16.5Postoperative Care

After surgery, patients are instructed to

1. Apply ice compresses ten minutes per hour while awake for 2 days after surgery.

2. Instill one drop of antibiotic/steroid combination eye drop (Tobradex, Alcon Laboratories, Irvine, CA) three times per day for the first week after surgery

3. Use a Medrol dose pack (Pfizer, Inc., New York, NY) if there are no contraindications.

4. Sleep with the head up (on two pillows) for the first week after surgery.

5. Avoid strenuous activity for the first 10 days after surgery.

The postoperative course typically involves normal bruising and swelling. We have not found postoperative pain to be a normal part of recovery, but blurred vision and tearing can be and usually resolve over the first week. If fat repositioning was performed, the Prolene bolster sutures are removed at day four. If Microfoam tape was applied, it is removed at 4–7 days after surgery.

16.6Complications

Most of the surgical complications for fat excision and repositioning are similar. They typically include excessive bruising and swelling, chemosis, and subconjunctival hemorrhage. Excess swelling is best treated with reassurance. A higher dose of oral prednisone may be given if there are no medical contraindications. In cases of prolonged or refractory swelling, a history of excessive salt intake, leg swelling, or previous

such history with other surgeries can sometimes be elicited. In these instances, a change in diet, compression, massage, and reassurance are often needed. When one side heals much different than the other, ask about sleeping on that side of the face and address the issue if needed.

Chemosis is subconjunctival edema which can occur with overzealous cautery, a low incision site, or when a canthal incision is added. There are various treatment modalities for chemosis depending on severity. Lubrication is important to prevent drying of the exposed conjunctiva. Topical and, especially, oral steroids can resolve the problem quickly. In persistent cases, temporary patching of the eye or an intermarginal suture can be of benefit by means of mechanical compression. On very rare instances, a conjunctival cutdown can be performed.

A subconjunctival hemorrhage can be very distressing to a patient. This is a bleed under the conjunctiva and typically reaches its maximum spread a few days after surgery and resolves in 1–2 weeks. Patient reassurance of the benign nature of the condition is important. If the patient describes conjunctival elevation of the hemorrhage, an evaluation is needed to rule out a more serious bleed.

An undercorrection or overcorrection of fat reduction can occur. This can lead to persistent fat prominence or hollowness. Undercorrections will require revision if the patient is bothered by the prominence. This is typically seen in the lateral fat pocket and a simple re-excision of fat can correct the issue. Overcorrections (hollows) can be problematic. This occurs less commonly with fat repositioning. This can be treated with a hyaluronic acid gel filler, or more permanently with autologous fat grafting.

An eyelid malposition is unusual with stand-alone transconjunctival surgery. Lower eyelid retraction is very

rare without associated skin excision. Lower lid elevation can occur, most typically nasally, probably related to excessive or prolonged postoperative swelling which may gape the wound for an extended period of time. This usually resolves with reduction in swelling and time. If no resolution occurs, a resection and reattachment of the lower lid retractors is needed. An entropion can occur with a transconjunctival incision. It is typically spastic, cicatricial, or related to retractor disinsertion. The correction depends on the etiology as with standard entropion repair. A postoperative ectropion can rarely occur if severe preoperative eyelid laxity is not addressed. Finally, on rare occasions, postoperative trichiasis can develop. This is most likely related to damage to the eyelid blood supply and/or postsurgical scarring. Selective lash removal by electrolysis can provide a permanent solution.

When fat repositioning is performed, complications unique to this procedure can occur. These include diplopia (beyond the immediate postoperative period), fat granulomas, prolonged edema, tear trough irregularities, and cutaneous pigment changes at the bolster suture site. Diplopia is typically transient and related to anesthetic injection, edema, or inferior oblique trauma. This can be treated with higher dose oral steroids which should be tapered over a 10-day period. Most cases resolve over this time period. If permanent diplopia occurs, referral to a strabismus specialist is warranted. Fat granulomas are rare, and are treated with intralesional injections of low dose and concentration steroids (Kenalog 5 mg/mL, 0.1 cc). 5-Fluorouracil (5FU) can also be injected (Chap. 27). The granulomas usually resolve with 1–2 injections given 2–3 weeks apart. Surgical resection is rarely required. Prolonged edema is treated in a similar manner to diplopia with higher dose steroids. Tear trough irregularities are typically due to fat granulomas and resolve with intralesional steroid (or 5 FU) injections. Transient hyperpigmentation can occur at the exit site of the cutaneous prolene suture. Topical bleaching preparations may be necessary if the hyperpigmentation does not spontaneously resolve.

16.7Conclusion

Transconjunctival lower blepharoplasty is an excellent procedure to address lower eyelid fat prominence. When an adjacent tear trough is present, fat repositioning is added to efface the depression. While the learning curve for surgery is steep, the procedure can be mastered with appropriate knowledge, guidance, and experience. When necessary, adjunctive techniques such as canthopexy, canthoplasty, skin excision, and fat grafting can be added to enhance the final outcome. This surgery maintains normal anatomy to a greater extent than does the traditional transcutaneous approach. This in turn leads to less postoperative cicatrization of tissue planes and potential lower eyelid malposition. In the hands of an experienced surgeon, postoperative complications are infrequent, generally self-limiting, and patient satisfaction is high.

References

1.Katzen LB. The history of cosmetic blepharoplasty. Adv Ophthal Plast Reconstr Surg. 1986;5:89.

2.Reidy JP. Swelling of eyelids. Br J Plast Surg. 1960;13:256.

3.Neuhaus R, Baylis H. Complications of lower eyelid blepharoplasty. In: Putterman AM, editor. Cosmetic oculoplastic surgery. New York, NY: GrundStratton; 1982.

4.McGraw BL, Adamson PA. Postblepharoplasty ectropion. Arch Otolaryngol Head Neck Surg. 1991;117:852–6.

5.Taban M, Douglas R, Li T, et al. Efficacy of “thick” acellular human dermis (alloderm) for lower eyelid retraction. Arch Facial Plast Surg. 2005;7:38–44.

6.Bourguet J. Les hernies graisseuses de I’orbite. Notre treitement chirugical. Bull Acad Med (Paris). 1924;92(3 ser):1270.

7.Baylis HI, Long JA, Groth MJ. Transconjunctival lower lid blepharoplasty. Technique and complications. Ophthalmology. 1989; 96(7):1027.

8.Mullins JB, Holds JB, Branham GH, et al. Complications of the transconjunctival approach: a review of 400 cases. Arch Otolaryngol Head Neck Surg. 1997;123:385–8.

9.Massry GG. Comprehensive lower eyelid rejuvenation. Facial Plast Surg. 2010;26(3):209–21.

One of the major complications of lower blepharoplasty (especially with transcutaneous surgery), has been postoperative eyelid malposition, primarily lower lid retraction, or ectropion [1–7]. This is a result of excessive skin excision, weakening of the orbicularis muscle, scarring of the orbital

G.G. Massry (*)

Director, Ophthalmic Plastic Surgery,

Spaulding Drive Cosmetic Surgery and Dermatology, Beverly Hills, CA, USA

e-mail: gmassry@aol.com

To understand the lateral canthus, some basic tenets of lower eyelid anatomy must be outlined. The horizontal palpebral fissure measures 30 mm in an adult. It terminates where the upper and lower lids fuse laterally. The angle formed by this union is known as the lateral canthus, while the point of fusion is termed the lateral commissure. The lateral canthus maintains its position and stability by a deeper (subcutaneous) connection to bone. This connection is called the lateral canthal tendon (LCT). I prefer the term lateral palpebral ligament (LPL) as this fibrous structure integrates dense connective tissue (the tarsus) to bone (Whitnall’s tubercle) (Fig. 17.1).

Fig. 17.1 Axial section of the lower lid and lateral orbital rim demonstrating the LPL (lateral palpebral ligament) with its posterior attachment to Whitnall’s tubercle

Fig. 17.2 Upper and lower lid orbicularis muscle (orbital, preseptal, and pretarsal) relationship to LPL

The eyelids are composed of both anterior and posterior lamella with components of both contributing to the formation and integrity of the LPL. The orbicularis oculi muscle is the protractor of the eyelids, comprises part of the anterior lamella, and is divided into an oribital and palpebral portion. This division of the orbicularis is anatomic and functional in nature [14]. The palpebral portion of the orbicularis muscle is further divided into a preseptal and pretarsal segment. The pretarsal portion overlies the tarsus. At the termination of the tarsus, it continues as a superficial and deep connective tissue band which forms the LPL. The deep head attaches to the lateral orbital tubercle (Whitnall’s tubercle), a boney prominence 3 mm posterior to the lateral orbital rim. This is the critical attachment of the LPL as it maintains the lid’s apposition to the globe (Fig. 17.2). Also of note is that the attachments of the LPL maintain the lateral canthus slightly higher than the medial canthus.

17.3Patient Evaluation for Canthal Surgery

The goal of aesthetic canthal surgery is to provide support and stability for the lower eyelid, while preserving the position and appearance of the lateral canthus. To do this correctly, the anatomic attachments of the LCT must be recreated and maintained in both an antero-posterior and superoinferior dimension. The preoperative evaluation is critical in determining the most appropriate way to accomplish this.

The presence of lower eyelid laxity must be identified on all patients. Eyelid laxity, a measure of the integrity of the canthal tendons and orbicularis tone, is determined in two standard ways. The first is the lower lid distraction test. The lower lid is pulled away from the globe (Fig. 17.3). Clinically significant laxity (poor canthal tendon support) is present if the lower lid can be pulled more than 8 mm from the globe. In addition, a snap-back or snap test can be performed. The lower lid is manually displaced inferiorly, and its ability to snap back into normal position, without blink, is assessed (Fig. 17.4). If the lower lid does not return to normal position without blink quickly, the eyelid tone is reduced. While the lower eyelid distraction test and snap test may primarily assess different parameters of lower lid support, the results are typically the same as both canthal tendon integrity and orbicularis tone are needed to properly support the lower eyelid.

The preoperative examination modalities reviewed above were initially described to assess eyelid laxity in the setting of eyelid malposition (ectropion, lid retraction, etc.). They measure gross eyelid deficiencies but may miss subtle changes. When performing blepharoplasty, subtle changes are important as preserving lid position; not treating eyelid malposition is the objective. This is particularly true with trancutaneous lower blepharoplasty. In this setting, when even small amounts of eyelid laxity are present, and/or tone is reduced,

Fig. 17.3 Lower lid distraction test