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Blepharoplasty

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blepharoplsty basics

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Blepharoplasty

  1. 1. BLEpHaRoPLaStY Dr.Akasha Amber Plastic Surgery department, BahawalVictoria Hospital, Bahawalpur
  2. 2. Introduction ▪ Rejuvination of upper and lower eyelids ▪ AIM: – Youthful upper and lower eyelids – Maintaining original shape ▪ Blepheraplasty; focus on entire periorbital structures
  3. 3. Principals: ▪ Proper brow positioning, corrugator muscle removal & lif fold invagination when necessary ▪ Restoration of lateral canthal tone & position, intercanthal axis tilt ▪ Restoration of lower lid tone and position ▪ Preservation of maximal lid skin, muscle & orbital fat ▪ Midface lifting through reinforced canthopexy, enhanced by composite malar advancement ▪ Correction of suborbital groove with tear trough(or suborbital malar) implants, correcting malar bags – Smooth transition between lower lid and cheek ▪ Control of orbital fat by septal restraint or quantity reduction ▪ Removal of only excessive tisse (skin, muscle, fat) ▪ Modification of skin to remove wrinkling, excision of small growths & blemishes
  4. 4. Aging eyes
  5. 5. ▪ Palpebral fissure: 28-30mm (H) ,8-10 MM (V) ▪ Lateral commissure; 2mm superior to medial commissure (canthal tilt) ▪ Upper lid margin arch peaks at centre of pupil – Lateral migration: (weakened medial levator horn) ▪ Lid crease – Occidental: 8-10 mm in Females, 7mm in Males – Asian: absent or 4-6mm from lash margin ▪ Lid fold( excess skin & muscle)
  6. 6. ANATOMY ▪ UPPER LID – Skin – Muscle – Structural support – Fat compartments – Gland ▪ LOWER LID – Skin – Muscle – Fat compartments – Supportive framework Upper lid Anterior lamella • Skin with subcutaneous tissue • Muscle(orbicularis occuli) Posterior lamella • Tarsoligamentous sling • (upper lid retractors,capsulopalpebral fascia,,tarsal plate,lateral & medial canthal tendons) • conjuntiva Lower lid Anterior lamella • Skin with subcutaneous tissue • Muscle(orbicularis occuli) Posterior lamella • Tarsal plate and capsulopalpebral fascia with inferior tarsus • conjuntiva
  7. 7. Anatomical changes of aging eye: ▪ Lateral migration of tarsal plate(weakening of medial horn of levator apponeurosis ▪ Skin elasticity loss: periorbital rhytids ▪ Weak septum: periorbital fat bulging; puffy eyelids ▪ Herniation of nasal fat pad of upper eyelid ▪ Hollowing;superior sulcal hollowing or A-Frame deformity: soft tissue volume loss ▪ Brow volume loss: brow flattening, brow ptosis; upper lid hooding,lateral brow descent, narrowed brow lash distance ▪ Glabellar lines ▪ Eyelid bags, accentuation of lid cheek junction, tear trough deformity
  8. 8. Indications: Dermachalasis(excess loose skin) Belpherochalasis(edematous eyelid) Excess orbital fat pads or muscle Cosmetic concern
  9. 9. How to proceed: ▪ Preop evaluation: ▪ history and detailed clinical examination ▪ Attention to surrounding aging face ▪ Rule out RED flags; conditions with high postoperative risk ▪ Photographs ▪ Patient’s concern and expectations ▪ Operative plan with or without adjunts ▪ Informed consent
  10. 10. Preop evaluation: ▪ Visual acuity by snellen’s chart ▪ Visual field ▪ Occular movements (6 positions of gaze) ▪ Globe position: (vector +-), (Hertel exophthalmometry) ▪ Shirmer’s test (DRY EYE) for tear production ▪ Poor bell’s phenomenon ▪ Rule out occular pathologies ▪ Any history of contact lens intolerance
  11. 11. Brow and Upper Orbit: ▪ Brow: – ptosis ,symmetry and shape ▪ Upper lid fold: – Symmetry,ptosis ▪ Levator function: – Excurtion ▪ Excess skin ▪ Excess preapponeurotic fat, ROOF ▪ Lacrimal gland ptosis ▪ Bony fullness or resorption ▪ FLOPPY EYELID SYNDROME 10-15mm(good) 6-9mm(fair) <5mm (poor)
  12. 12. Lower Orbit & Midface: ▪ Skin, muscle and orbital fat – Excess/laxity ▪ Malar bags/ tear trough deformity ▪ Lateral canthal position: – +ve or –ve tilt ▪ Lower lid tone/laxity – Snap test – Distraction test ▪ 1-2 mm minimal, ▪ 3-6mm moderate, ▪ >6mm significate laxity ▪ Scleral show ▪ Globe position – Vector (+ve or –ve) – Hertel exophthalmometry (16-18mm)
  13. 13. Systemic conditions: ▪ Any LASIK surgery during previous 6 months ▪ DRY EYE SYNDROME ▪ PRIMARY ESSENTIAL BLEPHAROSPASM ▪ GRAVES’ DISEASE ▪ EYELID INFLAMMATORY DISORDERS – Pemphigus, rosacea, sarcoidosis,
  14. 14. Opertive Techniques: ▪ Upper lid blepharoplasty: ▪ Markings ▪ Lower lid blepharoplasty: ▪ Markings
  15. 15. ▪ LA,GA ▪ MAC (monitored anesthesia care; LA with sedation and analgesia) ▪ Retrobulbar hemtoma or eyelid hematoma
  16. 16. ▪ To avoid risk of post op ptosis, a supratarsal fixationof pretarsal skin muscle to levator apponeurosis in midpupillary line, 6-0 vicryl ,mattress suture
  17. 17. ▪ Brow ptosis, excess brow fat pad corrected, lacrimal gland ptosis corrected with fixation sutures ▪ ROOF addressed ▪ For Asian blepheraroplasty: – low crease incision (4-6mm above lash line) – Conservative resection of skin and fat – To create a fold, multiple anchoring sutures through junction of upper tarsal plate, levator insertion and dermis of upper lid skin
  18. 18. Lower lid blepharoplasty: ▪ Two approaches: – Subciliary incision – Tarsoconjuctival plus skin pinch approach ▪ Trans-septal ▪ retroseptal ▪ Through conjunctiva and capsulopalpebral fascia, through or behind septum ▪ Minimal injury risks
  19. 19. Lower lid blepharoplasty: ▪ Two approaches: – Subciliary incision – Tarsoconjuctival plus skin pinch approach ▪ Subciliary Approach: ▪ Skin incision lateral to medial ▪ Stair-step incision through O.O muscle leaving 5mm pretarsal strip ▪ Skin muscle flap raised ▪ Dissection via septum to infraorbital rim ▪ Orbitomalar ligament released and tear trough deformity corrected. ▪ SOOF approached. Fat removed in conservative manner(all 3 compartments). ▪ Avoid injury to I.O.M (diplopia),avoid injury to arcuate expansion( further fat herniation) ▪ Arcus marginalis release, fat transposition, fat grafting
  20. 20. Canthoplasty and canthopexy
  21. 21. ▪ Two layered canthopexy: ▪ A: suture fixating tarsal tail into the drilled hole ▪ B: 2nd layer orbicularis suture ▪ C: lateral sutures fix lateral orbicularis to deep temporal fascia ▪ D:if midface is elected, inferior drill hole can be made to fixate midface tissues ▪ E: bury the knot into the drill hole
  22. 22. Postop care ▪ Eye drops; moisturizing ▪ Ophthalmic lubricating ▪ Intermittent forced lid closure ▪ Head; elevated posture ▪ Ice cold packs for 24 hrs ▪ Ophthalmic ointment at night ▪ Sutures removal (5-7 days)
  23. 23. Complications: ▪ Bleeding ▪ Over correction ▪ Retrobulbar hemorrhage ▪ Chemosis ▪ Globe perforation ▪ Vision loss (periorbital filler injection/intra arterial embolization) ▪ Injury to SOM/IOM: diplopia ▪ Corneal irritation ▪ Inflammatory/infectious complications ▪ Hypersensitivity reactions ▪ Deep orbital cellulitis with intracavernous extension ▪ Subcutaneous epidermoid cysts ▪ epiphora ▪ Suture abscess,granuolma,
  24. 24. Complications: ▪ Dry eye ▪ Assymetry ▪ Lagophthalmos ▪ Lid malposition ▪ Ectropion/entropion
  25. 25. THANK YOU
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blepharoplsty basics

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