blepharoplasty board

Question 1

What are the goals of modern blepharoplasty?

Answer 1

Identifying and treating lower eyelid laxity and upper eyelid laxity and ptosis. Correction of brow position and midfacial descent. Preservation of upper orbital fullness and a defined upper lid crease. In the lower lid, preserving the smooth transition between the cheek and lid junction while restoring youthful eye shape

Question 2

What is blepharochalasis?

Answer 2

A rare inherited disorder characterized by repetitive episodes of eyelid edema and subsequent levator dehiscence and
ptosis.

Question 3

What is dermatochalasis?

Answer 3

Loosening of the eyelid skin with fat protrusion.

Question 4

Discuss the anatomy of the eyelid in terms of lamellar structure.

Answer 4

The eyelid is a bilamellar structure consisting of an anterior lamella and a posterior lamella. The anterior lamella consists of skin and orbicularis oculi muscle, the posterior lamella includes the tarsoligamentous sling consisting of the tarsal plate, medial and lateral canthal tendons along with the capsulopalpebral fascia and conjunctiva. The septum originates at the arcus marginalis along the orbital rim and separates the two lamellae.

Question 5

Discuss the tarsoligamentous structure of the eyelid.

Answer 5

1. The tarsoligamentous sling creates the support structure for the posterior lamella.
2. The tarsal plates constitute the connective tissue framework of the upper and lower eyelids.
3. The upper lid tarsal plate is approximately 30 mm horizontal and 10 mm vertical at its widest dimension. The lower lid tarsal plate is approximately 24 mm horizontal and 4 mm in vertical dimension. The tarsal plates of the upper and lower eyelid are attached to the orbital rim by the medial and lateral canthal tendons and retinacular support structures.

Question 6

Discuss the anatomy of the lateral canthus.

Answer 6

The lateral canthus consists of a complex connective tissue framework that functions as an integral fixation point for the lower lid. The lateral canthal tendon, 5 mm in length, is formed by the fibrous crura that connects the tarsal plate to Whitnall’s lateral orbital tubercle within the lateral orbital rim.

Question 7

What forms the lateral retinaculum?

Answer 7

The lateral retinaculum is formed by ligamentous structures from the lateral horn of the levator aponeurosis, lateral rectus check ligaments, Whitnall’s suspensory ligament, and Lockwood’s inferior suspensory ligament that converge at the lateral canthal tendon.

Question 8

Discuss the anatomy of the lower lid ligamentous system.

Answer 8

The lower eyelid has an analogous inferior suspensory ligament, Lockwood’s ligament. Lockwood’s ligament arises from the medial and lateral retinacula and fuses with the capsulopalpebral fascia inserting on the inferior tarsal border. The arcuate expansion of Lockwood’s ligament, Clifford’s ligament, inserts into the inferolateral orbital rim and fuses with the interpad septum between the central and lateral fat compartments of the lower eyelid. The function of Lockwood’s ligament is to stabilize the lower lid on downward gaze while the lower lid retractors cause lid depression of the eyelid to increase the inferior visual field during down gaze.

Question 9

Discuss the key elements for preoperative blepharoplasty evaluation

Answer 9

Forehead
Brow position
Bony brow prominence or retrusion Fat excess or deficiency
Glabellar and forehead furrowsMidface
Vector analysis
Tear trough deformity Malar bags
Cheek ptosis
Skin quality and excessOrbit
Visual acuity
Visual fields
EOM testing
Eye prominence
Canthal tilt
Upper and lower eyelid laxity Lower eyelid malposition Orbicularis oculi hypertrophy Lacrimal gland ptosis
Upper eyelid ptosis
Skin quality and excess Postseptal fat herniation

Question 9

Discuss the fat compartments of the lower eyelid.

Answer 9

There are three fat pockets in the lower eyelid: central, nasal, and lateral. The nasal compartment in the lower eyelid is similar in makeup to the nasal compartment of the upper eyelid with more fibrous, pale fat. The inferior oblique muscle separates the nasal and central fat compartments. The central and lateral fat compartments are also separated by an interpad septum and a fascial extension from Lockwood’s ligament, the arcuate expansion.

Question 10

Describe the markings for upper blepharoplasty.

Answer 10

The upper eyelid crease is marked at the level of the mid pupillary line. In women, this is 8 to 10 mm superior to the lash margin and roughly 7 mm above the lash margin in men. At the lateral canthus, the lateral marking should be 5 to 6 mm above the lash line. The superior margin of the planned excision is determined by using utility forceps to pinch and identify the quantity of excess skin and muscle. At a minimum, 10 mm skin should be preserved between the lower border of the eyebrow and the upper lid marking at the level of the lateral canthus.

Question 11

Describe the difference in markings for Asian eyelids.

Answer 11

Determining if a single eyelid fold (absent crease) or a double eyelid fold (single crease) is desired. Defining the desired location of the crease as this is typically lower than in the Caucasian upper eyelid. A distance of 4 to 6 mm above the lid margin is usually used depending on the patients’ desires. Limit the amount of skin and preaponeurotic fat excision since this can lead to a high crease and supratarsal hollowness. Preserve the epicanthal folds unless change is specifically requested by the patient.

Question 12

Describe the technique for transconjunctival blepharoplasty.

Answer 12

The orbital fat can be removed by a trans-septal approach that divides the conjunctiva, capsulopalpebral fascia, and
septum or a retroseptal incision through the conjunctiva and capsulopalpebral fascia leaving the septum intact.

Question 13

Discuss the objective of canthopexy/canthoplasty.

Answer 13

Suturing the tarsal plate and lateral retinaculum to the periosteum of the lateral orbital rim thereby tightening the lower lid tarsoligamentous structure. Patients with lid distraction greater than 6 mm require lateral canthotomy and canthoplasty.

Question 14

Discuss the management of ptosis during blepharoplasty.

Answer 14

Levator advancement for mild and moderate cases of ptosis. Evaluation of levator function and the degree of ptosis
is essential for every patient.

Question 15

Discuss postoperative blepharoplasty care.

Answer 15

Head elevation and the application of ice to the periorbital region is used for 48 hours after surgery. Ophthalmic antibiotic ointment is applied along the suture line as well as on the globe to prevent or to reduce evaporative tear film loss. Sutures, including the Frost suture, are removed 5 to 7 days after surgery. Instruction to avoid the use of eyelid makeup on the suture lines and contact lenses for 2 weeks after surgery.

Question 16

Discuss the management of postoperative chemosis.

Answer 16

Persistent postoperative chemosis can be treated with liberal ophthalmic ointments and eyedrops. Severe chemosis that herniates through the palpebral fissure requires more aggressive management with liberal ophthalmic ointment, patching the eye closed for 24 to 48 hours, and applying gentle pressure from an ace wrap to reduce the swelling. The edematous conjunctiva can be surgically drained.

Question 17

Discuss the diagnosis and management of retrobulbar hematoma.

Answer 17

1. Retrobulbar hematoma (0.04%) is caused by retrobulbar hemorrhage compromising ocular circulation.
2. Progressive eye pain, increased intraocular pressure.
3. Management include rapid surgical decompression, administration of mannitol, acetazolamide and oxygen.

Question 18

Discuss the etiology of diplopia following blepharoplasty.

Answer 18

1. Diplopia is usually temporary resulting from edema.
2. Permanent diplopia can occur from thermal injury to the inferior oblique or superior oblique muscles from electrocautery.
3. Strabismus surgery may be required for patients who do not respond to conservative management.

Question 19

Discuss the management of lower lid malposition following blepharoplasty.

Answer 19

1. Mild lid malposition may contribute to lagophthalmos and corneal exposure. Lagophthalmos may require bandage contact lenses to protect the cornea and conservative massage of the lower lid margin until the patient has passed the critical 6-week postoperative time period.
2. Lower lid ectropion or persistent lid malposition following a 2- to 3-month period of conservative management may require surgical intervention including placement of a posterior lamella spacer graft and lateral canthoplasty.