eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Arcus Marginalis Release: Treatment

Author: Steven L Henry, MD, Staff Physician, Division of Plastic Surgery, University of Missouri Hospital & Clinics
Coauthor(s): Lawrence Ketch, MD, FAAP, FACS, Head, Program Director, Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Colorado Health Sciences Center; Chief, Pediatric Plastic, The Children's Hospital of Denver
Contributor Information and Disclosures

Updated: Feb 7, 2008

Treatment

Intraoperative Details

Some surgeons prefer general anesthesia because injection of local anesthesia into the lower lid can distort soft tissue anatomy. On the other hand, injection of an epinephrine solution can provide hemostasis and facilitate dissection. If performed with the patient under conscious sedation, the incisions should be marked with indelible ink prior to injection of the lids.

A transconjunctival approach may be preferable if no skin is to be resected. Using a blade or needle-tip cautery, an incision is made in the conjunctiva just inferior to the lower margin of the tarsal plate, entering the plane between the septum and the orbicularis. The orbital fat remains contained behind the orbital septum as long as the incision is made above the line of fusion of the septum and the capsulopalpebral fascia.

If skin is to be resected, a subciliary or subtarsal approach may be chosen. The subciliary incision is made in a line approximately 2 mm inferior to the lid margin, from a point inferior to the lacrimal punctum to one inferolateral to the lateral canthus. (Placing the incision too close to the margin can damage the eyelash follicles, whereas extending it medial to the punctum can disrupt the lacrimal canaliculi.) In stairstep fashion, the dissection plane first passes subcutaneously for several millimeters until the level of the lower margin of the tarsal plate is reached, at which point the dissection plane passes deep to the orbicularis. In this way, the pretarsal orbicularis is preserved, thereby minimizing the risk of denervation and consequent scleral show or ectropion.

The subtarsal incision is placed 5-7 mm inferior to the lid margin. While this incision also avoids the pretarsal orbicularis, it is associated with more edema and a slightly more noticeable scar than the subciliary incision.¹⁰ In either case, the incision should not be placed within the depth of a crease, as this increases the risk of scar contracture.

Regardless of the approach, dissection proceeds down the plane between the septum and the orbicularis and onto the anterior surface of the infraorbital rim. Now exposed, the arcus marginalis is incised with cutting cautery from medial to lateral along the infraorbital rim, taking care to avoid the inferior oblique muscle (located directly behind the medial third of the septum) and the lateral canthal tendon (see Image 2, bottom). A branch of the infraorbital artery is sometimes found ascending onto the central portion of the septum and should be ligated or cauterized before this step. In many patients, orbital fat pad herniation and consequent bags are present only medially and centrally. In these cases, the arcus marginalis release need not be extended over the lateral fat pad, unless malar contouring is desired.¹¹

The septum and orbital fat pads are then advanced over the infraorbital rim. Strong traction on the fat pads should be avoided, since this can tear deep orbital veins.

The fat pads may need to be sculpted to achieve a smooth contour. Meticulous technique is critical at this stage, since irregularities in the contour of the advanced fat pads are noticeable through the skin. The advanced septum and orbital fat are reset (as a unit) onto the periosteum of the maxilla inferior to the orbital rim with interrupted sutures of 5-0 polyglactin (see Image 2, bottom). The septum should be reset under minimal tension to avoid scleral show or ectropion. Lateral canthopexy is often indicated and should be performed prior to septal reset to establish and stabilize lid positioning.¹²

Skin resection, if indicated, is performed last. A skin flap is elevated just superficial to the orbicularis, and the skin is gently advanced. Prior to redraping and trimming the skin flap, the patient's mouth is opened maximally to place tension on the skin of the cheek. This maneuver helps to avoid overresection of skin. The incision is typically closed with running 7-0 nylon suture.

Postoperative Details

Infection of the lid following blepharoplasty is rare, making systemic antibiotic prophylaxis unnecessary. Nonetheless, antibiotic ophthalmic ointment may be applied to the incision line and cornea immediately after surgery and daily thereafter. After a few days, the patient may switch to Lacri-Lube ophthalmic ointment or its equivalent at bedtime and artificial tears throughout the day.

Significant postoperative pain is rare, and most patients are comfortable with a mild nonaspirin analgesic.

Substantial edema and ecchymosis may follow this procedure. Intermittent application of cold packs over the first 24-48 hours and elevation of the head at least 30 degrees helps to minimize swelling. After the first 48 hours, or when edema has largely resolved, warm compresses can help to expedite the resolution of bruising.

Increased pigmentation from hemosiderin deposition is sometimes observed in patients with excessive bruising. To minimize this complication, patients should avoid postoperative sun exposure until the ecchymosis has resolved entirely.

Eyelids are extremely sensitive to allergenic insult, and preexisting atopy can be aggravated by surgery. Patients should therefore not use cosmetics for at least 10 days after surgery in order to avoid an allergic reaction.

Skin sutures may be removed on postoperative day 3. However, the patient and surgeon must wait several weeks for swelling to resolve and healing to conclude before judging the outcome, since complete convalescence is longer after this procedure than after traditional blepharoplasty. While some patients may be comfortable appearing in public after 1-2 weeks, the final result may not be realized for 3-6 months.

Follow-up

For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Black Eye.

Complications

Retrobulbar hematoma

Significant postoperative pain is unusual and should alert the surgeon to the possibility of a serious hematoma. Hemorrhagic compression of the optic nerve can lead to visual loss, a complication reported to occur once per 40,000 blepharoplasties. The patient with a retrobulbar hematoma usually complains of a steady, lancinating pain, similar to that of glaucoma. The patient may also report scintillating scotomas or hemianopsia and may exhibit mydriasis, proptosis, chemosis, or conjunctival injection.

Because the consequences of retrobulbar hematoma are so severe, aggressive intervention is required. The surgeon should not wait for signs of nerve compression (eg, visual disturbances, afferent pupillary defect) to arise, because permanent damage may have occurred by that time. Rather, excessive pain and proptosis necessitate immediate surgical decompression. The incision should be opened and carefully explored. If necessary, lateral canthotomy may be performed to achieve emergent decompression. Medical decompression of the orbit with corticosteroids (methylprednisolone 100 mg IV), osmotic diuresis (mannitol 50-100 g IV over 30 min), and carbonic anhydrase inhibition (acetazolamide 500 mg IV) may also be used. Ophthalmologic consultation is imperative in this situation.

Oculocardiac reflex

The oculocardiac reflex manifests in approximately 25% of blepharoplasty patients but is almost exclusive to those undergoing local anesthesia. Characterized by intraoperative bradycardia or dysrhythmia, any ocular manipulation, including traction on the orbital fat pads, can trigger this reflex. Most patients demonstrating this reflex experience a heart rate change of less than 30%; however, profound bradycardia and even arrest have been reported. Young females appear most prone to experience the oculocardiac reflex.

Keratoconjunctivitis sicca

Keratoconjunctivitis sicca (dry eye syndrome) is most often observed in patients with preexisting lacrimal insufficiency or postoperative ectropion. Diminution of lacrimal function is a normal part of aging, but it can be hastened by diseases such as diabetes and hypothyroidism. Consistent postoperative use of artificial tears is imperative in these patients.

Ectropion

Temporary ectropion is common, particularly laterally, as a result of edema, wound contraction, and/or orbicularis hypotonicity. Steri-Strips can be applied obliquely and with tension at the lateral canthus. This provides the lower lid with superolateral support—a sort of "temporary canthopexy"—that can mitigate the ectropion. Permanent ectropion following arcus marginalis release is rare, especially if caution is exercised in septal resetting and skin resection. If the ectropion persists, skin grafting or canthoplasty may be required.

Epiphora

Epiphora is common in the first few postoperative days. Corneal irritation, which triggers hyperlacrimation, and ectropion, which removes the punctum from the surface of the globe, usually cause epiphora. 

Fat necrosis

Fat necrosis manifests as small, painful, indurated nodules. Compresses and massage hasten their resolution. Injection of steroids into the lesions is effective but carries the risk of subcutaneous atrophy and hypopigmentation.

Diplopia

Diplopia is usually caused by injury to the inferior oblique muscle. Permanent visual disturbances caused by blepharoplasty are much rarer than preexisting visual deficits. Performing a preoperative visual examination is imperative to protect the surgeon from unfair blame.

Medicolegal pitfalls

Almost all complications stem from inadequate preoperative evaluation. From a medicolegal perspective, a thorough history and ophthalmologic examination are key. At minimum, preoperative visual acuity should be documented and standard photographic views obtained. A Schirmer test and a referral to an ophthalmologist for a more detailed examination may be indicated.

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