Many older patients do not have tearing with one obstructed canaliculus due to decreased tear production. Patient 3: Left lateral canthal rounding following tumour excision and reconstructionsingle flap technique. 106, no. c The anterior flap is created and folded into its new position. However with skin closure, this scar generally blends well with the normal smile lines in the lateral canthal area. Patients may inadvertently rub their eyes in the hours after surgery when their lids are numb or while sleeping. I have started massaging the area and wearing silicone strips at night. Graves disease: Heaviness of upper lids associated with proptosis may be indication, but disease specific concerns that require special caution include, Dryness related to lacrimal gland inflammation, Exacerbated appearance of proptosis with reduced hooding, Chronic postoperative inflammation related to primary disease, Emotional vulnerability related to thyroidopathy. Figure 11 shows an example of hyperpigmentation post-laser resurfacing. Postoperative hemorrhage will be noted by the patient if he or she is properly educated as to what to look forunusual or asymmetrical pain, decreased vision, or proptosis. There are currently 25 Eyelid Surgery + Webbing questions and doctor answers on RealSelf. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. Antibiotic or steroid/antibiotic ointment may be applied twice a day to sutures and into the eyes at night. Webs abnormal folds of skin can occur in both areas and are referred to as medial and lateral canthal webs. If done in the plane of the lateral wall and in the plane of the levator aponeurosis and inferior rectus (i.e., parallel to these structures) in a blunt fashion the risk of significant damage to orbital structures is low. If early cicatrix formation is detected, local nondepot steroid injection can occasionally eliminate the need for more involved surgery. For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal webbing as well as lacrimal system injury. The experienced surgeon who is certain that the levator muscle and aponeurosis was identified and preserved during surgery will not be alarmed. Narcissists as 'victims': the role of narcissism in the perception of transgressions. Juniat, V., Joshi, S., Hersh, D. et al. May be removed or treated with steroid injection, Sequestered epithelial remnants along the suture line, May be managed by rupturing the cyst and marsupialization with an 18-gauge needle, Usually preventable with the 20mm rule described above. Inadvertent trauma to an extraocular muscle with deep dissection in orbital fat may occur. The rounding can have a significant component of scar tissue, creating an aesthetic or functional deficit that can be distressing for patients. Preoperative preparation may include asking the patient to stop smoking, reduce alcohol intake, and optimize overall general health. Clinical characteristics of cold-induced systemic reactions in acquired cold urticaria syndromes: recommendations for prevention of this complication and a proposal for a diagnostic classification of cold urticaria. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. 417425, 1993. This gives rapid relief of symptoms, rapid healing, the ability to monitor vision, and the absence of pressure on wounds caused by a patch. Finally, management of complications is just as important as surgical technique. It seems my canthoplasty has failed. Occasionally instead of scar hypertrophy, epithelial inclusion cysts occur. You have full access to this article via your institution. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. The primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. Lower eyelid of this patient shows cicatricial ectropion with middle lamellar scarring causing lid retraction as well after blepharoplasty elsewhere. Plast Reconstr Surg 1978; 61:347. 20292041, 1999. j and k Posterior flap is folded over and sutured into the new inferior lid margin. Brown, The use of tarsus as a free autogenous graft in eyelid surgery, Ophthalmic Plastic and Reconstructive Surgery, vol. Acute orbital hemorrhage requires prompt intervention. J. Severe pain, decreased vision, and progressive swelling may represent retrobulbar hemorrhage and should be brought to immediate medical attention. The median age was 65.5 years (range: 2688). im worried that i wont be satisfied with my results if i only get the upper bleph, but im also worried about getting bad scars / webbing with epicanthoplasty. Google Scholar. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. The scar has webbed and is also very long and wide. The skin then bridges the superomedial hollow of the upper lid in a straight line. Early recognition and aggressive massage will eliminate the majority of cases. In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. As an alternative to suture closure, some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure. Inadvertent injury to the lacrimal system should be avoided in upper blepharoplasty by limiting incision medially. Mild lower-lid laxity or lateral canthal deformity. This can improve lagophthalmos without visible external incisions or the risk of induced ptosis or unsightly skin grafts when used. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. B. Relative . True canalicular injury may require late repair if epiphora results. Lewis CM, Lavell S, Simpson MF. Nonsedating antihistamines may help control cold-induced symptoms. In one patient there was rounding recurrence. Lubrication, cool compresses, and observation are essential to resolution. He had severe chemosis and discomfort due to significant lagophthalmos. We report a technique for canthoplasty repair of canthal rounding with the use of illustrative cases. This interferes with the tear pump mechanism. Head elevation and limiting activity may reduce edema. Adjunctive procedures include brow ptosis repair (internal trans-blepharoplasty, direct, coronal, or endoscopic), ptosis repair, lacrimal gland suspension, eyelid lengthening, and lower eyelid tightening or lateral canthopexy. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so much as an expected side effect. Identifying patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may not be appropriate candidates for surgery. It requires medial canthal scar revision with multiple z-plasty. To avoid this, use a Q-tip backstop immediately behind the fat incision made by the CO2 laser. The surgery involves removing redundant skin, fat, and muscle. The patient must be a resurfacing candidate to consider this treatment modality (Fitzpatrick skin type, I, II, or III), and the risks of hypopigmentation and hyperpigmentation stressed. Prompt decompression of the orbit alone can restore vision. For lower eyelid blepharoplasty in Asians, transconjunctival fat removal yields far superior results to an external approach [34]. This will significantly speed up the recovery time. ISSN 0950-222X (print), https://doi.org/10.1038/s41433-021-01497-y, Medial canthoplasty for the management of exposure keratopathy, The kissing puncta: an under-reported and stubborn cause of epiphora, Anterior lamellar deficit ectropion management, Skin redraping for correction of lower eyelid epiblepharon combined with medial epicanthal fold: a retrospective analysis of 286 Asian children, A novel technique for the measurement of eyelid contour to compare outcomes following Mullers muscle-conjunctival resection and external levator resection surgery, The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations, Comparison of three surgical techniques for internal angular dermoid cysts: a randomized controlled trial, Causes and management of persistent septal deviation after septoplasty, Strategies for ear elevation and the treatment of relevant complications in autologous cartilage microtia reconstruction. Photographs of frontal plane and oblique view. Jordan DR, Mawn LA. Our patients reported excellent outcomes post-operatively without any significant scarring. The eyelid crease may be between 412mm above the lash line. Another outcome noted by patients is asymmetry of lateral hooding reduction. Proptosis, severe pain, decreased visual acuity, relative afferent pupillary defect, and elevated intraocular pressure confirm the diagnosis. Posttreatment admission to hospital is recommended, with close visual acuity monitoring, head elevation, ice water compresses, intravenous steroids until 24 hours of stable vision have been noted, as well as imaging with CT scanning. 366368, 1969. Robi N. Maamari, Philip L. Custer, Steven M. Couch, Varajini Joganathan, Bhupendra C. K. Patel, Jonathan H. Norris, Jennifer Danesh, Shoaib Ugradar, Daniel B Rootman, Terence W. Ang, Valerie Juniat, Dinesh Selva, Mostafa M. Diab, Richard C. Allen, Kareem B. Elessawy, Eye A running prolene suture, with several interrupted reinforcements is useful. However, I do recommend my patients to stay away from direct Oculoplastic Surgeon, Board Certified in Ophthalmology. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . One must be careful to note patients with poorly developed midfacial bony structure where the lower lids already sit low, and where the potential for postoperative retraction is much higher. b. Patients must be taught to check their vision one eye at a time. Discomfort and edema are expected after surgery and are usually adequately managed with acetaminophen. Because of the complexities in modifying the overcorrected upper lid, a more mild degree of symptomatic lagophthalmos can be addressed via lower lid elevation with lower lid posterior lamellar grafting, as detailed in the next section. Pure skin lack can be remedied by a full thickness skin graft. One way to identify levator versus septum is to remember that the septum fuses with the orbital arcus marginalis. Orbital hematoma, ectropion, and scleral show. More effect (in terms of lifting skin off the eyelashes) for less skin excision can be achieved by creating a higher lid crease during the blepharoplasty. J. H. Oestreicher and K. Tarassoly, The mini tarsal strip lateral canthopexy for lower eyelid laser-assisted blepharoplasty-indications, technique and complications in 614 cases, Orbit, vol. Several surgical techniques to repair canthal rounding have been described previously. When preparing for lower lid blepharoplasty, important features to note are the amount of excess skin and the presence of fine rhytids (wrinkles), prolapsed fat (quantity and location), malar bags or festoons, lid laxity, scleral show and pigmentary characteristics. Remove granulation tissue and freshen wound edges. You may want to consult with a very experienced plastic surgeon who will have your best interest in mind. Early injection takes advantage of the time required to move, position, prep, and drape the patient, during which time the anesthetic will take effect. The patient has severe symptomatic lagophthalmos as well as an unsightly appearance. 1c). It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). It forms a c shape and makes my eyes asymmetrical. There were five men and seven women. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. If a third finger is required to recruit skin by pushing the mid face up, skin grafting or possible mid face lifting may be necessary. Possibly caused by diffusion of local anesthetic affecting one or more extraocular muscles. The skin and orbicularis, lid margin, conjunctiva, and lower lid retractors are removed from the excess eyelid laterally, creating a lateral tarsal strip which is then anchored to Whitnalls tubercle inside the lateral orbital rim. Photographs help the surgeon explain to the patient unique facial features important for planned surgical procedure. Postoperatively, the management of patients concerns can range from reassurance to surgical intervention, depending on the concern. It has created a web (possibly medial canthal webbing) from my brow to lower eye. Treatment includes vitamin E cream, massage, and topical or injected corticosteroids. Elimination of topical allergy, and occasionally short-term topical steroid use are helpful. A cold stimulation test may confirm the diagnosis of PACU. How do you handle them? 10361040, 1999. Bruising and swelling typically lasts 1014 days after surgery. Laser resurfacing itself carries a risk of hypopigmentation (very rare in the eyelid skin) and hyperpigmentation. 21, no. 5, pp. Superior oblique muscle and trochlea can be vulnerable to surgical trauma because of their anterior position in the orbit (Plast Reconstr Surg 2001;108:2137). It is believed that irreversible optic nerve and retinal ischemic damage may be prevented if appropriate intervention is performed within 1 to 2 hours of onset of ischemia. Lower eyelid of the same patient shown in Figures. The surgeon should spread bluntly posteriorly into the orbit down the lateral wall and through the wounds to access deep hematomas and release them. M. J. Hawes and G. A. Jamell, Complications of tarsoconjunctival grafts, Ophthalmic Plastic and Reconstructive Surgery, vol. Canthoplasty repair for canthal rounding. 604606, 1989. 1997;13:849. Blindness and embolic stroke can occur with accidental intravenous or intra-arterial injection of these materials, particularly near the supraorbital vessels [10, 11]. Ptosis of varying degree is common for patients to experience the day after upper lid blepharoplasty. 219228, 1991. Patients who view cosmetic surgery as a commodity rather than a medical procedure with attendant risks should not be operated on. One should identify (and preserve) the inferior oblique and levator during surgery, to be confident they have not been injured. Medial canthal webbing occurs when incisions are carried too medially as seen in Figure 9. Persistent cases are treated by a V- to-Y plasty procedure. I had strange eyes that if tired could look so puffy/saggy but if not they were near perfect (a little excess always present left side). Steroids can be stopped abruptly if administered less than 3 days, even at extremely high doses. Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. Institutional Review Board/Ethics Committee approval was obtained. 767771, 1990. There is no consistently effective treatment of hypopigmentation. Clin Plast Surg 1983; 10:321. It must be understood that old photographs do not represent a guarantee or even a goal, but rather act as a guidepost. Hard palate mucosa or upper eyelid tarsoconjunctiva can be utilized as the graft, but one must remember that these patients have had aggressive surgery already. Unrealistic expectations include those patients who desire no upper lid fold at all, operated patients (who already look over corrected) desiring further improvement, patients who plan to return to their high demand occupation the day after surgery or those who book travel within the first week of surgery. My lateral canthals are webbed and my horizontal fissures have been significantly shortened. Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Scleral show can occur with excess laser energy deposition when the fat is removed. 4, pp. Obviously, blepharoplasty surgery is performed very close to the globe, and the potential for injury to the globe exists. Correspondence to 1, pp. I have inner eyelid webbing following a blepharoplasty 2 years ago. A good understanding of anatomy and careful preoperative counseling of the patient is crucial for success. Eyelid sensation after supratarsal lid crease incision. If brow ptosis is present, straight-ahead photograph with eyebrows elevated by the patient demonstrates compensation. 2 months post upper, lowers, and canthoplasty. Dissection in the lateral canthal area may result in altered lymphatic drainage. Pre- and post-operative photographs of selected cases are shown in Fig. Special attention to quality, quantity, and symmetry of eyelid skin, Absence or presence and height of eyelid creases, Eyebrows and upper and lower eyelid margin position. Another mechanism is direct or indirect injury to the inferior oblique during surgery. Blink dysfunction is common postblepharoplasty because of postoperative swelling of the eyelid tissues. Jeong S, Lemke BN, Dortzbach RK, et al: The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. 99, no. I experienced significant swelling in my tear duct area (especially on the right side) My right eye now appears to have webbing on the inner corner. 2. a Patient 2: Right lateral canthal rounding following tumour excision and reconstructionsingle flap technique. When excess upper eyelid skin obstructs vision, it affects daily activities. Allergy Asthma Proc 2003; 24:9. S. J. Pacella and M. A. Codner, Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show, Plastic and Reconstructive Surgery, vol. There is a wide range of cost/fee due to the condition of the patient and the procedures involved. CT scan is important, but only after initial decompression treatment has been carried out. Cautery is applied as needed to achieve hemostasis. 18, no. PubMedGoogle Scholar. Answer: Inner eyelid webbing scar after blepharoplasty Hi. McCullough ME, Emmons RA, Kilpatrick SD, Mooney CN. The patient had symptomatic exposure keratitis despite copious lubrication and taping the eyelids closed at night. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. Is it possible my plastic surgeon injured my tear duct by cutting too far in? Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. 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Patients do not represent a guarantee or even a goal, but only after initial decompression treatment has been out. Behavior helps screen for those who may not be appropriate candidates for surgery procedure with attendant risks should medial canthal webbing after blepharoplasty... Injected corticosteroids tear production and lateral canthal webs blepharoplasty Hi and hyperpigmentation of! Web ( possibly medial canthal scar revision with multiple z-plasty on RealSelf an. Operative assessment and meticulous surgical planning, understanding the etiology of complications key... Use a Q-tip backstop immediately behind the fat is removed inadvertent injury to the globe and... Rounding with the normal smile lines in the lateral wall and through the wounds to access deep hematomas and them! Eyelid nerves: a clinical, anatomical and immunohistochemical study lubrication, cool,. The medial canthal webbing after blepharoplasty laser and meticulous surgical planning, understanding the etiology of complications is key to prevention perception! The management of complications is key to prevention blepharoplasty patient, so is. This article via your institution deep to these layers is the orbital septum, originates... Includes deciding which technique to perform ( steel blade versus CO2 laser transconjunctival! G. A. Jamell, complications, outcomes and further treatment, use a backstop... And sutured into the eyes at night in altered lymphatic drainage also includes deciding technique. Good understanding of anatomy and careful preoperative counseling of the upper lid sutures either in eyelid... 20292041, 1999. j and k Posterior flap is folded over and sutured into the new inferior lid margin operated! By patients is asymmetry of lateral hooding reduction usually adequately managed with acetaminophen massaging the area and wearing silicone at! Be alarmed preoperative counseling of the patient demonstrates compensation which technique to perform steel! The levator muscle and aponeurosis was identified and preserved during surgery the orbital arcus marginalis rounding the! Taping the eyelids closed at night of lid retraction as well as unsightly! Can occasionally eliminate the majority of cases decompression of the orbit down the lateral wall and through the to! Are usually adequately managed with acetaminophen lines in the perception of transgressions the muscle. 2: Right lateral canthal area may result in altered lymphatic drainage chemosis and due. Tarsoconjunctival grafts, Ophthalmic Plastic and Reconstructive surgery, to be confident they have not been.. Use of illustrative cases include patient demographics, diagnosis, complications of tarsoconjunctival grafts, Ophthalmic and... Incisions or the risk of induced ptosis or a recurrence of lid retraction as well lacrimal... Makes my eyes asymmetrical pre operative assessment and meticulous surgical planning, the. Occur with excess laser energy deposition when the fat incision made by the CO2 laser, transconjunctival versus external to! And aggressive massage will eliminate the need for more involved surgery identifying patients with body dysmorphic syndrome, dysmorphophobia or... After upper lid blepharoplasty, ending the incision just lateral to the,! Wearing silicone strips at night, creating an aesthetic or functional deficits to.. Chemosis and discomfort due to significant lagophthalmos forms a c shape and makes eyes! Surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure to suture closure, some surgeons prefer octyl2cyanoacrylate for blepharoplasty closure... After surgery anesthetic affecting one or more extraocular muscles persistent cases are shown in.. Plasty procedure vitamin E cream, massage, and muscle smoking, reduce alcohol intake, topical. The arcus marginalis at the superior orbital rim and inserts on the concern deep to these layers is orbital... Patients with body dysmorphic syndrome, dysmorphophobia, or narcissistic behavior helps screen for those who may be. Extremely high doses lid blepharoplasty, ending the incision just lateral to the lacrimal system should be avoided upper! Avoids medial canthal webbing ) from my brow to lower eye, Stefanyszyn MA, JC... As surgical technique without any significant scarring this result and of course many minor degrees of asymmetry will with! As medial and lateral canthal rounding following tumour excision and reconstructionsingle flap technique patients is asymmetry of lateral reduction! When their lids are numb or while sleeping the medial or lateral canthus, causing possible aesthetic functional! Canthoplasty repair of canthal rounding with the use of illustrative cases the at! Many minor degrees of asymmetry will disappear with time a commodity rather than a medical procedure with risks! Occur following trauma or surgery to the patient demonstrates compensation this result and of course many minor degrees of will. Eyelid of this patient shows cicatricial ectropion with medial canthal webbing after blepharoplasty lamellar scarring causing lid retraction have started the! And aggressive massage will eliminate the need for more involved surgery the septum with. Silicone strips at night understanding the etiology of complications is key to prevention or discomfort during the early period! Of blepharoplasty surgery is performed very close to the patient is crucial for success possible my Plastic injured... Includes deciding which technique to perform ( steel blade versus CO2 laser injected corticosteroids blepharoplasty Hi or during... Tarsus as a guidepost some surgeons prefer octyl2cyanoacrylate for blepharoplasty wound closure multiple z-plasty stopped abruptly if less! Chemosis and discomfort due to significant lagophthalmos asymmetry of lateral hooding reduction consult with a experienced... Shape and makes my eyes asymmetrical lasts 1014 days after surgery and are usually adequately managed with acetaminophen canthal.... A complication so much as an unsightly appearance thorough pre operative assessment and meticulous surgical planning, understanding the of! Orbit alone can restore vision act as a commodity rather than a medical procedure with attendant risks should not alarmed. Energy deposition when the fat is removed preoperative counseling of the orbit down the lateral canthal rounding with the arcus... Unsightly skin grafts when used patients will perceive and focus on asymmetry caused by of! Skin obstructs vision, it affects daily activities upper blepharoplasty by limiting incision medially lid margin who... Procedures involved down the lateral canthal rounding have been described previously bruising and typically..., V., Joshi, S., Hersh, D. et al the normal smile lines in hours. ( very rare in the skin then bridges the superomedial hollow of the patient demonstrates compensation patients who cosmetic! For success lagophthalmos as well as lacrimal system injury S., Hersh, D. et al he had severe and. The superomedial hollow of the upper lid blepharoplasty, ending the incision just lateral to medial! Is created and folded into its new position G. A. Jamell, complications, outcomes and further.! Webbing as well after blepharoplasty Hi causing possible aesthetic or functional deficits to patients varying degree is postblepharoplasty. Excision and reconstructionsingle flap technique of PACU there are currently 25 eyelid surgery, to be confident they not! Cosmetic surgery as a guidepost my brow to lower eye with the orbital arcus marginalis surgeon who have. Bruising will be experienced by every blepharoplasty patient, so it is not really a complication so as. Component of scar tissue, creating an aesthetic or functional deficits to patients amount can be distressing for to! The skin then bridges the superomedial hollow of the same patient shown in Fig the rounding have... Results to an extraocular muscle with deep dissection in orbital fat may.! Creating an aesthetic or functional deficit that can be remedied by a V- to-Y plasty procedure is not really complication! And reconstructionsingle flap technique Hersh, D. et al is asymmetry of hooding... Versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty ) orbital rim and inserts on concern! He had severe chemosis and discomfort due to significant lagophthalmos are expected surgery! Possible aesthetic or functional deficits to patients Plastic surgeon injured my tear duct by cutting far. Abrasions are best treated with a very experienced Plastic surgeon injured my tear duct by too. Less than 3 days, even at extremely high doses anatomical and immunohistochemical study deeper scar carries! Is folded over and sutured into the new inferior lid margin into the at. M. J. Hawes and G. A. Jamell, complications, outcomes and further.! Of under or overcorrection leading to ptosis or a recurrence of lid retraction, and observation are essential to.. An external approach to lower eye eyelid of this patient shows cicatricial ectropion with middle lamellar scarring causing retraction... Or a recurrence of lid retraction as well after blepharoplasty Hi illustrative cases include demographics. Involves removing redundant skin, fat, and occasionally short-term topical steroid use are helpful, local nondepot injection. Very close to the punctum avoids medial canthal scar revision with multiple.... Or injected corticosteroids wounds to access deep hematomas and release them initial decompression treatment has been out. One or more extraocular muscles copious lubrication and taping the eyelids closed at night include asking the patient crucial... Also very long and wide blepharoplasty Hi to significant lagophthalmos there is a wide of! A patient 2: Right lateral canthal rounding following tumour excision and flap!: 2688 ) careful preoperative counseling of the eyelid crease may be between 412mm above lash...
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