Blepharoplasty

Description:

Blepharoplasty is surgical modification of the upper or lower eyelid to achieve or approximate an ideal anatomic result. It is often performed to correct excessive laxity (dermatochalasia) and involves the excision of redundant tissue. The procedure may also be used to correct congenital ptosis that results from fibrofatty replacement of normal levator muscle fibers, or acquired traumatic ptosis caused by levator tendon dehiscence. This chapter discusses the surgical technique for upper and lower lid blepharoplasty performed for dermatochalasia only, and does not address techniques used to correct ptosis.

Indications for Surgery:

  • Dermatochalasia, in which excessive eyelid skin is the result of laxity, aging or sun exposure
  • Blepharochalasia, a rare inherited eyelid disorder causing swelling and laxity
  • Correction of ptosis
  • Donor site for skin graft to replace lost eyelid skin elsewhere
  • Visual field loss owing to redundant skin
  • Pseudoherniation of periorbital fat
  • Hypertrophy of orbicularis oculi muscle

Contraindications to Surgery:

  • Medical comorbidities that would preclude surgical or anesthesia risk
  • Patients with absent blink reflex, orbicularis oculi paralysis, or other conditions in which corneal exposure is likely
  • Ptosis due to thyroid myopathy, ophthalmoplegia, or muscular dystrophies, as there is a high risk of lagophthalmos (inability to close the eyelid completely) and corneal exposure
  • Patients with extreme dry eye syndrome (keratitis sicca), as blepharoplasty may exacerbate the condition
  • In patients with extreme lower lid laxity, canthoplasty or canthopexy should be considered instead
  • Psychiatric instability

Pre-Operative Evaluation:

  • Detailed photographic analysis and measurements should be made of the eye
  • The degree of ptosis can be assessed by the margin-reflex distance, or the distance between the central corneal light reflex and the upper lid margin
  • Complete ophthalmologic examination should be documented, including visual acuity (and visual fields if obstructed)
  • Tear secretion can be assessed using the Schirmer test

Anesthesia:

Local with monitored anesthesia care (general anesthesia is necessary in children)

Surgical Technique:

  1. The upper eyelids are marked with the patient in an upright, seated position. Spindle-shaped (fusiform) incisions are designed, typically with the upper edge at or 1 mm above the natural lid crease and the lower edge 8 mm above the lid margin. The incision angles inferiorly 1-2 mm as it travels medially. The incision should not be carried more medially than the punctum of the medial canthus. Laterally, the incision curves slightly superiorly and travels in a natural skin crease. The extent to which the incision is carried laterally depends upon the degree of lateral hooding of the eyelid. The medial and lateral ends of the incision form approximately 30 degree angles.
  2. The breadths of both upper and lower eyelids are injected subcutaneously with 1% xylocaine with 1:200,000 epinephrine. Injection behind the orbital septum should be avoided to prevent anesthetizing the levator muscle.
  3. A #15 scalpel is used to make the incisions. After excising the skin, a small strip of orbicularis muscle is resected along the inferior portion of each incision. This creates a more distinct upper lid crease.
  4. The orbital septum is cauterized and the incisions are closed with 6-0 Prolene interrupted sutures. The eyes are checked for any evidence of lagophthalmos, eyelid skin eversion, or residual lateral hooding.
  5. Attention is turned toward the lower lids. Subciliary incisions are made 1-2 mm inferior to each lash line and carried medially to 1 mm lateral to the medial canthus punctum. Laterally, the incisions are carried to 5-10 mm lateral to the lateral canthus. The pretarsal skin is separated from the pretarsal orbicularis muscle. The lower incision should be at least 5 mm below the upper if both are done at the same time.
  6. The orbicularis muscle is then elevated in each eye, exposing the orbital septum, which is sharply incised.
  7. Excess lower eyelid fat is removed from the central compartment of each eye, followed by the medial and lateral compartments. The same amount of fat should be removed from each side. Care is taken to avoid the inferior oblique muscle, which sits between the medial and central fat compartments.
  8. The skin is redraped over the incisions and any redundant skin is excised. The incisions are closed with 6-0 Prolene interrupted sutures.
  9. Ice packs are placed over the eyes and the patient is discharged to recovery.

Post-Operative Care

  • Blepharoplasty is performed on an elective, outpatient basis.
  • The patient should be monitored postoperatively for signs of retro-orbital hematoma (worsening edema and ecchymosis, severe pain, visual changes).
  • The postoperative examination should include assessment of visual acuity and visual fields.
  • Cool compresses should be applied to the eyes for 48 hours after surgery.
  • Eye lubrication should be applied liberally for the first 48 hours after surgery.
  • The patient should keep the head elevated and avoid strenuous activity for 2 weeks after surgery.
  • Suture removal is scheduled for 5 days after surgery.

Complications:

  • Bleeding/retro-orbital hematoma
  • Wound infection
  • Corneal abrasion
  • Lagophthalmos
  • Ectropion (drooping of the lower lid away from the globe)
  • Entropion (turning of the lower lid in toward the globe)
  • Injury to lacrimal gland
  • Exacerbation of dry eye syndrome
  • Hypertrophic scar
  • Unsatisfactory cosmetic result




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