Subciliary Approach Blepharoplasty Treatment & Management
- Author: Antonio Riera March, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA more...
Discuss all aspects of the procedure with the patient. A member of the family or a significant other (eg, partner, spouse) can witness and participate in the interview. A booklet with the precise information is very useful for this purpose.
Discuss the surgical fee and other fees (eg, laboratory, anesthesiology, ambulatory facility) in advance. Cleary indicate the time of expected payment once the patient commits to the surgery. As with every cosmetic surgery, the best plan is to have all fees paid preoperatively.
Detailed discussion of surgical procedure
Explain the procedure in front of a mirror or have the preop digital images display on a monitor screen. Point out (1) any skin lesion localized in the lower eyelid; (2) scleral show, if present; (3) any abnormal brow position in the resting position or in the dynamic position; (4) the relationship of eyelid surgery to the position of the brow. 5) any facial asymmetry. In addition, advise the patient if brow surgery is indicated. Removal of eyelid skin prior to brow correction yields a definitively unpleasant result.
Explain the anatomical abnormalities that can be corrected with blepharoplasty. Explain the anatomical abnormalities that can be partially improved with blepharoplasty. Fine wrinkles, crêpelike skin, pigmentation changes, and skin lesions in the lower eyelid can be only slightly improved by lower eyelid blepharoplasty; the final result is totally unpredictable. Explain the anatomical abnormalities that cannot be improved with blepharoplasty. Finally, explain the surgical procedure itself.
See the tests recommended in the Clinical and Workup sections. Have the patient avoid aspirin and vitamin E for 2 weeks prior to surgery. Consult a medical service for patients on anticoagulation therapy. The patient must discontinue all herbal or natural substances that may have an effect on coagulation or anesthesia. Have the patient stop smoking for 2 weeks before surgery and avoid the use of alcohol and caffeine for 1 week before and after surgery.
Fully discuss surgical planning, risks, and complications with patients. Obtain informed consent. Check laboratory test results and information from consultations with the medical specialist; follow recommendations. Ensure that all this information is available for review prior to the day of surgery. Advise patients to take their usual medications up until midnight prior to the surgical procedure.
Advise patients to not wear makeup to the surgical suite. Also, instruct patients to take nothing my mouth after midnight the night before surgery.
Day of surgery (holding area)
Complete physical examination, laboratory results, and clearance reports must be on record at the time of admission for an outpatient surgery. Note in the past medical history allergies to medications, hypertension, diabetes, cardiopulmonary disease, chronic illness, and previous surgeries.
Write in the record the indications, the summarized problem, and the treatment plan with the selected surgical approach. Items to check include (1) that photographs are available for review, (2) that informed consent is signed and on record, (3) that an evaluation and premedication has been performed by the anesthesia service, and (4) that the patient has voided upon call to the operating room.
The different modalities to approach the subciliary blepharoplasty of the lower eyelid are via (1) a skin-muscle flap, (2) a skin flap, and (3) a repositioning of fat technique.
This procedure consists of elevating the skin and the orbicularis muscle as a unit in the plane medial to the muscle and anterior to the orbital septum. The advantage is that the flap is easier to develop, with less bleeding and with immediate access to the fat pocket. Its use is recommended when skin and orbicularis muscle must be removed.
The skin flap involves elevating the skin and the orbicularis muscle in 2 different planes prior to fat pad removal. It is used when the amount of eyelid skin is excessive compared to the orbicularis muscle. The skin flap is a more laborious flap, and bleeding is more common; therefore, it is infrequently used today.
Fat preservation/suspension technique
This technique can be executed in 2 ways, either by not removing the fat pads and reinforcing the retaining action of the orbital septum or by repositioning the fat pads over the orbital rim. The latter approach is the one most commonly used.
By preserving the fat and repositioning the fat pads with sutures to or over the orbital rim, a convex/youthful appearance is reestablished without adverse effects, such as a concave/sunken appearance. Using this technique, the vertical dropping of the orbicularis and the midface can also be addressed by suspending these structures in the vertical plane in order to counteract the negative effects of gravity.
Preparation, anesthesia, and design
The authors use local anesthesia with intravenous sedation for almost all blepharoplasties. Very rarely, general anesthesia with endotracheal intubation is necessary. This is required when blepharoplasty is performed concurrently with other facial plastic procedures.
Having the patient sedated but awake is advantageous for consistently good cosmetic results because the patient can cooperate with the surgeon by following basic commands.
In the authors' university facility, blepharoplasties are performed as outpatient procedures, with full attendance of an anesthetist under direct supervision of an attending anesthesiologist. They administer the intravenous sedation for the entire surgical procedure. Protocols and recommendations for anesthesia sedation vary slightly among different anesthesiologists in the authors' institution, and the reader is referred to references on this subject.
The authors recommend that the markings for the incision and the planning of the operation be made with the patient in the sitting position prior to lying on the operating table.
In every patient, the factors involved in the cosmetic problem are reviewed in the medical history and supported by photographs.
The authors do not usually use markings for the subciliary incision except for its lateral aspect; however, in an academic setting, delineating incisions, anatomical abnormalities, and asymmetries is useful. A sterile commercial skin marker or the tip of a broken cotton-tip applicator moistened with methylene blue is useful for this purpose.
The head of the patient is elevated slightly from the lying position, and the eyelids and orbital areas are fully cleaned with surgical soap and cotton-tip applicators. Re-marking of the incision is performed after cleansing. Sterile draping is used. Be careful that the draping does not cause any distortion of the lower eyelid. Plastic adhesive drapes are not recommended because they may lead to a miscalculation of the eyelid tissue to be resected.
In each eyelid, the authors use 1-2 mL of 1% lidocaine (Xylocaine) with 1:100,000 epinephrine injected subcutaneously with a 27- or 30-gauge, 1.5-inch needle. Other concentrations of lidocaine, such as 2% or even 0.5%, can also be used with 1:100,000 or 1:200,000 epinephrine. The needle moves from lateral to medial, going parallel to the edge of the lower eyelid. Avoid deep penetration with the needle, which could cause severe damage to the globe. A word of caution: in every incidence, the surgeon must personally verify the contents of the syringe before injection.
Timing of the injection varies depending on whether a 4- or 2-quadrant blepharoplasty is performed. Usually, 2 eyelids superiorly or 2 inferiorly are anesthetized at a time. Approximately 1 hour of painless time is achieved using the above technique. After that period, further anesthesia is added if needed. A waiting period of 10-15 minutes is generally needed to achieve both anesthesia and adequate vasoconstriction after the initial injection.
Skin-muscle flap technique
First, a stab incision with a No. 15 Bard-Parker blade is made below the ciliary line into the bony orbital rim approximately 10 mm from the external aspect of the lateral canthal area.
Note that the most external aspect of the incision is in a horizontal direction into the area of the crow's feet. If a 4-quadrant blepharoplasty is performed at one time, the external aspect of the lower blepharoplasty incision must be separated by at least 5 mm from the external aspect of the upper blepharoplasty incision.
A single or small double skin hook is used to elevate the tissue, while small curved iris scissors are used to create a skin-muscle flap just below the orbicularis muscle. The blades of the scissors are spread using blunt movements, creating a dissection plane from superior to inferior to medial.
The exact plane of the dissection is precisely in the submuscular plane, just above the orbital septum. With the assistance of the single or small double skin hook to keep the dissected plane elevated, one scissors blade is passed above the eyelid skin and the other in the previously created plane.
The cutting follows the stab wound incision and then the initial marking line or an imaginary subciliary line parallel to the lower eyelid edge just 2-3 mm below the line of the lashes.
The incision stops medially prior to reaching the lower eyelid puncta. Advancing the incision past the lower lid puncta produces postoperative scarring and fibrosis, which can lead to epiphora.
Bleeding is reduced to a minimum if the plane of dissection is correct. However, once the flap is developed, small bipolar electrocautery, ophthalmic disposable battery cautery, or a Colorado needle (Colorado Biomedical; Evergreen, Colo) can be used for coagulation.
A wet sponge is placed over the closed upper eyelid. Further exposure is achieved by clamping a small hemostat to a 4-0 or 5-0 silk suture, which is passed through the open superior edge of the lower eyelid and is used as traction. A small double skin hook is used for gentle retraction of the open inferior edge of the lower eyelid.
A clear vision of the orbital septum is achieved at this point. The amount of orbital fat to be removed has already been estimated. Removal of too much fatty tissue produces an unfavorable result, giving a sunken, debilitated look that is difficult to correct.
The orbital septum must be opened over the fat pads, either with the assistance of forceps and scissors or with the forceps and cautery. A horizontal strip of orbital septum must be resected, exposing the 3 fat compartments. The same can be accomplished by making a buttonhole incision just above each of the fat compartments using the described instruments.
The small layer of connective orbital septum just over the lateral fat pad is grasped and gently cauterized with the disposable ophthalmic cautery unit. The fat pad localized below is under direct view.
Gentle pressure to the globe over the superior eyelid makes identification of the fat compartments easier.
Grasp the fatty tissue with an ophthalmic forceps and isolate it with the assistance of a cotton-tip applicator.
Traction of the fatty tissue causes deep pain to the patient. Therefore, inject the base of the fat pad with 1% lidocaine (0.2 mL) with a 30-gauge needle before clamping the base with a small curved hemostat. Alternately, the base of the fat pad can be cauterized with a bipolar cautery.
Some surgeons believe that excising and cauterizing the fat pad without clamping its base with a hemostat is safer. The reason for this thinking is that the clamped hemostat places extra traction on the fat pad, thereby increasing the possibility of retroorbital hemorrhage. The authors feel that clamping is acceptable as long as gentleness is used in handling the fat pad at all times.
All fatty tissue above the hemostat is excised with scalpel or scissors. The cuff remaining below is cauterized before retracting intraorbitally. Hemostasis must be complete prior to return of the stalk to its previous position. Extra caution is needed to avoid damage to the inferior oblique muscle that divides the middle and the nasal compartment. No sutures of any type are needed to close the orbital septum.
After the fat pads are removed, some surgeons believe that the gentle touch of the ophthalmic cautery unit over the remaining septum reinforces the strength of its diaphragmatic action and keeps the fat in its compartment, avoiding protrusion or herniation.
The traction suture placed in the superior edge of the eyelid is removed. The skin-muscle flap is grasped with the forceps and tractioned superiorly for redraping over the subciliary incision with the assistance of a cotton-tip applicator. Care must be taken to ensure that the skin-muscle flap drapes over the underlying structures and is not tented, which would result in excess skin removal.
The authors ask the patient to open the mouth and look upward. This creates the maximum possible separation of skin edges and helps to maintain a conservative focus for the final excision.
Observing experienced surgeons performing this excision is highly recommended before performing the first case. In general, do not exceed 4 mm of vertical skin excision in the lower lid margin. Again, the authors emphasize a conservative approach for the vertical dimension of the resection.
The redundant skin-muscle flap is excised in a triangular form, ie, wider laterally and decreasing the amount of the excision from lateral to medial. This avoids shortening in the vertical dimension and prevents, as much as possible, postoperative ectropion and/or lid retraction. The excision is accomplished using a straight iris scissors with the blades beveled downward in order to cut the orbicularis muscle at a lower level of the flap border. This makes both sides of the incision even and avoids a step-off deformity at the skin margins. The amount of muscle to be removed is slightly more if a hypertrophied orbicularis muscle is present.
Meticulous hemostasis is achieved using bipolar cautery, ophthalmic portable cautery, and/or a Colorado needle. The skin is then sutured.
Lower lid closure can be accomplished in several ways, including (1) interrupted 6-0 polypropylene (Prolene), 6-0 nylon, or 6-0 silk sutures going from lateral to medial; (2) a running suture with untied long ends from lateral to medial using the same materials plus Steri-Strips; or (3) interrupted 6-0 fast-absorbing gut sutures going from lateral to medial. The eyes are irrigated with a normal saline solution, and antibiotic ophthalmic ointment is applied over the suture line.
Skin flap technique
The skin flap is developed in a similar fashion to the skin-muscle flap. The skin is dissected from the orbital muscle. More bleeding than with the skin-muscle flap is not uncommon. Therefore, complete hemostasis is required.
The subciliary incision is made after marking the incision line just 2-3 mm inferior to the lower lid edge with a No. 15 scalpel blade going only through the skin. Remember several points mentioned previously. First, keep away from the lower lacrimal punctum. Second, at the lateral aspect, extend approximately 1 cm into the crow's feet area. Finally, separation from the incision of the upper blepharoplasty, if performed, is at least 5 mm in its lateral aspect.
Using slightly curved scissors and the assistance of inferior traction placed on the lower lid skin and superior traction placed on the external skin area, the skin flap is undermined and developed. Once fully developed to the orbital rim, use scissors to complete the subciliary incision that was previously initiated with the scalpel.
The orbicularis muscle can be managed using 1 of 3 methods, including (1) division and separation sufficient enough to reach the orbital septum to access the fat pad, (2) small resection of the hypertrophied orbicularis muscle fibers across the septum to access the fat pad, or (3) elevation of the orbicularis muscle as a flap to access the fat pad below. The third approach is used most commonly by surgeons to access the fat pad, resect excessive sagging and/or laxity of the orbicularis muscle, and suspend the muscle to the orbital periosteum.
Then, removal of the fat pads is performed in a manner described for the skin-muscle technique. No sutures are needed to close the orbital septum.
Skin resection is slightly more than occurs with the skin-muscle flap because this particular technique is applied to patients with more redundancy of skin. Still, remember to remain conservative with skin removal.
Recommendations for closure, suture materials, and dressings are the same as described for the skin-muscle flap.
Fat preservation/repositioning technique
The information below is a synopsis of this particular technique. The reader is referred to recent publications on the subject for details of the surgical procedure.
The fat preservation technique can be accomplished by either the subciliary or the transconjunctival approach. In general, the subciliary approach is selected for younger patients and patients with adequate lower eyelid tone. The transconjunctival approach is preferred for older patients and patients with poor lower eyelid tone.
If the subciliary approach is used, the skin-muscle flap technique is developed as described previously in the preseptal plane.
The orbicularis muscle (relating to the lower eyelid) is elevated from periosteal attachments. The inferior midface route of dissection varies among surgeons. The 2 different routes are the subperiosteal route and the supraperiosteal route. The subperiosteal route creates a pocket to bury the transposed fat pedicles over the orbital rim.
The supraperiosteal plane or suborbicularis plane changes to a different plane in the lateral or medial aspect of the dissection. In the lateral aspect, the dissection proceeds below the zygomatic major and minor muscles. In the medial aspect, the dissection proceeds above the levator muscle of the lip and nasal ala. By doing this, the fat pads are suspended and the midface is elevated.
Then, the fat pads are localized and separated from the surrounding tissue with the assistance of a cotton-tip applicator. They are prepared in a T-shaped fashion and sutured to the periosteum of the infraorbital rim or adjacent tissue or buried into the subperiosteal pocket as described above. For all of these, 5-0 or 6-0 Vicryl is used.
The orbicularis muscle and the vertical dimension of the created flap are sutured to the orbital rim periosteum with buried 4-0 Vicryl. A conservative approach is mandatory when resecting skin and muscle if a subciliary approach is used with the fat preservation/repositioning technique.
Surgeries associated with lower lid blepharoplasty
See the list below:
Suspension technique for lower eyelid laxity: If the degree of laxity is not significant or prevention of eyelid retraction is intended, a suspension technique is used along with the cosmetic blepharoplasty. This technique is based on a single 5-0 noncolored nylon suture to perform the plication of the orbicularis muscle to the periosteum of the lateral orbital rim. Another way to produce the same effect, although less common, is placement of the same type of suture through the lower eyelid tarsal plate, just inferior to the lateral canthal tendon, and localization of the periosteum above the same tendon.
Horizontal shortening for lower eyelid laxity
- When patients present with a weak or atonic lower eyelid, a horizontal shortening procedure is performed with the cosmetic blepharoplasty. Lateral canthal tendon shortening and eyelid horizontal shortening are both used.
- For lateral canthal tendon shortening, the lateral canthal tendon is identified, isolated, and grasped in order to evaluate the amount of resection required to decrease the laxity of the lower lid. The tendon is transected and resected the amount necessary to tighten the lower lid. A 6-0 noncolored nylon U-type suture is used to reapproximate both ends of the cut tendon.
- In the eyelid horizontal-shortening procedure, shortening requires excision of a full-thickness lateral segment of the lower eyelid. The shape is usually triangular or pentagonal, with the apex directed inferiorly. After the initial cut is made, both ends are pulled facing each other to determine the amount of full-thickness including the tarsal plate to be removed for adequate tightening. The amount varies according to the degree of laxity. An average of approximately 4-5 mm is usually necessary.
- Closure is performed first in the marginal area starting at the gray line with a 6-0 silk suture. Ensure that both ends are long enough to be attached to the lower eyelid skin with a Steri-Strip, providing easy access for final removal. The remaining sutures are through the tarsal plate and soft tissue using an absorbable 6-0 Vicryl suture. The skin is reapproximated with 6-0 nylon. The conjunctiva remains open. The marginal silk sutures remain in place for approximately 7 days.
Chemical peeling/laser resurfacing
- The eyelid skin is very thin, the thinnest in the body. Therefore precise control of depth is crucial in ablative periorbital techniques such as: chemical peels, carbon dioxide (CO2) and Erbium: yttrium, aluminum, garnet (Er:YAG) laser technologies.
- Chemical peeling and laser resurfacing can be used for management of periorbital and eyelid rhytides. Medium-depth chemical peeling, 35% trichloroacetic acid and Jessner’s solution, are commonly used for this purpose. The advantage of a chemical peel is that it is less expensive than laser resurfacing. However, the new laser technology is replacing the chemical peeling in periorbital rejuvenation due to the controlled depth the tissue ablation, less thermal damage, rapid healing, efficacy and safety.
- Chemical peeling and CO2 and Er:YAG laser resurfacing at reduced power output, performed along with the muscle-skin flap technique, are safe according to recent medical literature. However, no chemical peeling or laser resurfacing is safe enough to be used in conjunction with the skin flap technique because of the high risk of lower eyelid skin necrosis.
- Some surgeons prefer to perform an independent chemical peeling or laser resurfacing at a later time, usually 2 months or longer postoperatively.
- The botulinum toxin may be useful to enhance the benefits of blepharoplasty once the healing process is over. It may improve wrinkles that would not be modified by any other treatment modality.
- The botulinum toxin type A is a neurotoxin that results in a transient paralysis of the related muscle when injected intramuscularly or subcutaneously. This is temporary, lasting an average of 5-6 months.
- Facial wrinkling is produced by continuous contraction of the related muscles and the loss of elasticity. Therefore, by paralyzing the involved muscle, wrinkling diminishes. This technique can be useful in the treatment of forehead, glabellar, lower eyelid, and lip regions and for crow's feet wrinkles. The dosage, timing, and injection techniques are not in the scope of this article.
- Blepharoplasty can also be performed in combination with a facelift, cervifacial liposuction, and/or submentoplasty. The authors strongly encourage the reader to review the medical literature regarding all the topics that can be performed in combination with blepharoplasty.
Other procedures are designed to improve the orbital area by restoration the infraorbital volume with injectable fillers and fat grafting.
Injectable fillers: The most common fillers used in this area are based with hyaluronic acid and calcium hydroxyl apatite. The hyaluronic acid used in the infraorbital area for temporary treatment of the "tear through" deformity has an specific formulation of nonanimal source. In this region, using topical and/or local anesthesia, the filler material is injected in small incremental aliquots into the supraperiosteal/suborbicularis plane. Following several injections a gentle massage is performed to smooth out possible irregularities. Calcium hydroxyl apatite fillers has the characteristic of a longer lasting time compared to fillers based on hyaluronic acid. 
Fat Grafting: The beneficial effect is based on volume restoration in the infraorbital area. The fat injection can be perform in conjunction with blepharoplasty or as an independent procedure without blepharoplasty. Fat grafting alone can be adequate to improve deformities to aging which do not involve the eyelids. Autologous fat is harvested from the lower abdomen and thighs using a low pressure liposuction technique. 
Secondary blepharoplasty: Minor "touch-up" surgery may be necessary after blepharoplasty and is usually related to insufficient removal of fat pads. After lower subciliary blepharoplasty, use extreme caution with any further removal of skin in the lower lid because of the high possibility of cicatricial ectropion. Rigorous analysis and a conservative approach are mandatory.
The patient is taken to the recovery room for monitoring over the next 3-4 hours. Patients are positioned on their back with their head slightly elevated.
Cool, wet gauze or an eye pad is applied over the eyes and changed or recooled every 30 minutes. No compressive dressing of any kind is recommended. Pain is uncommon, but discomfort is common. Therefore, oral analgesics that do not contain aspirin are given.
Personnel in the recovery room are familiar with this type of surgery. However, always write in the chart the specific orders and warning signs of possible complications (ie, persistent pain, visual disturbance, unusual swelling, proptosis). Also, clearly write in the chart cellular telephone numbers that can facilitate immediate communication between the recovery room staff and the surgeon.
When the patient is fully awake, hemodynamically stable, without complications, and cleared by the anesthesiologist, the patient may be discharged home. The assistance of a family member or friend is crucial in the transportation process and perhaps during the first night or two at home.
Instructions for the patient are as follows.
Day of surgery: Remain at rest at home during the rest of the day. When lying down, slightly elevate the head. Cold dressings can be used while awake, and change them or recool them every 30 minutes. Take mild analgesics that do not contain aspirin as needed, usually every 4-6 hours. Apply antibiotic ointment or bland ophthalmic ointment in small amounts to the incision line twice daily with a cotton-tip applicator for the first week. (Some surgeons recommend prophylactic oral antibiotics for 1 week after the operation.)
Next day: Ambulation at home is permitted, but otherwise continue with the instructions for the day of surgery. (Some surgeons request that the patient come to the office on this day for the first follow-up visit.)
Second day: Continue with the instructions of the first postoperative day. Be aware that an increase in eyelid swelling is expected. The use of eyeglasses is now permitted. Avoid using contact lenses in the early postoperative period.
Third day: Leaving the house is permitted, but use sunglasses.
Fourth day: Return to the office for removal of permanent sutures.
Seventh to the tenth day: The eyes can be washed normally with gentle soap and water. At this time, a return to work is permitted if this does not involve the risk of trauma to the surgical area.
One month: Full sport activity can be resumed.
In general, the use of mascara, eyeliner, makeup, and contact lenses can resume around the beginning of the third week, although this varies widely according to each patient's healing process.
Provide the patient with clearly written telephone numbers of the surgeon and staff, and instruct the patient to contact the physician (surgeon) and/or staff with any questions or concerns during the recovery period.
Discharge criteria are (1) hemodynamic stability; (2) an alert and oriented patient who has been cleared by the anesthesiologist; (3) no evidence of bleeding, hematoma, swelling, proptosis, or visual disturbance; and (4) no significant pain. Remember that pain is unusual. Persistent pain, deep pain, or severe pain represents a warning sign of possible complications. Written instructions must be provided for the patient, family, or assisting personnel prior to discharge. Make sure that the patient understands the instructions. Provide written cellular telephone numbers with the instructions.
A nurse, the resident, or the attending physician calls the patient the night of discharge.
The patient may be requested to return to the clinic the first postoperative day. For some surgeons, this is routine. This visit is good for the surgeon and patient alike. The surgeon can make sure everything is as expected, and the patient can take the opportunity to ask any questions. If the patient and the surgeon feel comfortable with a phone conversation, this visit can be omitted.
Have the patient return to the clinic on the fourth postoperative day if the patient has nonabsorbable sutures. Remove the sutures at this visit. Reinforce the instructions and address any patient questions or concerns. A Steri-Strip may be applied to the incision line. The patient returns 7-8 days after the initial operation for removal of the Steri-Strip and cleansing of crusts from the eyelids.
Have the patient return to the clinic on the seventh postoperative day if the patient has gut-absorbing sutures. Remove the remaining partially absorbed gut sutures and cleanse any crusts from the eyelids. Reinforce the instructions and address any questions or concerns.
When the patient returns to the clinic after 3-4 months, healing is usually complete and pictures are taken. The patient then returns to the clinic every 4 months for the first year for a follow-up evaluation. At each visit, more pictures are taken.
Lower blepharoplasty is a very common rejuvenating surgical procedure. In a busy facial plastic surgery clinic, complications and unsatisfactory results occur. Preventative measures, accurate analysis, and good patient selection are extremely important to reduce complications to a minimum. Preoperatively, an open discussion to educate the patient about possible complications is mandatory. This particular section focuses on general complications that can occur in lower eyelid blepharoplasty and specific complications that can occur in the lower eyelid blepharoplasty subciliary approach.
See the list below:
- The best way to avoid the patient being unsatisfied with the procedure, even after a satisfactory objective result, is in the preoperative evaluation. Carefully analyze the exact reason for the surgery and the patient's expectations prior to commencing with the surgical procedure. Prevention is the best defense.
- Once the patient is unsatisfied, key management is always to keep the communication line open, no matter how difficult. Select a time for an interview that is convenient for both surgeon and patient, and provide ample time to listen to the patient's concerns. Be honest and keep control of this difficult situation with meaningful comments. Always be available for and supportive of the patient's questions and concerns.
Dry eye syndrome
- Temporary dryness is a common occurrence in the immediate postoperative period. After the edema resolves progressively over 1-3 weeks, dry eye syndrome resolves.
- The medical history is the most important information from which to detect patients prone to dry eye syndrome postoperatively. Patients with a history of dry eye, eye irritation, foreign body, burning sensations, or decrease in tearing should be further investigated. Patients with illnesses such as scleroderma, systemic lupus erythematosus, Wegener granulomatosis, ocular pemphigoid, Stevens-Johnson syndrome, ocular rosacea, paralysis of the seventh cranial nerve, rheumatoid arthritis, or secondary Sjögren syndrome should prompt the surgeon to check for a potential postoperative problem.
- A patient with the aforementioned conditions or with clear symptomatology of dry eye syndrome should have a consultation with an ophthalmologist prior to a blepharoplasty procedure. In any case, a conservative surgical approach is the rule for these patients. Involvement of an ophthalmologist in the treatment of patients is highly recommended to achieve the best results possible.
- A routine Schirmer test is usually recommended in the medical literature in the preoperative evaluation of asymptomatic patients and is required for patients with an unclear history, older patients, or patients with minimal symptomatology.[8, 9] Keep in mind that the Schirmer test does not confirm the tearing deficiency in all patients.
- If dry eye syndrome is present after 2-3 weeks postoperatively, consultation with an ophthalmologist is advised, along with artificial tears and eye protection.
- Eyelid surface irregularities can occur if removal of skin, fat, or muscle is sufficiently asymmetrical to cause defects after redraping the skin. Furthermore, asymmetries are already present preoperatively. Therefore, even a well-planned blepharoplasty can result in asymmetrical eyelids. Small differences are not uncommon and can occur after the surgery heals. Importantly, show the patient the differences in symmetry preoperatively; asymmetries are present in almost every patient. This is the best prevention against postoperative disappointment. Fat removal should be planned prior to anesthesia injection. Use of preoperative photographs can help in this matter.
- Trimming and redraping of the skin and the orbicular muscle should be performed carefully, paying attention to details in order to avoid differences between both sides.
- Usually, hematoma is recognized in the immediate postoperative period by pronounced protrusion of the eyelid with ecchymosis of the flaps. Hematoma is usually due to orbicularis muscle bleeding. Most of the time, it is diagnosed several hours after the operation and the extension and the time of presentation determines the treatment.
- If a hematoma is recognized immediately, it should be treated by opening the incisions, eliminating the hematoma, and achieving hemostasis. If the hematoma is small, localized, and nonexpanding, it is usually self-limiting. If the hematoma is of moderate size and not expanding, it can usually be eliminated by waiting 7-10 days until the accumulated blood liquefies. Then, it can be evacuated with a No. 11 blade or a large-bore needle. Hematomas that are large and expanding, presenting early after blepharoplasty or causing symptoms such as pain, proptosis, or decreased visual acuity, should be explored immediately.
- If severe, consultation with an ophthalmologist and orbital decompression may be indicated.
Suture marks: All sutures can leave a mark on the skin. The most reactive sutures are plain gut, fast-absorbing gut, and chromic gut; the least reactive are polypropylene, nylon, and silk. Plain gut, fast-absorbing gut, and chromic gut are less than adequate compared to the other sutures. However, some surgeons favor the fast-absorbing gut for blepharoplasty because of its capability to dissolve in 3-4 days. The remaining sutures (ie, polypropylene, nylon, silk) should remain for no more than 4 days to avoid marking.
Milia: The epithelium grows rapidly around the skin sutures. If the sutures stay in too long, this induces a white, round nodule or inclusion cyst by obstructing the sebaceous glands at the suture opening. These can be resolved by unroofing the cyst with a surgical needle or a No. 11 surgical blade. Tunnels completely epithelized may require unroofing by opening with scissors along the created tunnel. Prevention involves removal of the sutures in 3-4 days.
Wound separation: Wound separation can occur, especially at the lateral aspect of the lower eyelid incision after early removal of sutures. Applying Steri-Strips to keep the edges approximated after suture removal can prevent this complication.
- Ocular injury, in particular corneal abrasion and ulceration, is not uncommon. Corneal damage is caused by iatrogenic trauma with gauze sponges, cotton-tip applicators, drapes, instruments, or sutures. Symptoms related to corneal trauma include eye pain, eye irritation, and blurring of vision. Corneal trauma is best demonstrated with fluorescein eyedrops and a slit-lamp examination. Treatment involves the application of an antibiotic ophthalmic solution and eye closure for 48 hours.
- Preventing this type of injury is mandatory. Protection of the eye at all times is imperative. Protection is accomplished by maintaining eye closure as much as possible. Do not pass sutures, cotton applicators, and instruments over the open eye. Some surgeons believe that corneal protectors are useful during blepharoplasty. Protection can also be achieved by using ophthalmologic ointment (eg, Lacri-Lube) in the inferior cul-de-sac and keeping the eye closed with a traction suture placed at the edge of the lower eyelid. For optimal protection, repeat instillations of ophthalmologic ointment throughout the surgical procedure. More severe injuries are rare. Penetrating globe injuries with a sharp instrument are extremely rare. If they occur, immediate intraoperative consultation with an ophthalmologist is required.
- Infection is a rare complication. It occurs more frequently in patients with diabetes or in patients with immunodeficiencies. The clinical picture is cellulitis in the orbital region with pain, eyelid edema, erythema, chemosis, and fever.
- Cellulitis can progress to abscess formation, manifesting severe pain, proptosis, diplopia, and decreased visual acuity. In most instances, the organisms involved are staphylococci and streptococci.
- Treatment consists of warm compresses, head elevation, culture, and broad-spectrum antibiotics. At the initial stage of the infection, an oral antibiotic may suffice. However, if no improvement is noted after 24-36 hours, intravenous antibiotics are mandatory. Intravenous antibiotics are used in patients with diabetes or in patients who are immunocompromised.
Loss of eyelid: One case of eyelid necrosis has been published. As reported by Putterman, this was due to the injection of formaldehyde instead of local anesthesia.  Remember, nothing should be injected unless first personally verified by the surgeon.
Loss of the eyelashes: This can occur if the incision is too close to the eyelashes, by direct trauma, or by thermal injury. Fortunately, most of the time the lashes regrow. Chronic inflammation, such as chronic blepharitis or chalazia, can occasionally reach the point of misdirection or loss of the eyelashes. In these cases, adequate treatment of the involved condition is necessary.
Overcorrection of fat pockets
- Excessive removal of fat tissue produces a deep, concave, unsatisfactory eyelid surface, resulting in a cadaveric appearance. This condition is difficult to correct. Therefore, it should be avoided by being cautious with the removal of fat, which should not be excessive and should be just below the orbital rim edge.
- Free fat grafting taken from the submental region may be used to correct this unpleasant result. However, reabsorption is unpredictable. Other techniques to increase volume in the concave areas include orbicularis muscle flaps, midface lifting, and autogenous fat pad sliding.
Undercorrection of the fat pockets: This situation is not as dramatic as overcorrection. If after 6-8 months the patient has evidence of insufficient fat removal, a new intervention can be planned to remove the excessive fat.
Chemosis: Chemosis is not common with the subciliary approach. It is usually temporary and resolves rapidly with the application of eye lubricants and artificial tears. Severe chemosis occurs with a greater frequency with the transconjunctival approach. Severe edema of the conjunctiva may develop, causing dryness not only of the conjunctiva but also of the cornea. At this point, in addition to increased lubrication, consultation with an ophthalmologist is advisable.
- Blepharoplasty does not adequately correct malar bags that are already present. Furthermore, if they are unrecognized preoperatively, they can be more prominent in the postoperative period. Thus, recognize malar bags initially and discuss their presence with the patient; this step is important to avoid postoperative dissatisfaction.
- Correction requires direct resection, necessitating another visible scar. Treatment of malar bags can be postponed until after the effects and results of the blepharoplasty are known.
- Always remember to rule out other causes of chronic swelling, such as heart, kidney, thyroid, or allergy problems.
- Blindness has been reported by DeMere, with an incidence rate of 0.04%. Usually, loss of vision occurs in the first 2 hours after surgery. The reason blindness occurs is not clear. Most of the cases have been related to retrobulbar hemorrhage after blepharoplasties with fat removal. Retrobulbar hemorrhage results in increased intraocular pressure, leading to central retinal artery occlusion and ischemia of the optic nerve.
- Another cause is vasospasm secondary to the adrenaline effect on the central retinal artery, leading to ischemia of the optic nerve.
- Avoid medications that can cause bleeding episodes, such as aspirin, steroids, and anticoagulants. These medications should be stopped prior to surgery. Aspirin should be discontinued 2 weeks before the surgical procedure. Warfarin should be managed as instructed by the medical consultant.
- Hemostasis is imperative in blepharoplasty. Avoid excessive traction of the fatty tissue. This maneuver can cause rupture of vessels deep to the fat.
- Injection of local anesthetic into the fat tissue should be performed with caution and direct visualization of the injection site. Cauterization should be performed carefully and meticulously to achieve hemostasis after the fat tissue retracts.
- For 2 days, patients should avoid maneuvers that increase intracranial pressure, such as straining, the Valsalva maneuver, or blowing their nose.
- Close monitoring and care, including blood pressure checks, head elevation, and cold noncompressive eye pads, are mandatory in the first 1-4 hours after surgery.
- Other symptoms include the eye pain (common, but not always present); proptosis, chemosis, and increased intraocular pressure; and Marcus Gunn pupil, edema of the optic nerve, or obliteration of the retinal artery.
- Treatment of retrobulbar hemorrhage should occur as soon as it is diagnosed. Consultation with an ophthalmologist is mandatory. The sutures should be opened immediately to relieve the pressure and to see if further hemostasis is needed. Continue with ice compresses and head elevation. Give (1) mannitol 20% solution at 2 g/kg of body weight for 24 hours intravenously, not to exceed 12.5 g intravenously over 5 minutes; (2) acetazolamide (Diamox) at 500 mg slow intravenous push and then 250 mg intravenously every 6 hours for 24 hours; and (3) dexamethasone (Decadron) at 10 mg intravenous push.
- If no improvement is achieved by these measures, consider lateral canthotomy with inferior cantholysis. Then, consider orbital decompression in consultation with the ophthalmologist.
Lower eyelid complications
- Transient diplopia is more common in blepharoplasty procedures in which the repositioning fat technique is used. Because of the swelling caused by injected local anesthetics and the edema of the tissues in close proximity to the surgical area, diplopia is not uncommon in the immediate postoperative period if the subciliary approach for blepharoplasty is used. This is a temporary diplopia and lasts only hours or several days.
- Permanent diplopia is rare. It is caused by damaging the inferior oblique muscle during dissection. This muscle is located between the medial and the middle fat compartment in the lower lid. Direct identification is advised in order to avoid damage by clamping, cutting, or cauterization. The consequences of its damage are diplopia in the upward and lateral gaze.
- Most diplopia resolves over time. If the damage has been severe enough and no improvement is recognized, secondary muscle repair is advised after 6 months of observation.
Malposition of the lower eyelid
- Malposition of the lower eyelid occurs because of an increased laxity of the lower eyelid or excessive skin removal.
- A classification has been established by McGraw and Adamson to understand the different degrees of progressive lower eyelid malposition. Grade 0 is normal lower eyelid position. Grade 1 is lateral rounding of the lower eyelid without scleral show. Grade 2 is lateral rounding with central retraction of the lower eyelid with scleral show. Grade 3 is lower eyelid margin eversion with clear pooling of tears in the lower eyelid pocket. Grade 4 is clear ectropion with visualization of the palpebral conjunctiva.
- Patients with scleral show should be told of their condition preoperatively, and, during the procedure, adjunctive surgical techniques should be used to avoid enhancement of this condition.
- Some degree of scleral show in the immediate postoperative period is not uncommon because of postoperative edema and a deficit in the function of the orbicularis muscle. Once these factors are resolved, this type of scleral show resolves.
- Mild degrees of scleral show can be treated conservatively with massage, Steri-Strips to hold and tighten the lateral aspect of the lower eyelid, and lubrication of the eye. At least 6 months of conservative management is necessary before advising surgery for this complication. An eyelid tightening procedure brings the lower eyelid to a higher position.
- Ectropion is a downward retraction of the lower lid. This complication is due to an unrecognized laxity of the lower eyelid preoperatively and/or excessive removal of skin and muscle during the surgical procedure.
- Surgeons should make every effort to avoid ectropion. A preoperative evaluation of lower eyelid tone is imperative. If laxity of the eyelid is found, the surgeon should plan an adjunctive horizontal lower eyelid tightening procedure in addition to the blepharoplasty.
- If the surgeon recognizes that excessive removal of skin has occurred during the surgical procedure, the skin should be replaced immediately. If ectropion is clearly recognized within 48 hours and the surgeon is sure that too much skin was removed, a skin graft should be placed during the 48-hour period after the initial surgery. If ectropion progresses in the postoperative period and fails to resolve with conservative measures, correction is indicated after 6 months. This usually requires a lower eyelid tightening procedure and/or possible skin grafting. The best donor sites for skin grafting are the upper lid (if not operated on previously), the postauricular skin, and the supraclavicular skin. Consultation with an oculoplastic surgeon is advisable.
- Two types of epiphora occur, temporary and permanent. Uncontrolled tearing is not uncommon in the immediate postoperative period. This phenomenon is due, in part, to an insufficiency in the function of the lacrimal drainage system produced by an increased swelling in the operated tissues and displacement of the lacrimal puncta. Another factor is related to an increase in the tearing production due to abnormal irritation and stimulation in the immediate postoperative period. These factors resolve spontaneously. Therefore, this type of epiphora is a self-limiting phenomenon lasting approximately 4-5 days.
- Permanent damage to the lacrimal drainage system (punctual and canaliculus) or eversion of the puncta by ectropion leads to constant, persistent epiphora. Extending the subciliary incision too close to the puncta leads to scarring and stenosis, causing damage to the lacrimal drainage system. Prevention is the best strategy. If noted during the operation, repair over Silastic stenting is advisable. If noted after surgery, permanent epiphora requires reopening, dilatation, and stenting of the lacrimal drainage system. Correction of epiphora is necessary for severe cases of eversion of the puncta. Consultation with an ophthalmologist is advisable any time the surgeon believes the epiphora is permanent.
Outcome and Prognosis
In the proper patient, any well-executed blepharoplastic approach, with precise attention to details, yields a satisfactory result for both the patient and the surgeon with minimal transient complications.
However, at present, no one particular approach achieves the best results in all patients. Selection must be on a case-by-case basis. According to recent blepharoplastic literature, selection of a specific approach is dictated by the particular characteristics of the patient, such as age, eyelid and orbital aging changes, and the presence or absence of adequate eyelid tone.
The subciliary approach has the advantage of an open flap with adequate exposure for resection of fat pads, orbicularis muscle, and skin and the possibility of correcting eyelid tone laxity if present. The main disadvantage is the increased possibility of eyelid retraction, malposition, and ectropion. Therefore, proper selection of candidates and a conservative approach in the resection of eyelid skin are advisable when applying this approach to avoid, in part, these problems.
The transconjunctival approach has the advantage of less trauma with the possibility of removing fat pads without causing eyelid retraction, malposition, or ectropion. The disadvantage is that eyelid skin and orbicularis muscle are not removed, giving less exposure and an inability to correct, if present, eyelid tone laxity. Therefore, proper selection of candidates for this approach is necessary in order to achieve the best possible result.
The repositioning/fat preservation blepharoplasty has been reported in recent publications to yield good results. It is a well-designed concept and approach that addresses the herniated fat problem. However, it is still in evolution, and the long-term results need to be evaluated further.
Standardization in the selection of the different approaches has not yet been fully achieved worldwide.
Future and Controversies
Information on cosmetic blepharoplasty will be made more available to the public due to the increase in information technology.
Cosmetic blepharoplastic web sites will become more interactive. Integration of voice, photography, and video capabilities will be available to patients and blepharoplastic surgeons alike.
The virtual cosmetic blepharoplastic office will become a reality. Dynamic interaction will increase among prospective patients, staff, and cosmetic surgeons. Postoperative blepharoplastic images will be available on the Internet for prospective candidates, even without having been seen in the surgeon's office.
For all the above reasons cosmetic blepharoplasties and blepharoplasty revisions will probably continue increasing in the future. Selection of the candidates will remain the most important step. Better standardization worldwide among surgeons using the different approaches is very possible.
The question of which blepharoplastic approach achieves the best results is tricky. No particular blepharoplastic approach yields the best results for all patients. One approach cannot be judged better than another. Furthermore, even among experienced surgeons, opinions about what is the best blepharoplasty approach varies. The artistic element in performing a blepharoplasty is difficult to measure, but unquestionably is present in each surgery.
Further, even excellent technique and great care cannot guarantee excellent or near perfect results. This is due to the individual characteristics of each patient, including their dynamic facial expressions.
The selection one approach over the other depends on the particular experience of the surgeon and the specific characteristics of the patient, such as age, eyelid and orbital aging changes, and the presence or absence of adequate eyelid tone.
Questions still remain about (1) whether the contemporary suspension/fat pad preservation technique will achieve popularity and satisfactory long-term results worldwide and (2) which patients and which eyelid changes will benefit the most from this particular technique.
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