9 Secondary blepharoplasty

Techniques

Glenn W. Jelks, Elizabeth B. Jelks, Ernest S. Chiu, Douglas S. Steinbrech

Synopsis

Serious complications of primary blepharoplasty surgery are rare, but should they occur, can be difficult to correct and be potentially disastrous.

Some serious complications which develop early, such as corneal exposure, require aggressive treatment, but lesser complications such as minor lid malpositions should be dealt with after time has passed to allow for scar maturation.

The eyelids can be divided into four anatomic zones.

Upper eyelid problems include ptosis and lid retraction. An understanding of Herring’s law is necessary to diagnose the problem responsible for lid level asymmetry.

Lower lid malposition is a common problem after primary blepharoplasty, and is due to an interplay between the patient’s unique orbital and eyelid anatomy, and the cicatricial forces. There are a number of predisposing factors.

Lower lid evaluation should address the presence of cicatricial contraction, a vector analysis of the globe in relation to the malar eminence, a soft tissue to bone distance at the lateral canthus, tarsoligamentous integrity (distraction and snap tests), lower lid eversion, and the level of the malar fat pad.

Lower lid malposition can be treated with various methods, including a wide variety of canthopexy and canthoplasty procedures, vertical spacer grafts and midface elevation. In severe cases, a combination of modalities is often indicated.

Introduction

Each year, over 200 000 people in the United States have a blepharoplasty operation.¹ These operations are generally very successful with a high level of patient satisfaction. Successful operations are the result of thorough preoperative evaluation, skillfully performed customized surgical procedures, uneventful anesthesia, proper surgical venue and individualized postoperative management. Although rare, complications and unfavorable results may occur following blepharoplasty. It has been estimated that the complication rate following blepharoplasty is 2%.²^–²¹ Minor complications are temporary and self-limiting with minimal visual disturbance or aesthetic consequence (Table 9.1). Major complications are definitely undesirable and potentially disastrous. They include visual loss, fixed eyelid deformities, corneal decomposition, and significant aesthetic compromise (Table 9.2). In addition, an apparent technically successful operation may produce a very unhappy patient.

Table 9.1 Minor blepharoplasty complications

From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.²⁷

Table 9.2 Major blepharoplasty complications

From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.²⁷

Once the complication is discovered, a careful and thorough evaluation of the patient’s anatomical deformity and its prognosis is essential. If impending visual compromise is apparent, early emergent intervention may be warranted. Most lid malpositions are temporary and resolve within 4–6 weeks postoperatively. It is important to protect the cornea during this time. If the lid malpositions aggravate and contribute to corneal decompensation, they should be corrected as soon as possible. However, lid malpositions that do not compromise visual function may be corrected after scar maturation. In general, a delay in secondary surgical procedures to address the problem is recommended. Secondary surgery is more predictable in a surgical environment that is less inflammatory. Better results are obtained if secondary surgery can be postponed for at least 6 months and preferably 1 year following the initial surgery.

The effect of blepharoplasty procedure complications on patient and physician can be profound. When the results of an elective aesthetic surgical procedure are suboptimal, the patient usually becomes more difficult to manage. It is easier to manage a dissatisfied patient when there has been a thorough preoperative discussion of risks resulting in a signed informed consent to the procedure. It is imperative to have a handwritten note by the operating surgeon in the patient’s chart documenting the explanation of the proposed surgical procedures including any risks or complications to their surgery. In addition, the alternatives to surgery should be discussed.

Once a complication occurs, more time and effort by the physician and his support staff will be required. This often translates into arranging for more frequent office visits. The physician must devote more time to help the patient through this disappointing situation. Reassurance by the surgeon in the face of temporary complications will aid in patient acceptance of prolonged healing.

The easiest complication to avoid is failure to recognize a pre-existing condition that would increase the likelihood of an unfavorable result from standard blepharoplasty (Table 9.3).²²^–²⁵ The pre-existing conditions include: (1) medical or ophthalmological conditions that may increase the risk of visual impairment; (2) morphological variants that predispose the patient to post-blepharoplasty eyelid malpositions; (3) anatomical variations that may be accentuated after eyelid skin, muscle; and fat removal and, most importantly, (4) the psychological status of the patient and assessment of their expectations of surgery. The presence of a pre-existing condition does not preclude cosmetic blepharoplasty; however, the surgical timing, venue, and technique may have to be altered.

Table 9.3 Prevention of blepharoplasty complications: preoperative evaluation

The following discussion contains relevant information regarding anatomical zones of the eyelids as well as prevention, diagnosis, and management of complications in the post-blepharoplasty patient. Although malposition of both the upper and lower eyelid are presented, a particular emphasis is placed on unnatural distortion of the lower eyelid as these are the most common types of defects encountered.

Anatomical zones

To facilitate complete and thorough anatomical analysis, the eyelids are divided into zones (Fig. 9.1).^22,²⁶ Zone 0 includes the ocular globe and orbital structures behind the arcus marginalis, posterior lacrimal crest, and lateral retinaculum. Zones I and II include the upper eyelid and lower eyelid, respectively, from the lateral commissure to the temporal aspect of canalicular puncti. Zone III is the medial canthus with the lacrimal drainage system. Zone IV is the lateral retinaculum. Zones I–IV are further subdivided into structures that are anterior (preseptal) or posterior (postseptal) to the orbital septum. Zone V includes the contiguous periorbital structures of nasal, glabella, brow, forehead, temple, malar, and nasojugal regions which merge with zones I–IV (Fig. 9.2). The diagnosis and management of upper eyelid (zone I) and lower eyelid (zone II) complications that occur as a result of blepharoplasty procedures will be discussed in detail.

Fig. 9.1 Surgical zones of the eyelids and periocular structures. Zone I, upper eyelid; zone II, lower eyelid; zone III, medial canthal structures including the lacrimal drainage system; zone IV, lateral canthal area; zone V, periocular contiguous area-glabella, eyebrow, forehead, temple, malar, nasojugal and nasal areas.

(From Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach. Plast Reconstr Surg 1993;91:1017.)

Fig. 9.2 Topographic anatomy of the eyelids and cheeks. (1) Superior eyelid fold; (2) inferior eyelid fold; (3) malar fold; (4) nasojugal fold; (5) nasolabial fold.

(Modified from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

Corneal protection

In both primary and secondary surgery of the eyelids and orbital region, protection of the cornea is essential. Specially designed, protective contact lenses should be routine (Fig. 9.3).²⁷ Colored lenses are preferred as they filter bright operating light if the procedure is performed under local anesthesia, and they are also less often inadvertently left on the cornea postoperatively. The contact shell prevents desiccation and inadvertent corneal injury by an instrument or gauze. In order to avoid postoperative corneal abrasions, deep sutures on or near the conjunctival surface should be placed in such a manner that the knots are buried in the tissue or placed externally. A continuous buried suture that may be pulled out after healing is particularly useful in the approximation of tissue over the cornea. Skin grafts should not be placed in the conjunctival sac if they are to be in contact with the cornea; only conjunctival or other mucosal tissue is tolerated by the cornea.

Fig. 9.3 Corneal protective shields manufactured with a steep central radius of curvature and a flat peripheral radius of curvature. This configuration prevents direct contact. Colored lenses are preferred as they filter bright operating light if the procedure is performed under local anesthesia, and they are also less often inadvertently left on the cornea postoperatively.

(From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

Upper eyelid

Upper eyelid malposition: evaluation and management

A thorough evaluation of the upper eyelid (zone I) level is facilitated by dividing the structure into anterior, middle, and posterior lamella (Table 9.4). The anterior lamella is composed of upper lid skin and orbicularis muscle. The middle lamella is composed of the tarsus, levator mechanism, orbital septum, and fat. The posterior lamella consists of the conjunctiva. The palpebral aperture is primarily influenced by the upper eyelid levels (Fig. 9.4). The palpebral aperture usually varies in shape, size, and obliquity due to hereditary, racial, traumatic, or other acquired situations. The surrounding bony orbital anatomy, the internal orbital volume, and the integrity of the eyelids, with their muscular and tarsoligamentous supports, are some of the factors that influence the palpebral aperture (Figs 9.5, 9.6). It is also influenced by the relative amount of associated periorbital skin, fat, and soft tissues. Unique individual combinations of eyelid and orbital anatomy can cause variations in the palpebral aperture (Fig. 9.4).²⁸

Table 9.4 Secondary blepharoplasty candidate evaluation: upper eyelid

Fig. 9.4 (A) Normal palpebral aperture. The upper eyelid is normally 1–2 mm below the superior corneal limbus. (B) Ptosis is seen when the upper eyelid level is below that seen in (A), interfering with the superior visual field. (C) Lid retraction is seen when the elevation of the upper lid is at or above the superior corneal limbus.

(Modified from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

Fig. 9.5 Sagittal section through the upper eyelid showing the relationship of the orbicularis oculi muscle, septum orbitale, levator palpebrae superioris, and Mueller’s muscle.

(Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

Fig. 9.6 Sagittal section illustrating the structures of the upper eyelid, including the levator muscle, its aponeurosis, and its relationship with Mueller’s muscle and the septum orbitale.

(Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)

The eyelid fold position should also be evaluated. In the occidental patient, the upper eyelid fold is normally 8–10 mm above the lid margin. This corresponds to the superior attachments of the levator aponeurosis to the subcutaneous tissue of the eyelid. Above the lid fold, the aponeurosis does not attach to the preseptal or orbital subcutaneous tissue, and the overhanging skin forms a fold. Inferior to the lid fold there are levator attachments to the subcutaneous tissue overlying the tarsus. In the Asian patient, the orbital septum inserts more inferiorly onto the distal expansion of the levator aponeurosis, which allows more preaponeurotic fat to descend into the upper eyelid and the resultant lower eyelid crease. Blepharoplasty in Asians requires the identification of suborbicular fat. Dissection through this fat layer provides access to the orbital septum and the retroseptal (preaponeurotic) fat.

Ptosis and lid retraction are conditions that alter the palpebral aperture by affecting the anatomic position of the upper eyelid. Localization of any major eyelid pathology facilitates the delineation of corrective procedures. The most commonly seen upper eyelid complications requiring secondary correction are ptosis and lid retraction.

Ptosis

Ptosis is the abnormally low level of the upper eyelid.²⁸^–³¹ Ptosis of the upper eyelid can result from damage to the levator complex during retroseptal dissection by direct trauma, hematoma, edema, or septal adhesions.^28,³²^–³⁸ The normal upper eyelid level covers 2–3 mm of the superior limbus or lies at the level midway between the superior edge of a 4 mm pupil and the superior corneal limbus (Fig. 9.4). Preoperative variations in upper eyelid levels may result from the level of alertness, pharmacologic agents, direction of gaze, size of the ocular globe, orbital volume, visual acuity, and extraocular muscle balance.²⁸ Occasionally, unrecognized ptosis manifests itself in the postoperative blepharoplasty patient. Review of the preoperative examination records and medical photography usually reveals the etiology. When no presenting condition can be documented, a surgical misadventure is implicated in the etiology.

Mechanical ptosis due to postoperative edema is symmetric and transient and usually resolves spontaneously within 48–72 h. A hematoma in the retroseptal space can cause impairment of levator muscle function, maintaining the upper eyelid in a ptotic position. Resorption of the hematoma may produce secondary fibrosis of the levator with persistent ptosis. Attempts to create high upper eyelid supratarsal folds involve fixing the skin muscle edges to the levator aponeurosis. This can lead to tractional ptosis if the lid fold is placed too high. The medial and lateral retinaculae become tense and lower the upper lid level. Treatment consists of observation and massage of the upper eyelid. If ptosis persists more than several weeks, removal of the supratarsal fixation sutures is necessary. Ptosis may also occur when adhesions develop between the orbital septum and the levator aponeurosis at a level higher than the original septal origin.

Ptosis is classified as mild at 1–2 mm, moderate at 2–3 mm, and severe at ≥4 mm.^4,^22,²⁸ The amount of ptosis is documented by measuring the vertical dimensions of the palpebral apertures at the midpupillary line. The amount of levator function in millimeters is measured whenever ptosis is diagnosed in order to plan a surgical correction. The test is performed by examining the upper eyelid excursion from complete down gaze to up gaze, while blocking any contribution to upper eyelid elevation by the eyebrow (Fig. 9.7). Asymmetric or absent lid creases must be identified, because asymmetry can be accentuated with standard blepharoplasty techniques. The vertical dimensions of the palpebral apertures at the midpupillary line are also measured.²³

Fig. 9.7 (A) Patient with acquired ptosis of the left upper lid. (B,C) Levator function of 15 mm was measured with a ruler from down gaze to up gaze while manually blocking brow elevation of the upper eyelid. Levator function >10 mm is considered good.

(From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

Aponeurosis disinsertion, or dehiscence, is the most common form of acquired ptosis. The typical clinical presentation is a mild (1–2 mm) to moderate (2–3 mm) case of ptosis associated with thin upper eyelids, high lid folds, and good levator excursion (Figs 9.8, 9.9).²⁸ The levator muscle originates from the apex of the orbit and passes anteriorly, becoming aponeurotic at the superior orbital margin to insert onto the anterior two-thirds of the anterior tarsal surface. Some fibers of the aponeurosis extend to the orbicularis fascia to attach to the dermis of the upper eyelid, forming the upper lid crease. The anterior orbital fat removed during upper blepharoplasty lies posterior to the septum and anterior to the levator aponeurosis. Inadvertent penetration or detachment injury to the levator aponeurosis can occur during removal of the preseptal orbicularis oculi muscle or retroseptal fat (Fig. 9.9A).

Fig. 9.8 Levator aponeurosis dehiscence produces a high upper lid fold, thin upper eyelid, and ptosis.

(Modified from Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

Fig. 9.9 (A) Patient who underwent cosmetic blepharoplasty with inadvertent disinsertion of the right levator aponeurosis during orbicularis oculi and retroseptal fat removal resulting in a right upper eyelid ptosis. (B) Patient following cosmetic blepharoplasty with a left upper eyelid ptosis from inadvertent levator aponeurosis detachment. (C,D) Patients with left upper eyelid cicatricial ptosis due to adhesions between the levator aponeurosis, orbital septum, and skin.

(From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC, ed. Complications and problems in aesthetic plastic surgery. New York: Gower Medical Publishing; 1992.)

The condition is repaired by levator exploration and advancement of the aponeurotic structures to the anterior tarsus.³²^–³⁸ Patients with levator detachment should be repaired by levator advancement to the anterior tarsus. The Fasanella–Servat³⁸ technique and its various modifications (Fig. 9.10), or variations of a tarso-mullerectomy are also excellent approaches to correct minimal ptosis.

Fig. 9.10 The Fasanella–Servat technique. (A) The eyelid is everted. (B) Two thin, curved hemostatic forceps are placed on the lower edge of the everted lid ≤3 mm from the upper border of the tarsus. The first of the interrupted incisions is made. The interrupted incisions are extended in steps of 4–5 mm. A mattress suture is placed after each incision. (C) The sutures are tied so as to hold the tissues firmly yet allow the lid to be returned to its normal position at the end of the procedure. (D) Fasanella’s alternative method of suturing a running continuous or “serpentine” fashion. (E) The running continuous or “serpentine” suture is returned, and the suture is tied on the temporal side.

(Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1990:1671.)