What is blepharoplasty? Surgical procedure aimed at improving theappearance of eyes. Goals- to improve the appearance of eyeswhile maintaining the natural shape of eyes. Upper and lower blepharoplasty removes:fold of skinfat pads
Function of eyelid Protect the globe Provide a sufficient and appropriately locatedaperture for vision Also assume a role of facial expression Tear production and distribution
Surface anatomyAppearance of eye largely determine by shape ofpalpebral fissure and it position relative to globe• Palpebral aperture• Skin• Lid margin• Grey line• Glands• Skin crease
Orbicularis oculi•Two partoPars orbitalisoPars palpebarum -divided into preseptaland pretarsalMedially divided intosuperficial head – formmedial canthal tendondeep head – insertinto posterior lacrimalcrest and lacrimal sacfascia
Eyelid support Primary by bony attachment of canthio Medial canthus - fixed to orbital wallo Lateral canthus – mobileLateral canthus is approximately 2mm heigher thenmedial Secondary from orbicularis muscle and its fascialattachment
Medial canthus tendon•Integration of pretarsal andpreseptal orbicularis oculi,septum orbitale, medial end oflockwood ligament, medial hornof levator aponeurosis andcheck ligament of medial rectusmuscle•Insert into frontal process ofmaxilla into tripartite manneroAnterior – onto anterior lacrimalcrestoPosterior – onto posteriorlacrimal crestoVertical – on medial orbital rimand contribute mainly to stability
Lateral canthus tendon•Y shape fibrouscondensation•Extend from upper andlower tarsal plate andreinforce by lateral hornof levator aponeurosis,lockwood ligament andcheck ligament of lateralrectus to form lateralretinaculum•Inset to lateral orbitalwall at whitnall tubercle
Tarsus•Crescentric shape,dense condensation ofconnective tissue•Maintain the integrity ofeyelid•Upper tarsus – 29 mmlong and 10 mm wide incentral part•Lower tarsus – 24 mmlong and 4-5 mm wide•Contain meibomianglands
Septal orbitale• Represent the continuation of orbital periosteum• Thin fibroelastic membrane• Attach medially to spine at lower end of anteriorlacrimal crest• Laterally attach to lateral canthal raphe• Arcus marginalis – junction of fusion of periosteumand septum• In upper lid, septum attach to levator aponeurosisabout 25 mm above the superior edge of tarsal plateto form the conjoined fascia• In lower lid, septum attch to capsulopalpebral fascialbelow the inferior edge of tarsus
Eyelid fat•Preseptal fat – extra orbital(ROOF), 6mm thick•Postseptal – intra orbital, are the fat extension fromadipose body of orbit except upper lid central fat padoUpper lid – two (medial and central)oLower lid - three (medial, central and lateral)•Eisler fat pad – between septum and lateral canthaltendon, use as a landmark for whitnall tubercle
Examination And Planning Accurate pre-op planning is important. EVALUATION BASICS: PT. seated in front Gen. appearance Symmetry & posture Skin & fat quantification Brow examination Modified snap test
Cntd….. Medical and ophthalmologic history Ocular examination Visual acquity Pupils Extraocular muscles Globe Retina Tear film- Schirmer`s test. Photographs
Upper blepharoplasty – Skinapproach•Appearance of aged upper eyelid is primarily due toexcessive skin, muscle, and fat often in conjunction withbrow descend•Approach should be individualize•Appreciation of volume shift which lead to fatmalposition•Volume loss lead to deepening of upper sulcus•Position of upper eyelid crease•Brow position
Incision•Patient with deepupper eyelid sulcusbenefit from 10 mm orhigher incision•In presence of browptosis , lower thecrease incision•Incision include onlyskin•Brow fold distance isthereby maximized toreduce ptotic browappearance
Pinch test•Serve as a guideto the maximumallowable skinresection•End point is thatof skin tautnesswithout theeversion ofeyelash margin
•Upper demarcationusually follow thecontour of eyebrow•Usually the amount ofskin excision shouldultimately be less thanthis specified amount
•Hemostasis bymonopolar cautery•Liberal application atlower edge of woundallow for creation ofadhesive interfacewhich facilitatesestablishment ofcrease, enhanced bytransorbicularisfibrosis and maintaintautness of thepretarsal soft tissue.
•A small button holethrough orbicularismuscle and orbitalseptum as made atmedial extent ofwound toaccommodate medialorbital fat excision•Minimal or none ofpreaponeurotic fat isexcised.
•Closed with multipleinterrupted 6-0 nylonsuture•If lateral retinacularsuspension forbrowpexy is to beperformed, the outerone fourth of woundremains open untilthe lowerblepharoplasty andcanthopexy isperformed
Discussion Over dissection of anterior upper eyelid structurecan result in loss of tight adherence andconjoined fascial relationships that are replacedby cicatrix of soft tissue layer Excision of orbicularis muscle avoided as it canlead to lagophthalmos and blepharoptosis This approach best consider the physiologicchange that occur in the aging of this region, anddelivers results that are most rejuvenative, withless stigmata of surgery.
Upper blepharoplasty in asian patientApproximately 50 % of asian population have upper eyelidcrease while remaining don’t have.
Surgical technique Conjuctival suturingo Non invasiveo Have disadvantage that crease disappear with time External incision
External incision technique•Vertical height ofcentral portion ofupper tarsus istranscribed onto theskin surfacecentrally•This serve as acentral point forlower line ofincision, with theoverall line dictatedby shape of creasedesired•Upper line of
•After the incision, awet field cautery isapplied forhemostasis and asurgical cautery isuse to incisethrough orbicularisoculi muscle alongthe superior incisionline
•Orbital septum isfirst opened with amonopolar cauteryalong the upper lineof incision and thenextend horizontallywith scissors
•A small amount ofpreaponeurotic fatpad is excised
•2- 3 mm of pretarsalorbicularis muscle isexcised along theinferior edge of skinwound to facilitate theinfolding of surgicallycreated crease.
•Placement ofinterrupted suture fromthe skin to the levatoraponeurosis to theskin for creaseformation
•Skin closure usingplacement of five to sixinterrupted 6-0 sutures toform the crease and acontinuous suture toapproximate the edge ofwound
Complication Hemorrhage Grossly asymmetric crease Obliteration or fading of crease Prolong postoperative edema Hypertrophic scar formation Excessive fat removal with a hollowed eyeapperance Formation of multiple creases
Transconjuctival approach toresection of lower eyelid herniatedorbital fat Useful for patient who have only herniated orbital fatwith minimal or no evidence of dermatochalasis andno hypertrophic orbicularis oculi muscle Also advantageous foro Younger patients with large amount of herniatedorbital fato Patient who have had previous blepharoplaties viaexternal approacho Patient with wrinkled or minimally excessive lowereyelid skin in whom plication of lateral canthi or laserresurfacing of lower eyelid is useful• Contraindicated to patient with minimal lower eyelidfat, inferior orbital rim or nasojugal hollowing
Advantageo Eliminates external scarringo Less ecchymosis Disadvantageo Develop conjuctival chemosiso Slight redundancy and wrinkling of skin
Surgical technique•Performed under localanaesthesia•Anaesthetic agent injectedsubcutaneously, into fat padand subconjuctivally•A colorado needle is appliedto inferior palpebral conjuctivahalfway between the fornixand inferior tarsal border andused to severe conjuctivafrom medial to temporal endof eyelid
•With forceps, thesurgeon and surgeonsassistant grasps theinferior and superioredges of severedpalpebral conjuctiva tofacilitate dissection ofmuller muscle andcapsulopalpebral fasciauntil fat is seen withcolorado needle
•A 4-0 black silk sutureis placed through theinferior edge ofconjuctiva, mullermuscle andcapsulopalpebral fasciaand is pulled upwardand clamped and tapedto drap
•Removes the temporalfat pad first, and thencentral and nasal orbitalfat pad by cutting alongthe hemostat blade andthen applying a cauteryto fat stump
Complication Hemorrhage Postoperative residual dermatochalasis Motility problem if procedure combined with tarsalstrip procedure Residual herniated orbital fat Shrunken lower eyelid
Lower blepharoplasty Traditional lower blepharoplasty, performed 20 yr agotypically incorporated a lower eyelid, infraciliaryskin/muscle flap and excision of orbital fat through thisincision by violating orbital septum and withoutcanthal reinforcement Aging pathology of lower periorbita is due tocomplicated combination of life long animation,descend and hypotonia of orbicularis and atrophy ofadjacent periorbita soft tissue. These days lateral retinacular suspension procedureto skin flap lower eyelid surgery has been themainstay Advantage of preserving orbicularis muscle iseliminating postoperative eyelid retraction andectropion and decreasing post operative edema from
Skin flap approach
Surgical technique•Performed under localanaesthesia•Infratarsal, subconjuctivaland subcutaneousinfiltration done•Incision is placed midwaybetween inferior tarsalborder and inferior fornix
•After incision, contouring oflateral fat pad done firstfollow by medial throughtransconjuctival approach•When minimal fat pad isnoted , diathermy may beused to shrinkage of fat pad•Contouring is performed tothe extent that lowerperiorbital bulges aresatisfactory transposed,excised or shrunk to the pointof optimal concavity when theglobe is balloted posteriorlywith surgeon finger.
•If there is a significant‘Tear trough deformity’ asmall pocket is dissectedthrough thetransconjuctival incison.•If mild, bluntdissection/reflection ofmedial orbicularis oculimuscle attachment toinferomedial bony orbitadjacent to visible troughis carried out.•If significant, free fatgraft is positioned into
Lower eyelid skin incision-after injecting anaestheticsolution subdermally, subciliaryincision is made•Subdermal dissection isperformed•Extent of which dependent onthe amount and type of skinpathology to address as well asextent of exposure of lateralorbicularis muscle and inferiorretinaculum required
•Orbicularis muscleincision then made 2-3mm below the lateralcommisure beginning atthe level of commisureand determined by theamount that requiremobilization andsuspension to achievethe desired effect.•Extent of dissection willdepend on the amount ofelevation desired withcanthoplasty
•Dissection is performedto lateral orbital rim andfor as much release asrequired for bothmobilization of orbicularismuscle, release of inferiorretinaculam from lateralcanthal tendon, andrelease of inferior tarsalstrap depending on howmuch super placement isrequired.
Lateral retinacularsuspension•Place the suturethrough the lateralcanthal tendon,through the inneraspect of lateral orbitalrim throughperiosteum and thendirect this through theorbicularis muscle atthe upper eyelid•Suture are placed 2-3
Orbicularis aculi musclesuspension•Usually 1 to 3 suture areplaced toward the cephaladportion of wound through thelateral orbital rim periosteummedially, temporalis fascialaterally and then advance theflap of orbicularis muscle tothis region•It raises the eyelid cheekjunction without distracting thelateral commissure and laterallower eyelid from the globe
•After orbicularis musclesuspension, skinredraping and excision isperformed which canvary from no excision toat times significant skinexcision depending onpatient presentation
•Skin closure isperformed withinterrupted orcontinuous 6-0 nylonsuture.•Sometime lateral suturetarsorraphy isperformed to promotegood lateral lid positionin immediate postoperative period
Skin muscle flap approach Performed in patients who have excessive lowereyelid skin and orbicularis usually associated withcheek bag. Combined with lateral canthal tendon tightening
Surgical technique•Infralash and lateralcanthal skin incisiongiven 1.5 mm beneaththe lower eyelid lashes.Incision begin belowthe punctum andextend temporally for adistance of 2-3 mmtemporal to lateralcanthus. The incision isextended for another 1cm in horizontallydirection
•After incision orbicularismuscle is severed alongthe skin incision sitewith scissor and bluntdissection done underorbicularis oculi muscle.
•After submusculardissection nasal,central and temporalherniated orbital fatpad are now visible.•A small opening ismade in the temporalorbital fat capsule andfat removed•After temporal fatpad, the central andnasal fat padremoved.
•After fat removal, skinand orbicularis muscleare draped over theincision site and areexcised.•A strip of orbicularismuscle is routinelyexcised over the skinmuscle flap, temporally tonasally, for a distance 4-5mm beneath the flap toprevent postoperativefullness
•A 6-0 black silksuture is runcontinuously fromlateral canthus totemporal end of theincision.•A second 6-0black silk suture isrun continuouslyfrom the nasal endof incision to lateralcanthus.
Post operative care Apply cold compress to lid for 2-3 hrspostoperatively Head end elevated 45 degree to reduce edema Check for bleeding associated with proptosis,pain or vision by finger counting every 15 minutesfor first 2-3 hr postop and then hourly. If patient cannot count fingers or there is severepain and proptosis, patient should immediatelyreturn to emergency facility for evaluation ofpossible retrobulbar hematoma Sutures removed 5-7 day postoperatively
Postoperative complication Eyelid retraction and ectropion If too much skin removed, a cicatricial ectropioncan occure Loss of eyelashes Suture cyst Retrobulbar hemorrage