23 Lower Eyelid Blepharoplasty - Facial plastic surgeon in San Diego

282 II Aesthetic Facial Surgeryof the lacrimal pump resulting from atony, edema,hematoma, or partial resection of the orbicularis oculi sling;and (3) a temporary ectropion resulting from lid loading.Outflow obstructions, secondary to a lacerated inferiorcanaliculus, are preventable by keeping the lower lid incisionlateral to the punctum. Should laceration injury occur,primary repair over a Silastic stent (Crawford tube; DowCorning, Midland, MI) is recommended. Persistent punctaleversion can be managed by cauterization or diamond excisionof the conjunctival surface below the canaliculus.Suture Line ComplicationsMilia or inclusion cysts are common lesions seen alongthe incisional line resulting from trapped epithelial debrisbeneath a healed skin surface or possibly from the occlusionof a glandular duct. They are typically associated withsimple or running cuticular stitches. Their formation isminimized by subcuticular closure. If they develop, definitivetherapy is aimed at uncapping the cyst (no. 11 bladeor epilation needle) and teasing out the sac. Granulomasmay develop as nodular thickenings within or beneaththe suture line and are typically treated by steroid injectionsif small and by direct excision if large. Suture tunnelsdevelop as a result of prolonged suture retention and epithelialsurface migration along the suture tract. Preventivetreatment includes early suture removal (3 to 5 days), anddefinitive treatment involves unroofing the tunnel. Suturemarks are also related to prolonged suture retention andtheir formation can usually be avoided by using a rapidlyabsorbing suture (fast-absorbing gut or mild chromic), byremoving a monofilament suture early, or by employing asubcuticular closure.Wound Healing ComplicationsAlthough rare, hypertrophic or prominent lower eyelidscars may develop because of improper placement ofthe lower lid incision. If extended too far medially in theepicanthal region, bow-string or web formation mayoccur (conditions usually amenable to correction byZ-plasty technique). A lateral canthal extension (whichnormally overlies a bony prominence) that is orientedtoo obliquely downward or is closed under excessivetension predisposes an incision to hypertrophic scarring,and during healing the vertical contraction vectors act onthe lateral lid to favor scleral show or eversion. If the lowerlid incision is oriented too far superiorly or too close tothe lateral aspect of the upper lid incision, the forces ofcontraction (now favoring a downward pull) provideconditions that predispose the patient to lateral canthalhooding. Again, proper treatment should be aimed atreorienting the direction of contracting vectors.Wound dehiscence may develop as a result of closureunder excessive tension, early removal of sutures, extensionof an infectious process (unusual), or hematoma(more commonly). Skin separation is seen most often inthe lateral aspect of the incision with the skin–muscle andskin techniques, and treatment is directed to supportivetaping or resuturing. If tension is too great for conservativemanagement, then a lid suspension technique and lateralgrafting should be considered. Skin slough may developas a result of devascularization of the skin segment. It isalmost exclusively seen in the skin-only technique andtypically occurs in the lateral portion of the lower eyelidafter wide undermining and subsequent hematoma formation.Treatment consists of local wound care, evacuation ofany hematomas, establishment of a line of demarcation,and early skin replacement to obviate scar contracture ofthe lower lid.Skin DiscolorationAreas of skin undermining are frequently evident ashyperpigmentation in the early recovery period secondaryto bleeding beneath the skin surface with subsequenthemosiderin formation. This process is usually self-limitingand often takes longer to resolve in darkly pigmentedindividuals. It is imperative during the healing process, andparticularly in this patient population, to avoid direct sunlightbecause this may lead to permanent pigment changes.Refractory cases (after 6 to 8 weeks) may be considered forcamouflage, periorbital peeling, or depigmentation therapy(e.g., hydroxyquinone, kojic acid). Telangiectasias maydevelop after skin undermining, particularly in areasbeneath or near the incision, and most commonly occurin patients with preexisting telangiectasias. Treatmentoptions may include chemical peeling or dye laser ablation.Ocular InjuryCorneal abrasions or ulcerations may result from inadvertentrubbing of the corneal surface with a gauze sponge orcotton applicator, instrument or suture mishandling,or desiccation developing as a result of lagophthalmos,ectropion, or preexistent dry eye syndrome. Symptomssuggestive of corneal injury, which include pain, eyeirritation, and blurred vision, should be confirmed by fluoresceinstaining and slitlamp examination by an ophthalmologist.Therapy for mechanical injury typically involvesuse of an antibiotic ophthalmic drop with lid closureuntil epithelialization is complete (usually 24 to 48 hours).Treatment for dry eye syndrome includes the addition ofocular lubricants, such as Liquitears and Lacri-lube.Extraocular muscle imbalance, manifested by gazediplopia, may be seen and is often transitory, presumably