23 Lower Eyelid Blepharoplasty - Facial plastic surgeon in San Diego

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272 II Aesthetic Facial SurgeryFig. 23.2 Major divisions of the m. orbicularisoculi into pretarsal, preseptal, and orbital components.inferior tarsal border, some extend through orbital fat contributingto compartmentalization, some penetrate the preseptalorbicularis to insert subcutaneously about the lowereyelid crease, and others extend from the inferior fornix superiorlyto contribute to Tenon’s capsule (Fig. 23.3).Orbital FatContained behind the orbital septum and within theorbital cavity, the orbital fat has been classically segmentedinto discrete pockets (lateral, central, and medial), althoughinterconnections truly exist. 5 The lateral fat pad is smallerand more superiorly situated, and the larger nasal pad isdivided by the inferior oblique muscle into a larger centralfat compartment and an intermediate medial compartment.(During surgery, care must be taken to avoid injury tothe inferior oblique.) The medial pad has characteristicdifferences from its other counterparts, including a lightercolor, a more fibrous and compact lobular pattern, and afrequent association with a sizable blood vessel near itsmedial aspect. The orbital fat can be considered an adynamicstructure because its volume is not related to bodyhabitus, and once removed it is not thought to regenerate.InnervationSensory innervation to the lower lid derives mainly fromthe infraorbital nerve with minor contributions from theinfratrochlear and zygomaticofacial nerve branches. Theblood supply is obtained from the angular, infraorbital,and transverse facial arteries. Situated 2 mm below theciliary margin, between the orbicularis oculi and the tarsus,is the marginal arcade, which should be avoided if asubciliary incision is used.Fig. 23.3 Cross-sectional diagram of the lower eyeliddemonstrating connective tissue expansion of inferiorrectus into its terminal insertions.
23 Lower Eyelid Blepharoplasty 273TerminologySeveral descriptive terms are used pervasively in the literatureof eyelid analysis and should be understood bythose involved in surgical management of this area.Blepharochalasis is a commonly misused term. It is anuncommon disorder of the upper eyelids, of unknowncause, which affects mainly young and middle-agedfemales. Blepharochalasis is characterized by recurrentattacks of painless unilateral or bilateral lid edema, causinga loss of skin elasticity and atrophic changes.Dermatochalasis is an acquired condition of increased,abnormal laxity of the eyelid skin interrelated withgenetic predisposition, natural aging phenomenon, andenvironmental influences. It is frequently associated withprolapsed orbital fat.Steatoblepharon is a condition of true herniation orpseudoherniation of orbital fat behind a weakened orbitalseptum, causing areas of discrete or diffuse fullness in theeyelids. This condition and dermatochalasis are the twomost common reasons why a patient presents to discusseyelid surgery.Festoons are single or multiple folds of orbicularis oculiin the lower lid that drape over onto themselves, creatingan external, hammock-like bag. Depending on location,this bag may be preseptal, orbital, or jugal (cheek). It maycontain fat.Malar bags are areas of soft tissue fullness on the lateraledge of the infraorbital ridge and zygomatic prominencejust superior to the palpebromalar sulcus. Theyare believed to be a result of recurrent dependent tissueedema and secondary fibrosis.Preoperative EvaluationA systematic and thorough preoperative assessment ofblepharoplasty candidates is essential to minimize potentialpostoperative complications. Thus, patient analysis isdirected to determining how much eyelid skin, orbicularisoculi, and orbital fat needs to be resected to optimizefunctional and aesthetic results, and whether the ocularand adnexal structures will tolerate such a surgical manipulationwithout undesirable sequelae.Risk Factors for PostoperativeDry Eye SyndromeRealizing that the protective physiological functions ofblinking and eyelid closure are temporarily impairedfollowing blepharoplasty, an appropriate ocular historyshould elicit information that might put the patient atgreater risk for postoperative dry eye syndrome. Excessivetearing, a burning or gritty sensation, ocular discomfort,foreign bodies, mucus production, eyelid crusting, anda frequent need to blink are all symptoms suggestive ofborderline or inadequate tear production. A possibleatopic cause has to be ruled out.Certain systemic diseases, particularly the collagenvascular diseases (i.e., systemic lupus erythematosus,scleroderma, periarteritis nodosa), Sjögren syndrome,Wegener granulomatosis, ocular pemphigoid, and Stevens–Johnson syndrome, can interfere with the glandular lubricatingfunction and should be identified. 6,7 The infiltrativeophthalmopathy of Graves’ disease can result in verticaleyelid retraction and inadequate corneal protection aftersurgery and should be managed with medical treatmentpreoperatively and surgical conservatism during surgery.Thyroid hypofunction associated with a myxedematousstate may mimic the baggy eyelids of dermatochalasisand should be ruled out. Incomplete recovery of a previousfacial nerve insult may interfere with eyelid closureand predispose a patient to dry eye syndrome.Risk Factors for Postoperative BlindnessPostoperative blindness, the most catastrophic complicationof blepharoplasty, is associated with retrobulbarhemorrhage. 8,9 Factors that influence bleeding tendenciesshould therefore be identified and controlled beforesurgery. 10 Ingestion of aspirin, nonsteroidal antiinflammatorydrugs (NSAIDS), antiarthritics, cortisone preparations,and vitamin E should be withheld for at least14 days before surgery because of qualitative effects onplatelet function. Over-the-counter medications shouldbe discontinued as well because gingko biloba, for example,has been implicated in excessive bleeding. Similarly,St. John’s wort is known to have hypertensive effectsthrough a monoamine oxidase inhibitor mechanism.Warfarin compounds, if medically feasible, should bewithheld to normalize the prothrombin time and may bereinstituted 48 to 72 hours after surgery.Any history of abnormal or easy bruising, prolongedclotting time, or family members with bleeding dyscrasiashould be noted with appropriate coagulation profiles.Hypertensive patients should be medically stabilized atleast 2 weeks before surgery to ensure a nonfluctuatingnormotensive state. Women have a greater bleeding tendencyduring their menstrual period than at other cycletimes, and this should be considered in planning surgery.Other important factors include drinking and smokinghistory, as the former (in large amounts) may influenceplatelet function, and the latter has been associated withdelayed wound healing and diminished flap viability.Finally, any patient with a documented or suspected historyof glaucoma must be evaluated and managed by an
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23 Lower Eyelid Blepharoplasty - Facial plastic surgeon in San Diego

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