Division of Dermatologic Surgery, Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA

ABSTRACT

Dermatologic surgeons are often faced with the repair of complex facial defects following Mohs micrographic surgery. While the size or absence of critical tissue layers may be daunting, the reconstruction of these complex defects follow similar principles to those for the closure of smaller, simpler defects. There are several issues specific to these closures including whether to delay closure in order to allow wound contraction, thus decreasing the size of the wound. Yet, if the defect is adjacent to a fixed anatomic structure, this may not be an option. The tumescent technique allows for effective anesthesia over large surface areas. Although choosing a method of closure may be specific to the anatomic area, if possible, it is best to choose a “workhorse” flap, e.g. multiple flaps or a flap and a full thickness skin graft. Occasionally, a tunneled pedicle flap may be appropriate. For large areas an artificial skin substitute may be necessary. While tissue expansion has a number of disadvantages, it may be the only option for large defects in immobile anatomic regions. While it would be optimal to close every Mohs defect, it is important to know when to refer a reconstruction that may require general anesthesia and/or hospitalization.

Key Words:
Tumescent, Bilobed, Paramedian, Mohs Defect

Increased public awareness of skin cancer, improved access to dermatologists, and greater availability of Mohs micrographic surgery have combined to decrease the average size of tumors and post-surgical defects. Yet, for a variety of reasons including socio-economic,psychologic, and tumor biology, the dermatologic surgeon may still encounter large facial defects. Previously, otolaryngologists and plastic surgeons repaired these types of defects under general anesthesia. However, dermatologic surgeons can now repair most large defects in an office setting using skin flaps and local anesthesia.

While there isn’t an exact size that determines the intricacy of repair, in general, a complex skin defect may be defined as one that is >50% of a cosmetic unit. Yet, defects are defined not only by their sheer size, but also by missing structures such as mucosal lining, cartilage, fat, and muscle, which are necessary for the subsurface framework.1 Accordingly, small defects on the nose or eyelid that include significant cartilage or posterior lamellar components also require complex closures.

Principles of Closure

When faced with a large repair, often there is a temptation to focus on the size, and to ignore fundamental principles of facial reconstruction. Not surprisingly, following these axioms will often facilitate closure of the surgical wound. These principles include determining if multiple layers must be replaced, locating the reservoir of skin, and maintaining both function and aesthetics.

If multiple layers are involved, the defect may require bulk or bulk-plus structure. For defects requiring bulk alone, muscle, or a fat graft may adequately fill the defect. For structural defects, calvarial bone, rib cartilage, nasal cartilage or auricular cartilage may be used to recreate the subsurface framework. These reconstructions most commonly involve the ear and nose.

Skin may be moved from a single cosmetic unit or from multiple adjacent sites and must be mobile enough to close the defect with minimal tension. When designing a flap to close a large defect, it is essential that the major tension vector is parallel to any nearby free margins to avoid distortion of critical units such as the eyelid, nasal ala, or oral commissure. In addition to placement of the flap incision, integrity of the cosmetic unit, layered closure, and wound eversion will promote a favorable aesthetic result.

To Wait or Not To Wait

The initial decision in closing a large defect is whether to delay the repair. This is often an appropriate strategy. Advantages include wound contraction, which closes the defect by shrinking it, as well as granulation, which improves the survival of delayed flaps and grafts. A disadvantage of delaying closure is that significant contraction may require up to 1 month, thus imposing substantial wound care challenges. Furthermore, contraction of large wounds may result in deformation of nearby structures such as the eyebrow, eyelid, nares, or mouth.

Anesthesia

Large head and neck defects are routinely repaired using local anesthesia. The key to these repairs is the use of tumescent anesthesia (0.1% lidocaine with 1:500,000 epinephrine), which provides adequate anesthesia and excellent hemostasis. On rare occasions when patients need additional oral sedation or pain medication, 0.25mg of alprazolam (Xanax^®, Pfizer) and one tablet of hydrocodone and acetaminophen (Vicodin^®, Abbott) is usually sufficient. Tumescent solution is infiltrated slowly, usually requiring no more than 100mL, and reconstruction is begun after waiting 25–30 minutes. The advantages of tumescent anesthesia are its decreased risk of lidocaine toxicity, excellent hemostasis, and hydrodissection of tissue planes, thereby facilitating flap elevation.² Nerve blocks and field blocks can also be utilized in conjunction with, or independent of, tumescent anesthesia, but because of redundant sensory nerve distribution on the head and neck, they often fail to achieve a full block when used alone.

Choosing the Flap

Deciding on the flap is partly dependent on the location of the wound, the lines of relaxation, and how the flap will affect fixed structures. In general, if one has a favored “workhorse” flap, it is often wise to use this method of tissue transfer because of its geometric familiarity. Additionally, scar camouflage is an important consideration for large defects. For defects on the cheek, this can often be achieved by using a rhombic flap with its relatively short, angular lines or with a cervico-facial rotation flap whose lines are confined to the periphery of the face. A bilobed flap is another alternative with its secondary lobes mostly hidden pre- and postauricularly.³

The depth of the wound also needs to be considered. A deep cheek defect may require an island pedicle flap with substantial fat or a muscular component. In both the lip and eyelid, multiple layers must be replaced when missing in order to restore both bulk and function. Full thickness lip defects may require a Karapandzic flap or, for more lateral defects, a staged Abbe-Estlander flap.⁴ Complex eyelid repairs may necessitate a lid sharing procedure such as the Hughes flap.

Repair of nasal defects follows the axiom of “replacing like with like.” For large nasal defects, this philosophy mandates replication of the inner lining, recreation of a subsurface framework, and restoration of proper skin thickness, texture, and color.⁵

For patients who have large, skin-only, tip and supratip defects, a birhombic repair or a Peng flap may suffice.6 When performing large flaps with multiple incision lines and wide undermining, addition of a cartilage brace is often beneficial even when the framework is intact. This helps prevent nasal valve compromise from extensive wound contraction.

For moderately large defects involving the nasal ala or lower sidewall, the one-stage Spear flap is an elegant method,7 although it often requires revision, thereby essentially converting it into a two-stage procedure. Alternatively, a staged melolabial flap provides a reasonable color match and a good vascular supply which enables detailed contouring. Traditionally, when this flap is contoured, it is defatted and inset. In selected patients with thin alar and narrow rims, the authors have shave-contoured the flap, which precisely recreates the rim.

For larger defects involving an entire nasal subunit or more, the paramedian forehead flap is often the repair of choice. Despite its complex design, it is a hardy flap, with a vascular supply based primarily on the supratrochlear artery along with branches of the infratrochlear artery.⁸ When recreating the alar rim, it is necessary to insert cartilage struts using auricular cartilage from either the conchal bowl or the anti-helix. The paramedian forehead flap is then used for coverage. Traditionally, this flap is divided and contoured at 3 weeks. In selected patients, the authors have divided the flap at 1 week and contoured at 3 weeks, improving patient quality of life.

While it can be tempting to repair a large defect with only a skin graft, the long-term results and health consequences of a large skin graft can relegate the patient to years of disfigurement, and difficulty breathing from contraction of the graft.

Combinations of Flaps/Grafts

Although it is always preferable to close a wound in one session, for large defects, delayed flaps can provide more reliable vascularization and superior long-term aesthetic results compared with skin grafting. On the scalp in particular, multiple rotation flaps in the form of a pinwheel may be needed to close a large defect.⁹ Bilateral transposition flaps can also close a large defect without causing significant alopecia. In other locations such as the cheek or forehead, a combination of flaps and a full thickness skin graft may be needed to close a large wound. Strategically, the full thickness skin graft can be taken from the dog ear created by the flap.¹⁰

Tunneling Pedicle Flaps

Though not as common in dermatologic surgery, plastic surgeons commonly use tunneled pedicle flaps for large head and neck defects. For regional repair on the forehead, a tunneled pedicle flap based on a branch of the superficial temporal artery can be raised laterally, and tunneled to cover a medial defect.¹¹ Similarly, for a large nasal root defect, a glabellar flap based on the supratrochlear artery can be easily manipulated to cover fairly sizeable defects. The drawbacks of tunneled flaps include the relatively limited distance that they can travel and the common presence of a ridge above the pedicle, which negatively affects the final esthetics.

Tissue Expansion

Tissue expansion has been frequently used in the past for large areas with immobile skin such as the scalp and forehead.¹² This technique is effective, but significantly delays closure and can increase patient morbidity. In brief, the method involves dissection of a pocket and insertion of a silicone expander which is then filled with saline. Volume is added on a weekly basis for up to 2 months until the desired expansion is reached. The expander is removed, and the appropriate flap is performed. In addition to having to undergo an additional procedure, the expander is temporarily disfiguring, and there is a risk of infection.

Skin Grafts/Artificial Equivalents

For large defects on the head and neck, skin grafts are best used in conjunction with a skin flap since, in the large majority of patients, the use of large skin grafts alone will lead to inferior cosmesis. In patients with very large defects on the scalp and no contiguous donor site for tissue transfer, a split-thickness skin graft may be indicated. For smaller facial defects, the use of artificial skin substitutes, such as Apligraf^® (Organogenesis) and Integra™ (Integra Lifesciences) have been reported as effective coverage methods.13 For deeper wounds, it is important to layer the Integra™ to fill the volume deficit, and if desired, Apligraf^® can be applied on top of the Integra™.

When To Refer

The question of when to refer is more complicated than it appears. In addition to the size of the defect, it depends on factors such as the skill of the dermatologic surgeon, and the health of the patient. Generally, nasal defects involving the sinuses and upper nasal defects that require calvarial bone would be appropriate to refer to an otolaryngologist. Similarly, though many dermatologic surgeons repair eyelid defects, patients who have full thickness defects >50% of the lid may be best served by an oculoplastic surgeon. Extensive deep facial defects that involve multiple cosmetic subunits and have no discernible donor site may require a large regional muscle flap, such as a pectoralis flap or a free tissue transfer by either an otolaryngologist or a plastic surgeon. Full thickness lip defects, in which the repair will significantly decrease stoma size, require hospitalization. If they involve the oral cavity they may have more favorable results from an otolaryngologist or oral maxillo-facial surgeon. Finally, near total auricular defects that require rib grafts should generally be referred to a plastic or facial plastic surgeon.

Pearls

A helpful technique for closing large wounds is the use of suspension sutures, also known as plication sutures. These sutures are commonly used in rhytidectomies to approximate deeper tissues and reduce wound tension. In brief, the technique involves an anchoring stitch to a stable structure such as the fascia or periosteum, and then taking a bite of tissue 1-2cm away from the initial bite, with approximation of these “edges” in a buried fashion.¹⁴ Large defects may require several plication sutures. They can work well on the cheek, particularly when performing a cervico-facial rotation flap. In this situation, plication sutures can also be used to elevate the malar fat pad in order to recreate the malar eminence.

Intraoperative tissue expansion may also be of value in closing a large defect. This type of expansion can be accomplished with either towel clamps or a series of temporary nonabsorbable sutures.¹⁵ Using this technique for as little as 30 minutes will lengthen enough of the collagen fibers to permit a better approximation of the skin edges. While this technique alone does not significantly aid closure of large defects, a combination of this type of expansion along with plication sutures and an appropriate flap will generally result in a satisfactory outcome. If the wound still will not close, a partial closure in many cases may be appropriate, followed by final closure in 2-3 weeks.

Figure 1A: A 45cm2 defect on the left cheek following Mohs micrographic surgery for a Lentigo Maligna Figure 1B: A rotation flap was designed. Wide undermining is necessary in order to mobilize this type of flap. Figure 1C: Immediate postoperative. The flap is well perfused. Figure 1D: Three months post procedure. The scars are well hidden, and because a malar suspension suture was placed, the patient does not have abnormal descent of her left malar eminence secondary to wound contraction.

References

1. Menick FJ. Reconstruction of the nose. In: Baker SR, Swanson NA, eds. Local flaps in facial reconstruction. St. Louis: Mosby p305-44 (1995).
2. Acosta AE. Clinical parameters of tumescent anesthesia in skin cancer reconstructive surgery. A review of 86 patients. Arch Dermatol 133(4):451-4 (1997 Apr).
3. Ricks M, Cook J. Extranasal applications of the bilobed flap. Dermatol Surg 31(8 Pt 1):941-8 (2005 Aug).
4. Kroll SS. Staged sequential flap reconstruction for large lower lip defects. Plast Reconstr Surg 88(4):620-5 (1991 Oct).
5. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 76(2):239-47 (1985 Aug).
6. Rowe D, Warshawski L, Carruthers A. The Peng flap. The flap of choice for the convex curve of the central nasal tip. Dermatol Surg 21(2):149-52 (1995 Feb).
7. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of lateral alar defects. Plast Reconstr Surg 79(6):915-20 (1987 Jun).
8. Shumrick KA, Smith TL. The anatomic basis for the design of forehead flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg 118(4):373-9 (1992 Apr).
9. Vecchione TR, Griffith L. Closure of scalp defects by using multiple flaps in a pinwheel design. Plast Reconstr Surg 62(1):74-7 (1978 Jul).
10. Kaufman AJ. Adjacent-tissue skin grafts for reconstruction. Dermatol Surg 30(10):1349-53 (2004 Oct).
11. Guerrerosantos J. Frontalis musculocutaneous island flap for coverage of forehead defect. Plast Reconstr Surg 105(1):18-22 (2000 Jan).
12. Hoffmann JF. Tissue expansion in the head and neck. Facial Plast Surg Clin North Am 13(2):315-24 (2005 May).
13. Gohari S, Gambla C, Heale M, et al. Evaluation of tissue-engineered skin (human skin substitute) and secondary intention healing in the treatment of full thickness wounds after Mohs micrographic or excisional surgery. Dermatol Surg 28(12):1107-14 (2002 Dec).
14. Robinson JK. Suspension sutures in facial reconstruction. Dermatol Surg 29(4):386-93 (2003 Apr).
15. Chandawarkar RY, Cervino AL, Pennington GA. Intraoperative acute tissue expansion revisited: a valuable tool for challenging skin defects. Dermatol Surg 29(8):834-8 (2003 Aug).

Division of Dermatologic Surgery, Stanford University School of Medicine, Stanford, CA, USA

ABSTRACT

A telltale sign of the aging face is upper eyelid skin redundancy and lower eyelid bags. These changes can contribute to a “tired” appearance. Upper and lower blepharoplasty procedures can correct these processes. By removing skin and muscle, an upper eyelid blepharoplasty can give the eye a larger appearance. A lower blepharoplasty can remove pseudoherniated fat, or transpose it to provide a smooth infraorbital contour. It appears that a transconjunctival approach for the lower blepharoplasty will lead to a lower incidence of eyelid malposition. An adjunctive procedure such as laser resurfacing may be appropriate. Patients should be counseled on all potential complications, including visual loss from muscle injury or hematoma, as well as the extent of postoperative recuperation.

Key Words:
blepharoplasty, dermatochalasis, transconjunctival

While cosmetic evaluation needs to address the face as a harmonious whole, it can be divided into the lower, middle, and upper face. Recently, the upper third, consisting of the eyes, brows, and forehead has drawn increased attention from esthetic surgeons. This
renewed interest may reflect the perception that an individual’s face begins with the eyes, underscoring the notion that the “eyes are the windows of the soul.” The hallmarks of upper third facial aging are: lowered brows; lines of expression on the forehead glabellar and periorbital regions; and lateral hooding, dermatochalasis, and fat pseudoherniation in the medial aspect of the upper eyelids. In the lower eyelids, there may be a tear drop deformity, pseudoherniation of the three fat compartments, and rhytides. These changes in the lower eyelid, combined with malar hollowing, leads to the so-called “double bubble” irregularity, a telltale sign of the aging face. The majority of patients who end up requiring an upper or lower blepharoplasty or both will give the chief complaint of “looking tired or not alert” even when they are rested and alert. Some will state that their eyes appear much smaller. Many women will also relate that they have no upper eyelid platform upon which to place make-up. Some patients who have significant upper hooding will have reduced lateral visual acuity. Lower eyelid bags will accentuate the tired look and may appear as unsightly dark circles. Essentially, the goals of blepharoplasty should be to restore a rested appearance to the eyes with a wider palpebral aperture and greater smoothness and symmetry.^1,2 When there is visual compromise, the aim is increased temporal vision. Depending on the patient, resection of skin, muscle, and fat will achieve these objectives. However, in recent years, most cosmetic surgeons have reduced the amount of skin and fat removed from both the upper and lower eyelids. Too aggressive an approach may lead to hollowing of the eyelids and a “cadaveric” appearance. In some patients, particularly those with a nasojugal depression, a fat pedicle or filler may be necessary. Some practitioners have advocated fat transfer to both the upper and lower eyelids, which may tighten the skin, decrease hollowing, and provide a more youthful appearance.

Decision-Making

Upper Eyelid
The basic decisions involved in upper eyelid blepharoplasty include whether to extend the incision laterally and superiorly if there is lateral hooding, and whether to remove fat in addition to the skinmuscle excision. Some surgeons warn against lateral extension of the blepharoplasty incision since it may invite visible scarring. In most cases, however, this scar can be hidden in the periorbital crow’s feet. While there has been a trend toward removal of skin rather than fat, if there is pseudoherniation, particularly in the medial fat pad, not removing fat will produce an unsatisfactory result.

When performing a four-lid blepharoplasty, there are no hard and fast rules for the order. Many surgeons will perform the upper blepharoplasty first, particularly if there has been a browlift.

The author performs blepharoplasties under local anesthesia with oral sedation, and finds it preferable to perform the upper and then lower lids because the patient may be more attentive initially in keeping his/her eyes closed. Another basic issue in performing upper and lower blepharoplasties is determining which cutting device to use: cold steel vs. cautery vs. radiofrequency vs.laser. Again, there is no correct answer. Laser may result in better hemostasis and less collateral damage, but many surgeons prefer the tactile feel of scalpel or electrocautery/radiofrequency. The author uses coldsteel for the upper blepharoplasty and a Colorado needle for the lower transconjunctival blepharoplasty. It has been reported that radiofrequency may result in less collateral damage and less risk of injury to orbital structures.³ The diamond scalpel has also been used successfully for blepharoplasties.⁴

Lower Eyelid

Similar to the upper eyelid, the lower eyelid should have a smooth contour. This contour may be disrupted by pseudoherniated fat, a reduction in volume in the nasojugal groove, static rhytides in the periorbital region, and crow’s feet. The overall aging process creates an unevenness of the lower eyelid and an undulation between the periorbital cosmetic unit and the malar region of the cheek. Therefore, the goal of rejuvenating the lower eyelid should be to create a uniform contour and surface.

If the patient has crow’s feet and static periorbital rhytides with only mild bulging, the best option would be to combine laser resurfacing with botulinum toxin A (BOTOX®, Allergan). If fat is to be removed, then a transcutaneous or transconjunctival approach can be chosen. Though technically more demanding, the latter technique reduces the likelihood of postoperative lower lid malposition.^5,6 There is also no visible scar. While fat will generally need to be removed from each of the three fat pockets, the philosophy again is to remove less rather than more. Experimentally, injections of phosphatidylcholine have been used to reduce a small amount of fat.⁷ If there is a tear drop deformity, then a fat pedicle will have to be raised and mobilized in the subperiosteal space. A bulge in a portion of the lower lid, particularly in men, is usually due to orbicularis oculi hypertrophy, and a partial resection
will need to be considered. The disadvantage of the transconjunctival approach is that it will not remove excess skin. Therefore, on practically all of the author’s patients, periorbital laser resurfacing is performed; however, if a patient has festooning, this procedure will not be adequate and some skin resection will be necessary. A small group of patients has undergone radiofrequency treatment of the lower eyelid for redundant periorbital skin with reasonable results and minimal downtime.⁸

If laser resurfacing is to be performed on a more mature patient who has pre-existing lid laxity, then it would be prudent to incorporate a canthopexy procedure.⁹ This procedure can also be used to produce a slightly more “almond” shaped eye as well as increasing the canthal tilt. Both of these anatomic characteristics communicate youthfulness and are accentuated in the female eye.

While the decisions in blepharoplasty focus on the removal of tissue, there is a school of thought that emphasizes replacement of tissue since facial aging does indeed cause volume loss. This loss can be replaced by fat transfer. The lateral brow can be elevated by injecting fat just inferior to the brow. Injecting fat into the upper eyelid sulcus will create fullness, while making the redundant upper eyelid skin taut. In the lower eyelid, fat injections can diminish hollowing, or potentially, even out the valleys between the pseudoherniated fat pads. This fat contouring will eliminate the “double bubble” and create a more youthful appearance. The disadvantages of fat transfer are that it is temporary and that it requires multiple treatments. It should be reserved for the subset of patients who have only
mild dermatochalasis, and where hollowing of the lower lids predominates over fat pad protuberance. In addition, this technique should be performed only by those who have a great deal of experience in fat transfer techniques.

Recently, other fillers such as hyaluronic acid, calcium hydroxyapatite10 and l-polylactic acid have been used in these areas, particularly in the tear trough. These injections offer ease of use and less downtime than fat transfer. However, there has not been long-term follow-up for these techniques, and they may provide only a short-term effect. Importantly, injections of these substances in this cosmetic unit are considered an off-label use.

Figure 1A, B: Pre- and post-operative images of patient with lower eyelid pseudoherniated fat pads and 3 months following transconjunctival blepharoplasty and erbium: YAG laser resurfacing of the infraorbital region.

Outcomes

Long-term outcome studies for upper eyelid blepharoplasty have not been performed. Yet, with natural senescence, the positive effects of an upper blepharoplasty should last at least a decade. If fat is appropriately removed, it is unlikely that there will be additional pseudoherniated fat for a substantial number of years. As mentioned, the opposite effect, that of hollowing, will be the major challenge in the ensuing years. An important factor determining the longevity of an upper lid blepharoplasty is the descent of the eyebrows. This phenomenon will create a pseudoredundancy of upper eyelid skin and will increase hooding.

This descent is genetic-, expressionand photodamage-related. Because of this natural descent, a minimally invasive transblepharoplasty browpexy may be indicated.^11,12

Transcutaneous vs. Transconjunctival Approaches

An unpublished review of the literature since 1970 compared 4,460 transcutaneous blepharoplasties with 3,438 patients who underwent the transconjunctival approach.13 In terms of complications, lid malposition was the most frequent in patients who received a transcutaneous blepharoplasty, occurring in 1.4% vs. 0.7% in the transconjunctival patients. However, the latter had significantly more edema, i.e., 18.4% vs. 0.2% for the transcutaneous blepharoplasties. Hematoma and inferior oblique injury were also more common in the transconjunctival approach, as were inadequate fat removal and overcorrection. Both of the latter occurred in 1.2% of the patients. Wrinkling of the lower eyelid remained in a far greater number of those undergoing the transconjunctival blepharoplasty, i.e., 11.4% vs. 2.4% in the transcutaneous group. Consequently, adjunctive procedures such as chemical peels and laser resurfacing were much more common, i.e., 32% vs. 1.5% with the transconjunctival approach. Yet, a large majority of the patients, 90.4%, were ultimately satisfied with the transconjunctival approach. There was minimal data in this outcome for those undergoing the transcutaneous blepharoplasty. Despite the higher rate of potential complications, the transconjunctival approach and an adjunctive resurfacing procedure was preferred by most practitioners in this review of the literature. The approach’s steeper learning curve may account for some its complications. Because the transconjunctival approach dramatically reduces the potential for ectropion (lid malposition was probably under-reported for the transcutaneous approach), it is a more versatile technique, particularly for elderly patients.

Counseling Patients

As with any procedure, appropriate patient expectations is one of the keys to a satisfactory outcome. The patient should understand that a blepharoplasty will not elevate the brows, or reduce rhytides or lines of expression. An upper blepharoplasty will make the eyes appear larger and more prominent in the upper third of the face.

The patient will appear more alert, and, if female, have a larger platform on which to apply make-up. This aspect will provide a rejuvenating effect, but middle-aged patients should not expect to appear as they did in their third decade. Similarly, a lower blepharoplasty will produce a smoother infraorbital contour and make the patient appear well rested. It will not affect a sagging malar eminence directly below this cosmetic subunit. A mid facelift would be needed to elevate the malar area and diminish a “double bubble” effect.

During the preoperative appointment, all complications, from conjunctival irritation and bruising to muscle injury and retrobulbar hematoma, should be explained.¹⁴ The possible visual consequences should also be discussed. There is an art to explaining these potential complications without having the patient forego the surgery. These explanations should be outlined in the informed consent. Postoperative care and length of recuperation also need to be discussed and reiterated. Optimally, a handout should be given to the patient that details what to expect following the surgery. While bandaging is minimal for blepharoplasty, the upper lid incision will be highly visible for at least 1 week. Swelling in both upper and lower eyelids may take months to resolve. Antibiotic ointment may cause a contact dermatitis, and the patient should be educated about this possibility. For a lower lid blepharoplasty, there may be conjunctival irritation and dry eyes. Artificial tears may be needed for several weeks, particularly if the patient has a history of this condition. If laser resurfacing is to be performed, then the patient needs to be educated about prolonged erythema and wound care. Most importantly, because of possible swelling, the final results of the surgery may not be fully apparent for 3 months.

Conclusions

Blepharoplasty is indicated for patients who have pseudoherniated fat pads in the upper and lower eyelids as well as those with redundant skin and hooding in the upper eyelids. While the outcomes of the device used—cold steel vs. laser—aren’t definitive, it does appear that in the lower lid, the transconjunctival approach is preferred. However, an adjunctive procedure such as laser resurfacing may be required. Patients should expect to appear less tired after these procedures, and should be counseled as to the complications and the postoperative recovery of blepharoplasty.

References

1. Baylis HI, Goldberg RA, Kerivan KM, Jacobs JL. Blepharoplasty and periorbital surgery. Dermatol Clin 15(4):635-47 (1997 Oct).
2. Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg 113(3):32e-42e (2004 Mar).
3. Eremia S, Newman N. Use of an insulated ultrafine point electrocautery for transconjunctival blepharoplasty of the lower eyelids. Dermatol Surg 27(12):1052-54 (2001 Dec).
4. Baker SS, Hunnewell JM, Muenzler WS, Hunter GJ. Laser blepharoplasty: diamond laser scalpel compared to the free beam CO2 laser. Dermatol Surg 28(2):127-31 (2002 Feb).
5. Rizk SS, Matarasso A. Lower eyelid blepharoplasty: analysis of indications and the treatment of 100 patients. Plast Reconstr Surg 111(3):1299-306 (2003 Mar).
6. Kim SW, Kim WS, Cho MK, Whang KU. Transconjunctival laser blepharoplasty of lower eyelids: Asian experience with 1,340 cases. Dermatol Surg 29(1):74-9 (2003 Jan).
7. Ablon G, Rotunda AM. Treatment of lower eyelid fat pads using phosphatidylcholine: a clinical trial and review. Dermatol Surg 30(3):422-7 (2004 Mar).
8. Ruiz-Esparza J. Noninvasive lower eyelid blepharoplasty: a new technique using nonablative radiofrequency on periorbital skin. Dermatol Surg 30(2 Pt 1):125-9 (2004 Feb).
9. Gladstone HB, Moy RL. Canthopexy as an adjunct to blepharoplasty. Presented at: the Combined American Society for Dermatologic Surgery – American College of Mohs Micrographic Surgery and Cutaneous Oncology Annual Meeting. Dallas, TX (2002).
10. Sklar JA, White SM. Radiance FN: a new soft tissue filler. Dermatol Surg 30(5):764-8 (2004 May).
11. Dailey RA, Saulny SM. Current treatments for brow ptosis. Curr Opin Ophthalmol 14(5):260-6 (2003 Oct).
12. Niechajev I. Transpalpebral browpexy. Plast Reconstr Surg 113(7):2172-80 (2004 Jun).
13. Gladstone HB. A comparison between the transconjunctival lower blepharoplasty and the transcutaneous approach. Presented at: the Combined American Society for Dermatologic Surgery – American College of Mohs Micrographic Surgery and Cutaneous Oncology Annual Meeting. San Diego, CA (2005).
14. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Ophthal Plast Reconstr Surg 20(6):426-32 (2004 Nov).