MANISH JAIN

BLEPHAROPLASTY

What is blepharoplasty?Surgical procedure aimed at improving

the appearance of eyes.Goals- to improve the appearance of

eyes while maintaining the natural shape of eyes.

Upper and lower blepharoplastyremoves:

fold of skinfat pads

Function of eyelidProtect the globeProvide a sufficient and appropriately

located aperture for visionAlso assume a role of facial expressionTear production and distribution

Surface anatomyAppearance of eye largely determine by

shape of palpebral fissure and it position relative to globe

• Palpebral aperture• Skin• Lid margin• Grey line• Glands• Skin crease

Orbicularis oculi

•Two part oPars orbitalis

oPars palpebarum - divided into preseptal and pretarsalMedially divided into superficial head – form medial canthal tendondeep head – insert into posterior lacrimal crest and lacrimal sac fascia

Eyelid supportPrimary by bony attachment of canthio Medial canthus - fixed to orbital wallo Lateral canthus – mobileLateral canthus is approximately 2mm

heigher then medial Secondary from orbicularis muscle and its

fascial attachment

Medial canthus tendon•Integration of pretarsal and preseptal orbicularis oculi, septum orbitale, medial end of lockwood ligament, medial horn of levator aponeurosis and check ligament of medial rectus muscle•Insert into frontal process of maxilla into tripartite manneroAnterior – onto anterior lacrimal crestoPosterior – onto posterior lacrimal crestoVertical – on medial orbital rim and contribute mainly to stability

Lateral canthus tendon•Y shape fibrous condensation•Extend from upper and lower tarsal plate and reinforce by lateral horn of levator aponeurosis, lockwood ligament and check ligament of lateral rectus to form lateral retinaculum•Inset to lateral orbital wall at whitnall tubercle

Tarsus•Crescentric shape, dense condensation of connective tissue •Maintain the integrity of eyelid•Upper tarsus – 29 mm long and 10 mm wide in central part•Lower tarsus – 24 mm long and 4-5 mm wide •Contain meibomian glands

Septal orbitale• Represent the continuation of orbital periosteum• Thin fibroelastic membrane• Attach medially to spine at lower end of anterior

lacrimal crest• Laterally attach to lateral canthal raphe• Arcus marginalis – junction of fusion of periosteum

and septum• In upper lid, septum attach to levator aponeurosis

about 25 mm above the superior edge of tarsal plate to form the conjoined fascia

• In lower lid, septum attch to capsulopalpebral fascial below the inferior edge of tarsus

Eyelid fat•Preseptal fat – extra orbital(ROOF), 6mm thick•Postseptal – intra orbital, are the fat extension from adipose 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 canthal tendon, use as a landmark for whitnall tubercle

Eyelid retractor

•Levator plapebrae superioris - •Muller muscle•Capsulopalpebral fascia – peripheral extension of inferior rectus muscle

Lacrimal system•Basic secretor•Reflex secretor

Blood supply•Internal carotid artery(predominant)oOphthalmic artery•Externl carotid arteryoAngular arteryoInfraorbital arteryoSuperficial temporal artery

Indications

Blepherochalasis :-Loss of tone & relaxation of lid

skin- Affect upper lid-Redundant fold of skin & often

muscle -Interfere with upward field of

vision

Dermochalasis : -Excess fold of skin of upper lid-Skin hangs over the ciliary margin .-Usually occurs from middle age onwards-aging process

Hypertrophy of the orbicularis oculi muscles : -Ridge of bulging muscle running horizontally along the lower lid below the ciliary margin

Goal-Symmetry-Aperture length & height-Limited scleral exposure.-Supratarsal fold.-Eyebrows-Scar

Examination And PlanningAccurate pre-op planning is important.EVALUATION BASICS:

PT. seated in frontGen. appearanceSymmetry & posture

Skin & fat quantificationBrow examinationModified snap test

Cntd…..Medical and ophthalmologic historyOcular examination

Visual acquityPupilsExtraocular musclesGlobeRetinaTear film- Schirmer`s test.

Photographs

Upper blepharoplasty – Skin approach

•Appearance of aged upper eyelid is primarily due to excessive skin, muscle, and fat often in conjunction with brow descend•Approach should be individualize•Appreciation of volume shift which lead to fat malposition•Volume loss lead to deepening of upper sulcus•Position of upper eyelid crease•Brow position

Incision

•Patient with deep upper eyelid sulcus benefit from 10 mm or higher incision•In presence of brow ptosis , lower the crease incision•Incision include only skin•Brow fold distance is thereby maximized to reduce ptotic brow appearance

Pinch test•Serve as a guide to the maximum allowable skin resection•End point is that of skin tautness without the eversion of eyelash margin

•Upper demarcation usually follow the contour of eyebrow•Usually the amount of skin excision should ultimately be less than this specified amount

•Infiltrate local anaesthesia with adrenaline•Plane of dissection – subcutaneous •Incision should be through skin only•Dissection begin at lateral ellipse

•Hemostasis by monopolar cautery•Liberal application at lower edge of wound allow for creation of adhesive interface which facilitates establishment of crease, enhanced by transorbicularis fibrosis and maintain tautness of the pretarsal soft tissue.

•A small button hole through orbicularis muscle and orbital septum as made at medial extent of wound to accommodate medial orbital fat excision•Minimal or none of preaponeurotic fat is excised.

•Closed with multiple interrupted 6-0 nylon suture•If lateral retinacular suspension for browpexy is to be performed, the outer one fourth of wound remains open until the lower blepharoplasty and canthopexy is performed

DiscussionOver dissection of anterior upper eyelid

structure can result in loss of tight adherence and conjoined fascial relationships that are replaced by cicatrix of soft tissue layer

Excision of orbicularis muscle avoided as it can lead to lagophthalmos and blepharoptosis

This approach best consider the physiologic change that occur in the aging of this region, and delivers results that are most rejuvenative, with less stigmata of surgery.

Upper blepharoplasty in asian patientApproximately 50 % of asian population have upper eyelid crease 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 of central portion of upper tarsus is transcribed onto the skin surface centrally•This serve as a central point for lower line of incision, with the overall line dictated by shape of crease desired•Upper line of incision usually include 2 mm of skin

•After the incision, a wet field cautery is applied for hemostasis and a surgical cautery is use to incise through orbicularis oculi muscle along the superior incision line

•Orbital septum is first opened with a monopolar cautery along the upper line of incision and then extend horizontally with scissors

•A small amount of preaponeurotic fat pad is excised

•2- 3 mm of pretarsal orbicularis muscle is excised along the inferior edge of skin wound to facilitate the infolding of surgically created crease.

•Placement of interrupted suture from the skin to the levator aponeurosis to the skin for crease formation

•Skin closure using placement of five to six interrupted 6-0 sutures to form the crease and a continuous suture to approximate the edge of wound

ComplicationHemorrhageGrossly asymmetric creaseObliteration or fading of creaseProlong postoperative edemaHypertrophic scar formationExcessive fat removal with a hollowed eye

apperanceFormation of multiple creases

Transconjuctival approach to resection of lower eyelid herniated orbital fatUseful for patient who have only herniated orbital fat

with minimal or no evidence of dermatochalasis and no hypertrophic orbicularis oculi muscle

Also advantageous foro Younger patients with large amount of herniated

orbital fato Patient who have had previous blepharoplaties via

external approacho Patient with wrinkled or minimally excessive lower

eyelid skin in whom plication of lateral canthi or laser resurfacing of lower eyelid is useful

• Contraindicated to patient with minimal lower eyelid fat, 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 local anaesthesia•Anaesthetic agent injected subcutaneously, into fat pad and subconjuctivally•A colorado needle is applied to inferior palpebral conjuctiva halfway between the fornix and inferior tarsal border and used to severe conjuctiva from medial to temporal end of eyelid

•With forceps, the surgeon and surgeons assistant grasps the inferior and superior edges of severed palpebral conjuctiva to facilitate dissection of muller muscle and capsulopalpebral fascia until fat is seen with colorado needle

•A 4-0 black silk suture is placed through the inferior edge of conjuctiva, muller muscle and capsulopalpebral fascia and is pulled upward and clamped and taped to drap

•Removes the temporal fat pad first, and then central and nasal orbital fat pad by cutting along the hemostat blade and then applying a cautery to fat stump

•The conjuctiva is reapproximated with three 6-0 plain catgut buried sutures

ComplicationHemorrhagePostoperative residual dermatochalasisMotility problem if procedure combined

with tarsal strip procedureResidual herniated orbital fatShrunken lower eyelid

Lower blepharoplastyTraditional lower blepharoplasty, performed 20 yr ago

typically incorporated a lower eyelid, infraciliary skin/muscle flap and excision of orbital fat through this incision by violating orbital septum and without canthal reinforcement

Aging pathology of lower periorbita is due to complicated combination of life long animation, descend and hypotonia of orbicularis and atrophy of adjacent periorbita soft tissue.

These days lateral retinacular suspension procedure to skin flap lower eyelid surgery has been the mainstay

Advantage of preserving orbicularis muscle is eliminating postoperative eyelid retraction and ectropion and decreasing post operative edema from lymphatic drainage interruption.

Skin flap approach

Surgical technique•Performed under local anaesthesia•Infratarsal, subconjuctival and subcutaneous infiltration done•Incision is placed midway between inferior tarsal border and inferior fornix

•After incision, contouring of lateral fat pad done first follow by medial through transconjuctival approach•When minimal fat pad is noted , diathermy may be used to shrinkage of fat pad•Contouring is performed to the extent that lower periorbital bulges are satisfactory transposed, excised or shrunk to the point of optimal concavity when the globe is balloted posteriorly with surgeon finger.

•If there is a significant ‘Tear trough deformity’ a small pocket is dissected through the transconjuctival incison.•If mild, blunt dissection/reflection of medial orbicularis oculi muscle attachment to inferomedial bony orbit adjacent to visible trough is carried out.•If significant, free fat graft is positioned into pocket

Lower eyelid skin incision-after injecting anaesthetic solution subdermally, subciliary incision is made

•Subdermal dissection is performed•Extent of which dependent on the amount and type of skin pathology to address as well as extent of exposure of lateral orbicularis muscle and inferior retinaculum required

•Orbicularis muscle incision then made 2-3 mm below the lateral commisure beginning at the level of commisure and determined by the amount that require mobilization and suspension to achieve the desired effect.•Extent of dissection will depend on the amount of elevation desired with canthoplasty

•Dissection is performed to lateral orbital rim and for as much release as required for both mobilization of orbicularis muscle, release of inferior retinaculam from lateral canthal tendon, and release of inferior tarsal strap depending on how much super placement is required.

Lateral retinacular suspension•Place the suture through the lateral canthal tendon, through the inner aspect of lateral orbital rim through periosteum and then direct this through the orbicularis muscle at the upper eyelid•Suture are placed 2-3 mm apart

Orbicularis aculi muscle suspension•Usually 1 to 3 suture are placed toward the cephalad portion of wound through the lateral orbital rim periosteum medially, temporalis fascia laterally and then advance the flap of orbicularis muscle to this region•It raises the eyelid cheek junction without distracting the lateral commissure and lateral lower eyelid from the globe

•After orbicularis muscle suspension, skin redraping and excision is performed which can vary from no excision to at times significant skin excision depending on patient presentation

•Skin closure is performed with interrupted or continuous 6-0 nylon suture.•Sometime lateral suture tarsorraphy is performed to promote good lateral lid position in immediate post operative period

Skin muscle flap approachPerformed in patients who have excessive

lower eyelid skin and orbicularis usually associated with cheek bag.

Combined with lateral canthal tendon tightening

Surgical technique•Infralash and lateral canthal skin incision given 1.5 mm beneath the lower eyelid lashes. Incision begin below the punctum and extend temporally for a distance of 2-3 mm temporal to lateral canthus. The incision is extended for another 1 cm in horizontally direction

•After incision orbicularis muscle is severed along the skin incision site with scissor and blunt dissection done under orbicularis oculi muscle.

•After submuscular dissection nasal, central and temporal herniated orbital fat pad are now visible.•A small opening is made in the temporal orbital fat capsule and fat removed•After temporal fat pad, the central and nasal fat pad removed.

•After fat removal, skin and orbicularis muscle are draped over the incision site and are excised.

•A strip of orbicularis muscle is routinely excised over the skin muscle flap, temporally to nasally, for a distance 4-5 mm beneath the flap to prevent postoperative fullness

•A 6-0 black silk suture is run continuously from lateral canthus to temporal end of the incision.•A second 6-0 black silk suture is run continuously from the nasal end of incision to lateral canthus.

Post operative careApply cold compress to lid for 2-3 hrs

postoperativelyHead end elevated 45 degree to reduce

edemaCheck for bleeding associated with

proptosis, pain or vision by finger counting every 15 minutes for first 2-3 hr postop and then hourly.

If patient cannot count fingers or there is severe pain and proptosis, patient should immediately return to emergency facility for evaluation of possible retrobulbar hematoma

Sutures removed 5-7 day postoperatively

Postoperative complicationEyelid retraction and ectropionIf too much skin removed, a cicatricial

ectropion can occureLoss of eyelashesSuture cystRetrobulbar hemorrage

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