Blepharoplasty
Avoiding Plastic
Eyelids
E. Gaylon McCollough, M.D.,
F.A.C.S., Jim English, M.D.
The goal of a facial plastic surgeon
should be to correct the undesirable conditions for which he has been
consulted and to avoid leaving his mark on the patient. By embracing the
concept that prevention is better than cure, it is generally possible to
avoid the "operated-on look" following cosmetic surgery. We
describe a number of safeguards we use to preserve natural-looking eyes
following lower lid blepharoplasty in men and women. The most common,
permanent complication described following conventional lower lid
blepharoplasty is the round eye. The condition is readily identified by
an increase in scleral show between the limbus and lower lash margin.
Closer evaluation will reveal inferomedial displacement of the lateral
commissure, increased slope of the lateral third of each eyelid, a
flattened, unanimated, pretarsal component, and an unnatural infralash
crease produced by the healed incisional scar. These findings are one
step short of ectropion; therefore, the methods herein described should
help reduce the incidence of this more dreaded and serious complication
of blepharoplasty. (Arch Otolaryngol Head Neck Surg 1988; 114:645-648)
A round eye is thought to occur
following iatrogenic disruption or weakening of the tarsofascial sling
or hammock. A more flaccid "hammock" is unable to resist the
inferior and medial pull placed on the lower lid margin by postoperative
contracture of the surgically created lower lid flap. Lower lid
abnormalities may also occur in the unoperated-on lid as the lateral
canthal tendon weakens and becomes more flaccid with age. Regardless of
the cause, increased scleral show is generally accompanied by widening
of the palpebral fissure and a more obtuse lateral canthal angle.
Many of the aforementioned unnatural
postoperative sequelae may be avoided by lowering the conventional lower
lid incision to a skin crease approximately 4 mm below the free border
of the eyelid. This distance usually corresponds to the inferior border
of the tarsus. As a direct result of a lowered incision, the pretarsal
area is undisturbed. The retained integrity of the skin-orbicularis-tarsal-canthal
tendon complex (hammock) is maintained and can better resist the
inferomedial pull of any contracting scar and/or excess skin removal.
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Skin Flap vs Skin-Muscle Flap
The two principal approaches to removing excessive tissues in the lower
lid are the skin flap and the skin-muscle flap. The diagnosis of the
problem determines which technique is used in a given patient.
Significant redundancy of lower lid
skin is best corrected with a skin flap (Fig 1).
When a skin-flap technique is used, it
is felt by some that downward traction on the lower lid during healing
may be aggravated by a sheet of contracting scar under the previously
undetermined flap on the more mobile lower lid margin.
The "classic" lower lid skin
incision, described by Castanares1 and Rees2, is made approximately 1 to
2 mm below the free border of the lower lid (Fig 2). An incision this
close to the lashes, however, could result in unnecessary disruption of
the tarsofascial hammock, particularly if, when exposing lower lid fat,
the surgeon removes any pretarsal orbicularis oculi muscle and/or
disrupts the integrity of the orbital septum close to its insertion on
the inferior border of the cartilaginous tarsal plate (Fig 3).
Despite the amount of skin excised, any
contraction of the lower lid flap during healing could produce an
unwanted inferior and medial pull on the lid margin postoperatively.
These combined vectors often produce blunting of the lateral commissure,
an undesired increase in the amount of scleral show, and leave the
patient with a more operated-on or unnatural-looking eye (Fig 4). If the
pretarsal orbicularis muscle is removed, the pretarsal portion of the
lid may be left with an abnormally flattened appearance.
The aforementioned undesirable sequelae
can generally be eliminated by placing the lower lid incision along a
line corresponding to the inferior border of the tarsus.
Contraction of the sheet of scar, which
is thought to occur throughout any undermined area, is not as likely to
occur with a skin-muscle flap technique. Still, it remains a factor that
the surgeon must consider in planning his operation. We contend that
avoiding disruption of the pretarsal hammock composed of skin,
orbicularis oculi, the cartilaginous tarsus, and the most superior
portion of the horizontal fibers of the orbital septum will tend to
resist these contracting forces, providing skin (and/or muscle) removal
is not excessive.
Webster 3,4 addressed the problem of
inferior displacement of the lid margin via a flap suspension technique
and lateral canthopexy. He felt that excision of tissue superior and
lateral to the canthus would suspend the lower lid flap to the lateral
orbital soft tissue when the wound was closed and would tend to offset
any inferomedial pull during healing. Later, he advocated suture
plication of an iatrogenically weakened or senescent lateral canthal
tendon in an effort to reduce the incidence of postoperative ectropion
and/or rounding.
We have attempted to avoid the unwanted
sequelae of blepharoplasty. Placing the skin incision farther inferiorly
from the lid margin seems to be a key factor in avoiding
surgical-appearing eyes.
Depending on the pattern of rhytids in
the lower lid, the incision is made approximately 4 mm below the lower
lash margin. By design, this leaves behind more of the overlying
orbicularis oculi muscle fibers attached to the anterior border of the
tarsal plate. Placing the incision through the orbicularis oculi muscle
and orbital septum farther from the lid margin leaves more of the septal
fibers attached to the inferior border of the tarsus, and better
preserves the lower lid hammock connecting the medial and lateral
canthal tendons (Fig 5). With more undisturbed tissue between the
initial incision and the free margin of the eyelid, the amount and
dynamic effect of postoperative scarring in the eyelid should be
diminished. Furthermore, by leaving more skin (and muscle) superior to
the initial incision, an additional safeguard is introduced. If, by
chance, the surgeon should remove too much skin during the procedure,
the undisturbed skin superior to the original incision may stretch with
the passage of time and relieve some downward traction placed on the
lower lid.
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Preoperative Consultation
Essential to any cosmetic procedure is the preoperative consultation.
During that time the surgeon has an opportunity to examine the patient
and look for those conditions that may herald a potential problem
postoperatively. The amount of preoperative scleral show, if present, is
noted and pointed out to the patient. Photographic documentation of the
preoperative state is essential.
The tonicity of the lower lid can be
ascertained by the "snap test," i.e., pulling the lid away
from the globe and releasing it quickly. A lid with a good
"hammock" will snap back into position. On the other hand, a
lid that floats back or remains in an abnormal position will usually
require additional surgical maneuvers in order to avoid round eye and/or
ectropion. (If a patient tends to have a rather lax lower lid, the
surgeon may consider a pentagonal full-thickness wedge resection of the
lower lid lateral to the limbus at the time of surgery. Webster 3, 4 has
advocated lateral canthal tendon plication as an alternative treatment
for hammock flaccidity.)
During the consultation, the surgeon
explains to the patient the limitations of surgery and attempts to evoke
the patient's expectations. If pathologic conditions of the eyes are
elicited or suspected, and preoperative ophthalmologic consultation
should be obtained.
During the initial visit the
patient’s eyelid-brow complex is analyzed to ascertain if adjunctive
surgical correction might be indicated (in addition to a blepharoplasty).
As a rule of thumb, blepharoplasty
tends to improve the sags and bulges, but does not appreciably remove
fine rhytids around the eye. If wrinkling is present, a discussion of a
postoperative chemical peel for correction of this condition eight to 12
weeks following blepharoplasty should be a part of the preoperative
consultation.
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Operative Procedure
With the patient lightly sedated and in a reclined position at about 45o,
the intended blepharoplasty skin incisions are outlined with a skin
marking pen prior to injection of the local anesthetic. The proposed
incision is planned for a skin crease approximately 4 mm below the free
border of the lash margin. The incision begins a few millimeters lateral
to the punctum medially and courses laterally just past a vertical line
dropped from the lateral commissure (Fig 6). At this point, the incision
curves inferiorly and laterally into a naturally occurring relaxed skin
tension line in order to obtain a more aesthetically pleasing scar.
Each lid is then infiltrated with 1%
lidocaine (Xylocaine) with 1:100,000 epinephrine for both hemostatic and
anesthetic purposes.
If it is to be done in conjunction with
a lower lid, the upper lid is corrected first. After the excessive upper
lid skin has been removed and the fat pads have been adequately excised,
one or two tacking sutures are placed to close the lateral aspect of the
upper lid wound.
The previously outlined lower lid skin
incision is made with a No. 15 blade, while a surgical assistance offers
countertraction medially, inferiorly, and superiorly. The operating
surgeon’s hand places countertraction laterally so that the skin
incision can be made quickly and precisely. This initial incision is
made only through the skin.
A small curved iris scissor is used to
spread and penetrate the orbicularis oculi muscle laterally. A more
blunted scissor is then used to undermine the entire skin muscle flap.
While freeing the orbicularis oculi
muscle from the orbital septum, it is wise not to disturb the periosteum
overlying the infraorbital rim. Disruption of the periosteum could allow
the orbicularis muscle to heal directly to the bone or frayed periosteum
during the postoperative period. If this should occur, undue downward
traction on the lower lid might produce lid distortions.
Once the undersurface of the
orbicularis oculi muscle has been freed from the orbital septum, one
blade of the scissor is placed in the previously created pocket beneath
the muscle. The other blade of the scissor is placed externally along
the initial skin incision. The incision through the orbicularis oculi
muscle and subcutaneous tissue is completed when the blades of the
scissors are approximated on a 45o bias through the full thickness of
the flap exiting at the previously made skin incision.
Since the skin-muscle flap is selected
in those patients with minimal skin redundancy, the flap is reflected
primarily to remove excessive fat (Fig 5). The fat pads can be more
accurately identified by making a "nick" in the orbital septum
while placing a small amount of digital pressure on the globe. This
maneuver causes the excessive fat to bulge through the orbital septum
for easy amputation. Prior to excision, the base of the fat stalk is
injected with local anesthetic and generously cauterized with bipolar
cautery before its removal. Only the portions of fat that exude easily
through the defect in the orbital septum are removed.
After each fat "compartment"
has been adequately treated, the skin-muscle flap is draped superiorly
and laterally. Small vertical cuts are made into the overlapping
portions of the skin-muscle flap, dividing the tissue to be removed into
three or four segments. This maneuver adds a measure of safety and tends
to prevent excess skin removal.
We have discovered that when both the
skin and muscle incisions are placed inferior to the tarsus, it is not
necessary to remove a strip of muscle from the undersurface of the
skin-muscle flap. Once the overlapping skin and muscle have been
removed, the wound edges are precisely closed with a 6-0 catgut suture.
In patients with festoons of lower lid
skin in which a skin-flap technique is used, the orbicularis oculi
muscle is divided with a separate incision 3 or 4 mm inferior to the
initial skin incision. The margins of the orbicularis oculi muscle are
reapproximated with interrupted 6-0 chromic catgut sutures after fat
removal.
When either skin flaps or skin-muscle
flaps are selected, the lower incision leaves behind more innervated
orbicularis oculi muscle on the anterior aspect of the tarsal plate. In
addition, fewer muscle fibers are disturbed laterally, thereby
preserving the circumferential contracting mechanism of the orbicularis
oculi superior to the blepharoplasty incision.
The surgical scar resulting from the
more inferiorly placed incision heals quite nicely, just like the
conventional higher placed incision, and is generally quite acceptable
(Fig 6).
We believe that prevention is better
than cure. If the safeguards herein described are embraced, the
incidence of postoperative displacement of the lid margin can be
significantly reduced (Fig 7) and, in most cases, ectropion or an
unsightly round eye can be avoided.
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Comment
Rounding of the eye can be a common postoperative sequelae of
blepharoplasty. In our experience, relocating the conventional lower lid
incision to a more physiologic position has proven beneficial. Leaving
the pretarsal soft tissues and the associated "hammock"
undisturbed may avoid the "operated-on" or surgical-appearing
eye. The scar from the more inferiorly placed lower lid incision is
aesthetically acceptable, and, in most cases, can be camouflaged with
makeup one week following surgery.
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References
1. Castanares S: Blepharoplasty for herniated intraorbital fat:
Anatomical basis for a new approach. Plast Reconstr Surg 1951;8:46-58.
2. Rees TD: Surgical procedures, in Aesthetic Plastic Surgery.
Philadelphia, WB Saunders Co, 1980, pp 470-524. 3. Webster RC: A flap
suspension technique in blepharoplasty on lower lids. J Dermatol Surg
Oncol 1978;4:159. 4. Webster RC: Suspending sutures in blepharoplasty.
Arch Otolaryngol Head Neck Surg 1979;105:601-604.
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