Dermatochalasis Treatment & Management

In general, the treatment of dermatochalasis is surgical. The following medical treatments may be appropriate:

• Dermatochalasis patients with blepharitis may benefit from lid hygiene and topical antibiotics.
• Dermatochalasis patients with dermatitis may benefit from topical steroid ointment.
• Dermatochalasis patients with dry eyes should be treated with the appropriate topical lubricant. In addition, placement of temporary collagen punctal plugs, permanent punctal plugs, or punctal cautery may be considered in patients with a history of dry eye or a physical examination consistent with dry eye. These measures may be used preoperatively to further evaluate the patient prior to embarking upon surgery.

Upper eyelid blepharoplasty should always be performed following a careful history and examination prior to the surgery.

• The upper eyelid creases are marked (usually 8-12 mm) and measured to ensure symmetry. The pinch technique is used to measure the amount of skin to be resected.
• One end of a toothed forceps is placed on the eyelid crease, and the other end of the forceps is used to pinch the skin in the upper eyelid.
• The amount of skin pinched should not cause the eyelid to open upon pinching. Multiple measurements are made on both sides to ensure symmetry.
• The lids are injected with 1% Xylocaine with epinephrine and hyaluronic acid mixture. The upper border of the incision should not be closer than 7-8 mm from the brow.
• The skin is excised using a No. 15 blade, laser, or radiofrequency device; then, a 2- to 3-mm strip of preseptal orbicularis is excised with tenotomy scissors. Some surgeons preserve orbicularis muscle. Certainly in patients with a severe dry eye, thought should be given to preserving the orbicularis muscle. Meticulous hemostasis is maintained throughout the procedure.^[5]
• The 2 upper eyelid fat pads are gently and meticulously dissected free, and then resected, and the fat pad stump is cauterized.
• The wound is closed appropriately with care being taken to ensure that the orbital septum is not incorporated into the closure.
• Occasionally, a modified W-plasty is indicated for the medial aspect of the wound. In some patients, resection of the retroorbicularis oculi fat pad (ROOF) is indicated to minimize brow fullness.

Note the before-and-after images below.

Transconjunctival lower eyelid blepharoplasty is indicated for the correction of steatoblepharon without dermatochalasis.^[6]

• The lower eyelid is everted over a Desmarres retractor, and the inferior conjunctival fornix is incised. The globe is protected with corneal protectors. Blunt dissection is used to identify the 3 lower eyelid fat pads.
• The inferior oblique muscle and the "valley of the inferior oblique" are identified and preserved. Care is taken not to resect too much fat, causing a hollow look to the lower eyelids.
• The conjunctiva is closed loosely with a 6-0 plain absorbable suture. A tight closure can result in a compartment syndrome should the patient experience postoperative hemorrhage. This can be combined with a canthopexy if lower eyelid laxity is identified.
• Another technique has been described whereby the 3 lower eyelid fat pads are draped over the inferior orbital rim to prevent a tear trough deformity. This is performed after the arcus marginalis has been incised; then, the fat pads are sutured to the periosteum on the anterior surface of the maxilla. The fat draping can be tailored to the individual patient’s needs (ie, draping the medial fat pad and resecting the middle and lateral fat pads).
• Alternatively, the fat pads and/or the orbital septum can be shrunk with a Colorado needle tip and/or carbon dioxide laser without resection to achieve an aesthetically pleasing result.^[7]
• A subciliary technique can be used if dermatochalasis is identified in the lower eyelid using the pinch technique with the patient in upgaze and the mouth open. The procedure is similar to that described above, except that a skin muscle flap is elevated in the lower eyelid prior to resecting or redraping the lower eyelid fat pads. However, the pretarsal orbicularis should be preserved when using this technique. This also can be combined with a canthopexy if indicated. It is often preferable to combine skin tightening using a laser or chemical peel than to overresect skin and cause eyelid deformities.
• With the open subciliary technique, the arcus marginalis can be released and the septum can be redraped over the infraorbital rim to smooth the transition from the lid to the cheek.
• Transcutaneous or transconjunctival blepharoplasty may also be combined with orbitomalar ligament suspension to improve aesthetics and to lessen the risk of postoperative eyelid retraction.^[8]

Note the before-and-after images below.

Autologous fat grafting has been used in the periorbital and midface regions for rejuvenation. In the periorbital region, submuscular and preperiorbital fat grafts may be placed to minimize the appearance of steatoblepharon. Studies have demonstrated a long-term graft survival rate of 32%. Additionally, use of a variety of filler materials has been shown to be useful in the periorbital region.^[9]

The completed clinical trial Vibration-Assisted Anaesthesia may be of interest.

All the patients undergoing blepharoplasty should have a careful ophthalmology consultation prior to surgery.

Smoking and rubbing the eyes postoperatively can delay wound healing. In addition, activity in the first postoperative week should be limited. No activity that causes the patient to Valsalva (ie, lifting) should be allowed. Postoperative vomiting is uncommon but should be controlled medically to prevent persistent bleeding and possible retrobulbar hematoma.