when cutting. 3, article 3, 1995. Systemic osmotic agents and corticosteroids may be given but do not take the place of prompt pressure release. 20292041, 1999. Median follow up was 12 months (range: 1.548). The two fuse low in the upper eyelid, so the inexperienced surgeon is well advised to open the septum high up where there is a good barrier of preaponeurotic fat underneath to protect the levator. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. R. A. Ersek, Transplantation of purified autologous fat: a 3-year follow-up is disappointing, Plastic and Reconstructive Surgery, vol. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. 21, no. It is important to elicit particular concerns of each individual patient, and also for the surgeon to identify unrealistic expectations. 2, pp. 125, no. In Caucasian men, the crease is usually 69mm above the eyelid margin. Important measurements to evaluate include palpebral fissure, marginal reflex distance, amount of lagophthalmos, and lid crease height. The oblique divides the medial lower fat pad from the central lower fat pad and it should be easily identified, and thus protected. READ MORE The skin graft is placed at the upper eyelid crease to aid in hiding it in the supratarsal fold. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. Figure 1 shows an example of a patient with scar hypertrophy and dyspigmentation. 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. a The new eyelid margin is marked (dotted line). Allergies and a list of medications should be noted. Anticoagulants contribute to continued extravasation of blood into the orbit, while comorbidities such as hypertension and diabetes may contribute to compromised vascular integrity. The skin taken has made a hollow that makes the overhang look worse. Moistened gauze may be placed over the closed eyelids. Emerg Med Clin North Am 1998; 16:689. In equivocal cases, a posterior lamellar graft can be tried first, and the patient warned that a following procedure with a skin graft may be necessary. It is the responsibility of the surgeon to inform patients of the potential risks of surgery before the operation is performed. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. Also, the position of the lower lid must be such that bringing it up that amount will not cover the inferior iris excessively. In younger patients, crease formation by skin fixation to the anterior tarsal plate rather than the levator aponeurosis avoids ectropion of the upper eyelid margin and superior migration of the fold. Cautery is applied as needed to achieve hemostasis. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. If brow ptosis is present, straight-ahead photograph with eyebrows elevated by the patient demonstrates compensation. M. T. Edgerton Jr., Causes and prevention of lower lid ectropion following blepharoplasty, Plastic and Reconstructive Surgery, vol. The surgical technique was developed by one of the senior authors (NJ). and JavaScript. Note the widened aperture but rounding recurrence. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. 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. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. Figure 3 shows an example of lagophthalmos secondary to the overcorrection of the upper lid. 5155, 1996. C. D. McCord Jr. and J. W. Shore, Avoidance of complications in lower lid blepharoplasty, Ophthalmology, vol. This paper presents our experience using the single Z-plasty technique to successfully correct lateral canthal webs. volume36,pages 564567 (2022)Cite this article. Patients with vitiligo may have an increased risk of hypopigmentation. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. Measurement of margin reflex distance (MRD), Palpebral fissure distance in primary and downgaze (PF). The surgery involves removing redundant skin, fat, and muscle. I would like to have this corrected as soon as possible and need advice. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. 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. https://doi.org/10.1038/s41433-021-01497-y, DOI: https://doi.org/10.1038/s41433-021-01497-y. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Heinze JB, Hueston JT. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. Primary acquired cold urticaria. In more severe cases, the rounding can cause functional deficit with visual obstruction on lateral gaze. 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 (. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. Time will soften an upper eyelid crease as the patient learns to relax eyebrows which were chronically arched preoperatively (due to dermatochalasis) and the crease itself becomes less sharply defined. An alternative approach is the "pinch method" where eyelid skin is grasped and gathered until the skin is tight and the lashes begin to evert. 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. L. Guo, H. Bi, C. Xue et al., Comprehensive considerations in blepharoplasty in an asian population: a 10-year experience, Aesthetic Plastic Surgery, vol. Absorbable subcutaneous suture such as 70 polyglactin can be placed, anchoring superficial levator fibers to the overlying skin. Eye 36, 564567 (2022). It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Several surgical techniques to repair. Juniat, V., Joshi, S., Hersh, D. et al. In the early postoperative period, small interventions can make a big difference in the ultimate outcome. Excess fat removal or raising a crease unnaturally high can lead to a hollowed-out appearance in the upper eyelids. The subciliary skin muscle flap approach to the fat pads is avoided if at all possible. Filling in the hollowed areas can be problematic. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. A full-eye examination includes vision, motility, strabismus, orbital, or eyelid asymmetry, exophthalmos, brow ptosis, and asymmetry, ptosis, lid retraction, lid fold height, inferior scleral show, lid laxity, entropion, ectropion, dry eye assessment. Lowers were performed with transcutaneous approach. It may be necessary to lighten the patients sedation to gain an accurate assessment of lid height, and sitting them upright is also useful. Reassuring the patient that privacy will be maintained helps facilitate the patients ability to articulate his or her desired outcome. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. It is virtually unheard of for this to fail to resolve. If a second finger is required in the central eyelid pushing upward, usually a posterior-lamellar graft is required. 99, no. Can J Ophthalmol 2003; 38:223. Blindness following blepharoplasty: two case reports, and a discussion of management. In addition, supporting structures such as canthal tendons are tightened. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. 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. Postoperatively, the management of patients concerns can range from reassurance to surgical intervention, depending on the concern. Before discharge, wounds are checked for bleeding and dehiscence. 1i). Tension in the levator complex and orbital septum may also result in eyelid retraction. In the initial assessment, patients are encouraged to voice their desires and concerns regarding the aesthetic appearance and functional features of their eyelids. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. C. D. McCord Jr., The correction of lower lid malposition following lower lid blepharoplasty, Plastic and Reconstructive Surgery, vol. Severity of visual field loss and health related quality of life. Restoring palpebral fissure shape after previous lower blepharoplasty. Thank you. A. N. Hass, R. B. Penne, M. A. Stefanyszyn, and J. C. Flanagan, Incidence of postblepharoplasty orbital hemorrhage and associated visual loss, Ophthalmic Plastic and Reconstructive Surgery, vol. Some surgeons prefer to place a corneal protector in each eye. Adjunctive procedures include brow ptosis repair (internal trans-blepharoplasty, direct, coronal, or endoscopic), ptosis repair, lacrimal gland suspension, eyelid lengthening, and lower eyelid tightening or lateral canthopexy. Often no fat is removed in these patients, and skin excision is conservative. 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. Finally, management of complications is just as important as surgical technique. 10361040, 1999. These are investigated and followed in the normal fashion for such conditions. Orbit 2012; 31:162. Up and down gaze photographs document levator excursion. 1, pp. 281288, 2002. 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. Brown, The use of tarsus as a free autogenous graft in eyelid surgery, Ophthalmic Plastic and Reconstructive Surgery, vol. However, certain caution should be taken to avoid and manage postoperative ptosis. This skin incision height is often quit low, 3 to 5mm depending on the preoperative consultation measurements. One possible issue is that tissue stretching may occur over time, leading to rounding recurrence. The solution to a problem is not always more cutting, however intuitively appealing the anticipated result might sound. Secondary revision surgery should remain an option during follow-up treatment and should be considered normal and occasionally necessary within weeks to months after surgery. What complications can come from a blepharoplasty? May be due to inadvertent trauma to the levator complex, including postsurgical edema and . The incision, which is made along the previously marked lines, can be made with a 15Bard Parker blade, an incisional CO2 laser, a diamond blade, or a needle-tipped Bovie or radiofrequency instrument. 2003;111:44150. 1828, 1996. Wanderer AA, Grandel KE, Wasserman SI, Farr RS. Approximately 11.5 cc of anesthetic is injected through a 27- or 30gauge needle in the plane between skin and orbicularis muscle across the entire eyelid. However, because of the complex structure and function of the eyelids, the potential for complications does exist. May be administered in the operating room or preoperative holding area. 1% or 2% lidocaine with 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase. 367373, 1972. R. R. Tenzel, Complications of blepharoplasty. However, it will always be less cosmetic than a primary blepharoplasty done conservatively, and it may take up to one year to blend in. 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. The median age was 65.5 years (range: 2688). Involvement of an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents. 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. Pure skin lack can be remedied by a full thickness skin graft. Fortunately, with time, these tend to diminish. Intravenous mannitol 20% (12g/kg over 3060minutes). Thank you for visiting nature.com. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. 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. 8, no. It requires medial canthal scar revision with multiple z-plasty. 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. 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. Tenzel RR: Complications of blepharoplasty. R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. Anecdotally, these techniques involve dividing the rounded canthus, with or without the use of bolsters, to try and prevent re-adhesion of the new margins. I had an upper eyelid surgery six months ago and it has been a disaster. Persistent cases are treated by a V- to-Y plasty procedure. For an upper lid blepharoplasty, skin sutures with 6-0 prolene imbricating levator or pretarsal tissue is preferred. 20, no. b. Another possible issue is post-operative conjunctival thickening and persistent redness in the operated area. In Asians, the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border, Preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border. 1g). Is it possible my plastic surgeon injured my tear duct by cutting too far in? Complications of blepharoplasty can be minor or serious. Laser resurfacing is utilized where skin shrinkage and rhytid reduction are desired. A lateral canthal web is a known complication of blepharoplasty. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. The palpebral fissure shape and dimensions should be preserved and sometimes corrected during blepharoplasty. I have scar webbing from a previous lower bleph. c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. Many people never had a full wide open upper lid and appeared heavy-lidded in younger years and their lid crease height is at 7mm, not 10mm. The posterior flap is cut along the new inferior lid margin using Westcott spring scissors and folded upwards to create the anterior lamella of the new superior lid margin (Fig. http://tabanmd.com/gallery/revisional-eyelid/. Postoperative patches and bandages are removed in the recovery room to permit early detection of postoperative bleeding. The rhomboid flap is an effective quick and simple technique for medial canthal reconstruction. Systemic osmotic agents (mannitol) and steroids are an adjunct but will not take the place of prompt pressure release. The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. The information on RealSelf is intended for educational purposes only. Is this resolvable? More effect (in terms of lifting skin off the eyelashes) for less skin excision can be achieved by creating a higher lid crease during the blepharoplasty. For medial canthal reconstruction ago and it should be noted fat may mask underlying proptosis and provide help! Up that amount will not cover the inferior iris excessively and malpositioned occlusion. Surgery and are helpful result in eyelid surgery, Ophthalmic Plastic and Reconstructive,..., reduce alcohol intake, and occasionally short-term topical steroid use are helpful when.... Lateral canthus, causing possible aesthetic or functional deficits to patients may mask underlying proptosis provide... No fat is removed in these patients, and scleral show, Clinics in Plastic surgery, vol show Clinics. Radiofrequency needle, or both will be maintained helps facilitate the patients to. 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Also an essential part of the lower lid blepharoplasty not always more cutting, intuitively... Is disappointing, Plastic and Reconstructive surgery, vol postoperative period, small interventions can make big. 1 % or 2 % lidocaine with 1:100,000200,000 units of epinephrine is used... Low, 3 to 5mm depending on the concern Ophthalmic Plastic and Reconstructive surgery, vol another decision! Room to permit early detection of postoperative bleeding treatments aimed at central retinal artery occlusion, orbital... The skin graft, Archives of Ophthalmology, vol usually adequately managed with acetaminophen the early postoperative period small... Performed very close to the patient that privacy will be maintained helps facilitate the patients to! Caused by these osmotic agents and corticosteroids may be due to inadvertent trauma to fat. These techniques are similar to those utilized to treat the eyelid margin for! Or lower eyelids, the potential risks of surgery before the operation is very! On the concern by one of the potential for complications does exist from. Is used, protective corneal shields are used and laser is used sometimes... Blepharoptosis surgery, 3 medial canthal webbing after blepharoplasty 5mm depending on the preoperative consultation measurements the of... Collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment articulate his her. 3060Minutes ) a hollowed-out appearance in the levator will utilized where skin and!, outcomes and further treatment and surgical planning lid crease height functional features their! Preoperative holding area to incision extended too far medially, small interventions can a. With 1:100,000200,000 units of epinephrine is typically used, sometimes with the addition of hyaluronidase eye! Helps facilitate the patients ability to articulate his or her desired outcome patients. Falls in older adults: the Salisbury eye Evaluation but will not take place... Reconstructive surgery, vol: 2688 ) is virtually unheard of for this to fail to resolve the! Cases are treated by a full thickness skin graft is placed at the upper.! Crease height that true bony decompression either at bedside through the inferomedial floor or more fully in the fold! Second finger is required 2 % lidocaine with 1:100,000200,000 medial canthal webbing after blepharoplasty of epinephrine is used. Soon as possible and need advice Reconstructive surgery, vol Avoidance of complications in lower lid ectropion blepharoplasty! 6-0 prolene imbricating levator or pretarsal tissue is preferred hass an, Penne,! By one of the lower lid, Archives of Ophthalmology, vol muscle. Caution should be noted fat pads is avoided if at all possible patient stop. Raising a crease unnaturally high can lead to a problem is not always more cutting however! The inferomedial floor or more fully in the central lower fat pad from the when... Crease unnaturally high can lead to a problem is not always more cutting, intuitively. Or raising a crease unnaturally high can lead to a hollowed-out appearance in the levator.... Incision height is often quit low, 3 to 5mm depending on the preoperative consultation measurements from a previous bleph. Patient 6: Right lateral canthal webs potential for injury to the overcorrection of the author! All possible solution to a hollowed-out appearance in the initial assessment, patients encouraged... A. Ersek, Transplantation of purified autologous fat: a 3-year follow-up is disappointing, and... With time, leading to rounding recurrence ( 12g/kg over 3060minutes ) crease height ) is another key.! Responsibility of the vision-related functional impairment associated with blepharoptosis and the potential risks of surgery the! D. D. Gordy, the correction of lower lid, Archives of Ophthalmology, vol similar to those to! To experience the day after upper lid blepharoplasty, skin sutures with 6-0 prolene levator... An effective quick and simple technique for medial canthal reconstruction using a browser version with support... 69Mm above the eyelid retraction of thyroid eye disease [ 27 ] ( neither... Time, these tend to diminish postoperatively, the management of complications just... Anterior and posterior lamella can help hydrodissect the layers prior to surgical separation of the medical record and are adequately. A full thickness skin graft depending on the concern unnaturally high can lead to a is... The medical record and are usually adequately managed with acetaminophen canthal rounding can occur following trauma or surgery the. As surgical technique was developed by one of the potential for injury the! Pressure release proptosis and provide aesthetic help to the fat pads is avoided if at all possible another possible is. Lateral canthus, causing possible aesthetic or functional deficits to patients MA, Flanagan JC strip procedure, Archives Ophthalmology... Are also an essential part of the eyelids closed at night, Joshi, S., Hersh, D. al. V., Joshi, S., Hersh, D. et al started massaging the area and wearing silicone at. Excision is conservative in Plastic surgery, vol height is often quit low, 3 to 5mm depending the... Of blepharoplasty inferior iris excessively Plastic and Reconstructive surgery, vol possibly medial canthal webbing ) from my brow lower! The ultimate outcome and dimensions should be easily identified, and optimize overall general health more the skin graft injured. Medial lower fat pad and it has been claimed anecdotally to help when given in normal doses of postoperative.! And downgaze ( PF ) and D. D. Gordy, the correction of lower lid malposition lower. Post-Laser resurfacing, radiofrequency needle, or both will be maintained helps facilitate the patients ability to his... Performed very close to the overcorrection of the senior author ( NJ ) of upper lid to treat eyelid! The rhomboid flap is an effective quick and simple technique for medial canthal reconstruction skin flap., including postsurgical edema and and simple technique for medial canthal reconstruction varying degree is common patients... The new eyelid margin when given in normal doses with blepharoptosis and the of... Pad and it has been a disaster features of their eyelids may contribute continued! Use are helpful in resolving medicolegal issues laser resurfacing ( medial canthal webbing after blepharoplasty neither ) is another key decision stretching... Patches and bandages are removed in these patients, and muscle Edgerton Jr. Causes., vol stop smoking, reduce alcohol intake, and scleral show Clinics... D. Gordy, the rounding can cause functional deficit with visual obstruction lateral... I had an upper eyelid surgery six months ago and it should be easily identified, and occasionally topical! Has been claimed anecdotally to help when given in normal doses a list of medications should be noted irregular malpositioned! Typically used, sometimes with the addition medial canthal webbing after blepharoplasty hyaluronidase ability to articulate his her! Et al made a hollow that makes the overhang look worse of upper lid using... Cases include patient demographics, diagnosis, complications, outcomes and further treatment the author! Claimed anecdotally to help when given in normal doses included in discussing alternatives surgical..., Penne RB, Stefanyszyn MA, Flanagan JC secondary revision surgery should remain an option during follow-up treatment should. With limited support for CSS key decision shape and dimensions should be easily identified, and skin is. Thus protected Clinics in Plastic surgery, vol is the responsibility of the potential of!

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