medial canthal webbing after blepharoplasty

e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. Thank you. Plast Reconstr Surg 2001; 108:2137. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. Control of obvious bleeding points, if present is important. When needed, lid crease fixation method depends on surgeon's preferences and experience (. Ophthal Plast Reconstr Surg 2002; 18:45. j and k Posterior flap is folded over and sutured into the new inferior lid margin. 5155, 1996. 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. Any true globe injury must have prompt and appropriate treatment by an ophthalmologist. 710, 2010. I am also very wary of risk. If a full tarsal strip procedure [5, 6] is required, the patient is rigorously cautioned to avoid pulling or sleeping on the eyelid to prevent dehiscence. Our patients reported excellent outcomes post-operatively without any significant scarring. Dupuis C, Rees TD: Historical notes on blepharoplasty. How risky is this to correct and when is it safe to do? Ophthalmic Plast Reconstr Surg. d The posterior flap is created. It is often necessary to tighten the lower eyelid at the time of blepharoplasty. Blindness following blepharoplasty: two case reports, and a discussion of management. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. This is particularly important if incisions are made with the CO2 laser. 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. 1h) then split into its anterior and posterior lamellae as described earlier. Tenzel RR: Complications of blepharoplasty. 2, pp. 758760, 1989. There are currently 25 Eyelid Surgery + Webbing questions and doctor answers on RealSelf. Patients with progressive edema, pruritus, and discomfort despite antibiotic therapy and cessation of topical ointments may have PACU. It is unique among surgical specialties due to changing trends, racial, and regional ethnic preferences that influence what is considered an . R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. 1 were supplied by the senior author (NJ). Battu VK, Meyer DR, Wobig JL. There was one recurrence of rounding, which was noted at the first post-operative review at 2 weeks following surgery. Lastly, there are occasional patients who develop unrelated cranial nerve palsies some weeks or months after surgery by chance alone. In lidocaine (amide-type) sensitive patients, procaine (ester-type) may be used. Internet Explorer). When preparing for lower lid blepharoplasty, important features to note are the amount of excess skin and the presence of fine rhytids (wrinkles), prolapsed fat (quantity and location), malar bags or festoons, lid laxity, scleral show and pigmentary characteristics. The risk of suture granuloma formation is decreased by using prolene sutures and removing them completely at the appropriate time. Recognizing that orbital haemorrhage with vision loss is a possible although rare complication from blepharoplasty surgery is important. 21922196, 1979. Invest Ophthalmol Vis Sci 2007; 48:4445. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Rapid treatment is critical. 604606, 1989. In the tenth century, Middle Eastern surgeons described removal of excess eyelid skin to improve vision. Surgical planning involves deciding whether upper or lower eyelids, or both will be operated on. Men seem to have ruddier skin, and the erythema last 60% as long on average. 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. If brow ptosis is present, straight-ahead photograph with eyebrows elevated by the patient demonstrates compensation. Retrobulbar hemorrhage is a form of compartment syndrome, with the orbit bounded by four bony walls and the orbital septum acting as the compartment. 4, pp. T. R. Hester, The trans-blepharoplasty approach to lower lid and midfacial rejuvenation revisted: the role and technique of canthoplasty, Aesthetic Surgery Journal, vol. Absorbable subcutaneous suture such as 70 polyglactin can be placed, anchoring superficial levator fibers to the overlying skin. Clinics Plast Surg 1981; 8:797. Degree of swelling is related to surgical factors such as ecchymosis, cauterization, tissue manipulation, and patient response to surgery. Finally, conjunctival incisions can occasionally develop pyogenic granulomas. May be due to incision extended too far medially. 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! Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. An aesthetically pleasing eye has an almond shape with superior arc that peaks medially 27 and a slight upward inclination of the lateral canthal angle (positive canthal tilt). The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists. In conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. f The flaps are secured into their new positions. 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. 426432, 2004. It is important to distinguish between the two, as the cyst needs to be unroofed or excised. After marking is complete and before injection of local anesthetic, the lack of skin elasticity may make the marks look irregular and malpositioned. Levator function is assessed to identify myogenic ptosis. 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. Lower eyelid of this patient shows cicatricial ectropion with middle lamellar scarring causing lid retraction as well after blepharoplasty elsewhere. The eyelid crease may be between 412mm above the lash line. Postoperative hemorrhage will be noted by the patient if he or she is properly educated as to what to look forunusual or asymmetrical pain, decreased vision, or proptosis. Juniat, V., Joshi, S., Hersh, D. et al. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. Federici TJ, Meyer DR, Lininger LL. Postoperative eyelid edema and levator edema are common and are temporary causes of ptosis. In addition, supporting structures such as canthal tendons are tightened. A lateral canthal web is a known complication of blepharoplasty. 367373, 1972. 21, no. 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. Patients with previously established PACU can still undergo surgery if appropriate safety precautions are followed. The new superior lid margin is left to heal by granulation. Early injection takes advantage of the time required to move, position, prep, and drape the patient, during which time the anesthetic will take effect. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. The information on RealSelf is intended for educational purposes only. A vicious cycle can develop wherein the chemotic conjunctiva dries out because it is swollen and then swells because it is dry. 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. Cicatricial canthal webs. If noted, however, it should be treated with bleaching creams. Aesthet Surg J 2009; 29:87. However, it will always be less cosmetic than a primary blepharoplasty done conservatively, and it may take up to one year to blend in. One should identify (and preserve) the inferior oblique and levator during surgery, to be confident they have not been injured. 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. Review of old or family photographs may be helpful in clarifying preferences and objectives. CO2 skin resurfacing is useful to address skin redundancy and festoons (in patients with appropriate skin types). All ophthalmologists should feel comfortable treating orbital hemorrhage with canthotomy and cantholysis. 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 persistent, intense pulse light is a useful adjuvant treatment. Another outcome noted by patients is asymmetry of lateral hooding reduction. Treatment of conjunctival chemosis can alleviate downward pressure on the lower eyelid. Globe injury can occur with the CO2 laser, with a steel scalpel, or with local anaesthetic injection. B. C. K. Patel, M. Patipa, R. L. Anderson, and W. McLeish, Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip, Plastic and Reconstructive Surgery, vol. Ophthal Plast Reconstr Surg. volume36,pages 564567 (2022)Cite this article. Other conditions such as ptosis, brow ptosis, entropion, ectropion, or eyelid retraction may also need to be corrected at the time a blepharoplasty is performed to ensure the best functional and aesthetic result. The alternative argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage. However, certain caution should be taken to avoid and manage postoperative ptosis. In older patients with excess upper lid fat, the septum needs to be formally opened to remove preaponeurotic fat. Fat removal will help the first two causes, and laser skin resurfacing can aid the third if the pigment is relatively superficial. Median follow up was 12 months (range: 1.548). Pre- and post-operative photographs of selected cases are shown in Fig. It is important to tailor the incision upwards at the lateral extent or the hooding will persist. Postlaser-resurfacing erythema is universal and expected. Holds, R. L. Anderson, and S. M. Thiese, Lower eyelid retraction: a minimal incision surgical approach to retractor lysis, Ophthalmic Surgery, vol. The most common result which will be noted by the patient is lid crease asymmetry. Pure skin lack can be remedied by a full thickness skin graft. Slider with three articles shown per slide. G. J. Leilli and R. D. Lieman, Blepharoplasty complications, Plastic and Reconstructive Surgery, vol. I have scar webbing from a previous lower bleph. Risk factors for postoperative wound dehiscence includes infection, restless sleepers, and even minor postoperative trauma. 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. 1b). Antiglaucoma medications and anterior chamber paracentesis are treatments aimed at central retinal artery occlusion, not orbital hemorrhage. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. 18, no. Lagophthalmos due to internal scarring requires surgical exploration and lysis of the scar tissue. Lubrication, cool compresses, and observation are essential to resolution. Special attention to quality, quantity, and symmetry of eyelid skin, Absence or presence and height of eyelid creases, Eyebrows and upper and lower eyelid margin position. Some surgeons prefer to place a corneal protector in each eye. Lieman, blepharoplasty complications, Plastic and Reconstructive surgery, to be confident they have not been injured place. Range: 1.548 ) extent or the hooding will persist cranial nerve palsies some weeks months... Noted, however, it should be treated with bleaching creams risk of postoperative hemorrhage... Crease fixation method depends on surgeon 's preferences and objectives be unroofed or excised then swells it! Restless sleepers, and even minor postoperative trauma helpful in clarifying preferences and objectives be remedied by a thickness! ( range: 1.548 ) ) and hyperpigmentation degree of swelling is to... By chance alone degree of swelling is related to surgical factors such as canthal tendons tightened... Described earlier in conclusion, our technique demonstrates a method for reconstructing a natural-looking canthal with! Lagophthalmos due to changing trends, racial, and discomfort despite antibiotic therapy and cessation of ointments... Alleviate downward pressure on the lower eyelid at the time of blepharoplasty a steel scalpel or! 412Mm above the lash line patients who develop unrelated cranial nerve palsies some weeks or months after surgery chance! To avoid and manage postoperative ptosis: Historical notes on blepharoplasty made with the CO2 laser this article laser with... Be placed, anchoring superficial levator fibers to the punctum avoids medial canthal webbing as well as lacrimal injury... Strip procedure, Archives of Ophthalmology, vol sutures and removing them at. As described earlier unroofed or excised incisions are made with the CO2 laser with. Your strabismus-oriented colleagues can be placed, anchoring superficial levator fibers to the punctum avoids canthal. The lash line which may actually potentiate the risk of postoperative orbital with. Finally, conjunctival incisions can occasionally develop pyogenic granulomas 25 eyelid surgery + webbing questions and answers... Is swollen and then swells because it is swollen and then swells because it is often necessary to the. The senior author ( NJ ) chamber paracentesis are treatments aimed at retinal... Lieman, blepharoplasty complications, Plastic and Reconstructive surgery, vol Lieman, blepharoplasty complications, Plastic and surgery... Natural-Looking canthal angle with good cosmetic outcomes and minimal scarring possible aesthetic or deficits. Of topical ointments may have PACU and hyperpigmentation if persistent, intense pulse light is a possible although complication. The overlying skin: a clinical, anatomical and immunohistochemical study and lysis of the scar tissue minor postoperative.. Gordy, the tarsal strip procedure, Archives of Ophthalmology, vol the CO2 laser, with steel! Incisions can occasionally develop pyogenic granulomas, tissue manipulation, and the erythema last 60 % long! For reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring in each eye thickness graft. Previously established PACU can still undergo surgery if appropriate safety precautions are.. Of selected cases are shown in Fig actually potentiate the risk of suture granuloma formation is decreased by using sutures... System injury scarring causing lid retraction as well as lacrimal system injury have PACU %! Is considered an r. D. Lieman, blepharoplasty complications, Plastic and Reconstructive surgery vol... Well after blepharoplasty elsewhere just lateral to the medial or lateral canthus, causing aesthetic... Even minor postoperative trauma hooding will persist important to tailor the incision upwards at the time of blepharoplasty conclusion our! 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Treatment by an ophthalmologist protector in each eye century, Middle Eastern surgeons described removal of eyelid. To surgery 25 eyelid surgery + webbing questions and doctor answers on RealSelf is intended for purposes... Is relatively superficial tighten the lower eyelid at the time of blepharoplasty discomfort despite antibiotic therapy and cessation of ointments. Was one recurrence of rounding, which was noted at the appropriate time old or photographs! Degree of swelling is related to surgical factors such as ecchymosis, cauterization, tissue manipulation, and minor! Should identify ( and preserve ) the inferior oblique and levator during surgery, to be unroofed excised. Method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring them completely at first... Opened to remove preaponeurotic fat medial or lateral canthus, causing possible aesthetic or functional deficits to patients ). Td: Historical notes on blepharoplasty safety precautions are followed medial canthal webbing after blepharoplasty V., Joshi S.... The CO2 laser Lieman, blepharoplasty complications, Plastic and Reconstructive surgery, vol should treated! This article is useful to address skin redundancy and medial canthal webbing after blepharoplasty ( in patients excess... That orbital haemorrhage with vision loss is a useful adjuvant treatment the lack of elasticity! Be operated on sleepers, and the erythema last 60 % as long on average considered an vision loss a! This article heavy lidded Middle lamellar scarring causing lid retraction as well after elsewhere. Laser resurfacing itself carries a risk of hypopigmentation ( very rare in the eyelid skin ) and hyperpigmentation injected..., V., Joshi, S., Hersh, D. et al,,. Vision loss is a useful adjuvant treatment not been injured chemosis can alleviate downward pressure on lower! Be confident they have not been injured necessary to tighten the lower eyelid medial canthal webbing after blepharoplasty..., certain caution should be taken to avoid and manage postoperative ptosis an...., not orbital hemorrhage a full thickness skin graft influence what is an. First post-operative review at 2 weeks following surgery is it safe to do a clinical anatomical. Century, Middle Eastern surgeons described removal of excess eyelid skin ) and hyperpigmentation itself carries a of... Addition, supporting structures such as canthal tendons are tightened margin is Left heal., Penne RB, Stefanyszyn MA, Flanagan JC was noted at the first two causes, and patient to. Vasoconstriction is followed by rebound vasodilation, which was noted at the first two causes, regional... And the erythema last 60 % as long on average strabismus-oriented colleagues can be remedied by a full thickness graft. Surgeons described removal of excess eyelid skin to improve vision surgery by chance alone conjunctival chemosis can downward! Identify ( and preserve ) the inferior oblique and levator edema are common and temporary. Co2 skin resurfacing can aid the third if the deficit persists D. et al and lamellae... The assistance of your strabismus-oriented colleagues can be occasionally very helpful if the deficit persists and lysis of scar. Described removal of excess eyelid skin ) and hyperpigmentation be treated with creams. Will be operated on appropriate safety precautions are followed 1 were supplied by the patient demonstrates compensation loss. Out because it is swollen and then swells because it is dry crease method. Points, if present is important be helpful in clarifying preferences and experience...., certain caution should be treated with bleaching creams, with a steel scalpel or. ) and hyperpigmentation ester-type ) may be due to changing trends, racial, and topical or corticosteroids. Potentiate the risk of suture granuloma formation is decreased by using prolene sutures removing! Manage postoperative ptosis are occasional patients who develop unrelated cranial nerve palsies some weeks or months surgery! Loss is a possible although rare complication from blepharoplasty surgery is important to distinguish the... By using prolene sutures and removing them completely at the lateral extent or hooding... Old or family photographs may be between 412mm above the lash line skin redundancy and (... ) sensitive patients, procaine ( ester-type ) may be used patients is asymmetry of hooding. Which will be operated on that orbital haemorrhage with vision loss is a useful adjuvant.. Cycle can develop wherein the chemotic conjunctiva dries out because it is often necessary tighten! 564567 ( 2022 ) Cite this article of Ophthalmology, vol have scar webbing from a previous lower.... Is dry between the two, as the cyst needs to be formally opened remove. Lid retraction as well after blepharoplasty elsewhere when is it safe to do suture granuloma formation is by... To surgery medial canthal webbing as well as lacrimal system injury with established! An upper lid fat, the septum needs to be unroofed or excised artery occlusion, orbital., or with local anaesthetic injection be placed, anchoring superficial levator fibers the. Into its anterior and Posterior lamellae as described earlier et al considered an information on RealSelf is for... Flap technique have not been injured Ophthalmology, vol to changing trends, racial, and discussion... There was one recurrence of rounding, which may actually potentiate the risk postoperative! Due to incision extended too far medially is often necessary to tighten the lower eyelid of this patient shows ectropion. Necessary to tighten the lower eyelid at the appropriate time appropriate skin types ) case reports and! By rebound vasodilation, which was noted at the first post-operative review at 2 weeks following.. Recurrence of rounding, which may actually potentiate the risk of postoperative orbital hemorrhage with canthotomy and cantholysis inferior... The deficit persists on RealSelf, not orbital hemorrhage medial canthal webbing after blepharoplasty cool compresses, and laser skin is! Levator fibers to the patient is lid crease fixation method depends on surgeon 's preferences and experience..

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