area with rubbing alcohol and then extract the keratinaceous debris as a single unit with a 25 or 22g needle. A small dab of ointment is then placed over the excision site. Recurrence in the same location is very rare. In larger or recurrent milia, excision and closure with a simple interrupted 7–0 polypropylene suture is warranted.

15.14.2 Dry Eye/Chemosis

The signs and symptoms of dry eyes include a scratchy or foreign body sensation in the eye, epiphora, and presence of conjunctival edema (chemosis). If identified early and managed aggressively, more serious problem of exposure keratitis can be avoided. The patients should be educated with respect to dry eye, as they may find it difficult to comprehend that the eye is dry when they are experiencing copious amounts of tearing. Generous and frequent application of ophthalmic lubricant drops throughout the day and ointment in the evening is emphasized. A transition to a viscous artificial tear product is beneficial to those with chemosis [18]. If the chemosis is persistent and/or prominent, other maneuvers, such as placement of a Frost suture, lateral tarsorrhaphy, or, at the least, taping of the lower eyelid, are often beneficial both for symptomatic relief and accelerated recovery.

15.14.3 Hematoma

Hematomas after blepharoplasty range from a small selflimiting pool of blood under the suture line to an expanding collection that may extend into the retrobulbar space. The incidence of hematoma, in the senior author’s experience, is extremely rare and is reduced by detailed history taking prior to surgery. A review of medications is essential. One must not only inquire about medications like aspirin and ibuprofen, but also herbal medications that may increase the risk of postoperative hemorrhage. Meticulous intraoperative hemostasis also greatly minimizes the risk of hematoma. Additional interventions include control of the blood pressure both intraoperatively and perioperatively, elevation of the head of the bed, application of cold compresses, and aggressive treatment of postoperative nausea with antiemetic medication.

While most small hematomas are benign and rare, their organization beneath the skin may result in an indurated mass which subsequently may lead to a thickened scar. Therefore, early treatment with steroid injection may be indicated.

Although extremely unlikely, a retrobulbar hemorrhage is a surgical emergency. There is a risk of blindness associated

with increased orbital pressure which may result in either central retinal artery occlusion or ischemic optic neuropathy. A lateral canthotomy with inferior cantholysis performed immediately will alleviate the pressure. On rare occasions, an orbitotomy is needed. An ophthalmologic consultation should be urgently requested and the patient managed in an inpatient setting. In the senior author’s experience of over 3,500 lower lid blepharoplasties, the incidence of acute retrobulbar hematoma is zero, in part due to meticulous bipolar cauterization of every fat stalk prior to excision.

15.14.4 Eyelid Malposition/Ectropion

Frequent patient follow-up in the initial 2–3 months after lower eyelid surgery can offer opportunities for intervention, which can prevent the need for further surgery. An important part of each examination is to look for and recognize early signs of lower eyelid malposition, such as increased scleral show, asymmetric positioning, decreased mobility, or early ectropion.

In most cases, gentle upward massage to release early scar formation and occasional corticosteroid injections will enable release of cicatrix and prevent the need for further intervention. In advanced cases, external superior traction with tape or placement of a Frost suture may be necessary. This is especially important when corneal protection is desired.

Revision surgery may be necessary after 6–8 weeks of conservative management if there is no improvement or the condition deteriorates. Earlier intervention is required when there is corneal exposure from rounding, scleral show, retraction, or ectropion. The cause of lid malposition should be determined. In cases of middle lamellar scarring, release of the middle lamella and resuspension of the skin–muscle flap may be all that is needed. Most often correction requires the performance of a lateral canthoplasty.

15.15 Conclusion

Transcutaneous lower eyelid blepharoplasty is an excellent and safe technique for lower lid rejuvenation. Figures 15.19– 15.23 demonstrate preoperative and postoperative results of various patients who have undergone the surgery with and without the addition of adjunctive procedures. The skin–mus- cle flap method, when performed properly, carries minimal risk and yields natural and predictable results. Important considerations for surgery include proper patient selection,

Fig. 15.20 Examples of preoperative and postoperative results in prototypical patients. Improvement is demonstrated in the (a, b) mild and (c, d) moderate cases of dermatochalasis with pseudoherniation of fat

(e, f) Male patients and (g, h) cases of severe dermatochalasis can also achieve excellent results with proper technique

careful health history screening, and a thorough examination. This technique may be combined with lower eyelid resurfacing procedures, such as chemical peels or laser resurfacing, to improve skin texture and reduce wrinkling. Other adjunctive

procedures such as malar extension, lower eyelid tightening, and fat transposition offer further refinement and versatility to the operation. Early and proper intervention of complications can greatly diminish the need for revision surgery.