Basic brow position is determined at
an early age and the tendency toward brow ptosis (droopiness) may be present
for many, many years and only recognized when the upper eyelid has become
significantly redundant. obviously there is a close interrelationship between
the brow and upper eyelid. As the brow position is raised, skin of the
upper lid is pulled out and the need for upper eyelid skin resection is
decreased. On the other hand, excision of large amounts of eyelid skin,
may in fact, pull the brow down to an even greater extent. If the need
for both upper eyelid skin removal and brow lift is apparent, then one
must determine which to perform first or if both should be performed at
the same time. A serious complication manifest as inability to close the
eyes, may be created by removal of too much skin from the upper lid or
by lifting the brow and forehead upon a second occasion after upper eyelid
surgery. When the brow is raised the need for upper eyelid resection is
decreased, and frequently can be delayed for years by simple brow lift
alone. Additionally, it is possible to remove fat from the recesses of
the upper eyelid through the brow-lift incision. For this reason frequently
brow lift is recommended as the first stage in eyelid restoration and may
delay the need for skin resection for a number of years if not indefinitely
(Patient I, Figure 2). On the other hand some settling of the eyelid position
usually occurs in the months following brow lift which results in increasing
to some extent the amount of skin on the upper eyelid. At this point in
time, upper eyelid surgery may be then recommended.
Both upper eyelid surgery (blephroplasty)
and brow lift may be performed under local anesthesia. Brow lift may be
accomplished either through the endoscopic approach or the open technique.
In the endoscopic approach very little or no skin is removed and the eyebrows
are raised by means of sutures suspended from fixed points on the bony
skeleton. In the open technique, an incision is made at the hair line and
carried into the hair laterally and a portion of skin is removed. In both
techniques, the corrogator and procerus muscles between the eye brows and
at the root of the nose are removed. These muscles are responsible for
the vertical and horizontal frown lines so common in this area. Additionally,
a portion of the frontalis muscle is removed to decrease the ability to
form horizontal frown lines in the forehead skin. Patient I, 1 and 2 show
preoperative and postoperative photos of a patient before and after brow
lift.
When upper eyelid surgery is to be
performed independently or subsequent to brow lift, careful assessment
of the amount of skin to be removed is made preoperatively by marking the
outline of the skin excision while the patient opens and closes the eyes.
As with brow lift and lower lid surgery, the operation may be performed
under general anesthesia or local anesthesia with sedation. Care is taken
to protect the eyeball during operation by insertion of scleral shields
made of plastic or metal. If laser resection of the skin and/or fatty tissue
is planned, then provisions for eye protection of the surgeon and the support
personnel must be made as well. The skin is resected, a portion removed,
excess fat excised from the lateral and medial fat pads and if necessary
the position of the resting eyelid is raised by taking a tuck in the muscle
responsible for opening and maintaining the position of the upper lid.
Frequently, the upper eyelid crease is accentuated by tacking down the
skin to the underlying structures. The skin incision is closed by either
absorbable sutures, which fall out in a few days, or by nonabsorbable sutures
which are removed three to seven days after surgery.
A variation on upper eyelid surgery
is that of removal of excess fat associated with the lateral brow. In this
instance, after removal of excess skin from the eyelid, the skin above
the lid is retracted and the excess fat underlying the orbicularis oculi
muscle is trimmed off. This is the so called retrorbicularis oculi fat
resection which is performed for the presence of heavy lateral brow appearance.
A common complication with this type Of surgery is the presence of (usually)
temporarily decreased sensation of the skin of the face lateral to the
brow.
As with all operations, potential complications
are those of infection, abnormal scarring, postoperative hemorrhage, and
a failure to achieve the desired result. It is important that smokers refrain
from tobacco use at least three weeks prior to surgery in order to cut
down the frequency of postoperative coughing which markedly increases the
chance for postoperative hemorrhage and serious bruising. Further, control
of blood pressure and activity in the early postoperative period is important
to avoid these serious complications.
Possible complications developing later
in the postoperative course include the presence of dry eyes, inability
to fully close the eye, and failure to achieve the desired result. It is
important that the patient begin eyelid mobilization, exercises early in
the postoperative phase in order to help avoid these possible complications.
Patient II, Figure 1 and 2, show preoperative
and postoperative photos of a patient who underwent brow lift, upper eyelid
blephroplasty, and lower eyelid blephroplasty at the same operation.
Lower eyelid blephroplabty may be accomplished
with or without removal of skin. In the type of lower eyelid lipomatosis
which may occur as a congenital inherited condition-either primarily in
the females or primarily in the males-the usual approach for excision of
this excess fat is through a transconjunctival approach. In this instance
the lower eyelid is pulled down, an incision is made in the conjunctiva
and carried down to the "fat pads" of the lower lid. Three areas-the
lateral, medial, and nasal areas contain more or less discrete collections
or "pads" of fat, which require removal in variable amounts depending
upon their excess. This is accomplished by teasing the fat out from the
depths of the incision, cross clamping the base of the fat, and excising
it. The excision line is then cauterized and the tissue allowed to retract
back into the wound. Few or no stitches are required to close the incision.
If used, they are absorbable and require no removal. Under ideal conditions
the patient can have surgery on a Friday and return to work on Monday -
with no significant bruising or other evidence - except an improved appearance
of having undergone surgery.
Where excess skin exists in the lower
lid, an incision is made along the line drawn just under the lower lashes
and carried out laterally for 8 to 12 millimeters. This incision is carried
through the muscle down to the orbital septum beneath which lie the three
"fat pads" which may be, by their weight, distracting and pulling
down on the lower lid. The orbital septum is opened or removed and excess
fat is excised in a fashion similar to the transconjunctival approach.
The eyelid skin is redraped and a portion of it excised taking care to
avoid abnormal distraction at the corner of the eye. The skin is closed
with absorbable or nonabsorbable sutures and a compression dressing applied
through the early postoperative period.
Complications of lower eyelid surgery
are that of hemorrhage, infection, abnormal scar formation, and failure
to achieve the desired result. The most common complication, however, is
that of distraction of the lateral aspect of the lower lid giving the patient
a "hound dog" eye. This may be due to removal of too much skin
from that area or failure to treat excess lid laxity unrecognized in the
preoperative assessment. Temporary lateral bowing may occur and may be
treated by tape support of the eyelid and medicine used to decrease the
amount of swelling.
Permanent significant distraction of
the lateral lower lid, however, requires operation to either shorten the
lid (canthoplasty), or support the lid (canthopexy). Complications of eyelid
surgery are rare and usually transitory and mild. However, serious complications
are possible and require meticulous attention to detail and careful follow-up
care for their prevention.
