www.drvaibhavshah.net
Karl Ferdinand von Gräfe coined the phrase Blepharoplasty
in 1818 when the technique was used for repairing deformities caused by cancer
in the eyelids. The two world wars laid the foundations of modern
reconstructive surgery and simultaneously with it with it the other branch i.e.
Cosmetic or to put it correctly Aesthetic Surgery evolved. Blepharoplasty can
be both a functional and cosmetic procedure designed to restore a more
youthful, bright, and energetic appearance to the eyes. The origin of the word
is from Greek; Blepharon - meaning eyelids and Plastikos meaning to mould.
The eyes are the focus focal point of contact when we meet. The smallest
change catches the eye. Age associated changes invariably appear around the
eyes. Skin looses its elasticity and tone due to changes in collagen and
elastin fibres, ground substance in dermis resulting in redundant tissue in
upper and lower eyelids. This leads to hooding of upper eyelids . There is
decrease of subcutaneous fat. Fine lines and wrinkles appear especially at the
lateral end of the eye called ‘crows feet’. Relaxation of connective tissue
leads to prolapse of fat. This may overstretch the orbital septum and lead to
dehiscence or weakness of levator aponeurosis leading to Ptosis. Skin may
thicken, is dry, pigmented and skin tumors may develop.
Hooding of upper eyelid
Orbicularis muscle and the ligaments loose elasticity producing
ectropion or entropion especially in the lower eyelid. Lacrimal gland droops.
The action of gravity produces downward displacement of fat. The septum weakens
and the intraorbital fat may herniate producing baggy eyes.
Natural aging process which is a continuous process starts around
thirties. This is called intrinsic aging or inherent aging process, it depends
on genetic inheritance. Aging is also due to extrinsic factors like excessive
sun exposure, repetitive facial expression, gravity and smoking. Even sleeping
postures can influence the aging changes.
The various symptoms with which patients present for Blepharoplasty are
vague. They complain of a feeling of heavy eyelids, restriction of visual
fields especially on looking upwards, tiredness, pressure on lashes, sometimes
visual axis blocked by eyelashes, headache due to constant lifting of the
eyebrows. In the lower eyelid an appearance of tiredness without being tired,
bagginess, prolapse of the fat, wrinkles and lax skin are the main issues
leading to a desire for a change and improved aesthetics. Occasionally patients
complain that when they look down a sort of obstruction comes in their field.
Some times they come with specific complaints of wanting improvement in
appearance.
Blepharoplasty is done most often to improve the appearance of the
patient. Hence the motivation and expectations of the patient must be well
understood
Physical examination
should consist of complete ophthalmic examination including visual acuity,
field, ocular motility mobility, corneal sensation, eyelid closure and
Shirmer's test to rule out dry eye. In Shirmer's test the conjunctiva is
anaesthetized by paracaine eyedrops. A Shirmer's strip is placed in the
inferior lateral corner of the eye. Wetness of less than 10mms in five minutes,
in the strip signifies dry eye. The specific examination for Blepharoplasty
should be done in sitting position. Presence of browptosis, height of upper
eyelid crease, amount of excess skin, fat and lacrimal gland herniation,
presence of skin tumors on the eyelid skin, if any, must be recorded. Ptosis of
the upper eyelid must be noted. In the lower lid one should look specifically
for elasticity of the lid by doing snap test to establish need for horizontal
tightening. Pulling the lower eyelid more than 6mms away from the globe
signifies laxity of the lower eyelid and is called snap test. Scleral show in
the lower lid should be measured. Note should be made of the positive or
negative vector of orbit. In the lateral view, a line dropped from the
supraorbital rim to the infraorbital rim just touches the cornea. If the cornea
is posterior to this line it is a positive vector, like an enophthalmos. When
the cornea is anterior to it then the eye is prominent and there is poor globe
support, this is called negative vector. In such cases the lateral canthoplasty
or canthorrhaphy should be done to avoid the inferior scleral show. Examination
of periorbital bony contours must be made. A detailed discussion must be held
with the patient regarding the surgical out come and the complications. A
photographic record is a must.
The
basic goal of Blepharoplasty is to achieve eyebrows at appropriate level, neat
and crisp looking eyelid well hidden scars of a limited length and correction
of fat bulges without creating a hollowed out eye.
Variations of upper lid Blepharoplasty
Excision of skin alone
Excision of skin and partial excision of prolapsed
fat pads
Ptosis correction with Blepharoplasty
Correction of lacrimal gland Ptosis
Upper lid Blepharoplasty can be done under local anaesthesia or general
anaesthesia. Infiltration with 2% xylocaine with adrenaline mixed with 0.25%
sensorcaine gives a very good anaesthesia. Adrenaline should be avoided for
hypertensives. In anxious patients some sedation can be prescribed. Marking is
generally done preoperatively in sitting position. Supratarsal fold is marked
as a curved line 9-10 mms above the lid margin in the mid pupillary line . In
the medial and lateral ends it should gently curve down to 7 mms above the lid
margin. The excess skin is marked by pinching with a non toothed forceps or
marking the upper line 10 mms below the inferior margin of the eyebrow. After
cleaning and local infiltration, incisions are made with a scalpel or RF
cautery. The orbicularis fibres are separated. By a gentle pressure on the
globe the orbital fat is made to protrude to help in identifying the septum and
incising it. It should be incised along its entire length. This would expose
the levator aponeurosis lying under it and the medial and central fat pads. The
dehiscence of the levator can be identified at this stage. It is reattached if
found dehisced . The fat pads are excised if in excess. Care should be taken
not to give traction to the fat pads. While dissecting the medial fat pad
injury to the superior oblique tendon must be avoided. The excess skin and
muscle are resected with a scissors. Conservative resection of the sub brow fat
should be done. Lacrimal gland Ptosis if present should be corrected by taking a
suture through the fascia around the lacrimal gland and suspending it to the
lacrimal fossa. After establishing haemostasis, the incision is closed with
interrupted 5/0 or 6/0 nylon sutures. Orbicularis muscle should be included in
the skin suture, aligning orbicularis muscle and skin. The upper eyelid crease
is created by attaching the levator aponeurosis to the orbicularis muscle and
skin near the upper tarsal border .
Upper lid Blepharoplasty with Ptosis correction
Lower eyelid Blepharoplasty rejuvenates and restores
youthful appearance to the eyes. Basic principles are to reduce excess skin and
fat, reduce horizontal laxity, there should be no scleral show inferiorly. If
there is no excess of skin but fine wrinkles, the skin can be resurfaced with
Laser or chemical peel.
Approaches in lower eyelid blepharoplasty
Trans-conjunctival
Transcutaneous
Combined
Transconjunctival for fat excision/ reposition
Lateral canthal tightening
Rejuvenation
Laser resurfacing / chemical peel
Lower lid Blepharoplasty can be done under local
anaesthesia. Some surgeons prefer general anesthesia, as injection of local
anesthesia into the lower lid can distort soft tissue anatomy.
Transconjunctival Blepharoplasty is indicated in
young patients with baggy eyes, puffiness and dark circles under eyes with no
skin wrinkles and in Hyperthyroid patients. It can be combined with skin
rejuvenation.
Transconjunctival incision was popular. It can be
preseptal or retroseptal. In the preseptal type the incision is made 2-3 mms
below the inferior border of the tarsal plate. Dissection is between the septum
and orbicularis muscle. Incision is deepened through the conjunctiva and lower
lid retractors gain access to the anterior surface of the orbital septum. The anterior
surface of the septum is relatively avascular. By a gentle pressure on the
globe the fat is made to herniate. Septum is opened in each compartment.
Excision of the fat is done carefully keeping a watch on the external contour.
The fat should remain behind the orbital rim on gentle pressure. Care must be
taken to avoid injury to the inferior oblique muscle which lies between the
central and medial fat pads. Maximal care must be taken to achieve good
haemostasis. Conjunctiva is approximated with 6-o Vicryl inverted sutures. The
knots must be buried. In the retroseptal method, the incision is made 5mms
below the tarsal plate, between the lower border of tarsal plate and inferior
fornix. Once the conjunctiva is incised, retroseptal area is directly entered
and trimming of the fat can be done.
Trans conjunctival incision lower lid blepharoplasty
Go to:
Transcutaneous lower lid blepharoplasty
A subciliary incision is made approximately 1.5-2 mm
below the lid margin, starting below the lacrimal punctum to lateral canthus
and beyond along a line of facial expression. Sometimes the incision can be
placed parallel and slightly superior to the inferior palpebral fold, but not
in the depth of it. This would produce edema of the lid which takes a long time
to resolve. Elevate the skin only leaving the orbicularis for a distance of
6-7mms. Then raise the skin with orbicularis creating a myocutaneous flap upto
the orbital rim. Retracting the skin and muscle flap, gentle pressure is placed
on the globe to herniate the fat. Orbital septum is opened along its entire
length exposing the three compartments of fat. The excess amount of fat is
trimmed using a cautery to avoid retraction of the bleeders.cautery. In a
conscious patient, he or she is asked to look up and the adequacy of fat
removal is judged. The laxity of the lid is reassessed. If there is laxity and
or inferior scleral show, lower lid tightening is done by lateral tarsal slip
procedure, which is described below. To prevent hollow look, orbital fat is
advanced over the infraorbital rim. Medial fat pad can be used to recontour the
nasojugal groove to prevent/treat the tear trough deformity. Lateral fat pad
can be used to contour the malar area. The excess amount of skin is assessed by
draping the skin flap and trimmed carefully. Excess skin is pulled laterally
and trimmed below the lateral canthus. This is adjusted by making the cut along
the lateral facial lines . The wound is closed with 6-0 nonabsorbable suture by
a running or subcuticular suture .
Lateral tarsal strip
An incision is made along the crease lateral to the
lateral canthus. The lower limb of the lateral canthal ligament is divided. The
soft tissue over the lateral wall of the orbit is dissected to expose the
periosteum. A tongue of tarsus is developed by dissecting the conjunctiva and
skin over the lateral end of the tarsal plate. This bare tarsal plate is lifted
up and anchored to the periosteum at a higher level than the medial canthus
with a mattress suture of nonabsorbable suture material. The length of the
tarsal plate to be bared depends on the laxity of the lower lid. This procedure
not only reduces the laxity but also prevents mild ectropion and inferior
scleral show
Postoperative details: dressing need not be given.
Antibiotic ointment should be applied twice or three times a day over suture
line. Artificial tear drops during day time and gel at night should be
prescribed. Pain is usually very minimal for which paracetamol can be
prescribed. If the patient complains of severe pain, the vision must be closely
monitored to rule out retrobulbar hemorrhage, a dreaded complication. There is
usually a lot of edema and ecchymosis. Cold packs during the first 48hrs and
alternating warm and cold packs after 48hrs are useful. This helps in reducing
the edema. Sometimes steroids are given for reducing post operative edema
provided there are no contraindications for them. Skin sutures are removed
after 6 or 7 days. Patients should be advised to avoid bending and lifting
heavy weights. Use of contact lenses are to be avoided for at least two weeks.
Patient must wait for six weeks for the swelling to resolve before judging the
final outcome.
Complications
Many of the complications are due to the inadequate
preoperative examination and counseling. Complications due to inadequate
preoperative examinations are presence of Browptosis and Blepharoptosis,
prolapsed lacrimal gland, inferior scleral show, and laxity of lower lid.
Browptosis should be corrected before Blepharoplasty.
Vision compromise is the most dreaded complication in Blepharoplasty It
is due to retro bulbar hemorrhage. Increasing pain with proptosis, mydriasis,
chemosis and congestion of conjunctiva should make one suspect retro bulbar
haematoma. This should be recognized early and treated. Orbital decompression
done early along with intravenous corticosteroids is effective in restoring
vision.
Lagophthalmos is often seen in the early period. Late lagophthalmos is
due to excessive skin removal. If noticed on the table, excised skin can be
replaced back. For late cases a full thickness skin graft from post auricular
areas is the choice.
Diplopia can occur due to injury to superior or inferior oblique
tendons.
In the Transconjunctival Blepharoplasty scarring of conjunctiva,
symblepharon or pyogenic granuloma can occur. Inadequate excision of fat,
asymmetric supratarsal folds are other complications due to technical errors.
In Transcutaneous Lower lid Blepharoplasty complications due to excessive skin
removal, lid malposition are often seen.
The most difficult complication is an unhappy patient. This may be due
to the unrealistic expectations of the patient.
There has been lot of changes in understanding the concept of fat
conservation in Blepharoplasty. The cause of facial aging was focused on
gravitational pull.
It is presumed that this occurs due to laxity of supporting ligaments
which allow cutaneous and subcutaneous soft tissue to shift inferiorly. In the
upper eyelid this occurs by descent of the eyebrow and in the lower eyelid
descent of midface
tissue account for the hollow appearance of the orbital rim and orbital fat
descent produces the bags.
Val Lambros proposed a hypothesis that focal loss of volume in areas of
cutaneous attachment to deeper structures can mimic the descent of soft
tissues. This he explained by comparing the previous photographs at a younger
age of people. The changes due to volume loss are seen clearly. This is due to
the deflation of fat and changes in skin. Similar changes are seen when
excessive fat is removed, resulting in accentuation of orbital rim and tear
trough deformity. With aging, the skin loses elasticity and tone and this is
seen as wrinkles. Some of the wrinkling relate to the loss of fat in the
subcutaneous tissue. Addition of volume can improve the skin quality. These
newer thoughts are bringing changes to the elegant surgery of Blepharoplasty.
In conclusion,
Blepharoplasty is an elegant procedure done to not
only rejuvenate the eyelid but also to provide confidence and happiness to the
patient. This can be achieved very well provided a proper pre-operative
examination, use of meticulous surgical technique/s and proper counseling of
the patient is done. The newer concepts in understanding changes occurring in
aging would help in further improving the results.
