Complications of Blepharoplasty

Educational Objectives

The goal of this program is to improve treatment of eyelid abnormalities. After hearing and assimilating this program, the clinician will be better able to:

1. Identify risks associated with blepharoplasty.

Summary

Introduction: all patients with dermatochalasis, ptosis, or brow ptosis present with heavy or droopy eyelids; speaker often uses tape to show patients expected results for different techniques

Patient examination: treat significantly dry eyes or exposure keratopathy first (removing excess eyelid tissue may worsen dry eyes); wait ≈6 mo after refractive or corneal surgery, or corneal or eyelid trauma

Patient preparation: discontinue anticoagulants for 2 wk, with guidance from patient’s cardiologist or internist; inform patients about risks (eg, bleeding, infection, swelling, scarring, need for repeat surgery); discuss intraoperative experience and expected postoperative appearance

Surgeon preparation: review eyelid layers (skin, orbicularis, septum, fat, levator aponeurosis, Müller muscle, and conjunctiva)

Surgical techniques: limit removal of tissue between lower edge of brow and upper skin marking (excessive removal may cause lagophthalmos or worsen brow ptosis; leave 18 to 20 mm for lid-crease height plus distance between lower brow and incision); if cauterizing, communicate with anesthesiologist about oxygen usage to avoid ignition; removal of skin and muscle does not appear to result in decreased function; speaker typically removes some fat, from preapocrinotic fat or medial fat pad; use caution around levator aponeurosis to avoid causing ptosis; excessive fat removal may age patient’s appearance; strive for symmetry; medial orbital fat pad — retracts back into orbit; has blood vessels that must be cauterized; if orbital hemorrhage occurs (12—24 hr later), patient must return to clinic as emergency case; aggressive handling of medial fat pads can damage trochlear nerves

Lower-eyelid blepharoplasty: check eyelid laxity; review anatomy from anterior to posterior (ie, transconjunctival and subciliary approaches possible)

Transconjunctival approach: requires no skin incision, so procedure favored for young patients who do not need skin removal; preservation of orbicularis minimizes eyelid malposition; preserves septum; minimizes bruising and edema; speaker uses monopolar cautery and makes conjunctival incision between fornix and lower edge of tarsus; caution required near inferior oblique (located between lower eyelid’s central and medial fat pads) because damage to this muscle can lead to torsional diplopia; excessive suturing or overcauterizing conjunctiva can cause entropion

“Open-sky” (subciliary) approach: used for older patients with diffuse prolapse of all 3 fat pads; allows direct visualization of fat pads and easy access to lateral fat pad; compared with transconjunctival approach, associated with greater risk for eyelid malposition, bruising, and edema; procedure — make incision 2 mm beneath lash line and dissect down in suborbicular fascial plane; remove fat; if eyelid laxity present, suture lateral canthal tendon to prevent ectropion (speaker performs suborbicularis oculi fat [SOOF] lift to further support lower eyelid); in patients with deep troughs, redrape fat over orbital rim rather than removing it

Postoperative care: support lateral canthal tendon with wound-closure strips; ice packs for 2 days; antibiotic ointment daily for 1 wk; elevate head; no heavy lifting, bending, or straining for 1 wk; keep water out of wounds; speaker removes sutures after 1 wk (some clinicians use absorbable sutures); patients can resume normal medications after 1 wk; speaker recommends use of arnica (Arnica montana) pads or pills to minimize swelling and bruising and vitamin K to minimize bruising (does not use steroids)

Summary: choose patients with true dermatochalasis and/or fat prolapse for blepharoplasty; set realistic expectations; be familiar with multiple surgical and nonsurgical approaches

Readings

Branham GH: Lower eyelid blepharoplasty. Facial Plast Surg Clin North Am 2016 May;24(2):129-38; Kang JY et al: Assessing the effectiveness of Arnica montana and Rhododendron tomentosum (Ledum palustre) in the reduction of ecchymosis and edema after oculofacial surgery: preliminary results. Ophthalmic Plast Reconstr Surg 2017 Jan/Feb;33(1):47-52; Lee WW et al: Advanced single-stage eyelid reconstruction: anatomy and techniques. Dermatol Surg 2014 Sep;40 Suppl 9:S103-12; Sand JP et al: Surgical anatomy of the eyelids. Facial Plast Surg Clin North Am 2016 May;24(2):89-95.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Lee spoke at Current Concepts of Ophthalmology, held Jan. 4-6, 2019, in Atlantic City, NJ, and presented by NYU School of Medicine and its Office of Continuing Medical Education. For information on upcoming CME activities from this sponsor, please visit https://med.nyu.edu/. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP572204

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.