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Treatment of Postblepharoplasty Lower Eyelid Retraction with Dermis Fat Spacer Grafting
Bobby S. Korn and Don O. Kikkawa
Lower eyelid retraction is a potential complication following transcutaneous lower eyelid blepharoplasty. Several mechanisms contribute to postblepharoplasty eyelid retraction, including excess skin removal, exuberant scarring of the middle lamella, and unforeseen lower eyelid laxity. Several techniques have been described to treat postblepharoplasty eyelid retraction using a combination of mid-face lifting with or without posterior lamella spacer grafts. We described a new method of lower eyelid retraction using dermis fat as a posterior lamellar graft combined with mid-facial lifting. 1,2
Surgical Technique
An elliptical mark is made over the donor site on the hip. A high-speed diamond burr is used to debride the epithelium until a fine, hyperemic surface is obtained. Sharp dissection is performed to remove the dermis and underlying adipose tissue. Attention is then turned to the lateral canthus, where a lateral canthotomy and inferior cantholysis is performed. The conjunctiva beneath the inferior tarsal border is incised with monopolar cautery. The dissection is then carried down to the inferior orbital rim, lysing all adhesions and liberating the orbitomalar ligament. Then the inferolateral suborbicularis oculi fat (SOOF) is imbricated with a 5-0 vicryl suture. Next, through an upper eyelid crease incision, blunt dissection is performed under the lateral canthal tissues with a mosquito clamp and this is used to pull the SOOF suture through the upper lid crease incision. Finally, the suture is fixated to the periosteum at the level of the frontozygomatic suture (Figure 61.1). The dermis fat spacer graft with the dermis side facing the ocular surface is then secured to the cut edges of the conjunctiva with 6-0 fast-absorbing gut
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Chapter 61 Treatment of Postblepharoplasty Lower Eyelid Retraction 199
suture (Figure 61.2). Any lower eyelid laxity is then addressed by a lateral tarsal strip procedure. A Frost suture is then placed over foam bolsters for 7–10 days. Figure 61.3 shows a patient after bilateral lower eyelid retraction repair with dermis fat spacer grafting and mid-face lifting.
Figure 61.1. Fixation of SOOF suture through an upper eyelid crease incision. A 5-0 vicryl suture is used to secure the SOOF and this suture is then passed under the lateral canthal tissues with a curved hemostat. The suture is then fixated superolaterally to the periosteum at the level of the frontozygomatic suture.
Figure 61.2. In situ placement of dermis fat graft. The dermis fat graft is oriented with the dermal side facing the ocular surface and the fat side directed towards the surgical bed. The graft is secured to the conjunctival edge with interrupted 6-0 fast abosorbing gut sutures.
200 B.S. Korn and D.O. Kikkawa
Figure 61.3. Preoperative and postoperative photographs of a patient before and after dermis fat grafting and midface lifting. On the left panel, the patient has postblepharoplasty lower eyelid retraction and exposure keratopathy. On the right panel, the patient has restoration of normal eyelid position after bilateral dermis fat grafting with midface lifting.
References
1.Kikkawa DO, Kim JW. Lower-eyelid blepharoplasty. Int Ophthalmol Clin 1997;37:163–178.
2.Korn BS, Kikkawa DO, Cohen SR, Hartstein MO, Annuziata, CC. Tratment of lower eyelid malposition with dermis fat grafting. Ophthalmology 2008; 115:744–751.
Part V
Forehead Rejuvenation
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Which Browlift to Do?
Andrea N. Hass
In patient evaluation we must take note of the patient’s hairline and hairstyle when evaluating him or her for a browlift.
Endoscopic technique works best in patients with a low to normal hairline. If the hair is thin but still along a normal hairline, endoscopic technique remains an option. The decision process is more difficult when a patient has a borderline high hairline. He or she may still be an endobrow candidate, but should not expect as tight a result as with a coronaltype browlift.
The patient with a high forehead presents the greatest challenge. An anterior-hairline coronal-type browlift is the best option for some of these patients. However, they need to be willing to wear bangs forever in case the scar is unsightly, and they need to be willing to accept potentially permanent numbness of the top of the head.
The patient with an extremely high or scarce hairline is not a candidate for either type of browlift. A direct browlift or trans-bleph browlift may be their only options, both of which have limitations. The direct browlift leaves the risk of an obvious scar on the brow, and the trans-bleph browlift provides only moderate improvement at best.
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Browlifting: Patient Evaluation
Andrea N. Hass
No evaluation for upper lid blepharoplasty is complete without considering the role of the brow. In the past, a browlift was a daunting operation with a long ear-to-ear incision that was very bothersome to most patients, and thus avoided by many. With the availability of using endoscopic techniques and a few other options, browlifts are now much easier for patient and surgeon alike. This unit will discuss the evaluation process and current techniques for browlifting procedures.
Evaluation
As with any patient–doctor consultation, listening to the patient carefully to understand their concerns is paramount in making a patient happy postoperatively. Occasionally the patient will make this easy for us by demonstrating what bothers them. If they pull up on the brow to show the look they want, a browlift will be part of the equation; if they pull forward on excess skin, an upper lid blepharoplasty alone may suffice
Often, however, the best plan is more elusive. While listening to patients, watch how they use their brows. Also watch carefully as they bring the mirror up to view themselves. Finally, look at their brow positions when their foreheads are completely relaxed.
At the same time, evaluate the upper lids. Do they have purely blepharochalasis, or are the brows contributing to the excess skin? Is there a significant lateral overhang of ”skin” which is actually due to brow position? Do they have ptosis and are they raising their brows to compensate? Is there significant tissue fullness at the top of the nose when the brows are relaxed?
Once you have these answers in your mind, go over all of them with the patient, whether or not they have indicated an interest in a browlift. Working from top to bottom, review hairline position, brow rhytids, brow position (both where the patient holds it and when relaxed), and then upper lids. Try to demonstrate the desired position of the brow and how the upper lid would look both with and without a browlift.
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The most complicated patient is the one with ptosis or severe blepharochalasis who raises his or her brow constantly in compensation. There is no way to determine whether or not this patient will relax the brow once the upper lids have been corrected. This is the time for careful discussion, so that should he or she decide not to do a browlift, it is understood that the postoperative brow position may be different from what he or she is used to. It is helpful to keep the possibility of a future browlift open to the patient and even more helpful if he or she understands this possibility prior to doing any surgery.
Many patients fear a ”deer in the headlights” look postoperatively. These are typically those who use their frontalistone to compensate for heavy lids. These patients will find that after a browlift, the eyebrow tends to maintain its position, and the forehead above the brow is smoother and less wrinkled after the browlift. Patients who do not use the frontalis significantly tend to desire a higher brow position and are the easiest to please.
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Preoperative Botox for Endoscopic Browlifting
Andrea N. Hass
Preoperatively for an endoscopic browlift is an excellent time to introduce a patient to the benefits of Botox. Over time, constant use of the brow depressor muscles (corrugator, procerus, and lateral orbicularis muscles) has worked with gravity to lower the brow to its current position. Temporary paralysis of these muscles allows the elevator muscles of the brow to work without counterbalance, thus making them relatively stronger.
In a borderline low brow, Botox may make enough of a difference to postpone a browlift for several years. In a truly low brow this will not make a big difference prior to a browlift. However, given 2–3 weeks prior to surgery, it will keep the patient from using those muscles to pull down against a freshly lifted brow. This allows the brow to heal with less stress during the first 2–3 months postoperatively. Once the Botox has worn off, it becomes up to the patient to decide whether to continue with the Botox. Encourage continued Botox at least every six months to maintain the results of the browlift as long as possible.
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Five Tips for Endoscopic Browlift
Sheri L. DeMartelaere, Todd R. Shepler, Sean M. Blaydon, Russell W. Neuhaus, and John W. Shore
1. Botulinum toxin type A injected in the glabellar area 1 week preoperatively can be a useful adjunct to promote wound healing in patients with hypertrophic corrugator and procerus muscles.
2. The endoscopic dissection is eased by use of a tumescent injection. We prefer to use a dilute local mixture (0.3 ml of 2% lidocaine with epinephrine 1 :100,000 with 2.7 ml of normal saline) to slightly elevate the periosteum across the glabellar region. The 2% lidocaine with epinephrine 1 :100,000 is drawn from a 50-ml vial in which 150 units of hyaluronidase and 5 ml of sodium bicarbonate 8.4% have been added.
3.An alternate “tumescent” technique is used to elevate the scalp across the forehead down to the glabellar area. A 50-ml vial of 2% lidocaine with 1 :100,000 epinephrine is drawn up and injected into a liter bag of IV normal saline or lactated ringers (creates a mixture with 0.1% lidocaine and 1 :2,000,000 or 0.5 g/ml epinephrine). For an additional anti-inflammatory effect 4 ml of Kenalog 40 mg/ml can be added to the bag. IV tubing is placed through a tumescent pump or the IV bag placed in a pump-up IV infuser. A 25 g spinal needle is attached to the tubing then placed through skin and into the subperiosteal plane. Under pressure the dilute local mixture is injected and spread subperiosteally down to the level of the glabella.
4.Because of the increased risk of postoperative hematoma formation, contour deformities, or unsightly splaying of the brow heads, we no longer transect the procerus and corrugator muscles unless there is significant hypertrophy of muscles in this area.
5.Some patients experience prolonged postoperative nausea and vomiting. One liter of intravenous fluid given towards the end of the surgical case lessens the risk of dehydration postoperatively.
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Anesthesia Options in Endoscopic
Forehead Lifting
Andrew S. Eiseman
The decision to use general anesthesia or local anesthesia with monitored anesthesia care is usually left up to the patient. The procedure can be completed quite comfortably with intraveous sedation. However, if the endoscopic forehead elevation surgery is to be combined with other procedures, general anesthesia may be a better choice simply because of the length of time the patient will have to remain still if awake. Even if general anesthesia is chosen, local anesthesia is infiltrated under the forehead region to aid in hemostasis and to provide postoperative analgesia. There are two main options when administering the local anesthetic. The first option is local infiltration of the entire forehead region. The second option is a tumescent technique that places dilute anesthetic in the subperiosteal plane centrally and under the superficial temporal fascia laterally.
Local Infiltration
If local infiltration is to be used, the entire forehead flap should be anesthetized. A 25-gauge needle is used to block the supraorbital and surpratrochlear nerves, the superior orbital rims, and the lateral orbital rims with either 1% lidocaine or 0.5% lidocaine with 1 :200,000 epinephrine.
Some surgeons use 0.5% bupivacaine with 1 :200,000 epinephrine to provide some postoperative analgesia as well. A slightly higher concentration of local anesthetic is used in these areas because they are typically the areas that cause the most discomfort for the patient during enoscopic dissection. The rest of the forehead flap and the scalp incisions are then anesthetized with 0.25% lidocaine with 1 :400,000 epinephrine. One slight alteration to the above technique is to create a “vasoconstrictive” tourniquet by infiltrating 1% lidocaine with 1 :200,000 epinephrine along the zygomatic arches and along the coronal line. Then 0.25% lidocaine with 1 :200,000 epinephrine is infiltrated beneath the forehead and temporal scalp. Finally, some bupivacaine 0.5% with 1 :200,000 epinephrine can be infiltrated along the superior orbital rims.
Fifteen to 20 minutes is then allowed to pass before dissection ensues to allow time for the epinephrine to take effect.
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