KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Blepharoplasty.

Question 0

Examine for blepharoplasty

Answer 0

As for examination of upper and lower 1/3s of the face (facelift).

Does patient need brow lift?
- Compensated brow ptosis: patient’s brow descends on eyelid closure.

Also:

• lagophthalmos.
• Bell’s phenomenon.
• blink reflex.
• visual acuity (Snellen chart).
• extraocular mvmts.
• visual fields.

Question 1

How do you assess a patient for blepharoplasty?

Answer 1

Establish:

1. Problems affecting eyelids and periorbital tissues.
2. Co-existing medical conditions that increase risk of complications.
3. Predisposing factors to dry eye and visual changes.

Medical history: DM, hi BP, CT, thyroid & heart disease, clotting disorders.
Medications: blood thinners, over-the counter remedies.
Smoking

Ophthalmological history

• visual problems.
• previous (peri)ocular trauma.
• glaucoma.
• contact lens use.
• dry eyes, epiphora.
• laser eye surgery (do not operate within 6mths).

Question 2

What happens if patient has compensated brow ptosis but only blepharoplasty is performed?

Answer 2

• after op, eyelids will open without frontalis overactivity, eyebrows descend resulting in hooded, stern or aged appearance.

Question 3

What other manoeuvres and measurements can be made after brow ptosis is corrected?

Answer 3

• Place fingers on brow at correct position.
• Pinch eyelid skin to estimate amount of excess.
• Press on globe, assess for prominent fat pads and lacrimal gland prolapse.
• Assess for upper eyelid ptosis (see ‘Oculoplastics’).
  Eyelid margin to superior limbus distance (normal = 2-3mm) and Margin reflex distance).

Question 4

How do you assess for lower eyelid blepharoplasty?

Answer 4

Assess skin excess and postseptal fat bulging.
Medial and lateral canthus position and canthal tilt.

Lid laxity - snap test, anterior lid traction.

Scleral show = proptosis, lower lid laxity or poor lower lid support.

Globe position

• ‘negative vector relationship’ = anterior cornea is anterior to infraorbital rim.
• patients have prominent eyes and poor globe support.
• need to overcorrect (more superior) lateral canthal position.
• ‘Positive vector relationship’ = deep-set eyes.
• need to place lateral cats more posterior.

Question 5

How do you counsel a patient pre-operatively for blepharoplasty?

Answer 5

• GA/LA, incisions.
• crow’s feet, festoons and malar bags will not be addressed.
• uncorrected brow ptosis affects result.

Post-op

• eye pads, ice pack.
• bruising ++
• gritty / sore eyes - chloramphenicol and damp eye pads.
• no straining / leaning over, avoid NSAIDs, no contact lens for 2wks.
• ROS in 1wk.

Question 6

What are the complications of blepharoplasty surgery?

Answer 6

Immediate

• Eyelid haematoma, bruising.
• Retrobulbar haematoma (1 in 2500) from post-septal bleeding. Immediate decompression required (lateral canthotomy).
• Visual changes (usually temporary): swelling -> diplopia, permanent strabismus if inferior / superior oblique damaged.
• Corneal abrasions.

Early

• dry eye syndrome (treat with lubrication, patches, compresses, head elevation, Frost sutures, lateral canthopexy).
• lower lid malposition (due to uncorrected lower lid laxity, excess removal, scar contracture, intramuscular haematoma, orbicular paralysis, orbital septum adhesions, proptosis).
• infection.
• chemosis.
• asymmetry.
• ptosis (from swelling or levator aponeurosis injury).

Late

• lagophthalmos.
• undercorrection.
• excessive postseptal fat resection.

Question 7

Take me through an upper blepharoplasty.

Answer 7

LA / GA
Markings:
- lower incision = supratarsal crease.
- upper border = pinch excess, mark multiple points (leave >10mm skin between brow and incision).
- medial = not past caruncle (avoid webbing)
- lateral = on a crows feet crease, not beyond lateral orbital rim.
- infiltrate with lignospan, hydrodissect.

Excise (and keep to compare):
- Skin.
- Small strip of orbicularis oculi muscle.
- Medial and central fat pads (post-septal) - make small incisions in orbital septum, press on globe to herniate fat, grab with forceps, diathermy base, meticulous haemostasis before fat retracts, do not over-resect.
+/- ROOF (retro-orbicularis oculi fat) - beware of supraorbital nerve and frontal branch.

+/- Re-suspend lacrimal gland.

May enhance supratarsal crease by suturing dermis and pretarsal orbicularis to levator mechanism during wound closure.

6/0 prolene sc, steristrips, chloramphenicol ointment

Do both eyes, close at the end.

Question 8

Draw a diagram of upper blepharoplasty markings.

Answer 8

Pg 545

Question 9

If you are doing concurrent brow lift or face lift with blepharoplasty, which operation do you do first?

Answer 9

If brow lift - do brow lift first.

If face lift - do blepharoplasty first.

Question 10

Take me through a lower blepharoplasty.

Answer 10

GA, Lignospan hydrodissection.

1. Subciliary incision
   - Incise on lateral skin crease 5mm past lateral canthus.
   - Preserve 10mm vertical skin bridge between upper and lower bleph incisions at crows feet to avoid webbing.
   - Using Jameson dissecting scissors, tunnel under skin below lashes over tarsal plate, elevating skin only flap. Cut 1mm below lashes taking care not to cut lashes. Avoid punctum medially.
   - Leave strip of pretarsal orbicularis to maintain tone of tarsal plate.

Elevate
(a) skin-muscle flap: lift skin leaving 5mm of pretarsal orbicularis, then preseptal orbicularis elevated with skin to inferior orbital rim.
skin-muscle flap is redraped and excess excised.

(b) skin flap only

Or

2. Transconjunctival incision (does not address skin excess):
   (a) preseptal or
   (b) retroseptal.

Question 11

How is orbital fat managed in lower lid blepharoplasty?

Answer 11

1. Excision:
   - medial, central and lateral compartments access through small incisions in septum.
   - inferior oblique lies between medial and central compartments.
2. Anterior repositioning with septal reset:
   - release orbital retaining ligaments.
   - aims to camouflage lid-cheek junction by releasing septum from arcus marginalis at inferior orbital rim.
   - orbital fat prolapses over IOM, and septum is reattached anteroinferior to IOM.
   - must have lateral canthal support (to avoid ectropion).

Question 12

How is the lateral canthus supported?

Answer 12

Consider vector relationship of globe to rim.
Canthal support first then excise excess skin.

Minor laxity (1-2mm anterior traction).
(a) Temporary tarsorrhaphy.
(b) Orbicularis muscle sling:
superolateral edge of preseptal orbicularis dissected free from skin and septum for 1cm, and transposed and secured to LOR periosteum via upper bleph wound.

Moderate (3-6mm).
- Lateral canthopexy:
suturing canthal ligament and tarsus to lateral orbital rim periosteum, by transcanthal canthopexy: small incision in lateral canthus, double ended prolene passed through incision and needles passed under skin bridge to upper bleph wound and sutured to lay orbital rim (inner, to avoid lid diastasis and epiphora) periosteum.

Severe (>6mm)

(a) Lateral canthoplasty: lateral canthal tendon is divided and repositioned through upper bleph wound.
(b) Kuhnt-Szymanowski procedure: cantholysis + FT lid resection.