Suboptimal Factors: 次优分析因素

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This chapter is an introduction to the more complicated topic of suboptimal results and its contributing factors, specifically in regard to the goals of reaching an appropriate crease height, crease shape, and one which appears naturally continuous and will stay permanent.

The revision of suboptimal results is a necessary part of any surgeon’s skills. Known factors that lead to suboptimal results include inaccurate placement of the crease incision, the use of reactive suture materials, excessive bleeding, excessive fat removal, inadequate or excessively tight wound closure, inappropriate technique and lack of knowledge on the part of the surgeon ( Figure 11-1 ).

There are often intangible factors that may be beyond the control of the surgeon. Examples are the patient’s lack of compliance with postoperative wound care instructions; overly vigorous physical exercises performed too soon after the procedure, resulting in prolonged edema of the eyelid margin; latent hypertension with rebleeding; weight gain; unpredictable wound healing in patients who have had multiple prior revisions; preoccupation on the part of patients who are not happy with the results even though the results are satisfactory; or unrealistic preconceived notions on the part of patients about what they expect the crease to do for them, such as launching a career in a certain field.

Assuming the physician is knowledgeable and capable, deviations from an ideal course may still occur inadvertently or even unnoticed, arising from an unusual coinciding of an event relating to the patient and an event relating to the physician. Suboptimal results may therefore occur even with the very best surgeon.

A physician may not be aware that the patient has anemia, or a low platelet count, or poor coagulative function, was on aspirin therapy, or was consuming herbal remedies. During surgery, intraoperative bleeding may thus be significant and disruptive. This requires extra countermeasures using unipolar or bipolar cautery. Under local anesthesia that same patient may become even more anxious and the blood pressure may escalate, resulting in the formation of a hematoma. Cautery and aggressive manipulation to reach the source of the bleeding blood vessel often results in postoperative ptosis. This further compromises the ability of the eyelid to form the desired crease. Swelling of tissue planes can result in unevenness of the crease, resembling the segmentation seen in bamboo, or crease asymmetry between the two sides. It may even cause an incision line to appear crooked, even though the surgeon has perfectly stable hands. An overly anxious patient may suddenly become claustrophobic and move during a critical part of the incision or excision process, resulting in a less than ideal outcome. The Asian blepharoplasty procedure requires total concentration, and even a friendly and talkative patient or innocent questions from staff in the operating theater may distract the surgeon.
There are other scenarios when physicians have absolutely nothing to do with the untoward outcome of particular cases, for example:
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  A slender young woman underwent successful Asian blepharoplasty. She was happy, and upon recovery from her borderline anorexia nervosa apparently gained 30 pounds body weight over a year. The crease on one side of the eye became obliterated, requiring an enhancement procedure with further excision of her newly gained preseptal fat pads.
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  A dentist had undergone successful Asian blepharoplasty. Six months postoperatively the crease looked excellent. While camping in the wild for a week he was bitten over one of the lid margins by an unidentified insect. That upper lid crease became shallow and the pretarsal tissues broadened, resulting in a higher crease on that eyelid. It required a revision to reset the crease to a lower level.
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  A 30-year-old lawyer developed erysipelas midway during the first week after surgery. Both creases turned red and the pretarsal segment became wider, accompanied by scaly eruptions over the cheek skin area. An oral antibiotic was used and the infection promptly subsided.
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These varied cases reveal why I now hesitate to use the term “complication” in Asian eyelid surgery. The term “suboptimal result” is more appropriate; and it may at times follow an otherwise properly performed technique. We think of complications in medicine and surgery being more related to serious illnesses, with often known risk factors (age, disease conditions, vascular status, intolerance for anesthesia, etc.) in the individual being pre-existent and subsequently complicating a procedure’s outcome. This is less clear in aesthetic upper lid surgery, especially in Asian eyelid surgery, where there may not have been any significant hemorrhage nor risk factors, but simply because the interrelation of various factors (which we will go into in further detail in later chapters and videos) may be so complex as to defy detection preoperatively by a specialty physician. It is difficult to say whether a lack of attention to certain findings may have led to the outcome if it turned out to be suboptimal. Observation, detection and appropriate execution to maximize the probability of successful outcome is always a helpful goal.

In my clinical practice, I continue to see patients who seek a second opinion after having undergone seemingly straightforward procedures elsewhere, and who are unhappy about their outcome.

The detailed discussion that follows almost always returns to some aspect of the patient–doctor interaction where certain aspects of the surgery or results were assumed, missed, not discussed or mis-presented or interpreted. This ranges from the type of anesthesia one should expect, to discomfort level or excessive swelling all the way to significant issues such as selection of crease height.

Invariably, we return to the four parameters that are most important: the Height, the Shape, whether it remains as a Continuous crease line and whether it lasts Permanently ( Figure 11-2 ).

HEIGHT

The crease may be placed too high or too low, each presenting unique problems.

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A high crease is often seen in conjunction with overzealous removal of preaponeurotic fat pads. It results in a high supratarsal sulcus or a “famined” look that is difficult to correct ( Figure 11-3 ). For a patient who has a slight hollow below the superior orbital rim preoperatively, the removal of preaponeurotic fat may give rise to a prominent supratarsal sulcus and the formation of multiple skin folds over the high crease ( Figure 11-4 ). In this situation the removal of more skin to eliminate these folds without addressing the problem of the sulcus usually leads to an even greater degree of deformity.

FIGURE 11-3

Hollow sulcus as a result of excessive removal of preaponeurotic fat.

FIGURE 11-4

Formation of multiple creases and false folds as a result of excessive fat removal.

One of the common factors in a suboptimal outcome involves excessive fat excision in patients who are susceptible to volume deficit . Excess fat removal results in deficit in the volume of the sulcus. Often the surgeon ends up placing the crease stitches high over the levator aponeurosis and this crease ends up merging into the deepened sulcus.

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A crease that is placed higher than it should be will often lead to a noticeably prominent pretarsal platform (lower segment), often with side effects involving motility impairment of the levator besides aesthetic imbalance (covered in Chapter 18 ).
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A crease that is placed too low will not support a crease that can adequately fold in. One would have created a potential surgical scar in the pretarsal region; and if one is fortunate, it may fade with healing.

Figure 11-5 illustrates a commonly encountered clinical situation where a high crease is placed, often of a semilunar shape. If there are skin remnants left that are still usable, correction can proceed through resetting the crease into a parallel crease of lowered height. More challenging will be trying to achieve conversion to a nasally joining crease (NJC; red dotted line-and-arrow in Figure 11-5 ) as the up-vectoring force over the medial canthal region may only be borderline at best (see also Chapter 26 ).