17.5Postoperative Care

Patients are instructed to perform the following:

1. Apply an antibiotic ointment to the sutures three times a day for the first week after surgery.

2. Instill a combination antibiotic–steroid drop to the eye three times a day for the first week after surgery.

3. Apply ice compresses 10 min per hour while awake for the first 48 h after surgery.

4. Sleep with the head elevated (few pillows) for the first week after surgery.

5. Avoid exercise and more than light physical activity for the first week after surgery.

Patients are seen at 1 week after surgery for suture removal if non-absorbable sutures are used. The grey line canthal angle suture is typically kept in place longer (10 days) in order to ensure that the angle remains anatomically intact. In the immediate postoperative period, patients typically have an over-correction of lower lid height with exaggerated slant, pain, and tenderness at the canthal angle, a degree of chemosis near the angle, and a feeling of tightness. These issues typically resolve within the first month after surgery.

17.6Complications

Surgery on the lateral canthus can lead to number of complications which are mostly benign in nature and short-lived, but often a nuisance to patients. Some of these problems require further intervention, and may persist indefinitely. As surgery secures the lower eyelid, patients may complain of a tight feeling. Patients have a difficult time describing the complaint, as it is an obscure sensation. This tightness usually subsides within the first month after surgery, but may rarely last for a year or more. The patient needs to be reassured that this is a normal part of surgical healing. In the rare case when this is prolonged, injections of low dose steroid (0.2 cc Kenalogue 5 mg/mL) or 5-flourouracil (5FU see Chap. 27) or a combination of the two solutions, mechanical massage, stretching, and botulinum toxin-A injections may be of benefit. I have not found a consistent correlation of releasing the canthus surgically with resolution of this symptom.

Pain and tenderness, without signs of cellulitis, abscess, or granuloma, at the canthus is another cumbersome complaint. This follows the same course and recovery as lid tightness described above. This is likely related to periosteal manipulation/disruption, nerve entrapment/injury, or low lying inflammation at the surgical site. Steroid/5FU injections as described previously may help in resolving this issue.

Suture abscesses and granulomas can also occur after surgery. They typically present a few weeks after surgery. Warm compresses and antibiotic treatment (oral and topical) may help in a small percentage of abscesses (the abscess can

self-express). If this does not lead to resolution, a canthal cutting down with suture removal in the office, under local anesthesia, should help resolve the abscess. In cases of granuloma, steroid/5FU injections as described previously are given. On occasion excision is needed.

Chemosis is usually treated with topical and oral steroid preparations. Rebound chemosis can occur, so a slow taper is warranted. In the more recalcitrant cases, pressure patching, a temporary tarsorrhaphy, and a conjunctuval cut-down can be considered depending on the mind-set of the patient.

Canthal angle discrepancies and changes from preoperative shape and position are especially troublesome, as they often require a surgical revision. The canthus is such a delicate structure and has such a great effect on lid appearance that even subtle changes can bother the patient significantly. The best way to handle this is preparedness (explain the possibility to the patient in the preoperative discussion), avoidance (manipulate the canthus as little as possible whenever possible), and readiness (become comfortable with surgery and revision). I have found canthal angle distortion is rarely a problem when the deeper attachments of the LPL are left undisturbed and no lid shortening is performed (as with most aesthetic procedures). If surgery is warranted, I like to wait 6 months to a year prior to intervening.

Canthal webs can occur, especially when upper blepharoplasty is simultaneously performed and there was insufficient distance between the upper lid incision and the canthotomy. The webs result from a relative shortage of skin in the vertical dimension compared to the horizontal plane, and can be addressed with various combinations of mini-flaps (Y-V and Z-plasties). Surgical revision should be performed no earlier than 6 months after the initial procedure. In the interim, the area can be injected with steroid–5FU combinations as previously described. The surgical revision can enhance outcome; however, scarring, wound contracture, and only partial improvement can occur.

An elevation of the canthus/lower lid with elevation of the brow is another rare but troublesome complication. This is typically seen in the setting of simultaneous upper eyelid blepharoplasty. This complication is likely a result of cicatrix at the junction of upper eyelid, lower eyelid, and canthus. This is a difficult problem to correct as patients often look great without brow animation. Early steroid/5FU injections and massage may help, but the issue typically persists. Patients usually acclimate to the problem with time if the aesthetic result is otherwise good.

17.7Conclusion

There are a variety of procedures which can be used to suspend and reinforce the lower lid via the lateral canthus during blepharoplasty. These procedures have improved surgical outcomes and reduced postoperative complications

significantly. Understanding the anatomy of the canthus, indentifying preoperative deficiencies that may lead to canthal/eyelid malposition, minimizing canthal disruption, and understanding the nuances of reconstructing the canthus correctly is critical to attaining these results. When these concepts are kept in mind, canthal suspension can be performed safely and reproducibly in aesthetic lower lid surgery.

References

1.Edergton Jr MT. Causes and prevention of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1972;49(4):367.

2.Rees TD. Correction of ectropion resulting from blepharoplasty. Plast Reconstr Surg. 1972;50(1):1.

3.Levine MR, Boynton J, Tenzel RR, et al. Complications of blepahroplasty. Ophthalmic Surg. 1975;6(2):53.

4.Tenzel RR. Surgical treatment of complications of cosmetic blepharoplasty. Clin Plast Surg. 1978;5(4):517.

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

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

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

8.Nowitzki T, Anderson RL. Advances in eyelid malposition. Ophthal Plast Reconstr Surg. 1985;1:145.

9.Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1990;85(6):971.

10. Shorr N, Goldberg R, Eshagian B, Cook T. Lateral canthoplasty. Ophthal Plast Reconstr Surg. 2003;19(5):345.

11. Fagien S. Algorithim for canthoplasty: the lateral retinacular suspension: a simplified suture canthoexy. Plast Reconstr Surg. 1999;103:2042–53; discussion 2054–2058.

12. Chong KK, Goldberg RA. Lateral canthal surgery. Facial Plast Surg. 2010;26(3):193–200.

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

14. Shovlin JP, Lemke B. Clinical eyelid anatomy. In: Bosniak S, editor. Principals and practice of ophthalmic plastic and reconstructive surgery. Philadelphia, PA: WB Saunders; 1996. p. 261–80.

15. Converse JM, Smith B. Canthoplasty and dacryocystorhinostomy. Am J Ophthalmol. 1952;35(8):1103.

16. Beard C. Canthoplasty and brow elevation for facial palsy. Arch Ophthalmol. 1964;71:386.

17. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol. 1979;97:2192.

Key Points

•Lower eyelid retraction after blepharoplasty surgery is perhaps the single most difficult challenge in aesthetic reconstructive surgery.

•The mechanism of eyelid retraction following surgery can be related to eyelid laxity, weakness of the orbicularis oculi muscle, inadequate anterior lamella, scarring of the middle lamella and/or posterior lamella, or any combination of these deficits.

•Common sequelae of lower eyelid retraction include exposure keratopathy, irritated eyes, blurry vision, lateral canthal dystopia, a round eye, and sclera show.

•The incidence of eyelid retraction can be reduced if the surgeon carefully evaluates the anatomical changes that prompted the patient to seek surgical treatment. Most patients have very little excess skin or muscle in the lower eyelids and removing these tissues is one of the most common causes of eyelid retraction after blepharoplasty.

•There are patients that respond well to removal of tissue, such as the young patient with a familial tendency towards excess fat in the lower eyelid and the older patient who truly has excess skin in the lower eyelids. In these patients, the appropriate layer of tissue can be conservatively removed.

•The blepharoplasty surgeon must recognize that some very common conditions, such as altered texture of the lower eyelid skin and fluid retention over the malar eminence, are not improved by removal of tissue from the lower eyelid.

D. Georgescu (*)

Clinical Assistant Professor, Wilmer Eye Institute, Johns Hopkins Medical Center, Baltimore, MD, USA e-mail: dan.oculoplastics@gmail.com

•Understanding the mechanism of eyelid retraction preoperatively is crucial for selecting the proper reconstructive technique to achieving the desired, long lasting result.

•Disrupting the orbicularis oculi muscle, with or without excision of tissue, can result in lower eyelid retraction related to paralysis or weakness of the muscle. This common cause of lower lid retraction is often reversible over a period of several months without surgical intervention.

•Cosmetic patients chose to have surgery for appearance, so they will rarely accept reconstructive techniques that negatively impact on cosmesis, such as full-thickness skin grafting. In many patients with lower eyelid retraction and anterior lamellar insufficiency, skin grafting can be avoided with midface elevation that recruits skin and muscle into the lower eyelid.

•Middle and posterior lamellar deficiency are best treated with lysis of the scar tissue and placement of a spacer graft.

18.1Introduction

Lower eyelid blepharoplasty is an operation that should aim first to maintain or regain proper eyelid function and structure and second to remove or reposition muscle, skin, and fat to give the patient a more youthful appearance. Unfortunately, even the most skilled surgeons will sometimes have a patient that develops postblepharoplasty round eyes and sclera show. Lateral canthal dystopia and lower eyelid retraction predictably occur in a small number of patients that underwent transcutaneous lower eyelid blepharoplasty by even the most experienced surgeons, sometimes years after surgery (Fig. 18.1) [1, 2]. In many cases, the eyelid retraction or laxity is the result of continued facial aging and sagging combined with the postoperative changes that occurred in eyelid structure. However, the most common scenario is when a “skin-focused” young surgeon removes too much anterior lamellar tissue at the time of surgery, which results in eyelid