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A Closer Look at the Eyes

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A Closer Look at the Eyes plastic corner BLEPHAROPLASTY: A CLOSER LOOK AT THE EYES igns of aging often appear first in the periocular area, and people pay attention rian Daly, M.D., D.D.S. Sto the appearance of these "windows to the soul." Cosmetic eyelid surgery is the most common esthetic procedure performed by plastic surgeons. Dr. Brian Daly graduated from the Factors that can adversely affect the appearance of one's eyelids include sun University of California, San Francisco, exposure, habits (squinting, smoking), age, heredity, recurrent bouts of swelling Dental School in 1971 • After completing (related to the menstrual cycle, systemic disease, etc.), unusual or asymmetrical eye­ a residency in oral and maxillofacial sur­ ball size, and forehead/eyebrow sagging. gery, he attended Drew/UCLA Medical School and completed residencies in gen­ Blepharoplasty can make a person look more alert, attentive, eral surgery and plastic surgery. Dr. Daly and enthusiastic. is board-certified in both oral and max­ illofacial surgery and plastic surgery, and he is currently in private practice in both BENEFITS disciplines. He is an assistant clinical pro­ Blepharoplasty improves dermatochalasis, more commonly known as "baggy eye­ fessor of plastic surgery at the University lids." As we age, fat that used to be inside the bony cavity surrounding the eyeball of California, San Diego. Dr. Daly also moves forward out of the eye socket. This produces bulging "bags" above and below enjoys serving underprivileged people the eyelids. Excess skin in the upper eyelids can be removed, which makes this area through volunteer programs. appear more youthful. A lesser amount of skin can be removed in the lower eyelids, which results in some smoothing of the skin adjacent to the lower lid margin. Blepharoplasty can make a person look more alert, attentive, and enthusiastic. 20 THE JOURNAL OF COSMETIC DENTISTRY • SPRING 2002 VOLUME 18 • NUMBER 1 POTENTIAL down the face during crying.) The "Festoons" of muscle that droop DRAWBACKS outer layer is composed of oil (layer toward the malar/maxillary areas are three), which slows evaporation of the also noted, as they can be improved Blepharoplasty alone does not nec­ tear film. A deficiency of any one of via plication and contouring. essarily improve wrinkled or baggy skin these layers results in "dry eye" symp­ much below the level of the bony rim toms. When the eye is irritated or dry, of the orbit. Eyelid surgery does not PROCEDURES the large lacrimal glands reflexively have a major effect on "crowsfeet," nor secrete large amounts of the water-like UPER BLEPHAROPLASTY does it alter skin characteristics. Eyelid liquid (layer two), which paradoxically The most common procedure that I surgery cannot compensate for asym­ can result in excessive tears, even perform is upper blepharoplasty with metry in eyeball size or position, nor when the person's eyeballs do not have removal of excess skin and some excess does it alter the bony contour of the a uniform protective three-layer tear orbicularis muscle. This can be accom­ orbit. When eyelid-related "bags" fluc­ film. plished in an appropriate treatment tuate in size, this is not improved— area under local anesthesia only. If the and may be worsened—by blepharo­ doctor is patient, knowledgeable, and plasty. Interestingly, when a person's PREOPERATIVE WORK-UP methodical, the anesthetic causes very eyebrow position is low, their forehead If the patient and doctor agree that little discomfort. The amount and (frontalis) muscle tone often increases, the potential benefits outweigh the shape of the skin to be removed is very to prevent further lowering of skin and risks, a surgical plan is formulated. The carefully drawn on the eyelid skin. The tissue onto the upper eyelid area. goal is to provide maximal improve­ corner of the eye that is toward the Then, when excess upper eyelid skin is ment while minimizing the risks. temple is called the lateral canthus. surgically removed (with blepharoplas­ Sometimes, raising the eyebrows via a The lateral end of the skin removal ty), the person's frontalis muscle tone forehead lift (without blepharoplasty) pattern usually extends 1 to 2.5 cm decreases. The brow often then is most appropriate. A forehead lift can beyond the lateral canthus (but not as descends, resulting in an upper eyelid be performed at the same time as ble­ far if a forehead lift also is performed or appearance that is not very different pharoplasty, or at a later date. planned). from the person's preoperative condi­ tion. Patients usually are surprised at how Patients usually are surprised at much skin can be removed. If there is how much skin can be removed. not a large amount of excess fat CONTRAINDICATIONS (bulging) in the upper eyelid, this may Relative and absolute contraindica­ be left alone, because there will be Important points to cover in the tions to blepharoplasty include signifi­ some fat loss with additional aging, preoperative work-up include findings cant ptosis (drooping) of the eyebrows and risks and recovery are affected by related to the above issues, family his­ (see above), eyes that are prominent in the removal of such fat. tory of eyelid abnormalities, thyroid relation to the lower and/or lateral disease, tobacco use, and prior eyelid bony orbital rim, lower lid laxity, sys­ surgery. Visual acuity and eye move­ LOWER BLEPHAROPLASTY temic conditions such as excessive ment is assessed. The surgeon looks bleeding, and symptoms of "dry eyes." The lower eyelid presents a unique for upper eyelid ptosis, symmetry of challenge, because if the lid were to be eyebrows and lids, and the position of pulled downward by the surgery, a "DRY EYES" the lacrimal glands and tear drainage "staring" appearance can result. This puncta. Frequent blinking can be a There is a moist "tear film" over the usually means that less skin can be eyeball, which has three layers. An sign of inadequate tears. Lower eyelid safely removed than the patient may inner layer of mucous (layer one) tone/elasticity is carefully assessed by desire, and even fat bag removal can pulling each lower lid forward and adheres to the eyeball itself; this cause subsequent scarring, which can watching the speed of lid recoil; this is mucous attracts and holds an overlying also pull the eyelid inferiorly. Thus, repeated after pulling each lower lid thin layer of the water-like tear liquid lower eyelid fat bag removal or reposi­ downward. Bulges of hypertrophic (layer two). (This water-like liquid is tioning often is performed via an inci­ the component of tears that can run orbicularis muscle are noted, as these sion in the conjunctiva. This fat can will be excised during the surgery. VOLUME 18 • NUMBER 7 SPRING 2002 • THE JOURNAL OF COSMETIC DENTISTRY 21 be removed, repositioned back into The addition of these prerequisites interfering with optic nerve function. the orbit, or brought down over the influences recovery and dramatically Infection also is rare, as is corneal orbital rim to fill the depression increases the cost. injury. Ptosis can occur due to separa­ beneath the "bag." It also is not tion of the levator palpebrae aponeu­ uncommon to tighten the lower eyelid RECOVERY rosis (a sheet of fascia that connects (canthoplasty) at the same time that the muscle that raises the eyelid to the blepharoplasty is performed. Several The recovery after blepharoplasty rim of the eyelid). This is rare, but can methods of canthoplasty are used. I varies quite a bit between patients, occur, for example, in an elderly most often use a technique of suturing even when similar procedures were patient with pre-existing weakness of the lateral canthal tendon upward and used. Sutures are removed within a this structure. If ptosis is present pre- laterally to the periosteum of the later­ week (makeup can be applied after the operatively, it is difficult to obtain per­ al orbital rim at about the level of the sutures are removed). The portions of fect symmetry; thus several techniques upper edge of the pupil. scars that extend lateral to the lateral for postoperative adjustment are canthus are barely visible at first, described in the literature. Very often, becoming more red over the first 6 to 8 blepharoplasty improves upon a The recovery after blepharoplasty weeks, and then usually fade to nearly patient's pre-existing asymmetry, how­ varies quite a bit between invisible. Few patients have enough ever, if some asymmetry persists for patients, even when similar pain to warrant more than about two several months, a second "touch-up" procedures were used. doses of pain medication. Some procedure is easily done. Certain skin patients are not quite able to com­ conditions, such as vascular telangiec­ Despite appropriate care, some pletely close their eyes for the first few tasias, can be worsened by blepharo­ patients develop a sagging of the lower days, and special care is necessary to plasty. prevent corneal drying. I prepare eyelid after lower blepharoplasty. This This article highlights that the pro­ patients for the "worst case scenario," usually resolves spontaneously, but if cedure of blepharoplasty itself is not which means that swelling can inter­ necessary, there are a number of surgi­ extremely complex, but that patient fere with visual fields and bruising can cal options to improve this condition. evaluation and the judicious use of last up to 3 weeks. After the above issues are addressed, adjunctive procedures require some wrinkled lower eyelid skin usually is sophistication. You are now well on still visible; this can be improved using POSSIBLE the way to a good understanding of the a resurfacing technique, but not with­ COMPLICATIONS benefits and challenges of esthetic eye­ out all of the recovery and side-effect lid surgery.
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