Blepharoplasty 01-22 Flashcards
A patient who is immediately postoperative forehead feminization as well as transconjunctival lower blepharoplasty complains of pain in the right eye and photophobia. On examination, she has marked swelling of both upper eyelids and increased epiphora and chemosis on the right. Which of the following is the most appropriate next step in management?
A) Administer topical anesthetic eye drops
B) Increase intravenous pain medication and serial examinations
C) Perform emergent bedside canthotomy and cantholysis
D) Perform emergent bedside canthotomy only
E) Return to the operating room for examination under anesthesia
The correct response is Option A.
The most likely diagnosis in this patient is a corneal abrasion. The cornea is highly innervated (300 to 400 times greater than skin) and any abrasion is associated with marked pain and epiphora. Topical anesthetic eye drops, such as proparacaine hydrochloride or tetracaine hydrochloride, can both treat the pain and be diagnostic. In the setting of a corneal abrasion, the patient would get relief within minutes after application and a formal ocular examination would then be possible. Treatment for a corneal abrasion would include symptom control with topical anesthetics as needed and prophylactic topical antibiotics. Eye patches should be avoided since they can decrease oxygenation of the cornea. Similarly, contact lenses should be omitted until the cornea is fully healed. The cause of corneal abrasions is any mechanical injury during induction, preparation, surgery, and emergence. Particular care should be taken by all team members during the entire surgery and up until the moment when the patient is coordinated enough to touch their face. A time that is particularly dangerous is the cleaning of the face at the end of surgery.
Camouflaging an acute pain episode with narcotics, without establishing and treating the root cause, is not sound medical care and can lead to a missed diagnosis with associated harm.
A return to the operating room, as a first step in management, is not indicated in this clinical scenario. If possible, an ophthalmological examination is best performed with an awake patient.
Both forehead feminization and lower blepharoplasty can lead to a retrobulbar hematoma, which may present similar to a corneal abrasion. Physical examination can distinguish between the two entities since a retrobulbar hematoma would present with proptosis. However, a canthotomy involves only the release of the lateral canthus without severance of the lateral canthal tendon that is found more posterior. This incision would inadequately treat a retrobulbar hematoma.
If topical anesthetic eye drops do not have an effect, then further escalation of care is warranted. If an acute retrobulbar hematoma is suspected, a canthotomy and cantholysis can be indicated. This is a procedure that can be done at bedside should the patient be unable to immediately return to the operating room. It is important that this is done properly and that the lateral canthal tendon is entirely released so that the retrobulbar pressure is released.
Which of the following surgical site preparation products is most likely to cause significant eye injury and should be avoided for use in or around the eye?
A) 3% Chloroxylenol
B) 4% Chlorhexidine
C) 5% Povidone-iodine
D) Unscented baby shampoo with sterile water rinse
The correct response is Option B.
Chlorhexidine is a known ocular irritant at 4% strength and can cause severe corneal damage and corneal toxicity, especially if inadvertently left to dwell in the eye during a procedure. Thus, products like hexachlorophene and chlorhexidine gluconate should be avoided in and around the eye. Dilute chlorhexidine at 0.04% can be safely used as an eye treatment and is clinically prescribed for acanthamoeba keratitis, associated with contact lens use.
5% Povidone-iodine is available in a sterile ophthalmic variety and is used for ophthalmic procedures. 10% Povidone-iodine may also be used around the cheeks, brows, and eyelids. Unscented baby shampoo with a sterile rinse can be used for those with povidone-iodine allergies. While chloroxylenol is a mild eye irritant, it can be used with care around the eye.
A patient reports diplopia 6 weeks after transconjunctival lower blepharoplasty. The best way to isolate the function of the muscle that is most likely injured is to have the patient move the eye in which of the following directions?
A) Inferior only
B) Lateral and inferior
C) Lateral and superior
D) Medial and inferior
E) Medial and superior
The correct response is Option E.
The inferior oblique muscle is the most commonly injured muscle during lower blepharoplasty.
The extraocular muscles include the lateral rectus, medial rectus, superior rectus, inferior rectus, superior oblique, and inferior oblique. Vertical movements require coordination between the superior and inferior rectus muscles as well as the oblique muscles. The contribution of each muscle group depends on the horizontal position of the eye.
When the eye is adducted, the oblique muscles are the primary vertical movers. The inferior oblique muscle causes elevation, and the superior oblique muscle causes depression.
When the eye is abducted, the rectus muscles are the primary vertical movers. Elevation is due to the superior rectus, and depression is due to the inferior rectus.
When the eye is looking straight, both of these groups contribute to the vertical movements.
A 45-year-old woman presents to the plastic surgeon’s office with complaints of dryness of the eyes and a burning sensation 1 week after a bilateral upper blepharoplasty with skin and muscle excision only by another surgeon. Her pre-operative history included use of contact lenses for over 20 years and laser-assisted in situ keratomileusis (LASIK) 3 months prior to surgery. Her pre-operative examination showed dermatochalasis of both upper eyelids, positive orbital vector, and normal upper eyelid position, and corneal protectors are used intraoperatively. Which of the following is the most likely cause of her postoperative symptoms?
A) Blepharoplasty technique used
B) History of contact lens use
C) History of laser-assisted in situ keratomileusis (LASIK)
D) Positive vector orbit
E) Use of intraoperative corneal protectors
The correct response is Option C.
Blepharoplasty should not be performed before 6 months following LASIK surgery. This delay is necessary to allow sensation to return to the cornea. The dryness is from the lack of sensation and decreased blinking leading to increased evaporation.
Transient dry eyes occur in up to 26% of patients after blepharoplasty. Initial treatment of dry eye consists of ocular lubrication. Patients with proptosis, exophthalmos, horizontal lid laxity, or a negative vector orbit are more prone to dry-eye syndrome.
Patients who wear contact lenses without difficulty have adequate tear production. If patients have been advised to not wear contact lenses, they should be evaluated for inadequate tear production.
Patients with prominent eyes have a negative vector orbit and are at increased risk of dry eyes. Positive vector indicates a posterior relationship of the anterior cornea to the malar eminence and does not increase the risk of dry eyes.
Blepharoplasty, upper or lower, will increase the risk of developing dry eye postoperatively. The risk is unrelated to technique and upper blepharoplasty may have less risk compared to lower blepharoplasty. When patients have risk factors for dry eyes postoperatively and want upper and lower blepharoplasty, consider staging the upper and lower blepharoplasties.
Intraoperative use of corneal protectors and lubricant is protective because it decreases ocular exposure.
Which of the following locations contains the extraocular muscle that is most likely to be injured during transconjunctival lower eyelid blepharoplasty?
A) Between the central and lateral compartments
B) Between the nasal and central compartments
C) Medial to lateral compartment
D) Medial to nasal compartment
E) Superior to central compartment
The correct response is Option B.
The inferior oblique muscle is the most commonly injured extraocular muscle during lower blepharoplasty and lies between the nasal and central fat pads. Injury can lead to diplopia typically seen postoperatively between 1 and 6 weeks. Initial treatment is conservative. Surgical repair can be attempted only after improvement stops.
Inferior oblique muscle is not found in the other locations.
The arcuate expansion of Lockwood ligament is located between the central and lateral fat pads.
A 55-year-old man presents for correction of periorbital puffiness under the eyes with a tear-trough deformity. Transconjunctival lower lid blepharoplasty, with release of the tear trough ligament, and fat redistribution are planned. Which of the following anatomical landmarks indicates entrance into the premaxillary space and release of the tear-trough?
A) Levator labii superioris
B) Levator labii superioris alaeque nasi
C) Orbicularis oculi
D) Zygomaticus major
E) Zygomaticus minor
The correct response is Option A.
Through a transconjunctival approach, the dissection begins in a preseptal plane and is then converted into a supraperiosteal dissection over the anterior orbital rim until the levator labii superioris is visualized. This ensures release of the tear-trough ligament and entrance in the premaxillary plane. Orbicularis oculi is the muscle that is released and is found more superficial, as are the zygomaticus major and minor, and levator labii superioris alaeque nasi.
A 60-year-old woman presents to the emergency department with severe pain and pressure in her right eye. She is 12 hours postoperative from a transcutaneous lower blepharoplasty performed elsewhere. Her pain and pressure began very early postoperatively. Although she called the clinic to report her symptoms, she was told to “take more pain medication.” On physical examination, there is bruising around the right eye with proptosis, diminished range of motion of the eye with diplopia, and decreased visual acuity compared with the left eye. Which of the following is the most likely diagnosis?
A) Acute glaucoma
B) Extraocular muscle entrapment
C) Orbital cellulitis
D) Retrobulbar hematoma
E) Superior orbital fissure syndrome
The correct response is Option D.
This patient is presenting with signs and symptoms compatible with retrobulbar hemorrhage following her blepharoplasty procedure. This is an emergency requiring prompt treatment. Symptoms and signs include: severe pain and pressure, decreased visual acuity, and decreased range of motion of her extraocular muscles, which may cause diplopia and nausea. She has marked bruising and proptosis.
Retrobulbar hematoma is the most common cause of visual loss after blepharoplasty. Other eye emergencies, such as extraocular muscle entrapment and superior orbital fissure syndrome, typically occur in the setting of trauma, with orbital bony fractures. While acute glaucoma can present with a painful red eye with diminished visual acuity, especially in elderly patients, it is not typically seen in the early postoperative period following blepharoplasty. Orbital cellulitis is an urgent soft-tissue infection that usually presents with fever, as well as a painful, swollen eye. It has been rarely reported after blepharoplasty but presents about 4 to 6 days following the procedure.
Nahai and associates estimate the risk of visual loss following blepharoplasty at 1:20,000, based on a survey of members of American and British aesthetic surgeons. They found that 82% of patients developed symptoms within the first 24 hours, with more than half of these occurring in the first 6 hours postoperatively. Hypertension and use of aspirin were the two most common comorbidities. When a retrobulbar hemorrhage is suspected, suture removal and even lateral canthotomy should be performed at the bedside while the patient awaits an operating room.
Parallel to surgical measures, medical treatment can be commenced to lower intraocular pressure. Acetazolamide (500 mg intravenously), 20% mannitol (1.5 to 2 g/kg; 12.5 g over 3 min), methylprednisolone (100 mg), betaxolol hydrochloride ophthalmic suspension (one drop then twice daily), and 95% oxygen/5% carbon dioxide can be administered for this purpose. At the same time, an ophthalmology consult should be initiated. Prompt decompression of the orbit is required to avoid permanent visual loss.
A 62-year-old woman with no medical or ophthalmologic history is scheduled for cosmetic bilateral upper and lower eyelid blepharoplasty under local anesthesia (1% lidocaine with 1/100,000 epinephrine) with intravenous sedation. The procedure is uneventful. At the end of the procedure, the patient develops new-onset bilateral mild lagophthalmos. Stimulation of which of the following structures is the most likely cause of this lagophthalmos?
A) Corrugator supercilii muscles
B) Levator palpebrae superioris muscle
C) Preseptal orbicularis oculi muscle
D) Superior rectus muscle
E) Superior tarsal muscle
The correct response is Option E.
Eyelid muscles are innervated by the facial nerve (cranial nerve VII), the oculomotor nerve (cranial nerve III), and sympathetic nerve fibers.
Sympathetic fibers contribute to upper eyelid retraction by innervation of the superior tarsal muscle, also known as the Müller muscle. Sympathetic fibers also innervate the inferior tarsal muscle, contributing to lower lid retraction. The superior tarsal muscle was stimulated by the epinephrine of the local anesthesia, causing temporary mild upper lid retraction.
The oculomotor nerve (cranial nerve III) innervates the main upper eyelid retractor, the levator palpebrae superioris muscle, via its superior branch. Oculomotor nerve is one of the four cranial nerves that transmit parasympathetic fibers.
The facial nerve (cranial nerve VII) innervates the orbicularis oculi, frontalis, procerus, and corrugator supercilii muscles, and supports eyelid protraction. The temporal and zygomatic branches of the facial nerve supply the orbicularis oculi, the main eyelid protractor. The facial nerve also supplies the corrugator supercilii and the procerus, both of which secondarily contribute to upper eyelid protraction.
A 56-year-old woman presents for a consultation for upper and lower blepharoplasty. She notes that she has a history of dry eyes. Abnormal production of which of the following is the most likely contributor to this patient’s condition?
A) Lipids
B) Lymph
C) Mucin
D) Protein
E) Sebum
The correct response is Option A.
The tear film is comprised of three layers: an outer lipid layer, a middle aqueous layer, and an inner mucin layer. The meibomian glands produce the outer lipid layer, which prevents tears from evaporating. Thus, meibomian gland dysfunction can lead to dry eyes. Anatomically, Meibomian glands appear posterior to the tarsal plate with an opening at the eyelid margin. The aqueous layer lubricates the eye and helps clear debris. The mucin layer, closest to the cornea, both nourishes the cornea and allows smooth distribution of tears.
Although sebum is often confused with meibum, or meibomian gland secretions, it is not the same. Sebum blockage of the meibomian glands can cause meibomian gland dysfunction. Thus, sebum is incorrect because while sebum can block the Meibomian glands, it is specifically the Meibomian gland dysfunction which causes the dry eye.
A 65-year-old woman is evaluated for inferior scleral show appearing 4 weeks after undergoing lower eyelid blepharoplasty. Preoperative examination shows the presence of a positive lower eyelid vector, horizontal lid laxity, and a retropositioned globe. The patient is euthyroid and is treated for open-angle glaucoma. Which of the following findings is most likely to predispose to the development of post-operative lower lid malposition?
A) Euthyroid status
B) Horizontal lid laxity
C) Open-angle glaucoma
D) Positive lower eyelid vector
E) Retropositioned globe
The correct response is Option B.
Complications arising as a result of blepharoplasty can be categorized as early (occurring during the first postoperative week), intermediate (occurring between the first and sixth postoperative weeks), and late (occurring after the sixth postoperative week).
Among the intermediate post-blepharoplasty complications, lower eyelid malposition is the most commonly reported. It results from the imbalance in tension between the anterior and posterior lamellae. Widely regarded predisposing factors include: negative vector in which the orbital rim is retropositioned relative to the vertical plane of the cornea, excessive skin resection, aggressive imbrication of the orbital septum, thyroid ophthalmopathy (e.g. Graves disease) with exophthalmos, excessive and/or persistent edema, and hematoma.
Horizontal laxity of the tarsoligamentous sling is the most likely predictor of lower eyelid malposition after lower eyelid blepharoplasty. It reflects the loss of normal upward, posterior, and superior tension across the lower eyelid margin. When this condition exists, manifested by a “snap test” in which the lid can be manually distracted anteriorly more than 8 mm away from the globe, surgical correction of horizontal eyelid laxity should be addressed during the lower eyelid blepharoplasty. This is accomplished with a tarsal strip procedure or similar form of canthoplasty. The euthyroid status with or without globe retropositioning of this patient confers less risk than hyperfunctioning thyroid conditions such as Graves in which exophthalmos increases the potential for lower eyelid malposition. A retropositioned globe will not affect the lower lid as much as the upper lid. Medical conditions such as glaucoma do not influence lower eyelid position.
A 62-year-old man with a history of pseudoherniation of the lower eyelid fat pad undergoes a bilateral blepharoplasty with a transconjunctival approach to manage the fat compartments and the pinch blepharoplasty technique to manage excess lower eyelid skin. During the procedure, the surgeon notes difficulty in locating the medial fat pad on the right side despite aggressive dissection. Three weeks postoperatively, the patient comes for follow-up and continues to have difficulty with elevating, abducting, and extorting the eye. Which of the following muscles was most likely injured during the procedure?
A) Inferior oblique
B) Inferior rectus
C) Pretarsal orbicularis oculi
D) Superior oblique
E) Superior rectus
The correct response is Option A.
The inferior oblique muscle is a thin, narrow skeletal muscle near the anterior margin of the floor of the orbit. This extraocular muscle is attached at its origin, maxillary bone, and the posterior, inferior, lateral surface of its insertion, and eye. The inferior oblique muscle receives its innervation by the inferior branch of the oculomotor nerve. This muscle moves the eye by extorsion, elevation, and abduction. The primary action of the inferior oblique muscle is extorsion/external rotation; secondary action is elevation; tertiary action is abduction. This muscle serves as the primary partition between the medial and central fat compartments of the lower eyelid. Careful identification and preservation of the muscle is important during lower eyelid surgery. In this case, the surgeon likely injured the muscle when having difficulty with fat resection of the medial fat pad.
The inferior rectus muscle is responsible for depressing, adducting, and extorting the eye. The orbicularis oculi muscle is responsible for closing the eye. The superior oblique muscle is responsible for intorsion, depression, and abduction. The superior rectus is responsible for elevation, adduction, and intorsion.
Which of the following is associated with the transconjunctival blepharoplasty with the skin pinch technique, when compared with transcutaneous blepharoplasty with a skin-muscle flap?
A) Decreased incidence of scleral show
B) Easier access to the lateral fat compartment
C) Easier access when performing retinacular suture canthopexy
D) Increased incidence of middle lamellar scarring
E) Ineffective resection of lower eyelid skin
The correct response is Option A.
Transconjunctival blepharoplasty with the skin pinch technique has a low rate of scleral show, compared with rates seen in studies of the transcutaneous blepharoplasty using a skin-muscle flap. However, because it uses a transconjunctival approach to the fat compartments of the lower eyelid, access is not improved but can be challenging, particularly for the lateral fat pad. This is considered a disadvantage of the transconjunctival method. Skin resection is believed to be more thorough with the skin pinch method than with the classical skin-muscle flap. The incidence of middle lamellar scarring with the technique is believed to be less, since the orbicularis oculi muscle is not violated. Performance of canthopexy is not changed by the selection of this technique.
A 74-year-old woman comes to the office to discuss blepharoplasty. She has bilateral dermatochalasis and right lid ptosis secondary to levator dehiscence. She does not have dry eyes and states that her vision is much improved after recent corneal refractive surgery. Which of the following is the minimum amount of time after her corneal refractive surgery that this patient should wait before undergoing blepharoplasty?
A) 3 Months
B) 6 Months
C) 9 Months
D) 12 Months
E) None; this patient is not a candidate for blepharoplasty
The correct response is Option B.
The current accepted time frame between corneal refractive surgery and blepharoplasty is a minimum of 6 months. Early post-corneal refractive surgery puts the patient at risk for worsening dry eyes and/or keratopathy.
In an adult patient, which of the following physical findings is most likely to support a diagnosis of involutional blepharoptosis of the upper eyelids?
A) Excess upper eyelid skin
B) Eyelid margin-to-reflex distance of 4.5 mm
C) Higher than normal tarsal crease
D) Less than 8 mm of levator function
E) Upper eyelid eversion upon downgaze
The correct response is Option C.
Blepharoptosis occurs as a result of acquired or congenital causes. Among the former causes is the most common one, involutional (senile), as well as traumatic, mechanical, neurogenic, and myogenic. The latter category includes myogenic or neurogenic causes only. Because surgical correction is the only effective, definitive therapy for acquired ptosis, it is important for the clinician to be able to differentiate between the causes. The involutional variety is due to attrition or dehiscence of the levator aponeurosis from the anterior upper part of the tarsal plate. Diagnosis of ptosis is confirmed when there is less than 2.5 mm of distance between the upper eyelid margin and the papillary light reflex. Physical findings that support the diagnosis of involutional ptosis include a lid drop during downgaze, a higher than normal upper lid crease, visibility of the eye through the thinned upper eyelid, and preservation of good levator excursion (greater than 10 mm). Rating the degree of ptosis is based on the upper eyelid margin to pupillary light reflex distance: greater than 4 mm is considered normal. Excess upper eyelid skin can obstruct visual field; however, it is not indicative of involutional ptosis.
A 65-year-old woman comes to the office because she is concerned about the appearance of her lower eyelid. A photograph is shown. Which of the following maneuvers is most critical to improve her periorbital appearance?
A) Botulinum toxin type A injections in the “crow’s feet” area
B) Fat injection limited to the lower eyelid
C) Orbital malar ligament release and fat repositioning
D) Skin resection and lateral canthopexy
E) Skin resurfacing using a phenol-croton oil peel
The correct response is Option C. The primary factor contributing to the patient’s concern is the relationship of the orbital malar ligament, orbital septum and retroseptal orbital fat. Release of the orbital malar ligament and fat repositioning offers the best option for improvement. The retroseptal fat compartments appear to be full so that fat injection alone would risk creating unwanted prominent fullness in the area. Skin resection should be conservative after fat repositioning to avoid lower lid malposition. Phenol-croton oil peeling is an effective treatment for aging changes but would not correct the anatomical relationships that underlie this patient’s chief concern. Botulinum toxin type A injections would not adequately address this patient’s concerns.
A 50-year-old woman comes to the office seeking cosmetic improvement of the lower eyelids. Transposition of a pedicled postseptal fat graft from the central compartment is planned through a transcutaneous approach. A preoperative photograph is shown. Which of the following is the most appropriate structure to release for transposition?
A) Capsulopalpebral fascia
B) Inferior oblique tendon
C) Lockwood ligament
D) Lower slip of the lateral canthal tendon
E) Orbicularis retaining ligament
The correct response is Option E.
The orbicularis retaining ligament or the orbital malar ligament is a bilaminar membrane that spans from the periosteum of the inferior orbital rim to the fascia on the underside of the orbicularis. During aging, this ligament accentuates the orbital malar depression and restricts the orbital fat from blending with the sub oribularis oculi fat (SOOF). This patient presents with a prominent orbitomalar sulcus and tear trough deformity. Release of the medial portion of the orbicularis oculi muscle and the orbicularis retaining ligament allows fat transposition over the orbital rim, thus softening and improving this deformity. This procedure can be performed through either a transcutaneous or transconjunctival approach.
The capsulopalprebral fascia is a retractor of the lower eyelid. It is incised during a transconjunctival fat excision. It is not incised in a transcutaneous approach.
The inferior oblique tendon of the inferior oblique muscle should be protected during lower eyelid surgery. Lockwood’s ligament is a supportive structure of the globe. The inferior limb of the lateral canthal tendon is not released for fat transposition. It may be released for canthal support and repositioning.
A 53-year-old woman is evaluated 6 weeks after undergoing blepharoplasty. Physical examination shows 1 mm of lagophthalmos with no dry-eye symptoms. The patient returns 8 months later for evaluation of dry eye, which began one month after undergoing laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following is the most likely reason for this patient’s dry-eye symptoms?
A) Blunted blink reflex secondary to decreased corneal reflex arc
B) Chronic use of vasoconstrictive eyedrops
C) Transient decrease in functioning of the orbicular muscle of the eye secondary to stretching from lid traction during surgery
D) Transient decrease in tear production caused by lacrimal gland pressure injury
E) Transient hypersensitivity of the cornea
The correct response is Option A.
Minimal lagophthalmos in the postoperative period following blepharoplasty is not uncommon and generally self-correcting. Minimal lagophthalmos may persist but is often asymptomatic owing to compensatory blinking and increased tear production, both of which are the result of the mild exposure and resulting corneal stimulation.
Laser-assisted in situ keratomileusis (LASIK) procedure involves creation of a corneal flap that interrupts the long ciliary nerves of the ophthalmic division of the trigeminal nerve. The interruption of these nerves results in decreased sensation to the cornea and a decreased corneal reflex arc. Patients with compensated exposure from blepharoplasty may lose the compensatory blink in reaction to corneal irritation following LASIK. This may cause dry-eye symptoms. With time, the corneal reflex arc improves, and the transient neurotrophic keratopathy and dry-eye symptoms improve. The other options are unlikely to cause her symptoms of dry eyes.
A 45-year-old woman comes to the office to discuss aesthetic improvement of the lower eyelids. Physical examination shows lower eyelid pseudoherniation of fat and fine skin wrinkles. A postseptal transconjunctival approach with skin pinch excision is considered. The most significant advantage of this approach compared with a transcutaneous skin-muscle flap is a lower risk of which of the following complications?
A) Capsulopalpebral fascia injury
B) Corneal injury
C) Hematoma
D) Infection
E) Lid malposition
The correct response is Option E.
Transconjunctival blepharoplasty preserves the middle lamella, which includes the orbicularis oculi muscle. Preserving this layer significantly decreases the incidence of ectropion and lower eyelid malposition. Disadvantages of this technique include more difficulty with visualization and access. Many authors believe that a cutaneous skin muscle approach is more effective in blending the lid-cheek junction and transposing fat.
Some studies have shown minor reductions in hematoma and infection rates with the transconjunctival approach; however, the differences are small and not the most significant advantage.
The potential for corneal injury is greater with the transconjunctival approach. Most surgeons use corneal shields to prevent this complication.
The capsule palpebral fascia is routinely cut to access the fat compartments during a transconjunctival blepharoplasty.
When skin excisions are designed for upper blepharoplasty, carrying the medial extent past the punctum is most likely to result in which of the following adverse effects?
A) Inadequate vertical skin excision
B) jury to the lacrimal system
C) Lagophthalmos
D) Retrobulbar hematoma
E) Webbing of the nasal skin
The correct response is Option E.
Extending the skin incisions too far medially can create a webbing of the nasal skin. Carrying the incision medially does not promote inadequate skin excision, lagophthalmos, or retrobulbar hematoma. Injury to the lacrimal system is unlikely to occur with a more medial incision.
A 61-year-old woman is evaluated 7 hours after undergoing bilateral lower blepharoplasty with septal release and fat repositioning. She reports pain and diminished vision in the right eye. Physical examination shows more swelling on the right side than on the left and tender proptosis of the right eye. Which of the following is the most appropriate treatment?
A) Administration of stronger pain medication
B) Head elevation and ice packs
C) Lasix administration and observation
D) Orbital decompression
E) Tarsorrhaphy
The correct response is Option D.
The most appropriate treatment is orbital decompression for retrobulbar hematoma. Most complications after blepharoplasty are correctable and minor. However, postoperative bleeding into the orbit causes a retrobulbar hematoma. With a large enough hematoma, orbital pressure increases, causing increased swelling, eye pain, and proptosis. With continued pressure, the optic nerve is compressed, leading to reduction in vision and ultimately blindness. The cause of a retrobulbar hematoma is bleeding within the orbit. As such, the blepharoplasty technique would be one in which the orbital septum was opened. Nevertheless, this complication must be considered in all blepharoplasty patients.
The treatment for retrobulbar hematoma is emergent orbital decompression. The incision needs to be opened and the orbital space accessed for the hematoma and soft tissues to decompress and alleviate traction or pressure on the optic nerve. A lateral canthotomy is done as well to ensure maximal decompression. In the past, mannitol has been given as a diuretic for reduction of edema, but also as a free radical scavenger in hopes of protecting the optic nerve from compressive ischemia. Lasix is often administered as a quick controllable diuretic to lessen edema.
This is a very rare complication of blepharoplasty. Mejia et al. surveyed plastic surgeons in the United States and Great Britain and derived data from over 750,000 blepharoplasties. In this study, 25 patients had permanent visual loss and 14 had temporary loss of vision. The overall incidence of visual loss due to retrobulbar hematoma was 0.0052% or one in 20,000 cases, with permanent loss occurring in 0.0033% or one in 30,000. Symptoms as noted above occurred in all patients within the first 24 hours, and hypertension was found to be the most common risk factor.
All patients will develop postoperative swelling and ecchymosis to varying degrees. Head elevation and ice packs are appropriate for standard swelling noted without findings of orbital pain, proptosis, or changes in vision. Tarsorrhaphy is useful for patients with lagophthalmos or ectropion but has no role in globe protection for acute proptosis in the above setting. Lasix infusion is part of the treatment for retrobulbar hematoma, but as a stand-alone therapy it is inadequate. Provision of more pain medication is inappropriate in the presence of pain and reduced vision and will only serve to mask some symptoms related to the hematoma.
A 62-year-old woman is evaluated for lower blepharoplasty. On examination, negative vector is noted. Postoperatively, this patient is at increased risk for which of the following conditions?
A) Dystopia
B) Ectropion
C) Enophthalmos
D) Lagophthalmos
E) Proptosis
The correct response is Option B.
The finding of a negative vector places the patient at an elevated risk for lower lid malposition and ectropion. The negative vector refers to the anatomic relationship on lateral view of the maximum projecting point of the globe and the maximum projecting point of the infraorbital malar prominence. If the globe projects less than the malar prominence, a negative vector exists. Conversely, if the malar prominence projects more than the globe, a positive vector exists.
The negative vector finding indicates potentially deficient globe and lid support based on skeletal anatomy. Such patients will often have minor scleral show or lateral lid lag. It is important to recognize these findings prior to blepharoplasty surgery in order to surgically address the risks of ectropion via primary lid suspension during the blepharoplasty. Occasionally, lower lid blepharoplasty may be avoided if a negative vector is present and other conditions such as dry eye exist. Other findings or conditions that are associated with postoperative ectropion and lower lid malposition are: orbicular weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, and eyelid laxity. Excessive or prominent middle lamellar scarring can occur after surgery, which can also lead to lid malposition.
Lagophthalmos is the inability to lower the upper lid fully and is a negative consequence of upper blepharoplasty due to excessive tissue resection or fibrosis. Enophthalmos is interior retraction or displacement of the globe related to increased orbital volume. This is unrelated to lower blepharoplasty surgery. Proptosis is an external displacement of the globe giving the appearance that the eyeball is extruding from the obit. This is most often associated with Graves disease, head trauma, and increased intracranial pressure. It can also be due to a retrobulbar hematoma after blepharoplasty, which is a surgical emergency due to the risk of blindness.
Dystopia refers to malposition of the globe related to skeletal changes of the orbit. This would not be a result of blepharoplasty, but can occur after facial trauma or facial tumor resection.
A 60-year-old man comes to the office because he desires improvement in the appearance of his lower eyelid and upper cheek area. Physical examination shows a prominent tear trough. Which of the following is the anatomic basis of the tear trough?
A) Attachment of the orbital septum to the arcus marginalis
B) Cleft between the palpebral and orbital parts of the orbicularis oculi
C) Osteocutaneous ligament arising from the medial portion of the maxilla
D) Prominence of the orbital rim following descent of the malar fat pad
E) Triangular confluence of the origins of the orbicularis oculi, levator labii superioris alaeque nasi, and levator labii superioris
The correct response is Option C.
Recent articles have greatly improved our understanding of the anatomy of the lower eyelid, tear trough, pre-zygomatic space, and the ligaments in the orbital area.
The tear trough ligament is a true osteocutaneous ligament between the palpebral and orbital portions of the muscle. It extends inferolaterally from the medial canthus to approximately the mid-pupillary line, where is connects with the bilayered orbicularis retaining ligament. Recent anatomic dissection work has shown that this ligament is the anatomic basis of the tear trough deformity.
Fillers should be placed inferior to the tear trough ligament; placing them superiorly will only serve to emphasize lower eyelid fat, and will emphasize the tear trough deformity.
A 16-year-old girl comes to the clinic because she is dissatisfied with the asymmetric appearance of her breasts. Physical examination shows the right nipple-areola complex is more superiorly located and the breast volume is small. There is absence of the right anterior axillary fold. Which of the following other physical examination findings is most likely?
A) Accessory nipple
B) Microtia
C) Right clubfoot
D) Scars consistent with repaired cleft lip
E) Shortened right-hand digits
The correct response is Option E.
The chest findings described are consistent with Poland syndrome with absence of the sternocostal head of the pectoralis major muscle. Poland syndrome can be associated with hand abnormalities, including shortened digits. Cleft lip, accessory nipple, clubfoot, and microtia are not known to be associated with Poland syndrome.
A 32-year-old Korean woman undergoes bilateral upper lid blepharoplasty for creation of a supratarsal crease. A partial incision technique is used. Which of the following is the most likely complication of this procedure?
A) Asymmetry
B) Epicanthal webbing
C) Fold loss
D) Lagophthalmos
E) Suture extrusion
The correct response is Option A.
Blepharoplasty is the most common facial cosmetic procedure performed on people of Asian descent. Unlike blepharoplasty in Caucasian faces, the goal of Asian blepharoplasty is to create a supratarsal fold. Asian eyelids are characterized by several key elements including absent or low lid crease, shorter tarsus, descending pre-aponeurotic fat, and minimal or absent connection between the levator aponeurosis and the upper lid dermis. The mainstay of surgical correction is creation of a permanent fixation point between the levator muscle and the supratarsal dermis and subdermal structures.
The most common complication after Asian blepharoplasty is asymmetry. It is important to remember that unlike Caucasian blepharoplasty, the motivation for Asian blepharoplasty is less frequently rejuvenation. Rather, Asian patients are typically younger and desire creation of a supratarsal fold or correction of a preexisting fold asymmetry. Asymmetry is a common preoperative finding and should be well documented and discussed with the patient before surgery. Small differences in positioning of the newly created crease can be very obvious to both patient and surgeon. When recognized immediately after surgery, early revision should be considered.
Other complications unique to Asian blepharoplasty include fold loss, suture extrusion, and epicanthal scarring. Lagophthalmos, which most often results from overresection of upper eyelid skin, is less frequent in Asian blepharoplasty because skin excision is typically more limited, particularly in a younger patient undergoing a partial incision technique. Fold loss may result from a technical error in securing the layers of dermis, epidermis, or levator aponeurosis, or from placing too few sutures. Revisional surgery would be required to correct this problem. Suture extrusion is not uncommon, given that permanent sutures are used for fixation. Meticulous placement of clear 7-0 nylon and trimming of suture ends will minimize the risk of this complication. If a suture becomes exposed in the first few months postoperatively, removal should be deferred until scarring is mature and fixation is more tenacious. Epicanthoplasty is commonly used is Asian patients with epicanthal folds undergoing blepharoplasty. Various techniques, including Y, W, and modified Z-plasties, have been reported. The epicanthal region is prone to hypertrophic scarring, particularly in Asians who have thick dermis.
Which of the following is the function of secretions of the meibomian glands?
A) Coats cornea as inner layer of tear film
B) Lubricates eyelid skin
C) Prevents evaporation of tear film
D) Promotes control of infectious agents
E) Promotes dispersion of tear film
The correct response is Option C.
Tears are a trilaminar fluid. The precorneal layer is formed by mucin-secreting goblet cells in the conjunctiva. This inner layer of the tear film covers the cornea and promotes the dispersion of the overlying aqueous layer.
The lacrimal gland secretes the middle layer. This aqueous layer is made of water and proteins. This layer promotes osmotic regulation and the control of infectious agents.
The meibomian glands produce the outer lipid layer. This oil layer helps to prevent the evaporation of the tear film. As a result, dysfunction of the meibomian glands can lead to dry eyes.
In a patient with facial proportions within the normal ranges, which of the following measurements best approximates intercanthal distance?
A) Eyebrow length
B) Nasal bone width
C) Orbital fissure width
D) Stomion-to-menton distance
E) Subnasale-to-stomion distance
The correct response is Option C.
Intercanthal distance most closely approximates orbital fissure width. Normal facial values are often described as proportions rather than absolute numbers. Many texts describe normal intercanthal distance as between 30 and 35 mm, but some studies have shown intercanthal distances of up to 40 mm in healthy cohorts. Thus, using the facial features as referents can be helpful. The face is often divided into fifths for analysis of width, and the intercanthal distance represents one fifth, as does the orbital fissure width. The nasal bone width is narrower than the intercanthal distance, and the eyebrow length extends lateral to the lateral canthus, representing greater than a fifth of the facial width. Subnasale, stomion, and menton distances are most often used to calculate facial height proportions. Although there is no reason why, theoretically, a measurement of facial height could not correspond to a measurement of facial width, these values do not.
A 65-year-old woman comes to the office for follow-up 6 days after undergoing bilateral upper eyelid blepharoplasty and repair of the right levator aponeurosis. Preoperatively, the patient had bilateral levator excursion of 13 mm and 4 mm of ptosis of the right eyelid. No ptosis of the left eyelid was noted. Physical examination today shows 2 mm of ptosis of the left upper eyelid. The right upper eyelid is well positioned. Which of the following is the most likely explanation for these findings?
A) Hering law
B) Horner syndrome
C) Müller maneuver
D) Todd paresis
E) von Graefe sign
The correct response is Option A.
Hering law describes equal innervation to the eyelids in that the signal to the levator is the same despite the potential need for each eyelid to work independently. In the scenario described, the patient had obvious ptosis of the right eyelid, and the signal to raise the eyelids was strong. When the right ptosis was corrected, the signal to raise the eyelids decreased, and the more mild ptosis of the left eyelid was uncovered. To help avoid this problem, a Hering test or a patch test can be performed. The Hering test is performed by elevating the ptotic eyelid and observing whether the other eyelid becomes ptotic. A patch test is when the ptotic eyelid is covered for a period of time (usually 15 minutes) and then observed for whether the non-ptotic eye becomes ptotic. The key to both tests is to decrease the excessive signal to raise the eyelids.
Horner syndrome includes ptosis of the eyelid, constriction of the pupil, and decreased sweating due to disease in the sympathetic system. This can be due to a tumor, congenital or iatrogenic.
von Graefe sign is lagophthalmos in downgaze. This is related to Graves disease. Müller maneuver is the reverse of the Valsalva maneuver. After a forced expiration, an attempt at inspiration is made with closed mouth and nose, thereby creating negative pressure in the chest and lungs. This maneuver is used to find weakened areas of the airway.
Todd paresis is focal weakness following a seizure. This can affect eye position.
A 48-year-old woman comes to the office because of pain and tearing of the right eye 1 week after undergoing upper eyelid blepharoplasty. Fluorescein stain test result is positive for corneal erosion. On physical examination, absence of which of the following is most likely to put this patient at risk for corneal ulceration?
A) Accommodation reflex
B) Bell phenomenon
C) Ocular convergence
D) Oculocardiac bradycardia
E) Pupillary light response
The correct response is Option B.
Transient lagophthalmos during sleep is not uncommon following blepharoplasty. During the first few weeks of recovery, it is important to protect the eyes with lubricating drops and ointment. Bell phenomenon, an upward and outer movement of the eye when the eye is closed, is a protective mechanism which keeps the cornea protected behind the upper eyelid. Bell phenomenon is absent in 10 to 15% of the population. Accommodation reflex, oculocardiac reflex, ocular convergence, and pupillary light response do not place the cornea at risk after blepharoplasty.
A 45-year-old woman comes to the office because of puffiness of both lower eyelids. Physical examination shows little lower lid skin excess, but prominent eyelid fat pads. Lid tone, snap back, and distraction test results show no abnormalities. Lid-cheek junction is smooth. A retroseptal transconjunctival approach of the lower lid is planned. Regarding the operative approach, which of the following statements is most accurate?
A) Fat pad reduction without violating the orbital septum is performed
B) Lower eyelid skin resurfacing with laser or chemical peel should not be performed concurrently with a retroseptal approach
C) The incision should be placed 1 to 2 mm below the tarsal border
D) The inferior oblique muscle will be noted between the central and lateral fat pad
E) The plane of dissection is deep to the orbicularis, but superficial to the orbital septum
The correct response is Option A.
The incision for a retroseptal approach is usually placed 4 to 5 mm below the tarsal border, or about 8 mm for the lid margin. The plan of dissection for a retroseptal approach is, by definition, deep to both the orbicularis muscle and septum. Because the fat pads are retroseptal, modification does not require entry through the septum when a retroseptal approach is used.
The preseptal approach is typically chosen for modification of the lid-cheek junction, and facilitates fat pad redistribution and access to the midface. The retroseptal approach is used for reduction of fat pads only. The inferior oblique muscle is located between the central and medial compartments of fat.
Multiple authors have shown that is it indeed safe to perform skin resurfacing with either chemical peel or laser simultaneously with a transconjunctival blepharoplasty.
A 50-year-old woman undergoes upper and lower eyelid blepharoplasty with local anesthesia and intravenous sedation. The procedure begins with no patient discomfort; however, the patient reports marked pain once removal of the lower lateral fat pad is initiated. Which of the following nerves is the source of pain in this patient?
A) Facial nerve
B) Infraorbital nerve
C) Infratrochlear nerve
D) Lacrimal nerve
E) Zygomaticofacial nerve
The correct response is Option E.
The zygomaticofacial nerve provides sensory innervation to the lateral fat pad of the lower eyelid.
Branches of the trigeminal nerve provide sensation to the face. The infraorbital nerve, the second branch of the trigeminal nerve, supplies innervation to the lower eyelid, cheek, and upper lip. The lateral palpebral branch of the lacrimal nerve, a branch of the infraorbital nerve, supplies sensory innervation to the superior lateral portion of the upper eyelid. The infratrochlear nerve provides sensory innervation to the medial aspect of the upper and lower eyelid. The lacrimal nerve provides sensation to the upper eyelid through the first branch of the trigeminal nerve. The facial nerve is a motor nerve to the face and is not responsible for sensation in the face.
Which of the following locations contains the extraocular muscle that is most likely to be injured during transconjunctival lower eyelid blepharoplasty?
A) Between the central and lateral compartments
B) Between the nasal and central compartments
C) Medial to lateral compartment
D) Medial to nasal compartment
E) Superior to central compartment
The correct response is Option B.
The inferior oblique muscle is the most commonly injured extraocular muscle during lower blepharoplasty and lies between the nasal and central fat pads. Injury can lead to diplopia typically seen postoperatively between 1 and 6 weeks. Initial treatment is conservative. Surgical repair can be attempted only after improvement stops.
Inferior oblique muscle is not found in the other locations.
The arcuate expansion of Lockwood ligament is located between the central and lateral fat pads.
A 50-year-old woman comes to the office for consultation because of upper eyelid dermatochalasis and lower eyelid bags. History includes hypothyroidism and type 2 diabetes mellitus. She underwent laser eye (Lasik) surgery 1 year ago. Medications include estrogen and thyroid hormone replacements as well as metformin. Upper and lower eyelid blepharoplasty is planned. This patient is at greatest risk for which of the following postoperative complications?
A) Bleeding
B) Blindness
C) Chemosis
D) Dry eye syndrome
Eyelid malposition
The correct response is Option D.
Dry eye syndrome (dysfunctional tear syndrome) is a problem of tear deficiency and eye discomfort that may result in damage to the cornea. Combining upper and lower eyelid blepharoplasty relative to staged upper and lower eyelid surgery presents a greater risk for dry eye syndrome due to orbicularis oculi dysfunction after surgery. Women on hormone replacement therapy also have a higher risk for developing dry eye syndrome after blepharoplasty. Eye lubrication before and after surgery needs to be strongly considered. Patients with prior laser vision correction should wait at least 6 months before pursuing blepharoplasty because of the effects on corneal sensation and tear production. In this case, the patient’s Lasik procedure 1 year prior would not impair her surgical outcome with upper and lower eyelid blepharoplasty.
Chemosis is characterized by conjunctival swelling and irritation after blepharoplasty surgery, requiring lubrication after surgery. Some surgeons advocate treatment of this condition with steroid drops.
Eyelid malposition is more likely in patients with a negative vector, defined as those with a maxilla that does not project beyond the orbital rim. It is also common in patients who have poor eyelid tone, diagnosed by snap test or evident as ectropion.
Major adverse postoperative events such as bleeding and loss of vision are rare. Bleeding is more risky with uncontrolled hypertension.
Smoking history, diabetes, and hypothyroidism are not directly associated with specific complications of blepharoplasty.
A 57-year-old woman comes to the office because she is dissatisfied with the appearance of her eyes. She says they appear “small” and “tired.” Physical examination shows dermatochalasis of the upper eyelids, 2 mm of eyelid ptosis, deep transverse rhytides of the forehead, and fine periorbital rhytides. She elevates her eyebrows 3 mm when she opens her eyelids. A skin-only blepharoplasty with formal eyelid ptosis repair is planned. After the procedure, which of the following clinical findings is most likely in this patient?
A) Blepharospasm
B) Brow ptosis
C) Decreased pretarsal show
D) Decreased volumetric convexity
E) Eyelid retraction
The correct response is Option B.
A patient who undergoes blepharoplasty and ptosis repair in the context of a compensated brow ptosis is likely to experience worsened brow ptosis after the procedure. Evaluation of the blepharoplasty patient requires careful examination of the entire upper third of the face. Patients may have, in addition to excess upper eyelid skin, an eyelid ptosis. In addition to identifying the ptosis, it is important to recognize compensated brow ptosis. A compensated eyelid ptosis occurs when the patient uses the frontalis muscles to raise the eyebrows, which results in a functional improvement in visual fields. This is most easily identified by having the patient close her eyes, and evaluate the automatic raising of the eyebrow on eyelid opening. In this case, the change in the position of the brow on downward gaze and on frontal gaze indicates a compensated brow ptosis.
After ptosis repair and blepharoplasty, brow ptosis can become more manifest as the need for compensation decreases.
A 48-year-old man comes to the office for consultation because he is dissatisfied with the appearance of his puffy, swollen eyelids and dry eyes. Physical examination shows mild bilateral proptosis and injected conjunctivae. Visual acuity and visual field testing are both normal. Extraocular motion testing reveals lid lag. Which of the following is the most likely cause of this patient?s condition?
A ) Allergic conjunctivitis
B ) Myasthenia gravis
C ) Optic neuritis
D ) Sjögren syndrome
E ) Thyroid ophthalmopathy
The correct response is Option E.
The most appropriate answer is thyroid eye disease, or thyroid ophthalmopathy. This is the most common cause of proptosis and diplopia in adults. It affects women approximately 4 to 6 times more frequently than men. Puffy, swollen eyelids, injected conjunctivae, eyelid lag, and proptosis are common in thyroid ophthalmopathy.
Optic neuritis is typically associated with visual loss, which is not a symptom in this scenario. Similarly, myasthenia gravis is associated with eyelid ptosis, worsening toward the end of the day—which is not a symptom in this scenario. Although both allergic conjunctivitis and Sjögren syndrome could cause conjunctival injection, neither would be associated with proptosis or eyelid lag.
Vision loss, due to compression of the optic nerve, can occur in the most severe cases. Fortunately, this
A 36-year-old woman is scheduled for lower blepharoplasty and mid face rhytidectomy using a transconjunctival approach. Which of the following structures is released to access the mid face for suborbicular muscle of the eye fat redraping?
A ) Capsulopalpebral fascia
B ) Lockwood ligament
C ) Orbital septum
D ) Orbitomalar ligament
E ) Parotid masseteric fascia
The correct response is Option D.
The orbitomalar ligament attaches the orbicular muscle of the eye to the orbital rim. It separates the lower eyelid from the mid face. Release of this structure is required to obtain access to the mid face when approaching it from the lower eyelid.
The capsulopalpebral fascia inserts on the inferior border of the tarsus. It makes up the anterior superior portion of the lower eyelid retractors distal to the Lockwood ligament. The capsulopalpebral fascia is divided during the transconjunctival incision. This affords access to the lower eyelid for the blepharoplasty procedure.
The Lockwood ligament is a fascial thickening that supports the globe. It surrounds the inferior rectus and inferior oblique muscles and fuses with the capsulopalpebral fascia. It is analogous to the Whitnall ligament in the upper eyelid. The orbital septum acts to contain the orbital contents. It attaches inferiorly to the periosteum at the arcus marginalis and superiorly to the eyelid margin. A transconjunctival blepharoplasty can be performed by a pre- or postseptal approach. The parotid masseteric fascia is within the mid face. It is distal to the orbitomalar ligament when approached from the eyelid. It does not need to be released to access the mid face.
A 48-year-old woman is brought to the emergency department after sustaining facial injuries in a motor vehicle collision. Physical examination shows a 4-cm laceration of the left upper eyelid. The levator palpebrae superioris is transected just superior to the tarsus, exposing underlying structures. Which of the following intact structures is now exposed?
A ) Lacrimal sac
B ) Müller muscle
C ) Orbital septum
D ) Preaponeurotic fat
E ) Retro-orbicularis oculi fat
The correct response is Option B.
Knowledge of periorbital anatomy is critical for plastic surgeons who perform eyelid procedures, both cosmetic and reconstructive. The levator complex originates at the orbital apex at the lesser wing of the sphenoid and travels horizontally until it reaches the Whitnall ligaments, where it changes to a more vertical direction before its aponeurosis inserts on the tarsus, orbital septum, and skin. Above the level of the tarsus, the orbital septum lies anterior to the levator, and preaponeurotic fat lies posterior to the orbital septum.
Retro-orbicularis oculi fat lies anterior to the septum and posterior to the orbicularis oculi.
Müller muscle inserts directly on the tarsus and lies just posterior to the levator directly superior to the tarsus.
A 50-year-old woman is scheduled to undergo transcutaneous blepharoplasty. Fat transposition and canthopexy are planned. The inferior oblique muscle of the eye is most vulnerable to injury when dissecting between which of the following structures?
A) Central fat compartment and lateral fat compartment
B) Lateral fat compartment and orbicularis retaining ligament
C) Medial canthal tendon and medial fat compartment
D) Medial fat compartment and central fat compartment
E) Orbicularis retaining ligament and arcus marginalis
The correct response is Option D.
The inferior oblique muscle of the eye can be found between the medial fat compartment and the central fat compartment. When performing either excision or manipulation of the medial and central fat compartments, the inferior oblique muscle is vulnerable to injury. These injuries include resection, cauterization, scarring, hemorrhage, edema, and suture injury while repairing the septum orbitali. Depending upon the extent of injury, the symptoms can be transient or permanent. One study suggested that transection of less than 50% of the muscle will not cause permanent diplopia.
The orbicularis retaining ligament is a structure that originates along the orbital rim and inserts into the overlying orbicularis oculi muscle. Laterally, it contributes to the lateral canthal ligament. Recent studies have demonstrated that the orbicularis retaining ligament is a circumferential structure. The arcus marginalis is the periosteal extension of the septum orbitale as it attaches into the orbital rim. The inferior oblique muscle lies deep to both of these structures.
A 50-year-old woman is scheduled to undergo transcutaneous lower eyelid blepharoplasty for periorbital aging. Which of the following is the most likely complication 3 months postoperatively?
A) Chemosis
B) Infection
C) Lacrimal system dysfunction
D) Lagophthalmos
E) Lower eyelid malposition
The correct response is Option E.
The most common complication following lower blepharoplasty is lower eyelid malposition. Lower eyelid malposition ranges from mild scleral show to severe cicatricial ectropion. Malposition of the lower eyelid results from abnormal downward forces on the eyelid. Excessive scarring, over-resection of skin, imbrication of the orbital septum, orbicularis paralysis, edema, and hematoma can all produce lower eyelid malposition. Predisposing factors for malposition that should be indentified preoperatively include malar hypoplasia, globe proptosis, high myopia, laxity of the lower eyelid, and thyroid ophthalmopathy. Postoperative mild scleral show can often be managed with massage and topical lubrication. However, severe ectropion may require scar release, skin grafting, or a lower eyelid tightening procedure such as a canthoplasty.
Chemosis is a postoperative sequela, but it usually resolves in 6 weeks. Infection of the lower eyelid following blepharoplasty is rare given that the eyelid is well vascularized. Lacrimal system dysfunction is rare and often returns to normal without surgical intervention. Lagophthalmos can occur following upper blepharoplasty and can lead to postoperative pain, guarding, or incomplete eyelid closure. Lagophthalmos is usually temporary and resolves with lubrication and eyelid massage.
A 69-year-old woman comes to the office for consultation regarding lower eyelid blepharoplasty. Physical examination shows a negative canthal tilt. Snap-back testing of the lower eyelid shows 8 mm of distraction. Transcutaneous lower blepharoplasty with fat transposition is planned. Which of the following is the most appropriate surgical choice to avoid postoperative malposition of the lower eyelid?
A) Horizontal wedge excision
B) Lateral canthoplasty
C) Orbicularis repositioning
D) Posterior lamellar graft
E) Tarsorrhaphy
The correct response is Option B.
Lateral canthal support can treat preexisting lower eyelid laxity and can help protect against postblepharoplasty malposition of the lower eyelid. The choice of treatment can be determined by the extent of eyelid laxity. For severe lower eyelid laxity (greater than 6 mm of eyelid distraction), a lateral canthoplasty with lateral cantholysis allows for increased superior mobility and precise positioning of the lower canthal tendon inside the orbital rim. While horizontal wedge excision of the lower eyelid addresses the horizontal lower eyelid laxity, it is not recommended in negative canthal tilt patients (lateral canthus at lower level than medial canthus), who also require lateral eyelid resuspension. Mild eyelid laxity (1 to 2 mm of eyelid distraction) can also be addressed with orbicularis repositioning. A posterior lamellar graft would not be an appropriate treatment for this condition. In minimal cases of eyelid laxity, temporary external support of the lower eyelid with a tarsorrhaphy stitch at the lateral limbus can help protect the cornea and prevent early cicatricial ectropion.
A 50-year-old woman comes to the office because of numbness of the skin of the right central forehead 10 weeks after undergoing upper eyelid blepharoplasty. The procedure involved transpalpebral resection of the medial brow depressor muscles. Injury to which of the following nerves is the most likely cause of this patient’s condition?
A) Abducens
B) Oculomotor
C) Supraorbital
D) Supratrochlear
E) Zygomaticotemporal
The correct response is Option D.
The most likely cause of numbness in the patient described is injury to the supratrochlear nerve. The supratrochlear nerve courses superiorly through the corrugator muscle and innervates the central forehead skin. It is subject to injury during muscle interruption via either of the transpalpebral, coronal, or endoscopic approaches. The abducens nerve is motor to the lateral rectus muscle of the globe and is not within the operative field. Although it can be injured distal to its exit from the frontal bone, the deep branch of the supraorbital nerve provides sensation to the frontal periosteum. The frontal branches of the facial nerve are motor only to the frontalis muscle. The oculomotor nerve would not result in these findings, as it does not supply sensation to the forehead. The zygomaticotemporal nerve renders sensation to the lateral orbital-forehead skin and is located far lateral to the medial brow depressors.
A 32 €‘year-old woman comes to the office for follow-up examination six months after she underwent repair of a fracture of the left orbit. A preoperative photograph is shown. Physical examination shows cicatricial ectropion of the lower eyelid. Which of the following is the most appropriate management?
(A) Complete tarsorrhaphy
(B) Pentagonal wedge resection of the lower eyelid
(C) Placement of a graft to the lower eyelid
(D) Punctal occlusion of the lower eyelid
(E) Resuspension of the lower eyelid retractors
The correct response is Option C.
Protection of the ocular surfaces is the primary goal in managing the cicatricial ectropion of the lower eyelid in the patient described. The patient €™s lower eyelid lacks height. Scarring between the capsulopalpebral fascia (lower eyelid retractors) and the orbital septum because of trauma or following aggressive lower eyelid blepharoplasty can cause vertical contracture of the lower eyelid, resulting in corneal exposure. Lower eyelid position can only be restored by placement of an autogenous or alloplastic spacer graft (hard palate, donor sclera, auricular cartilage, tarsus, and others), as in the postoperative image shown. In conjunction, eyelid-tightening procedures such as lateral canthopexy and canthoplasty address horizontal skin laxity.
Complete tarsorrhaphy is not an option for a young and active patient. It is an acceptable temporizing solution in cases of paralytic ectropion.
Pentagonal wedge resection of the lower eyelid is an adjunct procedure for cases of lower eyelid laxity with horizontal skin excess.
Punctal occlusion of the lower eyelid would alleviate the dryness caused by the increased exposure but would not restore normal anatomy of the lower eyelid in the patient described.
Repair of the lower eyelid retractors in conjunction with lateral canthal resuspension is used to correct lower eyelid entropion. The procedure would not address the scarring present in the patient described.
A 16-year-old girl has persistent ptosis of the eyelid (shown) six months after undergoing reconstruction of the forehead and supraorbital bar for fibrous dysplasia. One month postoperatively, a wound developed from extrusion of hardware through the medial eyelid. Debridement of the wound with excision of the involved inflammatory tissue and reconstruction with a pericranial flap were performed at that time. On current examination, no levator function is noted medially in the eyelid and lateral movement of the eyelid is minimal. Which of the following interventions is the most appropriate next step in management?
(A) Lysis of adhesions
(B) Kuhnt-Szymanowski procedure
(C) Fasanella-Servat procedure
(D) Suspension to the frontalis muscle with fascia lata grafting
(E) Advancement of the levator muscle
The correct response is Option D.
This patient has traumatic ptosis as a complication of prior surgical procedures. At the time of debridement, either a portion of the levator muscle was excised or the muscle function is limited by scar tissue. In either case, the function as shown in the photographs is minimal, and the ptosis is best managed by a frontalis suspension procedure. It is generally agreed the fascia lata is the material of choice for the sling. Alloplastic materials, such as silicone slings, can also be used but have a risk of extrusion and infection. The advantage of alloplastic sling reconstruction is that there are no risks to the donor site.
The Fasanella-Servat procedure involves excision of a portion of the conjunctiva, tarsus, orbital septum, levator aponeurosis, and Müller muscle. It can be used in cases of mild ptosis (1-2 mm). Levator function must be present.
The Kuhnt-Szymanowski procedure is used to correct lower eyelid ectropion. It involves a wedge excision of the lower eyelid.
Levator advancement surgery could possibly be used in this case if, during exploration of the eyelid, the levator was noted to be present and not compromised by scar. However, in this case, the levator mechanism was likely excised in the process of debriding the wound tract and inflammatory tissue. Therefore, in light of the degree of ptosis, the noted limited elevation of the upper eyelid, and the mechanism of injury, frontalis suspension is a better choice for ptosis repair in this patient.
With no evidence of muscle function, it is unlikely that adhesions alone are the cause of restricted eyelid movement. Therefore, lysing the scar would likely be inadequate treatment.
A 6-year-old child who has had chronic bilateral epiphora since birth has been treated with corneal lubrication for the past year. Slit-lamp examination by the child’s pediatric ophthalmologist one week ago showed bilateral corneal staining. On physical examination, the lashes on both lower eyelids rub against the inferior cornea (shown above). Which of the following is the most appropriate management?
(A) Daytime taping of the margin of the lower lid
(B) Initiate nighttime lubrication of the eyes
(C) Lateral tarsal strip with repositioning of the eyelid margin
(D) Reinsertion of the retractors at the base of the tarsus and subtotal excision of the preseptal orbicularis
(E) Resection of redundant pretarsal skin and orbicularis muscle
The correct response is Option E.
The most common cause of epiblepharon is excess pretarsal skin and orbicularis oculi muscle at the lower eyelid margin. In this congenital anomaly, a fold of skin and underlying orbicularis muscle override the eyelid margin, often pushing the cilia against the globe. The eyelid margin and tarsus are stable and maintain the proper orientation. Epiblepharon usually affects the lower eyelids, is more common among Asians, and may be accentuated on downward gaze. Most cases resolve with facial growth during childhood. Surgical correction is needed when the lashes cause significant corneal injury. Epiblepharon requires resection of the redundant pretarsal skin and orbicularis muscle as well as placement of sutures between the tarsal plate and the subcutaneous tissue to create adhesions.
Taping of the lower eyelid is not practical in a child. Nighttime lubrication of the eyes is not sufficient treatment because the lashes continue to cause damage during the day, which may cause permanent corneal scarring. Lateral tarsal strip and repositioning of the eyelid margin are a common treatment for ectropion. Reinsertion of the retractors at the base of the tarsus and subtotal excision of the preseptal orbicularis are the treatment of choice for involutional entropion with horizontal laxity from the tarsus, vertical laxity due to attenuation or disinsertion of the lower eyelid retractors or orbital septum, and migration of the preseptal orbicularis in the pretarsal position.
A 44-year-old woman has the defect shown above three days after undergoing excision of a squamous cell carcinoma from the lower eyelid. The resultant defect of the lower lid is 60%. Which of the following reconstructions is the most appropriate management?
(A) Composite contralateral lower lid graft
(B) Cutler-Beard flap
(C) Direct closure with cantholysis
(D) Hughes tarsoconjunctival flap
(E) Skin graft
The correct response is Option D.
This defect requires prompt surgical correction, because allowing the wound to granulate would result in a severely dysfunctional eyelid. With such a defect, a Hughes tarsoconjunctival flap is best used for reconstruction. This reconstruction involves taking a tarsoconjunctival flap from the upper eyelid, leaving 3 to 4 mm of the upper tarsus intact, and advancing the remaining tarsus and conjunctiva to the lower eyelid defect. This provides the posterior lamella of the eyelid. The anterior lamella is reconstructed by advancement of a skin-muscle flap from the lower eyelid or cheek.
Direct closure with cantholysis is appropriate for defects of less than 25% of the eyelid. The Cutler-Beard flap, which uses skin and muscle from the lower eyelid, is inappropriate for a patient with a lower eyelid defect. Because this patient=s defect affects more than 50% of the lower eyelid and because the eyelid requires a supportive base, a skin graft or composite contralateral lower eyelid graft would not provide adequate support.
The photograph shown above is of a 56-year-old man who underwent open reduction and internal fixation of a malar complex fracture on the right and cranial bone grafting of the right orbital floor three months ago after sustaining bony injuries in a motor vehicle collision. He had no skin lacerations at the time of injury.
Which of the following is the most likely cause of the lower eyelid deformity?
(A) Entrapment of Lockwood’s ligament
(B) Inferior displacement of the orbital floor
(C) Loss of skin elasticity
(D) Periorbital fat atrophy
(E) Shortening of the posterior lamella
The correct response is Option E.
This patient’s lower eyelid deformity is most likely caused by shortening of the posterior lamella. The lower eyelid is formed by the anterior, middle, and posterior lamellae. The anterior lamella consists of skin and orbicularis oculi muscle. The orbital septum comprises the middle lamella. The posterior lamella, or capsulopalpebral fascia, is comprised of the tarsus muscle, lower lid retractors, and conjunctiva. Injury or scarring of any of these structures can result in malpositioning of the lower eyelid, as seen in this patient. Shortening and scarring of the posterior lamella and septum are most common.
Entrapment of Lockwood’s ligament would lead to a loss of globe support, and inferior displacement of the cranial bone grafts and orbital floor would result in dystopia. Scleral show and ectropion resulting from excess skin excision are more typical of cosmetic blepharoplasty than internal fixation. Periorbital fat atrophy can result in scleral show and a change in globe position but rarely causes ectropion in patients with traumatic orbital injuries.
