Las Vegas -- "Be sure to recognize and correct ptosis at blepharoplasty or you may make it worse," says Richard L. Anderson, M.D., F.A.C.S., medical director of the Center for Facial Appearances in Salt Lake City.
Dr. Anderson gave a brief overview of upper blepharoplasty and offered some surgical pearls at Facial Cosmetic Surgery 2004 this summer.
Reason to perform
Blepharoplasty is performed to correct ptosis that can be caused by brow ptosis, dermatochalasis or true ptosis. True ptosis, associated with aponeurosis defects, often appears worse after routine blepharoplasty.
"Aponeurotic defects are defects in the levator aponeurosis (tendon) that raises the eyelid," Dr. Anderson says. "Most acquired ptosis is due to aponeurotic defects. If not corrected, the ptosis will persist or may become worse as the aponeurosis is further stretched. The droopy eyelid margin is revealed after the overhanging skin is gone."
Following surgery, lid-margin height and lid-crease asymmetry are both likely to be more obvious, and attachments of the levator muscle to anterior tissues may have been removed or further stretched, exacerbating the ptosis. For this reason it is essential to identify aponeurosis defects preoperatively and intraoperatively.
A routine evaluation of ptosis should rule out possible neuropathic and neuromyopathic conditions before surgery.
In his practice, Dr. Anderson performs the following assessments prior to blepharoplasty: lid-crease height, measuring the distance from the lower eyelid margin to the crease; fissure height, measuring the distance from the lower to upper eyelid margin; levator function, measuring the eyelid excursion from downgaze to upgaze; lid lag on downgaze, observing whether the lid margin is held up and does not follow the eye when the patient looks down; and the condition of the supratarsal sulcus and the degree of thinning of the eyelid.
"Lid crease is the key to upper blepharoplasty," Dr. Anderson tells Cosmetic Surgery Times. "Lid crease is determined primarily by insertion of the levator aponeurosis to the skin. If there is asymmetry in aponeurotic insertion, then lid crease will be asymmetric."
Before starting blepharoplasty surgery, Dr. Anderson uses a fine marking pen to outline the new eyelid crease while the patient is in a sitting position.
For occidental patients he recommends leaving at least 10 mm of skin above the crease to the brow and approximately 10 mm of skin below the crease to the lid margin. Skin and muscle should be removed to achieve a good lid crease and thin eyelid, but to avoid a shape deformity, it is important to be conservative on fat removal in the middle pocket, he says.
The medial pocket is the only pocket where the fat is "teased out" carefully.
"Sculpt fat ahead of the orbital rim," Dr. Anderson advises. "The temporal upper fat pocket is the lacrimal gland, and should be repositioned if prolapsed."
For a better definition of the temporal region and to achieve temporal brow elevation, Dr. Anderson sculpts the brow fat pad and releases the anterior leaf of the posterior galea. Finally, Dr. Anderson closes the incisions with interrupted 6-0 plain gut sutures, using a limited number of sutures in order to decrease the reaction and allow any exudate to ooze out.
When ptosis arises from aponeurotic defects, Dr. Anderson recommends aponeurotic surgery. This procedure offers multiple advantages. Results are predictable and aesthetically pleasing, and the surgery can be performed in some cases where surgery would otherwise not be recommended. The surgery involves minimal operative and postoperative resection and can be performed under local anesthesia via the blepharoplasty incision.
Disclosure: Dr. Anderson reports no conflicts of interest.
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