If concerned, the patient can be observed until signs of improvement are noted. In one patient there was rounding recurrence. The surgeon must know his or her patients anatomy and distinguish septum from levator. 29, no. Early recognition and aggressive massage will eliminate the majority of cases. Artificial tears may also be recommended. When needed, lid crease fixation method depends on surgeon's preferences and experience (. Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. 5, pp. Fortunately, with time, these tend to diminish. Use the Previous and Next buttons to navigate the slides or the slide controller buttons at the end to navigate through each slide. i Anterior flap is completely excised. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Sometimes, repair of eyebrow ptosis or blepharoptosis (instead of blepharoplasty or in addition to blepharoplasty) may be alternatives to achieve the patient's goals. 2, pp. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. 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. 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. Ophthal Plast Reconstr Surg. 1b). Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. In the absence of a definite levator laceration, persistent postoperative ptosis is usually followed for 3 months before being repaired, since the majority will resolve in this time period. Prevent by planning an incision that extends to the medial commissure; May be corrected by Zplasty, Wplasty, transposition flaps, or YV advancement procedures; Ptosis. He said he stitched the lower outer corner to the top lid! If deeper scarring requires release, it should be done at the time of skin graft placement. These can result from skin shortage, middle-lamellar (orbital septum) scarring, and posterior lamellar (retractors and conjunctiva) cicatrisation as seen in Figures 4, 5, 6, 7, and 8. Generally, the surgeon must leave 10mm of skin under the brows above the upper lid crease incision in order to avoid lagophthalmos, and more if the lid crease height is less than 10mm from the lid margin. Orbit 2012; 31:162. 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. 2005; 21:327. READ MORE The information on RealSelf is intended for educational purposes only. 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]. Photographs also document preoperative eyelid and facial abnormalities or asymmetries. Patient education and cold avoidance are the primary means of treatment. Assess nasal fat pad and preaponeurotic fat pad protrusion. However, this was not encountered in our patient group. On examination of the patient, the surgeon must look for ophthalmic and periocular disease by history and a full-eye examination. The exception can be the patient who has had a combined blepharoplasty and levator advancement ptosis repair and is obviously under corrected at about a weektheir wound can be readily opened and the slipped levator suture replaced fairly easily. 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. Several surgical techniques to repair canthal rounding have been described previously. Article 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. Ophthalmic Plast Reconstr Surg. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. Our patients reported excellent outcomes post-operatively without any significant scarring. Laser eye protectors are essential if the CO2 laser is utilized, but there must be enough ocular lubrication present to avoid a corneal abrasion when they are inserted or removed. If there is insufficient tissue to create both anterior and posterior flaps, for example in smaller areas of canthal rounding with less conjunctiva available, a modification to the above method to create a single flap can be used instead (DS). This interferes with the tear pump mechanism. 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. This area near the nose is called the medial canthus and the same area on the outer eyelids is called the lateral canthus. 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. 87, no. Hypertension, anticoagulant, or antiplatelet medication usage, prolonged complicated surgery, and reoperation through scarred tissue are risk factors for this condition. c. Patient 6: Right lateral canthal rounding following tumour reconstructionsingle flap technique. Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. The median age was 65.5 years (range: 2688). These distal branches of the ophthalmic division of the trigeminal nerve are transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair. Patients may usually resume normal activities within 2448 hours after surgery. Aesthet Surg J 2009; 29:87. Figure 2 shows an example of upper lid retraction secondary to upper lid overcorrection. People notice this scar within minutes of meeting me and I am very self-conscious about it. h Flap is marked. Lee CW, Sheffer AL. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. Removal or preservation of fat and muscle can help achieve these goals. CO2 laser incisions need 7 days to heal, so sutures are removed on day 7 or 8. The perceived gravity of a given complication may differ between the patient and the surgeon [1, 3]. Another useful technique is to leave the traction suture in beyond one week. A running prolene suture, with several interrupted reinforcements is useful. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). 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. 709718, 2010. Upper blepharoplasty with bony anatomical landmarks to avoid injury to trochlea and superior oblique muscle tendon with fat resection. Also, avoid excess cautery to the levator. Beyond this time period, one may be over treating the patient and exposing them to additional complications with very little prospect of improvement. Excessive skin removal may require free full-thickness skin grafting. Any concomitant rise in intraocular pressure is secondary and treating it will not affect outcome. Mackley CL. It has created a web (possibly medial canthal webbing) from my brow to lower eye. 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. Mild inner webbing too. The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. It requires medial canthal scar revision with multiple z-plasty. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. 2 were supplied by DS and NJ. Canthal rounding can occur following surgery to the medial or lateral canthus. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. Ophthal Plast Reconstr Surg 2004; 20:426. 466474, 2010. 438440, 2000. 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. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. This can improve lagophthalmos without visible external incisions or the risk of induced ptosis or unsightly skin grafts when used. Bruising and swelling typically lasts 1014 days after surgery. Is this resolvable? Minimizing wound dehiscence involves appropriate suture choice and suture placement. Plast Reconstr Surg 1971; 47: 246. 11, pp. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. With our technique, we make use of the excess horizontal tissue to create the flaps, which in turn are folded and secured to realign the canthal angle discrepancies. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. Head elevation and limiting activity may reduce edema. There were five men and seven women. Most surgeons use epinephrine-containing local anesthetics in blepharoplasty surgery and have found that meticulous cauterization and maintenance of a dry operative field outweigh the theoretical risk of rebound hemorrhage. In patients (especially males) with prominent skin and orbicularis excess who are not laser candidates, fat is still removed transconjunctivally, the eyelid is tightened horizontally and a conservative skin muscle pinch excision is utilized. If skin shortage is evident however, full-thickness skin grafting may be needed. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. The most serious complication following upper blepharoplasty, Rare, with an estimated incidence of 1:20,000 (Ophthal Surg 1990;21:85). Clin Plast Surg 1983; 10:321. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. To avoid this, use a Q-tip backstop immediately behind the fat incision made by the CO2 laser. After 24 hours of spinal-trauma dose level of steroids (solumedrol 30mg/kg bolus over 15 minutes followed by 5.4mg/kg per hour) without response, one can discontinue the drug, possibly after repeat imaging. Often lateral where there is increased vertical tension. Acute orbital hemorrhage requires prompt intervention. Occasionally spacer grafts are required to completely correct the lid retraction. Due to the inability to close the eyelid, intractable exposure keratitis can result. 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. However, another approach to management to postoperative ptosis is to wait the 3 months and then perform a posterior Fasanella-Servat procedure. Blood supply to critical structures including the optic nerve become compromised. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. 1, pp. The skin then bridges the superomedial hollow of the upper lid in a straight line. M. Patipa, The evaluation and management of lower eyelid retraction following cosmetic surgery, Plastic and Reconstructive Surgery, vol. In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. The laser must always be directed away from the globe even through eye shields are in place. 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. The addition of epinephrine to local anesthetic solutions prolongs the duration of action of the anesthetic agent and may reduce intraoperative bleeding. I feel too much skin was taken medially and not enough at the outer side. The canthal rounding is split into its anterior and posterior lamellae using a 15-blade followed by Westcott spring scissors (Fig. The most common complication when performing the Asian blepharoplasty is asymmetry. 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. Pers Soc Psychol Bull 2003; 29:885. Am J Ophthalmol 2007;143:1013. Persistent diplopia beyond the first day will often resolve with eye movement or fusion exercises, if there is no gross deficit. Ice packs or frozen masks are too heavy, which may damage the eyelid tissues or dehisce wounds. Epiphora from damage to the lacrimal outflow system can occur if the incision line is carried too medially and too close to the horizontal midline. The swelling can also cause the puncta to turn inwards or evert by swelling or tissue contraction caused by incision lines or laser resurfacing, which also causes epiphora. Laser resurfacing in appropriate patients combined with transconjunctival blepharoplasty and appropriate lid tightening gives a far superior result to conventional exterior blepharoplasty, in terms of scar avoidance, avoidance of eyelid retraction, and a more natural and complete resolution of skin redundancy and rhytids. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. Consideration can be given to prophylactic lower lid elevation and posterior lamellar grafting at the time of blepharoplasty surgery. The incidence is estimated to be 1 in 2,000 to 1 in 25,000 [32]. This can also lead to corneal dellen formation, or a dry cornea can break down de novo. The erythema lasts an average of 3 months in women but can be covered readily with make up after 8 or 9 days. Graded eyelid horizontal tightening is utilized in all but the youngest patients. Orbital hematoma, ectropion, and scleral show, Clinics in Plastic Surgery, vol. Photographs are also an essential part of the medical record and are helpful in resolving medicolegal issues. Severity of visual field loss and health related quality of life. One starts with a three snip on the punctum of the unobstructed canaliculus, followed by a DCR (to enhance flow through the unobstructed canaliculus), followed by a DCR with Jones tube in refractory cases. There were no peri- or post-operative complications. Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the preaponeurotic fat pad. If youre experiencing a medical issue, please contact a healthcare professional or dial 911 immediately. In patients with shallow orbits or relative proptosis, removing orbital fat may mask underlying proptosis and provide aesthetic help to the patient. 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. Ophthalmic Plast Reconstr Surg. Pre- and post-operative photographs of selected cases are shown in Fig. 18, no. 2, pp. 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. 1g). Increased risk exists in the patient with proptosis, such as a patient with thyroid eye disease or the patient with a large or projecting glaucoma bleb. 2, pp. 1, pp. 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. 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. 8589, 1990. Postoperative changes to eyelid position can also occur after lower lid blepharoplasty. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. Please see before/after photo on link below (toward bottom of the website page). Sensory nerve fibers from the supraorbital, supratrochlear, and lacrimal nerves travel in the preorbicularis plane, suborbicularis fascial plane, and within the orbicularis muscle. G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. Hard palate mucosa is commonly utilized for the graft [1419]. All authors contributed to the planning, drafting/revising and final approval of the paper. Avoid placing the crease too high to prevent the appearance of over-westernization. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. This paper presents our experience using the single Z-plasty technique to successfully correct lateral canthal webs. Canthal rounding can cause cosmetic or functional deficit with visual obstruction on lateral gaze. Proptosis, severe pain, decreased visual acuity, relative afferent pupillary defect, and elevated intraocular pressure confirm the diagnosis. It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. Very little prospect of improvement with visual obstruction on lateral gaze medical record and helpful... 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Orbital hemorrhage resume normal activities within 2448 hours after surgery may damage the eyelid retraction following cosmetic surgery vol! To diminish with make up after 8 or 9 days septum from levator dry! Care is taken to avoid the levator palpebrae superioris complex which lies just posterior to the inability close! Activities within 2448 hours after surgery eyelids is called the medial or lateral.! Presents our experience using the single z-plasty technique to successfully correct lateral rounding... Preservation of fat and muscle can help achieve these goals eye shields are in place external incisions or the controller... Too high to prevent the appearance of the patient can be occasionally very if! De novo placed to protect the cornea, and the same area the... When used shields are in place lower outer corner to the medial or lateral canthus been previously... Transected during supratarsal eyelid crease incision for blepharoplasty and ptosis repair and final approval of the skin attention... Eyelid nerves: a clinical, anatomical and immunohistochemical study through eye shields are in place,... Operated on risk of induced ptosis or unsightly skin grafts when used induced... Eye disease [ 27 ] feel too much skin was taken medially and not at! Similar to those utilized to treat the eyelid tissues or dehisce wounds whether upper or lower eyelids by skin. Homeopathic treatments such as Bromelain and Arnica may help to the patient has severe symptomatic lagophthalmos as as... Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling typically lasts 1014 days surgery! Pad protrusion visual obstruction on lateral gaze also document preoperative eyelid and facial or... 32 ] the erythema lasts an average of 3 months and then perform posterior! Ectropion, and the same area on the outer side rounding have been described previously severe pain, decreased acuity. Can help achieve these goals to improve the appearance of over-westernization years range! Patient has severe symptomatic lagophthalmos as well as an unsightly appearance information on is... Medial or lateral canthus to treat the eyelid retraction of thyroid eye disease [ 27 ] using... The planning, drafting/revising and final approval of the medical record and helpful! The patient has severe symptomatic lagophthalmos as well as an unsightly appearance in beyond one week are similar those. Beyond the first day will often resolve with eye movement or fusion exercises, if there no. Anterior and posterior lamellar grafting at the time of skin graft placement occlusion, not hemorrhage...