Presented by:Yasmeen El Saloussy MSc

BLEPHAROPLASTY

PreoperativePreoperative evaluation should include a complete examination including :• A detailed history concerning dry eyes• Recurrent herpes zoster or simplex infections• Thyroid disease

The physical examination shouldinclude :• A Schirmer test: The test is performed by first anesthetizing the conjunctiva in the inferior lateral fornix with tetracaine eyedrops. Any excess tear film is then blotted away and a Shirmer strip is placed in the lateral fornix and the patient is asked to gaze straight ahead. Decreased tear production is identified by less than 10 mm of wetting after a 5-minute period.• Tear film break-up time • Visual acuity :(Visual acuity is determined with the patient wearing eye glasses or contact lenses. This is to document the baseline preoperative vision)

• Fine examination of the lid margin for chronic blepharitis• Evidence for lid retraction or laxity• Signs of associated systemic disease such as thyroid disease

• Ocular mobility is then assessed by asking the patient to follow an object through the six cardinal positions of gaze.• Diplopia can occur as a result of injury to the inferior or superior oblique from prior blepharoplasty. • Visual field testing is important in patients with upper eyelid ptosis and upper eyelid skinfolds that interfere with the visual axis.

Canthal tilt• A positive canthal tilt is

one where the lateral canthus is positioned superior to the medial canthus. • A negative canthal tilt

may indicate descent of the lateral canthus from disinsertion, laxity, or the presence of a prominent eye.

• A positive vector is seen where the globe is posterior to the infraorbital rim and overlying soft tissue.• Normal globe prominence is

in the range of 15 to 17 mm. • Patients with enophthalmos

have a measurement of less than 15 mm • Patients with exophthalmos

have measurements greater than 17 mm.

• Both prominent and deep set eyes are at increased risk for complications. • Primary lower lid spacers and

infraorbital rim implants may be considered in patients with prominent eyes to correct the poor globe support.

• Of particular note is the presence of scleral show in the preoperative patient. This should serve as a “red flag” sign of caution since it is often associated with a prominent eye, lower lid laxity, and poor infraorbital support, which define patients at high risk for postoperative complications

Photographs are taken of each patient, these are helpful for:• Preoperative planning• As an intraoperative reference• In reviewing the objectives of surgery with the patient postoperatively

Perform an organized sequential assessment of the orbit, including the upper lid and browThe brow is evaluated for :• Ptosis• Symmetry• The relationship between the nasal and lateral brows. This is done with the brow under conscious relaxation, with the absence of active furrowing of the forehead.

• In women, the brow should arch above the supraorbital rim with a peak above the lateral limbus.

• In men, the brow should be more horizontal, traversing the supraorbital rim.

• Signs of brow ptosis include lateral upper eyelid hooding and descent below the orbital rim.• If brow laxity is not

corrected or if brow is not stabilized, it will predispose the patient to further descent of the brow following blepharoplasty. • An unstable brow will

require elevation or stabilization in order to avoid worsening of brow ptosis after upper blepharoplasty.

Upper eyelid fold asymmetry may be caused by several factors:

• upper lid ptosis• upper lid retraction• asymmetry in the amount of tissue in the upper lid• asymmetrical brow ptosis.

In patients presenting with upper lid ptosis, it is important to identify the etiology on history and clinical evaluation. The differential diagnosis includes:• Congenital ptosis• Aponeurotic dehiscence• Myogenic ptosis including

myasthenia gravis• Neurogenic ptosis including

Horner’s syndrome• Mechanical ptosis secondary

to a tumor or trauma.

• On physical examination, the levator function is measured by stabilizing the eyebrow and measuring lid margin excursion. • Congenital ptosis is present

from birth and characterized by poor levator function. The measured excursion is generally less than 4 mm and often requires correction by means of a frontalis sling procedure.

• In acquired ptosis, levator function is often normal with an excursion of 10 mm or greater. • The eyelid crease is

typically high in these patients as the dermal anchor of the levator fibers forming the crease have been disrupted. • This can be corrected with

tarsolevator advancement at the time of the blepharoplasty procedure. The cover test is recommended in the evaluation of minimal unilateral acquired ptosis.

Floppy eyelid syndromeFloppy eyelid syndrome, although uncommon, may be present in large sturdy men who present for blepharoplasty.

• The syndrome is characterized by upper eyelid eversion during forced lid closure and may be addressed by shortening the lid laterally. • This requires resection of a portion of the lateral tarsal plate along with a canthoplasty of the upper eyelid.

Dry eyes Patients at risk for postoperative eye dryness are easily identified with a history of contact lens intolerance. Each patient is then evaluated for the presence of a Bell’s phenomenon, as a poor reflex will predispose patients to significant postoperative corneal dryness. These patients are further evaluated using a Shirmer’s test.

• Patients with dry eyes should have conservative skin excision to minimize lagophthalmos and proper lateral canthal anchoring to prevent ectropion.

Liberal use of perioperative lubrication is advocated and postoperative insertion of punctual plugs may be needed in some refractory cases.

(LASIK)Patients who have had recent laser in situ keratomileusis (LASIK) surgery for vision enhancement should avoid blepharoplasty for at least 6 months in order to allow the corneal incision adequate time to heal and to minimize the risk of superinfection in the event lagophthalmos and dryness occur after blepharoplasty.

Redundant upper eyelid tissue Although the surgical approaches may be the same, an appreciation of the difference between blepharochalasis and dermatochalasis, that is, the etiology for the redundant upper eyelid tissue, should be understood.

Blepharochalasisblepharochalasis :redundant upper lid tissue secondary to underlying pathophysiology such as recurrent edema as found in renal failure, cardiac disease, or angioneurotic edema.

DermatochalasisDermatochalasis is the commonly found redundancy of upper eyelid tissue secondary to the senescent process with or without ptotic eyebrow changes.

Anatomy and pathophysiologybetween racial and age groups An important concept in appreciating upper eyelid functional and cosmetic surgery is illustrated by contrasting nuances in the anatomy and pathophysiology between racial and age groups.

• For example, the upper eyelid crease lies 6 to 8 mm from the lid margin in the young Caucasian. • The lid fold is created by extensions of the levator to the lid skin.

In the senescent or “baggy” Caucasian upper eyelid, septal laxity and tissue relaxation allow preaponeurotic fat to prolapse anteriorly, lowering the eyelid fold and moving it closer to the lid margin.

• This age-related pathophysiology is analogous to the normal anatomy found in the youthful Asian upper eyelid. Here the eyelid fold is low and variably closer to the lid margin, with fullness created above it owing to prolapsed preaponeurotic fat extending to the insertion of the levator aponeurotic elements on the overriding lid skin.

• Therefore, the aged Occidental upper lid resembles the youthful Asian lid.

• During the upper blepharoplasty dissection, care must be taken to avoid inadvertent removal of the gland, and gland suspension may be necessary. • Excess retroorbicularis oculi fat (ROOF) may be removed in a conservative manner lateral to the supraorbital nerve. This procedure may be combined with an internal browpexy in order to raise and suspend the lateral aspect of the brow.

Patients are asked to bring photographs taken approximately 10 years prior to their consultation. These images can be used as a guide to reestablishing the patient’s individual orbital contour and volume. • This may require the use of free fat grafting, in addition to a fat-conserving blepharoplasty, if the orbit has become skeletonized with age or previous excisional surgery

Operative technique Anesthesia • Blepharoplasty can be performed under general anesthesia or under intravenous conscious sedation. • Local anesthesia consisting of lidocaine 2% with epinephrine 1:100,000 is injected using a 27-gauge needle into the upper eyelid, lateral canthus, lower eyelid, and inferior orbital rim.• Care is taken to avoid injury to the marginal arterial arcades and the deep orbital structures in order to reduce the risk of eyelid or retro-bulbar hematoma

Upper Lid Markings

• Preliminary markings are made in the preoperative area to ensure that the scar will be in a crow’s foot with the patient smiling in the vertical position, and are completed on the operating room table following the induction of anesthesia.

• This is done using loupe magnification and calipers to ensure symmetry of markings on both eyelids. A fine, wooden-tip applicator is used to mark the incisions with methylene blue.

• First, the upper eyelid crease is marked at the level of the midpupillary line. In women, this is 8 to 10 mm superior to the lash margin, and roughly 7 mm above the lash margin in men.• The marking is tapered caudally at the nasal and lateral lid margins following the gentle curve of the upper lid crease. • The nasal aspect of the marking should not extend medially to the caruncle, so as to avoid webbing or the development of epicanthal folds above the medial canthus.

• At the lateral canthus, the lateral marking should be 5 to 6 mm above the lash line.

• The lateral extension should be hidden in a crow’s foot skinfold and not extend past the lateral orbital rim.

• 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 of skin should be preserved between the lower border of the eyebrow and the upper lid marking at the level of the lateral canthus. • The superior mark is drawn parallel to the contour of the lower marking.

• Nasally, the amount of tissue to be excised is tapered in a conservative fashion.

• Over-resection of skin and muscle is poorly tolerated nasally resulting in lagophthalmos that can cause corneal dryness in addition to a poor aesthetic result.

Lower Lid Markings• From the level of the lateral canthus, a line is extended inferolaterally for approximately 6 to 10 mm within a prominent crow’s foot crease.• Roughly 10 mm of skin is preserved between the lateral extension of the upper and lower blepharoplasty incisions.

• If the incisions are placed too close together, postoperative webbing or distortion can occur. The nasal extension of the marking parallels the lid margin and should be as close to the lash line as possible because the scar becomes more apparent when placed lower.

Upper Lid Blepharoplasty• Using a scalpel, the upper lid markings are incised through the skin and into the orbicularis muscle.

• A needle-tip cautery is used to incise the orbicularis oculi muscle along the superior incision.

• This exposes the orbital septum, which is then opened along the length of the incision • The septum is opened first along the upper incision in order to avoid injury to the levator aponeurosis, which is located immediately behind the orbicularis oculi muscle in the lower incision at the lid crease.

• Care is taken to preserve the interpad septum separating the central and nasal fat • pads.

• Over-resection of fat in this area will result in a hollow “A-frame” or peaked arch deformity of the supratarsal crease.

• Clamping, resecting, and cauterizing fat should be discouraged because this can result in uncontrolled bleeding. • Inadequate cauterization can result in bleeding from the nasal fat pad.• Fat preservation should be considered to avoid creation of a hollow, more aged-appearing orbit• Excess skin, muscle, and septum are then resected with scissors beveling away from the levator insertion into the upper lid crease.

• Resection of the lacrimal gland can cause postoperative dry eye syndrome and is not recommended. • If lateral brow instability is present, an internal lateral browpexy can be performed through the upper blepharoplasty incision. • To achieve the aesthetic goals, the peak of the brow should be placed just above the lateral corneoscleral limbus. • Internal browpexy should be considered to correct lateral brow instability and prevent further brow ptosis caused by upper blepharoplasty

• Following removal of excess skin, muscle, and fat, the upper lid incision is generously irrigated with normal saline to remove any residual liquefied fat that can result in postoperative granuloma formation.

Closure• The incision is closed with initial sutures placed superior to the lateral canthus with interrupted 6-0 nylon suture, which aligns the skin and muscle.• The incision lateral to the canthus is closed with interrupted 6-0 nylon and the incision medial to the lateral canthus is closed with a running 6-0 nylon suture. •While a subcuticular suture is commonly used, including the muscle in the repair may eliminate the fine, white dermal scar often seen following subcuticular closure.

• Repair of the orbicularis muscle reduces the tension on the dermis, resulting in a less perceptible scar. • In addition, the interposed muscle prevents adhesion formation from the dermis to the aponeurosis to the skin, thereby minimizing contour irregularity and lagophthalmos.

Asian lid blepharoplasty• A low crease incision, typically 4 to 6 mm above the lash line, is made in an Asian upper lid blepharoplasty. A conservative amount of skin is excised and minimal pre-aponeurotic fat is removed. To create a dynamic fold, multiple sutures are placed through the junction of the upper tarsal margin, levator insertion, and dermis of the upper skin margin

Lower lid blepharoplasty• The lower lid skin is incised lateral to the canthus with a scalpel exposing the underlying orbicularis oculi muscle.

• The orbicularis oculi muscle is divided with electrocautery into the submuscular space.

• Scissors are then used to incise the remainder of the lower lid skin incision along the lid margin with a second incision through the orbicularis preserving a 5-mm strip of pretarsal orbicularis muscle

• The skin muscle flap is dissected anterior to the septum to the infraorbital rim. • Dissection continues to the

infraorbital rim just superficial to the periosteum separating the orbicularis from periosteal attachments at the lateral orbital rim. • The orbito-malar ligament is

divided along the entire extent of the infraorbital rim.

•Release of the orbitomalar ligament allows elevation of the SOOF with the skin muscle flap.

• Fat can be removed in a conservative fashion from all three lower lid compartments, and the orbital septum is resected, along with the excess fat.

• Removal of the septum may reduce the risk of subsequent septal scar formation. Care should be taken to identify and avoid injury to the inferior oblique muscle between the nasal and central fat pads

• The inferior oblique muscle is reportedly the most common extraocular muscle injured during blepharoplasty from indiscriminate cauterization.

Lateral Canthal Anchoring• The degree of lower lid laxity should be further evaluated intraoperatively by placing anterior traction on the lower eyelid away from the globe and using caliper measurement to determine the amount of lid distraction.

• Lid distraction of 1 to 2 mm indicates minimal lid laxity, requiring minimal lateral canthal support with orbicularis suspension only.• Laxity measurements of 3 to 6 mm of lid distraction indicates moderate laxity of the lower eyelid. A lateral canthopexy should be used to correct moderate lid laxity

• When the lid can be distracted greater than 6 mm away from the globe, significant lid laxity is present and a lateral canthoplasty should be considered. • The objective of lateral

canthopexy is to suture the tarsal plate and lateral retinaculum to the periosteum of the lateral orbital rim, thereby tightening the lower lid tarsoligamentous sling.• A horizontal mattress suture

of 4-0 is used to incorporate the tarsal plate and lateral retinaculum.

• The suture is then placed inside the lateral orbital rim periosteum from deep to superficial, allowing the lateral canthus and lower lid to be tightened posteriorly and superiorly to maintain the position of the lower lid margin against the globe.

Postoperative Care• Significant periorbital ecchymosis or chemosis of the conjunctiva at the completion of the procedure may indicate signs of delayed healing. • In these situations, the use of a Frost suture should be considered. It is placed in the lower lid margin lateral to the lateral limbus and either sutured to the eyebrow or suspended to a Steri-Strip above the eyebrow.

• These techniques minimize corneal exposure in the immediate postoperative period. • 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. • Patients are asked to avoid the use of eyelid makeup on the suture lines and contact lenses for 2 weeks following surgery.

• Occasionally the edematous conjunctiva can be surgically drained.

• Persistent postoperative chemosis can be treated with liberal ophthalmic ointments and eye drops. • Additionally, Voltaren drops and fluorometholone (FML) 0.1% ophthalmic suspension can be used for 2 weeks to minimize the early inflammatory changes that result in chemosis. • 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 a wrap to reduce the swelling.

ComplicationsGiven the delicate anatomy of the periorbital region, complications can be common with blepharoplasty surgery. • The most devastating complication after blepharoplasty is visual loss. Although rare, the estimated incidence is 0.04% and is caused by either retroorbital hemorrhage compromising ocular circulation or direct globe perforation.

• Rapid surgical decompression and administration of mannitol, acetazolamide, and oxygen is advocated as part of the initial management of retroorbital hematoma.

• Diplopia can also occur following blepharoplasty and is usually temporary, resulting from edema.• Permanent diplopia can occur from thermal injury to the inferior oblique or superior oblique muscles from electrocautery. Strabismus surgery may be required for patients who do not improve with conservative management.

• In the upper lid, ptosis may occur after surgery from failed preoperative recognition or from levator dehiscence during surgery. To minimize this risk, supratarsal fixation of the pretarsal skin muscle to the levator aponeurosis should be performed.

• Signs of corneal irritation or impaired visual acuity require careful ophthalmologic evaluation. • 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, which corresponds with the proliferative phase of healing.

• Lower lid ectropion or persistent lid malposition following a 2- to 3-month period of conservative management may require surgical intervention.

Outcomes• Maintaining the preoperative shape of the palpebral fissure is emphasized, with particular attention to maintaining lower eyelid position.• Lateral canthal support, most commonly with lateral canthopexy, represents an important step in the technique to maintain lid shape and reduce the risk of lower lid malposition or postoperative round eye syndrome.• The compromise, which should be discussed with patients prior to surgery, is that the lower lid may appear tight, which may last 2 to 3 weeks after surgery.

Complications associated with lateral canthoplasty include:• Canthal angle webbing or asymmetry, which requires surgical revision. • The risk of frank ectropion is reduced when conservative skin excision and lateral canthal support are performed in combination.• In addition to minimizing the risk of complications, maximizing the aesthetic result is directly related to safe management of periorbital fat, the orbicularis muscle, and SOOF.