Blepharoplasty and Brow LIft Flashcards
1
Q
Define dermatochalasis and blepharaochalasis
A
- blepharochalasis - excess fat, skin and muscle in upper eyelid - inflammatory
- dermatochalaiss - only excess skin - laxity
2
Q
Define blepharoptosis and pseudoptosis
A
- blepharoptosis - upper lid margin inferior displcaed over limbus
- pseudoptosis - depression of upper lid secondary to enopthalmus/dermatochalasis
3
Q
Define the Shimer test, snap test and distraction test
A
- Schirmer test - to verify reflex and basic tearing, use 35x5mm filter paper, 5mins, normal is 10-30mm. Schirmer 1 test both reflex/basic, test 2 w tetracaine to eliminater relfexive response
- Snap test - lid pulled downward, if >1sec to return to position =laxity
- Distraction est - lid pulled away from globe, if can be distracted >6-10mm =laxity
4
Q
What are aesthetic measurments deifning an attractive periorbital region
A
- Intecanthal distance 1/5 of facial width
- Hairline to brow at pupil 5-6cm
- brow to midpupil 2.5cm
- pretarsal skin show 3-6mm
- lash line to upper tarsal crease 10mm
- brow to SOR 1cm
5
Q
Describe the anatomy of o.oculi
A
Pre-tarsal
- Medial - superficial head inserts on ant limb of MCT, deep head inserts on posterior crest posteriro to lacrimal sac
- Lateral - inserts with LCT onto Whitnalls tubercle
Pre-septal
- Medial - superficial heads inserts on ant limb of MCT, deep head inserts on posterior lacrimal crest w pretarsal OO
- Lateral - forms a raphe of fibers which insert directly into skin
Orbital
- MEdial - inserts onto SOR and IOR
- Lateral - lies superficial to frontalis, corrugator, ZM/m, lip and nasal levators
6
Q
Describe the sensory innervation in the periorbital region
A
- STN, SON (V1)
- Infratrochlear nerve (V1) (both upper and lower lids)
- lacrimal n (V1)
- Infraorbital (V2)
- Zygomaticofacial/zygomaticotemporal (V2)
7
Q
Describe the intra and extraorbital fat compartments
A
Post-septal (intraorbital)
- Upper (2) - medial pale yellow fat w medial palpebral artery + infratrochear n. Central butter yellow fat. Lacrimal gland lies laterally
- Lower (3) - medial pale yellow (separated by IO) central butter yellow (seperated by lateral extension of arcuate ligament) lateral butter yellow
Pre-septal (extraorbital) lies deep to orbicularis, anterior to septum
- Roof - Retro-orbicularis oculi fat
- SOOF - sub-orbicularis oculi fat
8
Q
What are the origins and insertios of the orbital septum
A
Origin: IOR and SOR - named arcus marginalis
Insertion - Upper lid - 15mm above uppe rtarsal birder
Insertoin - Lower lid - 5mm below lower tarsal border
9
Q
What forms supratarsal crease?
A
insertion of OO and fibrous levator aponeurosis into skin
10
Q
Describe your history and physical for patient presenting with periorbital complaints of againg
A
History
- Deformity, desires, expectations
- Ocular Hx: corrective lens/contact, dry sx, visual sx, last ophtho asx, cataract, glaucoma, Lasix surgery
- Symptom (ptosis/laxity) - onset, duration, progression, uni/bilat
- PMHx: HTN, thyroid, coagulative D, endocrine, meds/allergies
PE
- Visual Asx: pupils, EOM, VA, VFs, conjuntival ingection, fundoscopy, corneal reflex
-
Upper lid:
- Static - > lid position (ptosis/retraction), brow position, excess skin/muscle/fat, supratarsal crease
- Dynamic: levator fx, Bells, lagophthalmus, orbicularis fx
-
Lower lid:
- Static: malar bag, festoons, excess skin/muscle/fat, lip position (ectro/entro/scleral show)
- Dynamic: Snap and distraction test (laxity)
-
Globe:
- canthi
- exoph/enop, vertical dystopia
- Vector
- Proptosis
11
Q
What does negative vector predict
A
- risk of dry eye syndrome
- risk of ectropion
- may require canthoplasty as part of the procedure
12
Q
What are the principles and goals of blepharoplasty
A
- restore sharp crisp tarsal folds
- restore symmetry
- retain/restore lateral canthal angle
- reposition/remove poorly positioned skin/fat/muscle
13
Q
Describe the steps of the upper blepharoplasty
A
-
Marking
- w pt standing, at jx of lateral and central 1/3 , mark inferior extent of incision 9-12mm from the lash line, with gentle curve medial and lateral, stopping belore medial canthus
- pinch test to determine amount of skin removal
-
Skin excision/muscle
- incisions made and skin excsied
- if muscle excision, done next as small strip
- septum opened to remove medial fat pad which protrudes, minimal centrally
- careful hemostasis
- +/- anchoring stitches, ROOF excision, gland suspension
14
Q
Describe steps in Lower blepharoplasty
A
-
Marking
- subciliary - 1-2mm below lash line and lateral extensio into crease
- trasncutaneous (below vascular arcade through conj/CPF
- incise skin w scalpel puncture then scissors, step to then incise through muscle to reach septum
- May excise muscle
- open septum, release protruding fat
- release ORL, ZRL
- conservative skin excision
Modifications as per Dr. Ford
- +/- canthoplasty +/- o.oculi sling
- release tear through below rim supraperiosteal
- release ORL and ZRL below rim supraperios
- transpose medial fat below tear through depression
- excise post-septal lateral fat pad
- +/- resuspension of o.oculi to DTF
- temporary tarsorrhaphy at lateral limbus 5-0 nylon x1wk
- tear naturall q2h, lacrilube qhs
15
Q
List complications of blepharoplasty
A
Immediate
- corneal injury
- lacrimal injury
- diplopia
- blindness
- glaucoma
- OCR
- hematoma
- subscleral
- periorb
- retrobulbar
Early
- conjunctivitis
- keratoconj sicca
- ecchymosis
- chemosis
- lagophthalmus
- asymmetry
Late
- asymmetry, underover correction
- ectropion/entropion
- levator dysfx
- Lacrimal dysfx: epiphora/dry eye
16
Q
How do you manage chemosis
A
- Def: edema of conjunctiva
- Secoandry to lymphatic disruption - conj is drained by lympatics of eyelid
- Prevention is key
- intra-op BSS< HOB elevation, , normotensive anesthesia, minimal iV lfuid, limit exposure
- Treatment
- tears naturalle q2h, lacrilube qhs. if not resolving, tobradex or forte liquifilm, neo-synephrine, +/- patching/cold compress
- If not esolving 2wks - optho cnosults for oral steroids
