Dermatochalasis Treatment & Management

Updated: Oct 08, 2019
  • Author: Grant D Gilliland, MD; Chief Editor: Edsel Ing, MD, MPH, FRCSC  more...
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Treatment

Medical Care

Although temporary transparent eyelid tape is available, the most effective treatment of dermatochalasis is surgical.

Occasionally ancillary medical treatments may be appropriate, as follows:

  • 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.
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Surgical Care

A careful history and examination, including eversion of the eyelids, should be performed prior to blepharoplasty.

The upper eyelid creases are marked (usually 8-12 mm in white patients) and can be measured to ensure symmetry. Some use the pinch technique to determine the appropriate amount of skin to resect. 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.

Some clinicians routinely lubricate the corneas and place a cornea protector prior to lid surgeries. The lids are injected with 1-2% lidocaine with epinephrine. Hyaluronic acid, if available, can be used. The upper border of the incision should not be closer than 7-8 mm from the brow to prevent a postoperative "brow on lashes" appearance.

The skin is excised using a No. 15 blade, laser, or radiofrequency device. Some clinicians elect to preserve the orbicularis, especially in patients with dry eyes or past facial nerve palsy. Other clinicians routinely excise a 2- to 3-mm strip of preseptal orbicularis is excised with tenotomy scissors. Meticulous hemostasis is maintained throughout the procedure. [9]

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.

To prevent webbing, the nasal incision is usually not extended past the puncta. 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.

Preoperative image prior to upper blepharoplasty. Preoperative image prior to upper blepharoplasty.
Postoperative image after upper blepharoplasty. Postoperative image after upper blepharoplasty.

Transconjunctival lower eyelid blepharoplasty is indicated for the correction of steatoblepharon without dermatochalasis. [10]

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 arcuate expanse can be closed with a 6-0 plain gut suture over the lateral fat pad to prevent recurrent fat herniation.

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. This can be approached subperiosteally or preperiosteally. 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). Some surgeons believe that the fat pads do not persist long-term after a "re-draping" procedure.

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. [11]

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. [12]

Note the before-and-after images below.

Preoperative image of a patient with thyroid eye d Preoperative image of a patient with thyroid eye disease, dermatochalasis, eyelid retraction, and steatoblepharon.
Postoperative image after 4-lid blepharoplasty and Postoperative image after 4-lid blepharoplasty and canthopexy.

Autologous fat grafting has been used in the periorbital and midface regions for rejuvenation. [13] 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. [14]

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

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Consultations

Patients undergoing blepharoplasty should have a careful eye examination prior to surgery. Perimetry may be required for insurance approval of functional upper lid blepharoplasty.

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Activity

Smoking, rubbing the eyes postoperatively, and sleeping in a prone position can delay wound healing. Strenuous activity and activities that cause the patient to Valsalva (eg, heavy lifting) should be avoided in the first postoperative week. Postoperative vomiting is uncommon but should be controlled medically to prevent persistent bleeding and possible retrobulbar hematoma.

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Complications

Lagophthalmos in dermatochalasis

Lagophthalmos can occur if overzealous resection of the skin and/or muscle is performed or if the orbital septum is incorporated into the wound closure or undergoes excessive scar contraction.

Some patients may have lagophthalmos prior to surgery. It is unlikely that resection of a small amount of preseptal orbicularis oculi causes lagophthalmos or dry eye.

Keratitis in dermatochalasis

Keratitis can be a potentially serious complication. This is most commonly due to lagophthalmos but can occur in its absence. It is imperative that patients be evaluated preoperatively for dry eye.

Dry eye is treated with topical lubricants, taping of the eyelid shut at night, punctal plugs, spectacles, or moisture chamber.

Scarring is rarely a significant problem after blepharoplasty. If hypertrophic scarring develops, it is treated with topical steroid ointment, massage, and silicone gel.

Corneal topography may change after upper eyelid blepharoplasty surgery. With a skin-only excision, minimal astigmatic changes are noted. [15, 16]  However, with removal of large fat pads, corneal astigmatism has been shown to change approximately 0.2 diopters.

Diplopia is very rare after blepharoplasty and occurs most commonly after lower eyelid blepharoplasty. In most cases, it is due to injury to the inferior oblique or inferior rectus muscle; rarely, the lateral rectus muscle can be injured. [17]

Ptosis in dermatochalasis

Ptosis is a rare complication of upper eyelid blepharoplasty. It is imperative that ptosis be ruled out prior to surgery.

In most cases, ptosis is due to prolonged eyelid edema with dehiscence of the levator aponeurosis or injury to the levator aponeurosis.

Eyelid retraction in dermatochalasis

Eyelid retraction is the most common complication after lower eyelid blepharoplasty. The incidence of this complication after transconjunctival blepharoplasty is approximately 0.5%, and, after subciliary blepharoplasty, it is 3-5%.

The treatment is directed initially at massaging the lower eyelid. Subcutaneous steroid injection can be considered.

If the retraction persists despite aggressive massage, canthopexy, tissue grafts (eg, skin, hard palate, Alloderm, ear cartilage), and cheek elevation may be indicated.

Conjunctival chemosis in dermatochalasis

This usually resolves spontaneously in a few weeks but may persist for months. [18, 19]

Treatment consists of sleeping with the head of the bed up, topical lubrication, and topical steroids.

If chemosis persists, conjunctival incision and temporary tarsorrhaphy may be considered.

For chronic chemosis, subconjunctival injection of tetracycline 2% may be useful. [20]

The incidence has been reported as high as 26% and is more common in patients undergoing concurrent upper and lower blepharoplasty. [21]

Blindness in dermatochalasis

Blindness is a rare but devastating complication of blepharoplasty surgery. [22, 23]

In most documented cases, blindness results from retrobulbar hemorrhage with resultant optic nerve and vascular compression.

Central retinal artery occlusion has also been documented as a cause of blindness after blepharoplasty.

If orbital hemorrhage occurs, emergent canthotomy and orbital decompression should be performed.

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Prevention

Smoking and eyelid rubbing should be avoided.

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Inpatient & Outpatient Medications

Topical antibiotics and lubrication of the cornea are indicated postoperatively.

Some patients may have lagophthalmos in the first week after surgery. Artificial tears can be prescribed with nocturnal lubricating ointment to prevent corneal exposure.

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