Avoidance of Complications in Lower Lid Blepharoplasty

Avoidance of Complications in Lower Lid BJepharopJasty CLINTON D. MCCORD, JR., MD, FACS, LIEUTENANT COLONEL, JOHN W. SHORE, MD Abstract: The most common complication of lower lid blepharoplasty is lower lid malposition either lower lid retraction or frank ectropion. This is caused by the vertical pull of skin shortage or shrinkage on a lax tarso-ligamentous sling. A method of tightening the tarso-ligamentous sling combined with a lower lid blepharoplasty is presented. An alternate method of lower lid fat removal through the fornix without skin incision is presented to be used in patients with taut lower lid skin. [Key words: blepharoplasty, complications, fat removal, fornix, horizontal tightening, lower lid.] Ophthalmology 90:1039-1046, 1983 Since lower lid blepharoplasties are, generally speaking, performed purely for cosmesis, complications with this procedure are particularly annoying to the patient and to the surgeon. Although rare, complications of extreme severity such as blindness following lower lid blepharoplastyl have been reported but by far the most common complication is that oflower lid malposition. 2-4 A number of other adverse findings that are mainly of cosmetic consequence5 are seen in Figure 1. The most common type of lower lid malposition is that in which the lower lid is simply retracted downward producing a "scleral show." This separation between the lower limbus and the lid margin may, in some cases, be accompanied by an out-turning of the lid and a true ectropion. Lower lid malposition is not only troublesome because of the unsightly appearance but in patients who have poor eye protective mechanisms such as a reduced precorneal tear film or a poor Bell's phenomenon it produces symptoms of exposure keratitis and a generally miserable patient will result. 6 The milder problems of residual skin folds, asymmetric contour because of asymmetric fat removal, and the other conditions can be avoided by meticulous attention to surgical planning with preoperative photos and precise surgical technique. There are techniques available for restoring contours following asymmetric or excessive fat removal with fat pad sliding and fat grafting for leveling lid depressions. 7 Residual fat can be removed with a technique that will be described. From the Department of Ophthalmology, Emory University, Atlanta, Georgia. The views herein are those of the authors and do not necessarily reflect the views of the U.S. Air Force or Department of Defense. Reprint requests to Clinton D. McCord Jr., MD, FACS, 1938 Peachtree Road NW, Suite 103, Atlanta, GA 30309. 0161-6420/83/0900/1039/$1.20 © American Academy of Ophthalmology LOWER LID MALPOSITION The mechanism that produces a lower lid malposition, either that of scleral show or ectropion, is a shortening of the skin muscle layer to the point that it overrides the elasticity of the tarso-ligamentous sling, either pulling the sling downward causing "scleral show" or everting it outward causing ectropion. This downward pull is caused by excessive removal of tissue or postoperative scarring and contracture of tissue in the plane of the orbital septum. 2,4 With even a conservative removal of skin or skin and muscle, patients with increasing laxity of the lower lid are at risk for this lower lid malposition. It is important to measure this laxity in the tarso-ligamentous sling before surgery by pulling the lid outward and observing its retraction or return to the globe (without blinking). If the lid does not return briskly without blinking then the lid must be considered lax. There is a strong tendency for increasing laxity of the tarso-ligamentous sling with age, and the older patient should be examined thoroughly for this problem. In a series of 190 normal patients, ranging in age from 15 to 89, Shore has shown that there is a marked increasing tarso-ligamentous laxity in the lower lid particularly in the 50+ age groUp. 8 This lower lid laxity is also positively correlated with a lower resting position of the lid so that some incipient "scleral show" and lower lid malposition may already exist before surgery in these patients. These findings indicate that the middleaged to older age group were extremely prone to lower lid malposition. When lower lid retraction occurs following lower lid blepharoplasty, if there is not a severe shortage of skin, normal lid position can be restored with a horizontal tightening procedure by tightening the lateral canthal tendon and reattaching the tendon to the periosteum. This 1039 OPHTHALMOLOGY • SEPTEMBER 1983 • COMPLICATIONS: LOWER LID BLEPHAROPLASTY 1. Lower lid malposition • scleral "show" • ectropion 2. Residual skin folds 3. Residual fat • assymetric fat removal 4. Excessive fat removal 5. Scars - sutu re tracts 6. Hematoma - pigment Fig 1. The most common complications or adverse findings following lower lid blepharoplasty. procedure may be combined with lysis of any fibrous bands within the lid if necessary. It has been shown that tightening of the lateral canthal tendon by lysis and reattachment to the periosteum produces much greater leverage than mid-lid resection procedures. Since the underlying pathology is laxity of the ligamentous portion of the sling, it would seem logical to strengthen this tissue as opposed to resecting tarsus in the mid-lid position when the tarsus has not been shown to undergo lengthening or laxity with age. This lateral tightening also avoids VOLUME 90 • NUMBER 9 resection of the margin of the lid in an area where it could possibly cause a margin deformity or trichiasis. Because of the very definite risk oflower lid malposition in the mid to old age group, it has become this author's practice to perform horizontal tightening combined with lower lid blepharoplasty at the time of the initial procedure and has been proven to prevent any retraction or ectropion in these patients. Lower lid tightening at the lateral canthal tendon, in this author's experience, has been proven superior to mid-lid resections or orbicularis flap procedures. 9 •10 TECHNIQUE OF HORIZONTAL TIGHTENING IN LOWER LID BLEPHAROPLASTY A skin muscle flap is preferred because of its avascular plane. It is important that the incision to elevate the skin muscle flap in the lower lid is placed as high as possible underneath the lashes (Figs 2A, B). The skin muscle flap is then dissected downward and countertraction with 4o silk suture in the margin of the lid is very helpful in aiding this dissection (Fig. 2C). One important point is that the incision beneath the lashes must be carried out to the exact canthal angle so that when the horizontal tightening is performed that the incision lines do not overlap. The orbital septum is then penetrated and the fatty pads are removed and cauterized in the usual manner (Figs 2D-G). Figure 3 shows usual fat distribution. Following the removal of the fat pads after adequate hemostasis is obtained, sharp scissors are then used to perform a canthotomy and lysis of the lower limb of the Fig 2. Steps in the technique of lower lid blepharoplasty with the horizontal tightening. A, a 4-0 silk traction suture is inserted in the lower lid margin and an incision through the skin and muscle is made as high as possible underneath the lashes carrying the line to the exact canthal angle and then a dog leg downward in a wrinkle line. B, the skin muscle flap is elevated from the anterior tarsal surface and at the canthal angle. 1040 McCORD AND SHORE • LOWER LID BLEPHAROPlASTY Fig 2. (continued) C, the skin muscle flap is dissected downward exposing the capsulopalpebral fascia and the orbital septum is seen to balloon forward with pressure on the globe on the inner surface of the skin muscle flap. D, the orbital septum is penetrated with sharp scissors throughout it's entire width. E, with pressure on the globe the three orbital fat pads in the lower lid can be teased forward using traction and dissection with a cotton applicator stick. F, the fat pad in the lower lid is clamped with the hemostat and excised. 1041 Fig 2. (continued) G, the stump or pedicle of the fatty pad is cauterized with the bovie before allowing it to retract into the orbit. H, photo showing surgical step after the fat pads have been removed. The skin muscle flap is reflected and sharp scissors are used to perform a cantholysis of the entire lower lid separating it from the orbital rim. I, after the lower lid is detached from the rim a full thickness resection of the temporal portion of the eyelid is performed to produce the desired tightening of the lid. J, a double-armed 4-0 polydek suture with a half circle ME-2 needle is introduced into the edge of the tarsal plate and then introduced inside the periosteal edge of the lateral rim about mid pupillary level. This is tied permanently under the desired tension. 1042 McCORD AND SHORE • LOWER LID BLEPHAROPLASTY Fig 2. (continued) K, the skin muscle flap is then elevated in a rotational manner towards the upper tip of the ear. L, where the skin muscle flap overlaps the underlying cut edge, Methylene blue is used to mark out a triangular excision. M, the edge of the skin muscle flap is then reapproximated with a 4-0 silk suture and is introduced through the flap in a position to assure an equal sided wound edge laterally. It is then introduced into the periosteum at about the level that the tightening sutures were introduced, and then brought out through the superior skin muscle edge and tied. N, this shows the 4-0 silk skin muscle flap fixating suture tied producing a second triangle of skin muscle to be excised underneath the lashline margin. 0, the excision of the skin muscle flap from underneath the lash margin is then performed. Conservatism is observed. The skin overlaps the cut edge under gentle traction. P, final closure is obtained with a running suture of 7-0 silk with interrupted sutures temporally. canthal tendon at the canthal angle. It is important to detach the lower limb of the canthal tendon and other attachments so that the lower lids swings freely from the canthus. An adequate full-thickness resection of the lower lid can be carried out at this point (Figs 2H, I). After fullthickness lid resection is carried out at the temporal portion of the lid so that stretching the lid temporally produces the desired amount of tension, a double-armed nonab1043 OPHTHALMOLOGY • SEPTEMBER 1983 • VOLUME 90 • NUMBER 9 ｾｉｮｴ･ｲｰ｡､＠ septum Preaponeurotic fat pad ｾ＠ Fig 3. Diagramatic representation of the fat pads present in the eyelid. In the lower lid there are generally three fat pad prominences that present clinically. The nasal and central fat pad are divided by the inferior oblique muscle, the temporal fat pad is separated from the central fat pad by a well defined septum. It is possible that interconnections exist between the three fatty pads. sorbable suture with a half circle needle is introduced at the edge of the tarsal plate. These half circle needles are useful in that one can reach around to the inside rim of the periosteum of the lateral orbital wall easily. The sutures are then placed in the periosteum inside the orbital rim at the mid pupillary level. The upper reflection of the canthal tendon and, perhaps, the lacrimal gland will be encountered when the upper margin is retracted (Fig 2J). The sutures are then tied permanently. The skin muscle flap is then stretched in the usual manner so that two separate triangles of skin can be excised. The first triangle is excised from the temporal portion of the flap after the desired smoothing effect has been obtained. The flap is then reattached to the periosteum at the canthal angle about the same level although more anterior to the point where the horizontal tightening suture has been placed (Figs 2K, L, M, N). The second triangle of skin muscle underneath the lashes is then excised. Conservatism must be used with this excision, and if the patient is awake one may ask the patient to look upwards and excise the amount of skin muscle that slightly overlies the upper edge of the incision. If the patient is under general anesthesia then one must simply drape the skin muscle edge over the upper edge of the incision so that only a small amount of tension can be seen and then the flap is excised (Figs 20, P). Conventional sutures are then used to close the incision. It is important to use ice compresses after surgery to prevent swelling. THE FORNIX REMOVAL OF FATTY PADS FROM THE LOWER LID-THE "BEHIND THE LID BLEPHAROPLASTY" In patients who have already had a blepharoplasty with inadequate removal of fatty tissue, the removal of the residual fat can be accomplished through the fornix to produce the satisfactory result. In most of these cases the skin may have already been stretched a maximum amount and a further skin incision and elevation may "tip the scales" through fibrosis and contracture to produce a lower lid malposition. This technique is also very helpful in the very young patient who has taut skin in the lower lids but has the strong familial tendency of herniated fat pads. In most of these patients the main complaint is the bulge in the lower lid and there are very few, if any, skin folds present. It is possible to expose the fatty pads in these patients through a skin muscle flap; however, one must recognize the risk of some contracture of the flap after elevation even though no skin or skin and muscle is excised. Fornix removal offat in these patients would seem to be the safest way to avoid complications of lower lid malposition. Fig 4. Steps in the lower fornix fat removal for the "behind the lid" blepharoplasty. A, the lower lid is retracted downward with Blair retractors and a protective contact lens is inserted. B, pressure on the upper lid exerted onto the protective contact lens causes ballooning out of the fat in the lower fornix. 1044 McCORD AND SHORE • LOWER LID BLEPHAROPLASTY Fig 4. (continued) C, incision is made just below the tarsal plate (about 2 mm) through the conjunctiva and capsulo palpebral fascia with needle tip of the bovie machine set on a cutting/coag blend. D, the fatty pads are seen to protrude from behind the capsulo palpebral fascia in the central area. The cut edges of the conjunctiva and the capsulo palpebral fascia are readily visible. E, with the use of gentle traction and forceps and dissection with a cotton applicator stick, the nasal and central fat pads are teased forward until they present into the incision. F, the fatty pads are then clamped with a hemostat. G, after excision of the fat pads the needle coagulation cautery is used to thoroughly cauterize the pedicle before it is allowed to release into the orbit. H, the temporal fat pad can be isolated without a canthotomy however the rake retractors must be inserted at the lateral canthus to retract laterally to expose the pad. This pad does not prolapse as easily but is teased and clamped and cauterized in a similar manner. 1045 OPHTHALMOLOGY • SEPTEMBER 1983 • Fig 4. (continued) I, closure is obtained by running 5-0 Proline suture which is introduced on the external surface of the lid and closes the conjunctiva and capsulopalpebral fascia internally and then exists and is tied with two loops. TECHNIQUE OF FORNIX FAT REMOVAL OR "BEHIND THE LID BLEPHAROPLASTY" Infiltration of the lower fornix with red label Xylocaine with 1 cc of Wydase added is performed. It is very important to insert a protective haptic contact lens to prevent corneal injury. The lower lid is then everted with small rake retractors and pressure applied (Figs 4A, B). The use of the needle electrode on the bovie unit set to a blend between cutting and coagulation is used to penetrate through the conjunctiva and capsulo palpebral fascia underneath the tarsal plate. This technique is used because of the extreme vascularity of the capsulopalpebral fascia and allows a practically bloodless exposure of the fatty pads in the lower lid. The first fat pad that is exposed is the central fat pad, however, the incision can be extended nasally and until the nasal fatty pad can be identified (Figs 4C, D, E). The fat pads are then teased into the incision with gentle traction with forceps and dissection 1046 VOLUME 90 • NUMBER 9 with a cotton applicator stick. It should be noted that there are very large blood vessels within the fat pads themselves and even though the capsule is opened they are a source of major bleeding if they are not gently handled. These vessels are noted to be even further engorged in patients who have had thyroid disease. The fatty pads are then clamped, excised, and cauterized (Figs 4F, G). The temporal fatty pad may not be readily seen with downward traction so for adequate exposure the rake retractor must be inserted inside the cut edge of the capsulopalpebral fascia in the lid retracted temporally exposing the temporal pad. One may perform a canthotomy at this point for better exposure if necessary. In most cases this is not needed. After the fatty pads have been excised and any needed hemostasis obtained, closure is accomplished with a running 5-0 Proline suture which is introduced on the external surface of the lid and closes the conjunctiva and capsulopalpebral fascia internally and then is brought out externally and looped for fixation (Fig 41). Ice compresses are used after surgery. REFERENCES 1. Putterman AM. Temporary blindness after cosmetic blepharoplasty. Am J Ophthalmol1975; 80:1081-3. 2. Hamako C, Baylis HI. Lower eyelid retraction after blepharoplasty. Am J Ophthalmol1980; 89:517-21. 3. Levine MR, Boynton J, Tenzel RR, Miller GR. Complications of blepharoplasty. Ophthalmic Surg 1975; 6(2):53-7. 4. Edgerton MT Jr. Causes and prevention of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 1972; 49:367-73. 5. Smith B. Postsurgical Complications of cosmetic blepharoplasty. Trans Am Acad Ophthalmol Otolaryngol1969; 73:1162-4. 6. Jelks GW. McCord CO Jr. Dry eye syndrome and other tear film abnormalities. Clin Plast Surg 1981; 8:803-10. 7. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 1981; 8:757-76. 8. Shore JW. Lower eyelid dynamics. Thesis. American SOCiety of Ophthalmic Plastic and Reconstructive Surgery, 1982. 9. Tenzel RR. Complications of blepharoplasty. Orbital hematoma, ectropion, and scleral show. Clin Plast Surg 1981; 8:797-802. 10. Rees TO, Tabbal N. Lower Blepharoplasty with emphasis on the orbicularis muscle. Clin Plast Surg 1981; 8:643-62.