Chemical Blepharoplasty

18.1 Introduction

Surgical blepharoplasty can solve skin flaccidity and fat bags around the eyes, but crow’s feet and dark circles are not solved by surgery alone. Chemical peeling is a technique used to renew the skin at the skin surface in order to destroy selected layers of the epidermis and/or dermis [1, 2]. Chemical blepharoplasty can be the sole procedure in certain cases of eyelid rejuvenation or it may be performed approximately 3 months after surgical blepharoplasty, in order to offer a maximum result. This technique may be also indicated as the sole procedure in patients who have constitutional borderline scleral show, in whom surgical blepharoplasty may lead to complications.

To perform chemical blepharoplasty a specific buffered phenol solution named Exoderm [3] (composed of 12 components, including phenol, resorcin, citric acid, and a variety of natural oils) is used in the periorbital and eyelid skin. This solution will effectively melt the epidermis. Due to the presence of oils in the solution, percutaneous absorption is gradual and controlled [4–7]. Melanocytes are only partially destroyed and a self-limiting arrest of the solution in the mid-dermis will guarantee an excellent peeling effect without dermatologic or systemic toxicity. As a result of this exfoliation, tighter skin with less or no wrinkles will be seen in the periorbital and eyelid area. The dark circles

C. Santos

Dermatology in Private Practice, Department of Dermatology, Avenida Brasil, 583 Jardim Europa, CEP 041431-000

São Paulo, Brazil

e-mail: clara_santos@terra.com.br

around the eyes will also disappear, leading to a fresh and healthy “pink” skin color [8, 9].

18.2 Skin Preparation

As with any other peeling technique, skin preparation or conditioning is of particular importance. The skin should be prepared in advance, as it leads to homogeneous penetration of the peeling agent. This improves healing and there is also less risk of post-inflammatory hyperpigmentation. It is important to prepare the eyelid and periorbital area as well as the face. In addition to the chemical blepharoplasty, the facial skin can benefit from a medium peel done concomitantly.

For facial skin, preparation is commonly performed with the following, where a gel/cream is the vehicle for medication delivery:

For periorbital and eyelid skin, a similar but weaker formulation is recommended:

Skin preparation or conditioning should ideally be performed a month before the procedure. In cases where a month of conditioning is not possible, a shorter period of 2 weeks may be acceptable in patients with lighter skin. In the case of patients with darker skin, it

is wise not to perform peeling unless a full month of preparation has been completed. If there is a delay to the peeling procedure, it is advantageous to continue the conditioning regimen for longer than 1 month.

As tretinoin and hydroquinone (or other bleaching agents such as kojic acid or azelaic acid) have the potential to cause skin irritation, the patient should be instructed to start applying these formulations gradually. Beginning every other night for 7–10 days is recommended, after which the skin will have developed a better tolerance and the skin preparation should be applied daily. This local treatment should be discontinued 2 days prior to the procedure in patients with sensitive skin.

18.3Skin Evaluation and Chemical Agent Selection

It is important to remember that there are differences within the skin within the eyelid and periorbital area. The upper lid shows local and textural differences, which can be divided into three regions. The upper third displays thicker skin that is lighter in color; the medium third displays thin skin and is the region with the darkest pigmentation; and the lower third or tarsal skin displays the thinnest skin which can also be darkly pigmented (Fig. 18.1). Though these differences exist, it would be impossible to apply three different agents

Fig. 18.1 On upper lid, the medium and lower thirds shows differences in thickness and coloration

of different concentrations to each separate area. The agent of choice is the characteristic of a self-limiting arrest or self-blockage mechanism within the middermis. Using this solution, eyelids can be evenly peeled without the need of using different solutions or concentrations within such a small area. One of the most important aspects of skin beauty is evenness in color and texture, so that performing a facial mediumdepth chemical peel, in addition to the chemical blepharoplasty, will achieve excellent results in this regard.

18.4 Anesthesia and Sedation

Chemical blepharoplasty is an ambulatory procedure and is safe due to the buffers present in the Exoderm solution; however, it is recommended that the procedure be performed in an operating room setting, as the patient will receive intravenous sedation and analgesia in order to control pain and burning.

18.5 Details of the Procedure

It is recommended that a medium-depth facial peel be performed in combination with the chemical blepharoplasty in order to achieve the best possible facial rejuvenation results. Before the peel has begun, the patient’s skin is deeply cleansed using water and a neutral skin cleanser. One drop of Lacrilube® ointment is placed in each eye, the excess of which is removed, should it encroach on the periorbital or eyelid skin. The skin to be treated is degreased with gauze and 70% alcohol. This is performed in a gentle manner, and when the gauze is almost dry, the periorbital and eyelid areas are degreased, which avoids excessive trauma to those areas. Facial nerve blocks may be carried out using 2% lidocaine without epinephrine. If pre-procedure skin preparation has not been carried out in the weeks prior to the peeling, or if the patient’s skin is thick, Jessner’s solution may be applied in one or two coats to the face and one coat to the eyelid areas. Ideally, a medium-depth peel is then performed on the face, with the eyelid areas remaining for the chemical blepharoplasty.

After the facial peel has been completed, Exoderm solution is applied to the eyelid and periorbital areas,

including the crow’s feet. It should be remembered that performing a chemical peel is an art form, part of which relies on working carefully and gently. During this, it is important to squeeze the cotton tip applicator against the Exoderm solution bottle in order to remove excess liquid. When applying the solution to the skin, the cotton tip applicator should not be pressed down with excessive pressure. It is useful to have a cotton ball in the nondominant hand in order to wipe off excess fluid from the skin after each area has been treated. Application should begin on inner cantus of the upper third of the upper eyelid and should extend until the crows’ feet. After the upper third has been treated, the medium and lower thirds will follow (Fig. 18.2). During this stage, it is imperative that the patient’s eyes remain closed.

Once the upper eyelid has been completed, the lower eyelid is treated. Unlike with the upper eyelid, the patient is asked to open the eye, and to look up and back. This maneuver improves lower lid exposure and moves the ocular globe away from the surgical field (Fig. 18.3).

Though tears may occur, unlike with trichloracetic acid (TCA) and other some agents, they will not leave marks on the skin. Once completed, a thin coat of bismuth is applied. On the lower eyelid, in order to enhance the action of the solution, and in particular in the area of the crow’s feet, Micropore® is placed for 24 h (Fig. 18.4). After 24 h, the Micropore® tape is removed, and a thin coat of bismuth is applied for 1 week.

a

b

c

18.6 The Postoperative Period

The only medication that need be given to the patient is analgesia. Routine use of antibiotics is not required. Antiviral medication is also not routinely prescribed, unless the patient has a prior personal history of herpes simplex infection. Soon after the peel has been performed, the eyelids will become swollen. Over the course of the following 48 h, the swelling will often become more pronounced, and will eventually begin to decrease after 72 h. Tearing of the eyes is common at this stage. Cylodex® should be used every 6 h to avoid eye irritation. The Exoderm solution liquefies the epidermis within the initial 24 h, after which regeneration occurs between the second and eighth day. Four days

Fig. 18.2 Upper lid chemical blepharoplasty. (a) stat in internal upper third, then (b) medial upper third and finally (c) external upper third. The eyes are kept closed

following the procedure, facial skin where the mediumdepth peel has been performed will begin to peel off (Fig. 18.5). During this time, the patient is requested to apply Vaseline® ointment on an hourly basis, in order to massage the old, peeling skin until this is complete.