HUGO CORTES, M.D.
BOARD CERTIFIED MEMBER OF THE COLOMBIAN SOCIETY OF PLASTIC SURGERY
Blepharoplasty means, generally speaking, all surgical procedures that involve the extirpation of excess skin and muscle, with or without extirpation of orbit fat. Blepharoplasty can correctdownfallen upper eyelids and “bags” that are formed in the inferior eyelids. These features of eyelidsmake us look older and more tired than we really are, and also, in some cases, can interfere with our vision.
However, Blepharoplasty does not eliminate some wrinkles, including “crow’s foot wrinkles”. Also, downfallen eyebrows can’t be treated with Blepharoplasty.
Blepharoplasty can be practiced as an isolated technique or together with other facial aesthetic surgeries, such as cervicofacial lifting, or frontal lifting.
Anesthesia can be either general or local.
Superior eyelids surgery (Superior Blepharoplasty)
Indications and diagnosis:
In general, blepharoplasty of the upper eyelids includes the resection of excess skin, together with the extirpation of parts of the orbicular muscle, orbitary septum, and preaponeurotic fat. Anyway, there are variations of these basic techniques, according to patients and surgeons decisions.
It is essential to diagnose the exact upper eyelids alterations, in order to know the right indications. The term “dermatoachalasia” means a distention of elastic and collagen skin fibers, which could be associated to an hernia of retroseptal adipose bags. Blepharoachalasia consists on repeated eyelids inflammations that cause alterations in support tissues.
Finally, it is important to note the existence of some anomaly concerning the protective mechanisms of the cornea, measuring, and grading the orbicular muscle function, Bell’s reflex, and lachrymal secretions of the eyes, among other things.
Indications and diagnosis:
Inferior eyelids blepharoplasty consists on the different surgical procedures that pretend to eliminate excess skin, fat or muscle, alone or combined. It also treats several palpebral anomalies, such as the existence of ectropion, sclera exposition or hyperlaxity.
A right diagnosis is essential to practice the correct surgical indication. Excess skin is evaluated and the amount of skin to be extirpated is also measured. Fat tissue hernias are located, at the inner, medium, and outer compartments, doing a light pressure on the eye globe through the upper eyelid. Muscular excess is measured by making the patient look upwards or open his mouth.
Finally, the doctor will look for the existence of palpebral or ocular anomalies which could be associated. Doctor’s diagnosis is also helped by frontal and side view pictures.
Treatment. Surgical Procedure:
Blepharoplasty is carried out in a hospital operating room. It usually does not require a stay in the hospital for more than some hours after surgery. To evaluate excess skin and draw the upper incision line, the surgeon uses special tweezers, lifting tissues at the palpebral furrow, taking excess tissue until upper eyelids lashes start an eversion process, when tweezers are closed. Once the area to extirpate is drawn, a local liquid anesthesia, with adrenalin, is infiltrated. After 10 minutes, doctor starts the procedure.
Local anesthesia plus sedatives is usually needed. General anesthesia is seldom used. It depends on the surgeon’s choice. By using local anesthesia plus sedatives, patients are fully relaxed, and there is no pain. In case of using general anesthesia, patients are asleep during the whole procedure.
Surgery lasts from 1 to 3 hours. (It could be longer, if combined to other aesthetic surgeries). Surgery starts at the upper eyelids, when the 4 eyelids are treated.
Most of the time, cuts are done following upper eyelids natural lines and just beneath eye lashes in case of inferior eyelids surgery. These incisions can reach “crow’s foot wrinkles”, in some cases. Through the incisions, skin is separated from fat and muscle and excess fat is removed.. Sometimes, excess skin and muscle are also removed. Sutures are extremely fine.
When treating young patients with only excess fat, a transconjuntival blepharoplasty of inferior eyelids can be practiced. Incision is located inside the inferior eye lid, no scar is visible.
Results of blepharoplasties are probably the best results of aesthetic surgeries. However, periorbital aesthetics involves complex factors, both static and dynamic.. Osseous support and ocular protective mechanisms must be evaluated. The resulting position of eyebrows is essential for a good outcome.
In order to get excellent results, some complementary techniques must be used besides blepharoplasty itself.
Cantoplasties and /or cantopexies. (surgery of external eyelids)
Most eyelids surgeries involve the risk of inducing wrong positions, mainly of the inferior eyelids, if there is no adequate support. Several techniques of lateral cantoplasties and/or cantopexies are practiced in order to avoid this complication.
All procedures are, in general, based on similar surgical concepts, no matter how recently established.
These last procedures are not indicated in case of no big excess fat or muscle, no big laxity in the eyelids or no wrong position. They are indicated for the following cases:
A clear laxity or wrong position of the inferior eyelid, a maxillary hipoplasia, or a desired lateral raise.
Patients with a clear palpebral laxity and/or wrong position, and/or with a previous palpebral surgery need a lateral cantopexy to relocate and reshape the external eyelid. When this procedure is combined to a facial lifting, fixing will be practiced to the orbitary periosteum or to the temporal muscle fascia.
Transposition of adipose bags
Conventional surgeries of inferior eyelids could create aesthetic deformities of eyelids outlines. These are the basic aspects of relocating subseptal fat, as a primary procedure or as a necessary treatment after a previous blepharoplasty:
Once inferior bags are liberated, they are anchored from the capsulopalpebral fascia to the periosteum of the infraorbitary edge.
Recently developed techniques pretend to anchor and reposition fatty pedicles via transconjunctival, to a maxillary subperiosteum pocket created by the surgeon.
Sometimes, it is necessary to partially dissect the base of elevator muscles, both of upper lip and nasal wings. Reabsortion of fatty pedicles is minimum, and aesthetic results are very satisfactory.
Some other techniques
New and recently published techniques include the pexy (raise) of eyebrows through the incision done in superior blepharoplasty. Also, treatment of corrugator muscles through the same incision. New important developments are Laser CO2 treatments and the combination of CO2 and laser (Erblum’s YAG laser), to eliminate fine wrinkles or to practice incisions with practically no bleeding, among other advantages.
Results obtained with blepharoplasties are the best in aesthetic surgeries, being satisfaction of patients extremely great and complications extremely rare.
However, the apparent simplicity of surgical procedures and the very high rate of good results, doesn’t mean that surgeons must not be very careful when choosing the proper technique, and selecting the patients. Also, surgeries must be extremely precise and accurate. The purpose is to achieve aesthetical and functional outcomes, maintaining or improving patient’s ocular system.
There are three general kinds of complications.
Hypertrofic cicatrisation: It is very rare.
Suture cysts: Epithelial tissue penetrates suture threads.
Pigmentation alterations: If the preventive measures are practiced, it is extremely rare.
Queratoconjunctivitis: It usually happens when the protective mechanisms of the eye are not
working correctly. It is important to diagnose xerophthalmia (dry eyes), exophthalmia, motor alterations of the eyes, etc. It is essential to keep a perfect palpebral occlusion, in such a way that the cornea is not exposed during sleep hours; this could happen during the first days after surgery, if both eyelids in the same eye are treated. Proper treatment includes artificial tears and antibiotics.
- Lymphatic vessels disorders: They appear after surgery, and heal spontaneously. Eye drops with corticoids can be used.
- Blindness: Risks are almost nonexistent, (0.04 %) but people fear them very much. It is caused by the compressive intraorbitary hematoma. Treatment consists on a surgical reopening of sutures, lateral cantotomy (surgery of the external eyelid), exploration and evacuation of hematomas and hemostasis.
- Resulting wrong positions: The most frequent is the “rounded eye”, which consists on an excessive exposure of sclerotic at the sides and bottom of the eyes. It is due to excessive resection, or excessive laxity of the lateral ligaments system, which was not detected before surgery.
Upper eyelids resulting wrong positions are much less frequent. Eyelid ptosis can be produced, by an edema, but it heals spontaneously. Ptosis due to lesion and cicatrisation ectropion could also occur. However, results obtained when treating upper eyelids are even better than those of inferior eyelids; so, complications are almost nonexistent, if there are right diagnoses and procedures.
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