Blepharoplasty

Question 1

Complications following upper lid surgery are rare but
include lagophthalmos and dry eye

Answer 1

T

Question 2

the lateral canthus may become lax, causing lid malposition and rounding of the lateral commissure with aging process

Answer 2

T

Question 3

The goal of blepharoplasty is to
restore a mor� youthful appearance without any compromise of phys-
10log1c function

Answer 3

T

Question 4

margin of the upper eyelid should cover the superior 1 to 2 mm of the
cornea whereas the margin of the lower eyelid is usually within 2 mm
of the inferior border of the cornea

Answer 4

T

Question 5

The pretarsal portion is important for voluntary blinking

Answer 5

F The pretarsal portion is important for involuntary blinking The preseptal and orbital
portions of the orbicularis are involved with voluntary blinking and
forced eyelid closure

Question 6

Which part of orbicularis can cause brow depression

Answer 6

The orbital portion of the orbicularis can cause
brow depression in the upper lid, and attenuation of this muscle can
contribute to festoons in the lower lid

Question 7

the central and
medial (or nasal) fat pad, separated by the superior oblique extraocular muscle

Answer 7

T

Question 8

The medial fat pad is lighter in color than the central fat pad
and sits near the supratrochlear nerve and vessels

Answer 8

T

Question 9

the ligaments that connect the lacrimal glands to the bone
(Sommering ligaments) attenuate, the palpebral lobe can cause a prominent fullness in the lateral upper lid fold

Answer 9

T

Question 10

The levator is innervated
by cranial nerve III and Muller muscle is innervated by the sympathetic nervous system.

Answer 10

T

Question 11

The lid crease is higher in men .

Answer 11

F The lid crease is generally lower in men (6-8 mm) than women
(8-10 mm;

Question 12

The superior tarsal conjunctiva contains an abundant number of
goblet cells responsible for forming the mucous layer of the tear film.

Answer 12

T

Question 13

The tarsal plate of the lower eyelid is shorter,
only 3 to 4 mm in height

Answer 13

T

Question 14

The medial
and central fat pads are divided by the inferior oblique extraocular
muscle.

Answer 14

T

Question 15

The lower eyelid retractors

Answer 15

the capsulopalpebral fascia and inferior tarsal muscle,

Question 16

Extend of the tear trough

Answer 16

nasojugal groove and extends inferolaterally from the medial canthus to
approximately the midpupillary lin

Question 17

represents the lower edge of the orbicularis

Answer 17

zygomatical-facial (or cutaneous) ligament, which forms attachments from the bone to the dermis.
This usually represents the lower edge of the orbicularis

Question 18

The lateral canthus t has a deep limb that attaches to a tubercle 1.5 mm posterior to the lateral orbital rim (Whitnall tubercle)
as well as a superficial limb, which inserts on the rim.

Answer 18

T

Question 19

The medial canthus has a large
anterior limb and a small posterior limb, inserting on the anterior or
posterior lacrimal crest, respectively. They surround the lacrimal sac

Answer 19

T

Question 20

The Asian eyelid differs significantly from Caucasian anatomy HOW ?

Answer 20

The upper lid crease may be absent, low, or present only laterally
because of a lack of connections between the skin and levator.
A medial epicanthal fold may be present,
the upper tarsus may be shorter.
The Asian upper lid has more fullness because of preaponeurotic fat
that extends more caudally,
There is an upward lateral canthus tilt.

Question 21

unrealistic self-image or who are not capable of understanding the
limitations of the procedure are poor surgical candidates.

Answer 21

T

Question 22

Blepharoplasty should
not be considered within 6 months of refractive surgery as this predisposes the patient to dry eyes.

Answer 22

T

Question 23

Examination of the lid laxity

Answer 23

Snap pack
lid distractiion test

Question 24

A lid distraction test pulls the lower lid from the globe anteriorly, and a distance of greater than 6 mm is considered abnormal

Answer 24

t

Question 25

the ocular surface for dryness examination

Answer 25

Schirmer test fluorescein dye test

Question 26

Schirmer test

Answer 26

placing a 5 by 35 mm strip of filter paper in the lateral conjunctiva! cul-de-sac, and waiting 5 minutes. Normal eyes show 10 or more mm of wetting of the filter paper

Question 27

In clinical practice, Schirmer testing is infrequently used

Answer 27

T

Question 28

fluorescein dye

Answer 28

Staining of the ocular surface with fluorescein dye and examination under blue light reveals punctate staining corneal erosions in patients with dry eyes. This examination is more efficient in identifying patients with dry eye and is preformed routinely in ophthalmology offices.

Question 29

A. squint test delineates the function of the upper orbicularis

Answer 29

F A. squint test delineates the function of the lower orbicularis

Question 30

the Bell phenomenon

Answer 30

This is done by forcibly holding the eyelids open as the patient tries to close them, and seeing if the globe rolls up to protect the cornea. Absence of this reflex puts the eye at risk for dryness and ulceration if postoperative lagophthalmos is present

Question 31

Modern techniques rely on a careful diagnosis of the patient, restoration of more youthful anatomy, and preservation of fat

Answer 31

T

Question 32

The lateral edge of the mark should be extended to the orbital rim along a crow's foot crease, but no more than l O mm beyond the canthus

Answer 32

T

Question 33

The medial marking should not extend beyond the punctum to avoid webbing

Answer 33

T

Question 34

There should always be at least 10 mm of skin left below the brow.

Answer 34

T

Question 35

A safe rule of thumb is that skin resection should preserve a brow to margin distance of at least 20 mm

Answer 35

T

Question 36

Great care is taken to avoid any traction on the fat as this can lead to bleeding posterior to the septum and a retro-orbital hemorrhage

Answer 36

T

Question 37

Minimal conservative fat removal is recommended

Answer 37

T

Question 38

Patients with fat prolapse or tear trough deformity and minimal excess skin can be approached with a transconjunctival lower lid blepharoplasty with fat excision or redraping

Answer 38

T

Question 39

The incision is then stairstepped so that the muscle incision is made 5 mm below the lashes to spare the pretarsal orbicularis

Answer 39

T

Question 40

Vicryl suture is used to resuspend the orbicularis to the soft tissue and periosteum in the area of the lateral orbital rim to provide mechanical support for the lower lid and prevent ectropion.

Answer 40

T

Question 41

If the patient was found to have significant lower eyelid laxity during the preoperative evaluation, they are at higher risk for ectropion with any skin resection

Answer 41

T and a lateral canthal tightening procedure should be performed

Question 42

A canthopexy can be used for mild laxity.

Answer 42

T

Question 43

canthoplasty or lateral tarsal strip addresses moderate to severe lower lid laxity.

Answer 43

T

Question 44

Lateral canthal support is generally not needed in a transconjunctival approach, as the orbicularis is not weakened by division.

Answer 44

T

Question 45

Severe festoons treatment

Answer 45

muscle resection, redraping, or suspension along with midface lift, liposuction, or direct excision.

Question 46

Patients should avoid strenuous activity or bending below the waist for 2 weeks

Answer 46

T

Question 47

presents as severe pain, pressure, and decreased vision. in first 24 hours indicate what

Answer 47

retroseptal hematoma

Question 48

Examination is diagnostic as there is proptosis, limitation of extraocular movements, and increased intraorbital pressure

Answer 48

T

Question 49

In the case of vision threatening hematomas

Answer 49

t urgent opening of the incision for evacuation of the hematoma. A lateral canthotomy can be performed to relieve intraorbital pressure. If the patient has developed vision loss, high-dose IV steroids should be initiated to maximize visual recovery.

Question 50

Persistent lagophthalmos is usually the result of aggressive skin removal or scarring of the orbital septum

Answer 50

T

Question 51

Erythema and purulent discharge should be treated with antibiotics and culture, and computed tomography may be necessary to evaluate for an orbital abscess.

Answer 51

T

Question 52

Diplopia is usually transient and is managed conservatively.

Answer 52

T

Question 53

Tearing is usually transient

Answer 53

T

Question 54

Acute Complications

Answer 54

Orbital Hematoma Corneal Abrasion Lagophthalmos Chemosis Infection Corneal Exposure/Dry Eye Diplopia Epiphora

Question 55

Long-Term Complications

Answer 55

Asymmetry Lid Malposition Dry Eye Syndrome Unsightly Scars

Question 56

Lower lid surgery carries more risk

Answer 56

T

Question 57

Blepharoplasty the 4th leading cosmetic procedure for plastic surgeons

Answer 57

T

Question 58

The tarsus, or tarsal plate, is the cytoskeleton structure of the eyelid. It is made up of connective tissue and Meibomian glands, which secrete an oil that prevents evaporation of the eye's tear film

Answer 58

T

Question 59

The orbital fat pads behind the septum are separated from the inferior fat pad by the orbitomalar ligament, in lower eyelid

Answer 59

T

Question 60

Beneath the orbitomalar ligament is the prezygomatic space where the suborbicularis oculi fat resides

Answer 60

T

Question 61

Malar mounds are defined as chronic soft tissue edema between the infraorbital rim and the midcheek. If chronically and severely swollen, then the skin and muscle in this area may elongate and form permanent cascades called festoons

Answer 61

T

Question 62

The lateral canthus is approximately 10 mm in length

Answer 62

T

Question 63

The marginal arcade is usually found 2 to 3 mm from the lid margin on the anterior surface of the tarsus

Answer 63

T

Question 64

The upper lid has an additional peripheral arcade, found on the anterior surface of the Miiller muscle

Answer 64

T

Question 65

Inferior to the zygomatic-facial ligament, the malar fat is present anterior to the facial muscles

Answer 65

T

Question 66

Dry eye history is elicited by asking about blurry vision that clears with blinking,

Answer 66

T

Question 67

always some degree of asymmetry present in human eye

Answer 67

T

Question 68

The margin to reflex distance (MRDl) Measurement

Answer 68

This is the measurement in millimeters from the light reflex on the patient's cornea to the level of the center of the upper eyelid margin, with the patient gazing in the primary position. Ifthe margin to reflex distance is 2 mm or less, the patient is considered to have visually significant ptosis

Question 69

The amount of excess skin ofthe upper eyelid (dermatochalasis) should be assessed.

Answer 69

t

Question 70

lower eyelid blepharoplasty is generally functional.

Answer 70

F In contrast to upper eyelid blepharoplasty, lower eyelid blepharoplasty is generally cosmetic.

Question 71

The position of the globe relative to the orbital rim in noted. If the globe is more anterior than the orbital rim, this is called a positive vector and may suggest thyroid disease or a patient prone to dry eye problems. If the globe is posterior to the rim, this is called a negative vector

Answer 71

T

Question 72

capsulopalpebral fascia (a fibrous extension from the inferior rectus that inserts onto the inferior tarsus)

Answer 72

T

Question 73

Whitnall tubercle

Answer 73

Small elevation ofthe zygomatic bone just inside the lateral orbital rim that serves as the attachment point for the lateral canthaI tendon, the lateral horn ofthe levator aponeurosis, the check ligament ofthe lateral rectus and Lockwood ligament

Question 74

Retro-orbicularis oculi fat (ROOF)-Fat pad deep to the brow, which may also descend with aging

Answer 74

T

Question 75

Dermatochalasis-Excess skin ofthe upper or lower eyelid, and may obstruct the upper visual field

Answer 75

T

Question 76

Blepharochalasis-Excess skin caused by repeated episodes ofedema

Answer 76

T

Question 77

Steatoblepharon-Excess or protruding fat

Answer 77

T

Question 78

Functional benefits are noted for an MRD I of 2 mm or less measured in primary gaze, superior visual field loss of 12 degrees or 24%,

Answer 78

T

Question 79

The medial and lateral crease is generally 4 to 5 mm above the lid margin.

Answer 79

T

Question 80

If the position of the lid crease is different on each side, choose one crease height and mark symmetric incisions for each eyelid

Answer 80

T

Question 81

Eyelashes should just evert with the pinch test

Answer 81

T

Question 82

not always needed, removal of muscle may be done to decrease fullness or to create a crisp supratarsal fold. A strip of 3 to 5 mm is removed

Answer 82

T

Question 83

The medial orbital fat pad typically requires debulking more often than the central pad

Answer 83

T

Question 84

Some patients have a prominent fat fad under the lateral third of the brow, which is below the orbicularis. This is called retro-orbicularis oculi fat and can be resected at the time of blepharoplasty

Answer 84

T

Question 85

Double armed sutures can be used to engage the inferior tip of the gland and secure it to the periosteum just inside the superior orbital rim at the lacrimal fossa.

Answer 85

T

Question 86

sutures are typically removed 7 days after surgery

Answer 86

T

Question 87

The lower incision should be 5 to 7 mm inferior to the upper lid incision.

Answer 87

T

Question 88

A subciliary skin incision is marked 2 mm below the lower eyelid lashes

Answer 88

T

Question 89

The incision is then stairstepped so that the muscle incision is made 5 mm below the lashes to spare the pretarsal orbicularis

Answer 89

T

Question 90

A skin-muscle flap is dissected inferiorly to below the orbital rim. The orbitomalar ligament is completely released so that the skin is no longer fixed to the bone.

Answer 90

T

Question 91

conservative in the amount of skin resected because this can cause retraction of the lower eyelid

Answer 91

T

Question 92

If the patient was found to have significant lower eyelid laxity they are at higher risk for ectropion with any skin resection and a lateral canthal tightening procedure should be performed

Answer 92

T

Question 93

In a lateral tarsal strip, the lid is redraped laterally.

Answer 93

T

Question 94

Transconjunctival Approach

Answer 94

A scalpel or cutting cautery is used to incise the conjunctiva just below the tarsal plate.

Question 95

The lower eyelid retractors are divided. Dissection proceeds inferiorly, between the septum and orbicularis, to expose the fat pads and orbital rim

Answer 95

T

Question 96

Patients are advised to elevate their heads and apply cool compresses or ice to the eyelids for the first 24 to 48 hours.

Answer 96

T

Question 97

Patients should expect postoperative swelling and bruising to persist for up to 2 weeks after surgery

Answer 97

T

Question 98

Measurement to decrease the orbital hematoma

Answer 98

careful tissue handling to avoid traction of the fat pads and careful hemostasis of the base of the fat pad. Preoperative considerations such as control of hypertension and the avoidance of aspirin and blood thinners can decrease this risk as wel

Question 99

The patient presents immediately postoperatively with severe eye pain, tearing, andblurredvision withaforeignbodysensation. Ophthalmology consultation may use fluorescein and a Wood's lamp to document an abrasion

Answer 99

t

Question 100

Persistent lagophthalmos is usually the result of aggressive skin removal or scarring of the orbital septum. Reoperation with lysis of scar tissue and/or skin grafting may be required in severe cases.

Answer 100

t

Question 101

Conjunctiva! edema is common after surgery and is usually self-limited. Artificial tears and a steroid eyedrop/ ointment can be prescribed if the swelling is severe

Answer 101

t

Question 102

Infection is rare because of the excellent vascularity of the face.

Answer 102

t

Question 103

The superior and inferior oblique muscles are the most commonly injured extraocular muscles in upper and lower blepharoplasty, respectively

Answer 103

t

Question 104

Strabismus surgery or prism glasses may be used to correct persistent diplopia.

Answer 104

t

Question 105

An altered lid position may also cause tearing. Tearing is usually transient

Answer 105

t

Question 106

The tear trough ligament is an osteocutaneous ligament between the palpebral and orbital portions of the muscle.

Answer 106

t

Question 107

The inferior oblique arises from the orbital surface of the maxilla, lateral to the lacrimal sac and inserts into the scleral surface

Answer 107

T

Question 108

A superior rectus palsy would present with limitation ofupgaze in abduction

Answer 108

T

Question 109

superior oblique injury would have limited downgaze in adduction

Answer 109

T

Question 110

An inferior rectus palsy would limit abducted downgaze.

Answer 110

T

Question 111

A Jones test

Answer 111

evaluates lacrimal outflow by placing fluorescein into the conjunctiva and then testing for it in the inferior nasal meatus.