Filling in the hollowed areas can be problematic. . For an upper lid blepharoplasty, ending the incision just lateral to the punctum avoids medial canthal. The operation is booked for the end of February, and I have to tell my husband — he will drive me to hospital and back the next morning. For many years, blepharitis and dry eye disease have been thought to be . of toxins that, when found in other areas of the body, can cause acute, .. are all manifestations of end-stage chronic inflammatory lid disease .. Baudouin C. Ocular surface and external filtration surgery: mutual relationships.
Temporary forehead hypesthesia is a predictable adverse effect. Internal brow elevation has high patient acceptance, saves time and cost, and reduces morbidity, while producing enhanced natural elevation of the brow rather than reduced motility from fixation. Methods A retrospective review of patients in the practice of 1 of the authors R.
Informed consent was obtained from each of the subjects in accord with Health Insurance Portability and Accountability Act regulations, and the principles outlined in the Declaration of Helsinki were followed.
Anatomy The anatomy and function of the brow is an important consideration in cosmetic surgery. Several forces act segmentally on the eyebrows to create a dynamic equilibrium that determines brow position. The motility of the brow fat pad is an important concept in determining how to best manipulate eyebrow position.
Lemke and Stasior 3 describe the mobile plane within the brow created by a division within the deep galea aponeurotica. The divisions of the deep galea, the anterior leaf and posterior leaf, envelop the brow fat pad Figure 1. The frontalis muscle and the orbicularis muscle have strong attachments to the frontal bone medially but less so laterally.
This dearth of lateral support of the eyebrow and the mobility of the brow fat pad help account for the prevalence of involutional lateral brow ptosis. The forces that cause descent of the lateral eyebrow include orbicularis muscle action and the mass effect of the eyelid, brow fat pad, and soft tissues of the temporal forehead. The primary force that elevates the lateral eyebrow is contraction of the frontalis muscle, which is limited by the attenuation of the frontalis muscle lateral to the temporal fusion line of the skull.
The orbital ligament attachment to the superolateral orbital rim tethers the eyebrow and restricts it from full superior mobility Figure 2 A.
While this check ligament may be useful to limit overelevation of the temporal brow in youth, it only tethers the brow in older patients. As the brow fat pad descends, it places more tension and weight on the orbital ligament and anterior leaf of the posterior galea, causing temporal eyelid fullness and further restriction of the frontalis.
We address the lateral eyebrows and eyelids by excising the lateral orbicularis underlying the blepharoplasty skin removal, releasing the orbital ligament and sculpting and debulking the sagging brow fat pads.
The release of the anterior leaf of the posterior galea aponeurotica enhances the effect of the frontalis on the lateral eyebrow by reducing restriction. The overall aesthetic improvement is a natural elevation of the lateral brow. Patient selection is paramount for internal brow elevation. Most patients with severe brow ptosis or facial paralysis require more aggressive procedures such as direct brow elevation, small incision elevation techniques, or forehead-lifts. Prior to the present study, we used internal fixation at blepharoplasty.
Blepharitis PPP - - American Academy of Ophthalmology
We were dissatisfied with the complications, which included restricted brow movement, dimpling of the brow, and irregular contours. It makes poor anatomical sense to fixate and thereby cause the brows to be adynamic. The medial eyebrow is influenced by a different set of forces. The depressor muscles include the corrugator supercilii, the depressor supercilii, and the medial portion of the orbicularis oculi muscle. Contraction of the frontalis muscle raises the medial eyebrow and relaxes the glabellar furrows.
By weakening the medial eyebrow depressor muscles, the medial brow is elevated and the glabellar furrows are reduced similar to that seen with botulinum A toxin use. Compared with other brow procedures, internal brow elevation usually provides less brow elevation but much better weakening of the depressor muscles and furrow reduction.
Patients who present for upper face-lift rather than blepharoplasty usually require a more aggressive lift than the technique described herein. However, most patients presenting for eyelid surgery are pleased with the aesthetics and natural appearance of the internal brow elevation. Surgical technique Preoperatively, it is important to design the surgery with the patient in a sitting position. A fine marking pen is used to draw the standard blepharoplasty incision lines and mark the most prominent areas of the brow fat pads.
The vertical and horizontal glabellar furrows are then marked for accurate intraoperative orientation. A supraorbital block is performed, and the corrugator, procerus, and depressor supercilii muscles are infiltrated, as well as the brow fat pads. The patient's face is then prepared and draped in sterile fashion. Blepharoplasty incision and skin muscle excision are performed with care taken to completely remove the orbicularis muscle underlying the temporal skin incision.
This enhances the temporal brow elevation by weakening the depressor action of the lateral orbicularis and thinning and lightening the eyelid. After hemostasis is obtained, the anterior leaf of the deep galea overlying the brow fat pad is grasped with forceps Figure 2 B.
DEBS – a unification theory for dry eye and blepharitis
Manipulating this dense tissue clearly demonstrates the orbital ligament and its tethering effect on the lateral eyebrow. The orbital ligament is transected at its most inferior extent between the lateral canthal tendon and the zygomaticofrontal suture. No complications due to overexcision were observed, but revision was performed for two patients with asymmetry of the lid folds and five patients with recurrence of drooping. Preoperative measurements of upper eyelid heights stretched and at rest appear useful in determining the amount of skin excision required in blepharoplasty for senile ptosis.
Complications of Blepharoplasty: Prevention and Management
For patients experiencing these issues, aesthetic blepharoplasty can be combined with ptosis treatment techniques such as plication or reinsertion of the levator aponeurosis. Several reports have described procedures to excise redundant skin in the upper eyelids for blepharoplasty, but no consensus has been reached regarding quantitative methods for preoperatively determining the amount of skin to be excised.
Instead, the so-called pinch test has been used as a qualitative method. In this article, the authors present a method of preoperatively calculating of the amount of redundant upper eyelid skin to be removed, after which they performed blepharoplasty followed by ptosis surgery.
They report on the relationship between the amount of excised skin and excessive skin as measured preoperatively, as well as describe the results of their method for treating patients with senile ptosis. Methods Fifty patients 17 men, 33 women with bilateral senile ptosis were included in this study.
All patients were treated surgically by one of three authors JM, YY, or KY between January and March and followed for more than six months postoperatively. Patients who were treated during that time but did not complete the follow-up period of at least six months were excluded from the study. All patients had been diagnosed with bilateral senile ptosis based on physiological examinations and subjective symptoms. RLH was measured as the distance between the midpoint of the lower margin of the eyelid Point B; Figure 1 and the point at which the line perpendicular to the lid margin from Point B Line Y; Figure 1 crossed the lower border of the eyebrow Point E; Figure 1 during passive closure of the eyes.
These measurements were performed during a preoperative clinic visit where patients were evaluated for blepharoptosis.
View large Download slide Schema of the design for blepharoplasty. Left Resting lid height RLH is measured as the distance between the midpoint of the lower margin of the eyelid Point B and the point at which the line perpendicular to the lid margin from Point B Line Y crosses the lower border of the eyebrow Point E with passive closure of the eyes.
Markings In the operating room, we drew three perpendicular lines Lines X, Y, and Z on the lid margin, passing through the medial canthus Point Amidpoint Point Band lateral canthus Point C with the patient in a supine position. We then selected the lower margin of the skin excision, which corresponded to the lid crease. In patients without an obvious upper eyelid crease, we usually placed a mark for the lower margin of the skin excision 6 to 8 mm from the lid margin.
We then designed the upper margin of the skin excision and a triangle outside of Line Z for excision of adequate skin Figure 2. Care was always taken that the medial skin excision did not extend beyond Line X, because scarring medial to Line X in the upper eyelid becomes quite noticeable.
DEBS – a unification theory for dry eye and blepharitis
View large Download slide Clinical photographs showing markings for blepharoplasty. Three perpendicular lines Lines X, Y, and Z are drawn on the lid margin—passing through the points of the medial canthus, midpoint, and lateral canthus—with the patient in a supine position. We then select the lower margin of the skin excision, corresponding to the lid crease.