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To give more direction for the placement of volume and to encourage structural in-
tegrity, I often graft a quantity of structural fat from the oral commissure all the way
out to the lateral infraorbital rim.
In this patient 2.5 cc was placed into the right lateral orbital rim and 2.2 cc into the
left lateral orbital rim using a type II cannula from the cheek and oral commissure
incisions and using a type III cannula from the incision laterally in front of the
hairline.
After nishing the placement into the anterior malar fold of the lower eyelid and
the lateral orbital rim, I usually begin placement into the inferior portion of the an-
terior malar fold in the cheek. It is easy to overlook this area, because the swelling
that occurs from placement in the lower eyelid at the beginning of the procedure
often makes the rest of the cheek look much larger than it is.Therefore the surgeon
should plan the amount for placement into this area before the procedure. I most
often use a type II cannula in this area and place it at varying levels, depending on
my goals. If I am hoping to soften wrinkles, reduce pore size, or reduce acne scar-
ring, I graft the tissue immediately under the skin. If I am attempting to disguise a
bulge in the anterior cheek above the nasolabial folds, I place more of the tissue
deep against the maxilla to counterbalance the bulge.
In this patient 2.5 cc was placed into the right anterior malar fold and 2 cc into the
left anterior malar fold super cially next to the skin with a type II cannula.

A transition zone in the lateral eyelid is important to achieve the most aesthetic
appearance; if placement along the infraorbital rim ends too abruptly at the lateral
extent of the eyelid, a deepening of the wrinkles in that area (crow’s-feet) can oc-
cur. Therefore, even if the upper eyelid is not included in the surgical plan, feath-
ering into the upper eyelid from the lateral eye gives a more natural appearance.
This is especially true if in ltration into the upper eyelid is planned. Placement
into the upper eyelid and lower eyelid without adding to the lateral eyelid will
leave an unnatural hollow in this area. On the other hand, too much fullness in the
lateral eyelid can create a bizarre bulge. Obviously, overplacement should be
avoided. In general, I rarely place more than 1 cc into the lateral eyelid. To avoid
hematoma formation, I always attempt placement into the lateral eyelid rst with
a type I cannula. Because of the fibrous ligaments and occasional scarring from pre-
vious procedures, placement with such a blunt cannula can be dif cult. If this is
the case, I will try a type II or even a type III cannula.To encourage stability, I ap-
proach the lateral eyelid from at least two different directions, either above or be-
low and laterally.
In this patient 0.5 cc was placed into each lateral eyelid with a type I cannula.
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Usually the circulating nurse records the amounts of tissue placed into each area, as
well as the type of cannula used for placement, if appropriate.The amount is placed
into the corresponding location on the face, but to avoid confusion at a later date,
I name each area as I give the nurse the amount.
This patient had minimal swelling at
the end of the procedure, with almost
no bruising. In a case such as this, a rel-
atively good idea of the nal result can
be obtained at the end of the case.
POSTPROCEDURE CARE
At the end of the procedure, only a minimal amount of swelling is present in the
cheeks. However, this appearance can be complicated by unusual amounts of bruis-
ing, swelling or even hematomas. In the absence of these factors, the surgeon can
become adept at estimating the nal outcome from the post-procedure condition.
Of particular importance, any dips, lumps or irregularities will probably not resolve
themselves.These problems should be addressed with the addition or removal of fat
as appropriate.The incision sites are closed with 6-0 simple interrupted nylon suture.
A dressing of one layer of Microfoam
tape is applied over most of the areas
that were in ltrated.
This patient’s surgery was so recent
that long-term follow-up is not possi-
ble at this time.

SPECIAL DRESSINGS
Placement of a layer of Microfoam tape on the lower eyelids from below the ciliary
margin extending out past the limits of fat placement seems to help reduce swelling
more than any other single factor in my experience.While distracting out the lat-
eral eyelids, I place the Microfoam tape over the lateral eyelid to more or less stint
the area and keep the patient from squinting as easily.
Over the malar and buccal cheeks,I also place one layer of Microfoam tape.No Res-
ton foam is used in this area. In addition, if a chin-neck bandage is used, care should
be taken to avoid pressure on the newly augmented malar cheeks.
MASSAGE
When the dressings are removed, sometimes between 3 and 5 days, the of ce staff
will instruct the patient in a gentle downward rolling massage to encourage lym-
phatic drainage of the swelling. Patients are encouraged to perform this massage 4
to 6 times a day for one minute on each lower eyelid.
I also suggest iced compresses; however, I tell patients to avoid ice dressings that
might press in an irregular fashion on the lower eyelid, especially after a dif cult
placement.
PATIENT EXAMPLES
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This 50-year-old patient presented after a face lift and blepharoplasty complaining
that although she felt tighter, she thought that she did not look younger. In partic-
ular, she was bothered that her lower eyelids were developing dark circles and ne
crêpiness.

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As exempli ed in the next two patients, markings before 1995 did not include lim-
its of placement.Therefore the green markings in this patient and the following one
delineate the major amount, but do not necessarily identify the extent of feather-
ing; 0.7 cc was placed into each tear trough on this patient, with signi cant feath-
ering above and below the marked area.The area of grafting extended over into the
malar cheek anteriorly and out toward the mid cheek where a diffuse general in-
ltration was performed from the lower lit to the buccal area. Over the entire lat-
eral infraorbital rim out to the midmalar region, another 7.5 cc was placed on the
right and 5.5 cc on the left.
The patient returns 1 year after placement with feathering from the infraorbital
rim into the anterior malar and mid-malar regions. Fat was also placed into the
glabella, forehead and temples, but not the upper eyelids below the eyebrow. Dur-
ing the year since the procedure, the patient had not used Retin-A and had no
chemical peels or laser therapies.

Not only is the tear trough or anterior malar fold lled in completely, but also the
quality of the skin over the region has improved dramatically.The crosshatching of
ne wrinkles over the entire lower eyelid is replaced with a smooth, tight and full
eyelid devoid of wrinkles in the locations of fat placement. Pores, which in the pre-
operative views had been previously hidden in the depths of wrinkles, are now vis-
ible as separate entities. A sharp demarcation can be discerned at the most cephalic
placement of the fat grafts where the ne wrinkling that was present preopera-
tively contrasts with the smooth, fuller eyelid below.
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Chapter 16
Revisional Fat Grafting of the Cheek and Lower Eyelid
The patient returned at 3 years and 7 months after the described fat placement
with no further periorbital procedures. She used Retin-A intermittently during the
last 2 years, but not consistently. The oblique view of the upper face and close-up
of the left lower eyelid shows continued improvement of the texture of skin over-
lying all of the areas of placement over the last 2 years and 7 months.
As in the 1-year close-up of the lower eyelids, there is a sharp demarcation from the
lower eyelid where fatty tissue was placed and the cephalic area where it was not.
The skin appears to be even smoother without any additional fullness in the tear
trough, and the area above continues to have the ne wrinkling present preopera-
tively. I have observed this improvement in skin texture with many patients from
4 months to a year and then from a year to 2 or 3 years.There is the possibility that
fatty tissue placed immediately subdermally may be able to repair or otherwise im-
prove the quality of skin over a long period of time.7

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The patient returned at 8 years with no further periorbital procedures. She has an
obvious retention of the entire volume visible in the 1-year and 3-year photo-
graphs, but with some loss of the textural improvements seen earlier.

Correction of Special Problems Following Fat
Grafting to the Orbital Region
INFRAORBITAL IRREGULARITIES
The most likely complications of fat grafting are infraorbital irregularities. If 1⁄10 cc
is placed into the lower eyelid, a lump can occur. In ltration into the lower eyelid
should never be in increments of greater than 1⁄30 cc.
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Chapter 16
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This 48-year-old man went to a well-known and respected plastic surgeon, who at-
tempted fat grafting to the lower eyelids and cheeks.When he returned to the plas-
tic surgeon with multiple irregularities, the surgeon injected catabolic steroids into
the transplanted fat. According to the patient, the steroid injections made the irreg-
ularities more noticeable, and he developed hyperpigmentation with thinning of
the skin in the areas of the injections.
This result is most likely from one of two causes.The surgeon in ltrated the fat in
increments that were too large and/or the surgeon tried to place fat and then mold
it into the shape he wanted. Both of these can result in irregularities.
The treatment of this problem is removal of the fat with restoration of a smoother
layer by rein ltration. The most common technique that I use is simply to take a
type I cannula and apply negative pressure with a 3 cc syringe over the irregulari-
ties. Occasionally, I have also performed open removal of in ltrated fat in the lower
eyelids, but the trauma from the open removal is much greater than from a closed
suctioning. Unfortunately, this usually will take more than one time.

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This patient is shown before and then after two attempts at fat removal to remove
these irregularities followed by structural fat grafting to the area.
OVERCORRECTION IN THE INFRAORBITAL
REGION
After the surgeon understands the technique of structural fat grafting to the lower
eyelids, and obtains consistently smooth results, the next common problem is over-
correction.This is manifest by slight fullnesses especially in the anterior malar fold.
The treatment of this is also suctioning with a type I cannula connected to a small
syringe.
KEY TECHNICAL MANEUVERS
APERTURE DIRECTION AND R EMOVAL OF GRAFTED FAT
Although the direction of the aperture is not usually a concern, since
the fat is grafted by placement during the withdrawal phase, the direc-
tion of the cannula aperture is important during any attempt at re-
moval of super cially placed fat. I suggest keeping the cannula facing
upward toward the skin and maneuvering the cannula so that the fat
is between the cannula and the skin.
With the cannula in this position, a little gentle suctioning with a curetting motion
will often remove most of the super cially placed tissue.

During in ltration of the lower eyelids, I use my thumb to guide and
to protect the globe. My thumb can also be used to detect the correct
level for placement and guide the cannula to that level whether deep
or super cial.
When the cannula is grafting tissue onto the periosteum or in even more super -
cial planes, this added sensory input can be helpful, particularly along the entire in-
fraorbital rim, from the medial commissure to the lateral commissure.
435
Chapter 16
Revisional Fat Grafting of the Cheek and Lower Eyelid
As the placement moves to a more super cial plane, sometimes it is helpful to place
traction on the skin to detect more accurately the position of the cannula.This can
be accomplished by pulling the skin with the ngers of the left hand. In addition,
when approaching the cephalic lower eyelid, traction on the upper eyelid can pro-
vide better visualization of the skin of the lower eyelid.

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MALAR PROMINENCE: AN IMPORTANT LANDMARK
Identify the prominence of the cheek preoperatively and maintain it at
that proposed height.
The attractive malar prominence usually is most protuberant along a line running
from the alar base to the base of the auricular helix. I mark this line using dia-
monds with the patient standing and participating.This keeps me oriented during
the placement of the malar prominence. If the markings are not visible while the
malar prominence is being determined, careful attention should be paid to the
above landmarks to ensure that the prominence will be maintained in an attractive
direction and level.
USE OF A TYPE III CANNULA NEAR VEINS AND ARTERIES
From the eyebrow incisions and the lateral temple sideburn incision, I am always
concerned about the potential for disrupting a vein or artery and precipitating a
dreaded hematoma.That is the reason I always try to use a type I cannula through
those incisions. However, there are times that it is dif cult to remain in the proper
plane with a type I or the tissues are too brous for placement with a type I. In
those situations, I rst try to force a plane in the tissue with a type I or II.Then af-
ter a plane is somewhat established, I will switch to a type III for placement. Un-
fortunately, it does not always work, but it has been helpful many times.
V-DISSECTOR IN THE PERIORBITAL R EGION
Although I occasionally will use a V-dissector to free up adhesions or scars in the
periorbital region, I do not use routinely. To avoid the accidental use of this more
destructive instrument, I remove the V-dissector from my eld during placement of
periorbital structural fat.
CONCLUSION
Supporting the midface and lower eyelids should be a consideration in any attempt
at rejuvenation. Simply excising and suspending structures in this area can create
unnatural and unhealthy appearances. Many of these problems can be improved on
by restoring support or fullness with structural fat.
However, the lower eyelid in particular is probably the most dif cult area for struc-
tural fat grafting. If the surgeon is not intimately familiar with the properties of
transplanted fat in the lower eyelid, areas of excess fullness and even irregularities or
small lumps will be visible through the skin when the swelling resolves.The lower
eyelid is not the area to learn transplanting fat. Augmentation in this region should
only be attempted after a surgeon has performed enough grafting in other areas to
approach the lower eyelid with con dence in the technique.

References—With Key Annotated References
1. Coleman SR. Structural Fat Grafting. St Louis, Quality Medical Publishing, 2004.
The author’s technique for fat grafting to provide long-term natural rejuvenation in the face and body
is described, with guidance for mastering this technique for facial rejuvenation, adjustment of facial pro-
portions, hand rejuvenation, and correction of liposuction and postsurgical deformities. Detailed infor-
mation is provided on incisions, levels of in ltration, volume ranges, technical considerations, key strate-
gies, most likely technical mistakes, and possible complications.
2. Coleman SR. My view: Structural fat grafting. Aesthetic Surg J 18:386-388, 1998.
3. Coleman SR,Grover R.The anatomy of the aging face:Volume loss and changes in 3-dimensional
topography. Aesthetic Surg J 26:54-59, 2006.
4. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy. Aes-
thetic Plast Surg 10:115-117, 1986.
The idea of correcting soft tissue defects with an injection of fat obtained by liposuction is presented.
The technique is described and the results are demonstrated in several patients treated over a period
of 1 year.
5. Coleman SR. Structural fat grafts:The ideal ller? Clin Plast Surg 28:111-119, 2001.
A description of the characteristics of fat as an ideal ller is provided, as well as the keys to the tech-
nique behind successful fat grafting.
6. Carraway JH, Coleman SR , Kane MAC, et al. Periorbital rejuvenation. Aesthetic Surg J
21:337-343, 2001.
7. Coleman SR. Structural fat grafting: More than a permanent ller. Plast Reconstr Surg 118
(3 Suppl):108S-120S, 2006.
8. Coleman SR. The technique of periorbital lipoin ltration. Oper Tech Plast Reconstr Surg
1:20-126, 1994.
Coleman’s rst article on fat grafting described a new technique with results that demonstrated every
indication of permanence.The technique described is almost identical to the current structural fat tech-
nique. Patient examples demonstrate the use of infiltrated fat for rejuvenation of the eyelids and
cheeks, elimination of the lower lid tear trough deformity, softening of “herniating”lower lid fat, re-
duction of infraorbital fat and correction of exophthalmus.
9. Carraway JH, Mellow CG. Syringe aspiration and fat concentration:A simple technique for au-
tologous fat injection. Ann Plast Surg 24:293-296; discussion 297, 1990.
10. Chajchir A, Benzaquen I,Wexler E, et al. Fat injection. Aesthetic Plast Surg 14:127-136, 1990.
11. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue llers. Aesthetic
Surg J 22:555-557, 2002.
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1. In considering the aesthetic ideal, the most prominent protuberance of the
cheek should extend along a ridge that runs from the:
a. Lateral canthus to the tragus
b. Oral commissure to the ear lobule
c. Alar base to the base of the helix
d. Alar base to the ear lobule
e. Midnasal sidewall to the tragus
2. Which is not a result of loss of soft tissue fullness in the cheek/ lower eyelid?
a. Easier ability to discern the orbicularis oculi tone beneath the skin and the
resultant crow’s-feet
b. Darkening of eyelid skin caused by closer approximation of skin to darker
muscle and overlying veins
c. Diffuse loss of subcutaneous soft tissue overlying infraorbital septum facil-
itating easier perception of infraorbital fat “bags”
d. Enophthalmia and more pronounced isolation of the globe from the sur-
rounding face
e. Inferior drift of the bony malar cheek prominence
3. Which of the following is an indication for structural fat grafting?
a. Inadequate cheek fullness following iatrogenic, pharmacologic, or idio-
pathic intervention
b. Scleral show
c. Lower eyelid hyperpigmentation
d. Eyelid wrinkling
e. All of the above
4. When harvesting fat in preparation for structural fat grafting:
a. Only abdominal/ ank fat should be used, because fat harvested from other
anatomic sites may have decreased longevity
b. Minimize mechanical trauma to the lipocytes by using plunger-locking
devices during harvesting, which provide a constant amount of negative
pressure
c. Remove as much oil from the harvested fat as possible by “wicking”
d. Superwet or tumescent techniques should be used when harvesting large
volumes of fat or when multiple harvest sites are used
e. The 10 cc syringes used during centrifuging should be used for place-
ment/ injection of fat;transfer of fat into smaller syringes for injection ex-
poses the fat to unnecessary additional trauma
R EVIEW QUESTIONS

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Chapter 16
Revisional Fat Grafting of the Cheek and Lower Eyelid
5. In ltration of fat into the lower eyelid should never be in increments of greater
than:
a. 1 cc
b. 0. 25 cc
c. 0. 1 cc
d. 0. 33 cc
e. 0. 01 cc

(Trang không có chữ)

441
It has been well documented that with the greater longevity of the general pop-
ulation, the growing acceptance of plastic surgical procedures in general, and the
simple desire of people to look better, the number of individuals seeking aesthetic
surgery, and eyelid and facial aesthetic surgical procedures in particular, has in-
creased. As younger individuals seek primary aesthetic surgery, there is a growing
subpopulation of patients who want revisions and secondary operations to address
the effects of aging. As more procedures are performed, more postblepharoplasty
complications occur.The purpose of this chapter is to discuss the prevention, diag-
nosis, and management of the most common complications after blepharoplasty.1
Reoperative Blepharoplasty
James H. Carraway, James R. Miller, and Bradley K. Lewis
C ha pter 1 7
Reoperative Problems
Hematoma
Scars
Epiphora
Undercorrection
Infection
Ptosis
Corneal abrasion
Incomplete or excessive orbital fat excision
Lagophthalmos
Inadequate lid crease
Visual problems
Increased scleral show and ectropion
Dry-eye syndrome
Lower lid retraction and notching
The face is the mirror of the mind,
and eyes without speaking confess the secrets of the heart.
Saint Jerome
Surgery of the Eyes, Nose, and Ears

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PATIENT EVALUATION
When a patient returns after blepharoplasty with an obvious problem or de ciency,
he or she should be fully evaluated for the possibility of conservative or operative
treatment.If the rst operation was performed by another surgeon,the patient should
be given the opportunity to return to the operating physician after it is explained
that complications can occur and that the original surgeon can most likely take care
of the problem. At that time, patients will usually declare their intentions. Some
patients take the reassurance to heart and return to the original surgeon, whereas
others have already lost con dence.These patients may even be angry about the re-
sults of the rst surgery and not wish to return to the original operating surgeon.
When faced with postoperative blepharoplasty complications in one’s own patient
or in a patient from another surgeon, the surgeon should determine the cause of the
patient’s complaints, obtain a thorough history, and perform a physical examination,
not only for medicolegal reasons and to establish a diagnosis, but also to gain rap-
port with the patient.Patients with long-standing complications from previous bleph-
aroplasty surgery often manifest a wide range of intense emotions including anxi-
ety, fear, anger, and guilt. The best approach is to acknowledge the situation and
attempt to work through these feelings with the patient.
The patient should be encouraged to explain any concerns. These concerns may
differ from the surgeon’s, and for this reason it is good to prepare a patient preoper-
atively for potential postoperative problems. We explain to the patient preopera-
tively that although the postoperative result will, in all likelihood, be acceptable and
pleasing to both the patient and the surgeon, there is always a risk of a postopera-
tive problem that the surgeon, the patient, or both may evaluate as a condition that
necessitates a postoperative revision.To this end, it is good to evaluate the aesthetic
postoperative results with the patient while assessing the postoperative problem.
A thorough patient history detailing current and past medical problems is essential
in a complete preoperative evaluation. Conditions such as hypertension, diabetes
mellitus, cardiovascular disease, thyroid disorders, and menopause should be iden-
ti ed and optimally managed before elective surgery is performed. Speci c ques-
tions about eye problems should also be posed.The rst line of questioning and ex-
amination should focus on eye function itself. Is the patient having problems with
vision, such as blurred or partial vision loss? Tear function, redness, irritation of the
sclera and cornea, and the blinking mechanism must be considered. The patient
can reveal much if the surgeon listens carefully. A history of eye irritation that is
worse on waking but that clears during the day may indicate that the eyes are not
closing well during sleep as a result of lid tightness. During the day the patient is
able to forcefully blink and overcome the dryness that occurs with nonclosure.The
patient may state that the eyes feel so tight that blinking is dif cult.
A thorough ophthalmologic examination should also be performed to evaluate vi-
sual acuity, visual elds, muscle balance, intraocular pressures, fundoscopy, and asym-

metries. Particular attention should be paid to patients with poor protective mech-
anisms, such as dry eye, absent Bell’s phenomenon, facial nerve palsy, and weakness
in lid closure. Other eyelid diseases such as rosacea of the eyelid, blepharitis, and oc-
ular pemphigoid should be diagnosed. Individuals with a history of using arti cial
tear substitutes or antihistamines should have tear production and tear lm assessed
using the Schirmer test for lacrimal secretion.
The Schirmer test, which measures tear production, is usually performed after a small
amount of topical anesthetic is instilled in the eye. In our experience, performing the
Schirmer test in an irritated eye without topical anesthetic leads to excessive tearing,
which alters the results and fails to give an accurate assessment of tearing function. If
tear secretion is less than 10 to 12 mm, close attention must be paid to the actual func-
tion of the lids and a history of eye irritation. A thoughtful review of the potential
causes of this problem, and complicating factors must be undertaken.
Other common problems found in patients who are to undergo secondary bleph-
aroplasty include tearing, corneal irritation, rounded lateral canthus, bowing of the
lower eyelid, and increased scleral show, all of which should be evaluated before
secondary blepharoplasty is performed. In primary gaze the patient must be exam-
ined for these conditions and for poor closure on standard blinking. Muscular tone
of the lower lid should be determined to prevent postoperative ectropion. Asking
the patient to gently squeeze the lids closed helps the surgeon to evaluate the con-
dition of the pretarsal orbicularis oculi muscle.To test for lid retraction or tightness,
the patient is asked to look upward. If there is lid laxity, ectropion or signi cant
scleral show may be obvious. Other methods for testing lid laxity or tightness in-
clude the snap-back test and the pinch test. The snap-back test is performed by
pulling the lower eyelid down and then releasing it.With the pinch test, the eyelid
is folded away from the globe on itself to determine whether there is more than
6 to 8 mm excess.
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Chapter 17
Reoperative Blepharoplasty
Inferior tarsal plate
Orbital septum
Orbicularis oculi muscle
Capsulopalpebral fascia
Inferior oblique muscle
Inferior rectus muscle
Inferior retractor muscle
In evaluating lid tightness, one must consider that three layers compose the lower
lid: the external layer of skin, the middle layer of orbicularis oculi muscle and or-
bital septum, and the deeper layer of capsulopalpebral fascia and conjunctiva.

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If, after blepharoplasty, the skin is tight but the deeper layers seem to be more re-
laxed on digital palpation, it is likely that appropriate treatment with massage will
be suf cient.The patient must be instructed in the technique:the index nger pad
is placed on the lower lid at against the pretarsal muscle area, pushing slightly in-
ward with an upward sweep to stretch the super cial and deeper tissues as much as
possible.This maneuver stretches the capsulopalpebral fascia, reduces edema in the
lower lid, and allows expansion of the lid in the vertical direction, which is impor-
tant for recuperation of motility in the lower lid.
Pinching or pulling the eye laterally is not suf cient to correct stiffness or vertical short-
ening.If it is not possible to push the lower lid up, massage may not be of any value.
Therefore, using digital palpation, the surgeon can determine whether one or more
layers are involved in lid tightness and can develop an appropriate treatment plan.
Most eyelids that have undergone blepharoplasty have lost some elasticity. Elasti-
city of the lower lid is assessed by placing the index nger or tip of the thumb un-
der the midpart of the ciliary margin and gently pushing in the upward direction.
In a normal eyelid, it is possible to push the lower lid gently to the level of the up-
per limbus. In the postblepharoplasty patient, this lid can usually be pushed to the
upper limbus; however, some degree of tightness or stiffness of the tissue may be
noted (left). If a patient has a signi cant scleral show, which may be the result of scar
tissue causing some contracture of the capsulopalpebral fascia, the lower lid cannot
be brought up to a reasonable level with digital palpation (right).

Levator palpebrae superioris muscle function, the state of the lateral canthal tendon,
and degree of lid retraction are important factors that should be assessed preoper-
atively.The patient should be observed to determine how well the eye closes with
casual blinking in contrast to voluntary lid closure. Furthermore, when the patient
exhibits epiphora, the location of lacrimal puncta and lashes should be assessed. Fi-
nally, the medial canthal area should be checked for webbing, and the lateral can-
thal area should be evaluated for excess rhytids or crow’s-feet. The patient should
be reminded that surgery will not remove all of the wrinkling and that other pro-
cedures may be necessary to improve the skin’s appearance, such as chemical peel,
collagen injection, or dermabrasion (see Chapter 15). Malar pad prominence may
be made more obvious by blepharoplasty and in fact may worsen the first few
months postoperatively. Resolution may require steroid injection, minute liposuc-
tion, and/or extended secondary lower lid blepharoplasty.
Certain concomitant conditions may require surgical procedures in addition to sec-
ondary blepharoplasty. When secondary blepharoplasty is considered, the surgeon
must determine whether upper lid improvement may be obscured by signi cant
eyebrow ptosis. Brow laxity should be evaluated and corrected before secondary
blepharoplasty is performed.To see whether a brow lift would bene t the patient,
the proper position of the brows can be evaluated by elevating both brows with the
ngers to a normal anatomic position at the supraorbital rim. Another condition to
consider is hypoplastic malar complex, which is manifested by shallow orbits,
prominent globes, and increased scleral show. With the use of malar implants, lat-
eral canthopexy, lateral tarsal strips to horizontally shorten the lid, or a malar lift, this
problem may be improved.
The location and extent of excess lid skin should be assessed. Excess skin creating
a skin fold or an extra set of wrinkles can sometime detract from the postoperative
result. If there is wrinkling of the skin of the upper or lower eyelids, further treat-
ment by skin excision, brow lift, or even chemical peel might be indicated. If the
skin wrinkling is in the lateral and upper eyelid area and a maximum amount of
skin has been excised, perhaps the patient should be offered the option of a brow
lift. Ideally, brow lift should be discussed with every patient before blepharoplasty
simply so the issue will have been broached and the patient will be prepared for the
possible need for secondary brow lift (see Chapters 12 and 13).
The presence of excess orbital fat should be assessed. Gentle pressure applied to
the globe with the lids closed helps to de ne the location and extent of fat pock-
ets bulging against the orbital septum. If a fat pad is prominent postoperatively, the
patient must be informed that some residual fat pad exists and should be removed
either through a transcutaneous or transconjunctival route.
Determining the location of the upper lid in relation to the pupil and measuring
palpebral ssures and lid creases are important parameters in assessment and plan-
ning. Preexisting asymmetry of brows and lid creases should be noted.The lid mar-
gin and lid creases should be evaluated for level and symmetry, and their dimensions
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should be recorded. Removal of large amounts of upper lid skin in a patient with
extensive dermatochalasis may uncover a minimal lid margin asymmetry that be-
comes obvious once the patient has healed and the bruising has subsided. In such
a case it is best to document this preexisting asymmetry preoperatively by taping the
lids and photographing the patient. If postoperative ptosis exists after removal of
eyelid dermatochalasis, the patient often believes that the asymmetry has been
caused by the surgeon. If this asymmetry is an obvious problem that either existed
before surgery or was caused by the surgery, the patient must be apprised of a tech-
nique that will help to solve this problem and obtain eyelid symmetry.
Before a secondary procedure is performed, the goals of secondary surgery must be
outlined thoroughly for the patient—possibly more than for the original surgery—
and informed consent obtained. The physician should carefully describe the limi-
tations of the planned secondary operation, emphasizing that no procedure is per-
fect and that even after corrective surgery, additional revisions may be required.
The surgeon should describe what the proposed surgery can and cannot do and
present the potential risks of the surgery.The purpose of the discussion leading to
informed consent is to provide enough information to enable the patient to make
an intelligent decision as to whether to proceed with further surgery.
The aspect of cost to the patient must be considered. If an unhappy patient with a
complication is referred to a surgeon, the insurance carriers will often support a
claim for surgery to correct the dif culty. For example, cicatricial ectropion occur-
ring after blepharoplasty is a problem that is usually covered by insurance carriers.
However,if a lot of attention is paid to the fact that this problem occurred after bleph-
aroplasty, the insurance reviewers may conclude that although there is a true physi-
cal problem, this is something the patient has “done to himself,” and they will resist
paying.Therefore, if the surgeon makes a point in communications with the insur-
ance company of calling the problem a postblepharoplasty complication, the insur-
ance company will often review this information and decide to “let the blepharo-
plasty surgeon take care of the problem” and not pay for the correction. However,
if this defect is simply referred to as a cicatricial ectropion, which it surely is, the insur-
ance carrier might be more inclined to reimburse the costs for this reoperation.
Documentation of problems by written history, physical examination, and pho-
tographs is imperative. Both frontal and lateral preoperative views with proper head
positioning are excellent not only for postoperative comparison but also for preop-
erative and intraoperative evaluation.
TIMING
Timing is an important consideration in reoperation after blepharoplasty. Often the
patient with eyelid problems will present 1 or 2 years postoperatively, when it is
clear that the condition has improved as much as possible with conservative meas-

ures and that corrective surgery or other maneuvers are indicated. However, in the
case of the patient who presents 1 day or 1 week postoperatively with a distinct
problem, there is some controversy as to when operative procedures should best
be performed. This determination relates mostly to the severity of the postopera-
tive defect. In some cases simple manipulation by massage, intermarginal tarsor-
rhaphy, or traction sutures will solve the problem. If a patient has a defect that can
be partially solved by manipulation or massage but needs to be followed up with
surgery, it is best to proceed with the manipulation therapy and then perform the
necessary surgery at the earliest possible date.
We tend to proceed with operative intervention as soon as possible, simply because
the patient is so miserable and because if the problem is not corrected early, it will
compound itself. For example, if a patient is unable to close the eye and this con-
dition persists for only a few days, the corneal changes that occur are temporary and
can easily be reversed. However, if this situation is allowed to persist for a long time,
a corneal ulceration and scar will develop, leaving a defect that is not so easily re-
versed and that may lead to a lifetime of difficulties with the eye. Therefore, in
terms of timing reoperative blepharoplasty, early intervention and correction of the
problem are often performed as early as possible to prevent the cycle of corneal or
scleral exposure and perpetuation of the problem.
SKIN MARKINGS AND INCISIONS
Upper eyelid crease symmetry may be the most important aspect of successful bleph-
aroplasty. Skin markings and incisions are thus critical and must be based on an ac-
curate and reproducible technique. Absolute symmetry of lid creases is generally not
present preoperatively, and likewise seldom exists postoperatively. Attention to tech-
nical detail remains crucial in avoiding gross lid crease disparities. Complete and
precise stabilization of the eyelid is necessary to accurately control the placement
and depth of the skin incisions. The inferior incision of the upper eyelid should
never be less than 9 mm above the lash line or lid margin. Inappropriate placement
of an incision may result in a lower-than-normal eyelid crease. Failure to recreate
skin attachments to the levator aponeurosis may also result in a lower-than-normal
eyelid crease. Aggressive medial skin excision and placement of the skin incision too
close to the lid margin may result in webbing or a pseudoepicanthus.VY plasty or
serial Z-plasties may be used to correct this problem.
At least 7 mm of separation between the lateral extent of the upper and lower eye-
lid incisions should be maintained to prevent webbing or unpleasant scarring.
Rounding of the lateral canthus and temporal retraction of the lower lids can result
from inappropriate placement of the lower lid incision. The lower lid incision is
made within 1 mm of the lash line, and the temporal extension should be only
slightly below the horizontal position to prevent lateral pull.
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COMPLICATIONS
As with all types of surgery, blepharoplasty is associated with certain complications.
Traditionally complications have been grouped into two categories: minor, associ-
ated with limited functional disturbance and minimal aesthetic problems, and ma-
jor, associated with functional loss and more severe aesthetic deformities. Similarly,
complications can be categorized as temporary, lasting for several days to weeks but
being self-limited, and more permanent, lasting for a protracted period of time and re-
quiring medical and surgical treatment.These distinctions are somewhat arbitrary,
however, as seemingly minor complications, if unrecognized and untreated, can lead
to several weeks or months of prolonged treatment or to the need to reoperate.
HEMATOMA
Small localized hematomas discovered under skin or skin-muscle aps can be evac-
uated with needle aspiration or stab wound drainage after spontaneous clot disso-
lution 7 to 10 days postoperatively. Evacuation should be thorough and may be re-
peated to avoid residual areas of organized clot, which can result in persistent
nodular irregularities or cicatrix deep within the lid or in subcutaneous tissue.
VISION LOSS
Vision loss or blindness from orbital hemorrhage is the most devastating and seri-
ous complication associated with blepharoplasty.The incidence is low, occurring in
less than 1 in 40,000 patients or less than 0.4% of cases.2,3 The most serious threat
to vision results from retrobulbar hemorrhage and hematoma. Bleeding within the
orbit produces increased intraocular pressure with subsequent central retinal artery
occlusion and/or optic nerve ischemia by direct compression. Both mechanisms
potentially result in vision loss.The exact cause of retrobulbar hemorrhage has been
debated with several theories expounded, but vascular injury seems to be the most
common explanation.Vision loss from orbital hemorrhage is associated with open-
ing of the orbital septum and subsequent fat excision. Hemorrhage related to ves-
sel injury from injection of local anesthetics, traction on posterior vessels during ag-
gressive fat resection, or poorly controlled fat pad vessels that have retracted deep
into the orbit seems to be the culprit.3,4 Orbital hemorrhage is most likely to oc-
cur when the vasoactive effect of epinephrine has dissipated, followed by rebound
vasodilation, or during a hypertensive episode up to several days postoperatively.5
To decrease the risk of retrobulbar hemorrhage:
Maintain normal blood pressure.
Inject anesthetics with care.
Manipulate orbital fat gently during dissection.
Ensure meticulous hemostasis.
Place the patient in a head-up position postoperatively.
Provide pain-control measures.
Instruct the patient to avoid strenuous activity.

Preoperatively, any patient history of prior intraocular eyelid surgery, comorbid
medical conditions such as hypertension, and the use of medications that interfere
with clotting or platelet function should be determined. Signs and symptoms char-
acteristic of orbital hemorrhage include severe pain, ophthalmoplegia with diplopia
and diminished visual acuity, increased ecchymosis of the eyelids, and proptosis.
The orbit will feel tense and resistant. If orbital hemorrhage is suspected, examina-
tion should include assessment of visual acuity, fundoscopic visualization, and
tonometry to evaluate intraocular pressures.
When retrobulbar hematoma is recognized in the immediate postoperative period,
medical and surgical treatment should be instituted promptly to decompress the
orbit. A patient undergoing blepharoplasty, especially when the surgery is per-
formed on an outpatient basis, should be made aware that the incidence of unusual
pain, diminished visual acuity, sudden increased orbital swelling, and other problems
should be immediately relayed to the surgeon, who in turn should be readily avail-
able to initiate appropriate therapy (see Chapter 5).
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Administer acetazolamide (Diamox) and/or mannitol unless contraindicated medically.
Return the patient to the operating suite to remove sutures.
Open the wound to allow egress of accumulated blood.
Provide immediate pain relief (we prefer intravenous morphine).
Perform immediate visual acuity check.
Examine the retina to determine the status of the retinal vessels.
Consider surgical release of the lateral canthal tendon.
Insert a cottonoid wick or a Penrose drain into the hematoma site.
Closely monitor the evacuation site and assess the wound status visually.
Treatment of Retrobulbar Hematoma
EPIPHORA
Epiphora is usually a transient problem, resolving in days. It is caused by edema
distorting the lacrimal canaliculi, but persistent ocular irritation from another cause
should be ruled out. Refractory punctal eversion can be corrected by cautery ap-
plied below the lacrimal canaliculus on the conjunctival side to produce contrac-
tion and inversion of the lid margin at the level of the lacrimal punctum. Naso-
lacrimal duct obstruction has rarely been reported after blepharoplasty. A canalicular
laceration detected at surgery should be promptly repaired primarily to ensure ade-
quate tear drainage postoperatively.
INFECTION
Infection after blepharoplasty is rare. Minor in ammation, generally associated with
sutures, resolves uneventfully after suture removal. Orbital cellulitis, orbital abscess,
and dacryocystitis after blepharoplasty have been reported but are extremely un-

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common and probably are related to the extensive vascularity of the eyelid and its
inherent resistance to infection. If cellulitis develops, early diagnosis and prompt, ag-
gressive therapy consisting of antibiotic administration and/or incision and drainage
are indicated.
CORNEAL ABRASION
Corneal abrasions must be avoided by taking intraoperative precautions to protect
the globe. Drying is prevented by corneal lubrication, with frequent instillation of
balanced salt solution or arti cial tears. A contact shell can be used for protection.
The surgical wound should be sponged minimally during surgery and, when
sponging is necessary, a soft wick sponge should be used to avoid corneal and scleral
abrasion.
LAGOPHTHALMOS
Lagophthalmos is relatively common after blepharoplasty, especially in patients un-
dergoing both upper and lower eyelid blepharoplasty. In the presence of a normal
Bell’s phenomenon, this condition is usually asymptomatic. In addition, it is usually
self-limiting and transient, and generally resolves in several days as edema subsides.
Dry-eye symptoms may be managed in the interim with lubricating drops and
ointments. Initial therapy should include vigorous massage of the eyelids and eye-
squeezing exercises.Taping the eyelids closed at night before sleeping, the use of a
plastic moisture chamber, and insertion of protective contact lenses may be added
to the regimen if needed.
If these conservative measures fail after a short period, cicatricial lid retraction
caused by levator aponeurosis adhesions or excessive skin excision should be sus-
pected. Gentle downward traction on the upper eyelid margin may allow the sur-
geon to palpate septal adhesive bands and to determine whether there is an obvi-
ous lack of skin. Lid retraction resulting from ipsilateral thyroid ophthalmopathy or
contralateral lid ptosis (Hering-Breuer re ex) should also be considered in the dif-
ferential diagnosis. If the problem is caused partially or totally by excessive skin ex-
cision, a full-thickness skin graft is appropriate. Cicatricial adhesions are corrected
by surgical release and creation of a new eyelid crease. Elevation of the lower eye-
lid has also been described for treatment.
VISUAL PROBLEMS
When a patient has visual and ocular problems postoperatively, ophthalmologic in-
tervention must be performed as soon as possible. Drying of the cornea can cause
alterations in visual acuity. Persistent need for ointments can also change visual acu-
ity and instill in patients a fear that their vision is deteriorating. Massage and peri-
orbital edema also can alter a patient’s astigmatism to a slight degree and can cre-

ate a problem with vision that the patient had not experienced before. In addition,
widening an extremely narrow palpebral ssure, which before aided the patient
with “pinhole vision,” can create problems because the patient can no longer rely
on this pinhole vision mechanism. It is not uncommon for patients to require ad-
justment of their glasses or a change in their prescription after eyelid surgery in
the absence of any complications or prolonged swelling.
Muscle imbalance, although uncommon, can occur after injury to the superior
oblique tendon or the inferior oblique muscle. Excessive cautery use in the supe-
rior nasal quadrant places the superior oblique tendon at risk for damage. During
secondary lower blepharoplasty the inferior oblique muscle is at risk, because pre-
vious scarring distorts the normal anatomy.This problem may also occur with pri-
mary transconjunctival blepharoplasty. Early postoperative diplopia may be stimu-
lated by edema and may be transient. As with postoperative ptosis, conservative
management should be continued as long as improvement is noted. However, sig-
ni cant postoperative diplopia with diminished motility may be an early sign of
retrobulbar hemorrhage; immediate evaluation and treatment are indicated.
DRY-EYE SYNDROME
The patient with postoperative dry-eye syndrome is very unhappy, and this annoy-
ing and not uncommon sequela has become increasingly recognized by plastic sur-
geons.6,7 Minimal or subclinical forms of dry-eye syndrome exist, making detailed
preoperative evaluation essential. Even minimal widening of the palpebral ssures
with blepharoplasty can produce keratopathy in patients with low tear production.
Patients in their fties or sixties (when tear production is diminished), women re-
ceiving estrogen replacement therapy, patients with contact lens intolerance, or
those with a history of increased sensitivity and dry-eye irritation are especially at
risk for dry-eye syndrome.The Schirmer test, lactoferrin immunoassay test, blink-
ing rate, and preoperative assessment of the orbit, lid, and adnexal anatomy are im-
portant adjuncts in the preoperative evaluation of these patients.7-9 Patients with
absent Bell’s phenomenon and signi cant diminution of tear production are not
suitable candidates for aesthetic blepharoplasty.
Dry-eye syndrome is treated with early postoperative massage of the lower lids to
maintain laxity and upward motility, massage of the upper lids (if tight) to maintain
the same level of laxity and correction of any factors that predispose to additional
drying of the cornea or sclera. Ectropion or extreme stiffness of the lower lid that
prevents upward movement on blinking and scleral show must be corrected (see pp.
459-472 and Chapter 18). A temporary lateral intermarginal suture tarsorrhaphy
may help to overcome the symptoms of dry eye for several weeks until the massage
process has loosened up the lower lid. If the temporary intermarginal tarsorrhaphy
suture helps to solve the problem of dryness, it may be necessary to perform a per-
manent lateral tarsorrhaphy, which would give long-lasting relief. This procedure
can be performed in an aesthetically acceptable manner to improve lateral canthal
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support. If the eyelid cannot close because of problems with either denervation of
the facial nerve to the upper eyelid or excessive removal of the orbicularis oculi
muscle in the upper lid, a gold weight may be placed to aid in lid closure.
DELAYED HEALING
Delayed or prolonged healing is unusual and may be associated with extensive
cautery use or excessive edema, ecchymoses, and scarring, each of these factors be-
ing patient dependent. Conspicuous cicatricial scarring is unusual but may be re-
lated to improper incision placement, which is best avoided by meticulous tech-
nique. Hypertrophic scarring may result from wound separation secondary to
hematoma, trauma, or premature suture removal. Massage, topical steroid cream,
and occasionally injection of triamcinolone (Kenalog) are the mainstays of treat-
ment. Dermabrasion has also been used to successfully treat supraciliary scarring.
HYPERPIGMENTATION
Hyperpigmentation of the lower lids from excessive ecchymoses and prolonged
absorption of blood is a cosmetic problem.The risk of this is reduced with the use
of a skin-muscle ap technique. With extensive skin ap elevation, there may be
more edema, ecchymoses, and vasolymphatic obstruction, predisposing to hyperpig-
mentation. Any congenital preexisting periocular pigmentation is generally not
corrected with routine blepharoplasty; this limitation should be discussed in the
preoperative consultation with the patient. Dermabrasion or a light chemical peel
may be considered if blepharoplasty does not improve this condition.
SCARS
The management of scars around the lids is often a challenge. A patient who has a
small scar around the lateral canthus that is creating a little pull in the lateral can-
thal or lower lid area is anxious to have this defect corrected as soon as possible.
However, judicious nonintervention early in the postoperative course is probably
the wisest choice.Teaching a patient the art of massaging the lids is very important.
Hypertrophic and contracting scars are best managed by direct digital pressure on
the scar, preferably against the underlying bony orbital rim.
In some instances, hypertrophic scars may be injected with a small amount of a
weak solution of triamcinolone. We inject approximately 0.2 ml of Kenalog-10
into an area of hypertrophic scarring to resolve some of the scar tightness. For the
patient who is massaging the lower lid and needs only a little extra help, this injec-
tion may help to gain better position and function. Blindness has been reported
after steroid injection in the eye area, and therefore small quantities must be used;
the injection of a large bolus into any one particular area is avoided. Instead small
injections in multiple areas are performed. Steroid injection can cause atrophy of
the subcutaneous tissue, and therefore injections should be made deep to the skin
rather than just in a subdermal area.

Other ancillary procedures are sometimes necessary. If the lateral canthus is dragged
into a downward position, a lateral canthoplasty in the form of a Z can be per-
formed. If there is scar contracture in either the medial or lateral area of the lids in
the blepharoplasty incision lines, Z-plasty can be used. Care must be taken to make
the Z-plasty limbs large enough so that they will release the scar deeply. If the limbs
are too large, however, the scars may show, particularly in the medial canthal area.
UPPER LID PROBLEMS
UNDERCORRECTION
Undercorrection of the upper eyelid as the result of too little fat or skin excision is
a relatively common postoperative complication and is usually easy to remedy.The
previous excision, scar line, and the nature of the problem should be evaluated. If
there seems to be excess skin but the distance from the eyebrow to the lid margin
is shortened, an anchor blepharoplasty technique without skin excision will prob-
ably take up the excess skin. Occasionally, failure to recognize an unusually low
eyelid crease can result in inadequate upper lid skin excision. More common, how-
ever, is the failure to recognize patients with brow ptosis, which results in excessive
fullness and apparent redundant upper eyelid skin. Complaints of ocular fatigue and
evidence of continuous occipitofrontalis muscle action with resultant deep forehead
furrows are related ndings. Failure to recognize and correct brow ptosis can lead to
excessive upper skin excision,producing poor functional and aesthetic results.Meth-
ods of estimating the degree of brow ptosis have been described, as well as tech-
niques of correction, including direct excision of brow skin and subcutaneous tissue,
temporal brow lift, coronal forehead lift, and browpexy techniques.6,10-13
To treat excessive skin of the upper eyelids, the excess is directly excised, the lid fold
is anchored to a deeper level, or the brow is lifted partially or completely. If there is
excess skin that is simply manifested by wrinkling,a chemical peel may be performed.
If the excess skin is obviously caused by brow ptosis, the need for a brow lift, either
direct or coronal,should be discussed with the patient.If there is simply an excess skin
fold that can be excised, this technique can easily be explained to the patient and
performed. If the upper lid crease is not clearly de ned after surgery and this lack of
de nition allows wrinkling and apparent skin excess, this situation can be corrected
by further deepening of the sulcus with an anchor blepharoplasty technique.
INCOMPLETE OR EXCESSIVE O RBITAL FAT EXCISION
Less than optimal results can be associated with both incomplete and excessive or-
bital fat resection.14 Excessive fat excision can result in an overly accentuated supe-
rior sulcus. If bilateral, the results may not be necessarily poor aesthetically, but if
unilateral, the results are clearly unacceptable and obvious because of the asymme-
try.The surgeon and patient must decide whether to further resect the remaining fat
on the contralateral eye or to augment the depression defect to equalize the result.
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PTOSIS
Ptosis may be considered a postoperative problem, but the most common “cause”
of ptosis is the failure to recognize this condition preoperatively. Often preopera-
tive ptosis is not visualized because of dermatochalasis, which hides the lid margin
from view. Appreciation of ptosis preoperatively allows levator aponeurosis adjust-
ment during blepharoplasty; the technique employed is generally dictated by the
surgeon’s preference. Ptosis can occur if the levator aponeurosis is injured during
blepharoplasty. If the aponeurosis is cut during blepharoplasty, ptosis will not imme-
diately result but will occur only later in the postoperative course. Other etiologic
factors include (1) inappropriate high placement of sutures in the aponeurosis dur-
ing supratarsal xation and (2) traction dehiscence of the aponeurosis caused by
the blepharoplasty procedure, which was unrecognized by the surgeon. Conserva-
tive management should be followed as long as improvement is noted. However, if
ptosis persists for more than several weeks, surgical exploration should be under-
taken. Most often, dehiscence or transection of the aponeurosis is found, requiring
appropriate aponeurosis advancement and repair. Minimal ptosis secondary to
supratarsal xation usually resolves with massage over a 2- to 3-week period. Again,
if ptosis persists, reexploration is indicated.
Preoperative markings
Mild ptosis of left eyelid
To correct postoperative ptosis, it is wise to plan a procedure that will give great ac-
curacy and near or total symmetry with the contralateral eyelid. We have found
that secondary aponeurosis plication offers the best possibility of a predictable re-
sult. Usually the amount of postoperative ptosis is only approximately 1 mm.

By plication of the aponeurosis 3 mm per each millimeter of ptosis, the lid level is
usually brought up to proper position.
W hen correction of secondary ptosis is planned, one must keep in
mind that anesthetizing only one lid makes it dif cult to note symme-
try at the operating table.Therefore we anesthetize both upper eyelids,
paralyzing the eyelid being corrected as well as the contralateral lid to
prevent arti cial alteration of lid height differences.
After anesthetic in ltration of both upper eyelids, aponeurosis plication is the pro-
cedure of choice for secondary ptosis repair after blepharoplasty.
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Intraoperative exposure of aponeurosis
Markings for aponeurosis plication
Immediate postoperative view
Six-week postoperative view

INADEQUATE LID CREASE
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After a primary procedure fails to create a good lid crease, the simple attachment of
the orbicularis oculi muscle to the aponeurosis, or the anchor blepharoplasty tech-
nique, creates a clear, well-de ned upper eyelid crease. To this end, incision to the
previous scar, exposure of the aponeurosis, suture of the orbicularis oculi muscle
with a permanent stitch to the aponeurosis, and simple closure establish this lid
crease nicely. In our experience, suturing the orbicularis oculi muscle to a higher
point on the aponeurosis may cause ptosis or lagophthalmos of the eyelid. There-
fore the orbicularis oculi muscle should be sutured directly to the aponeurosis ly-
ing underneath it. If a technique is used in which the skin margin is sutured to the
aponeurosis, it has been our experience that this maneuver creates an irregular or
sharp lid fold that is not forgiving in terms of minor variations from the contralat-
eral eyelid.15
Preoperative view
Intraoperative exposure of aponeurosis
Anchoring of orbicularis oculi muscle
to aponeurosis

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Postoperative view
In other words, symmetry is easier to achieve with the orbicularis oculi muscle-to-
aponeurosis technique.This procedure can be gratifying and can take up the appar-
ent additional skin that may be present after blepharoplasty when a clear lid crease
has not been created.
LOWER LID PROBLEMS
INCOMPLETE OR EXCESSIVE O RBITAL FAT EXCISION
Excessive fat excision of the lower lid can result in inferior eyelid concavity and a
prominent orbital rim with the appearance of sunken eyes.Volume augmentation is
the treatment of choice. Underresection of fat can likewise produce suboptimal aes-
thetic results. A temporal fat pad is the most commonly underresected area of fat in
the lower lid. Even if this region has been resected, a bulge may sometimes appear
in the lateral area,creating the need for a secondary procedure to remove even more
fat. In the upper lid, the medial fat pad tends to be the most dif cult to completely
eliminate, causing one side to appear more prominent in this area postoperatively.
The most common residual fat pad after blepharoplasty in our experience is the
lower lateral fat pad.Despite apparent adequate removal at the time of primary bleph-
aroplasty, this fat pad will sometimes manifest as an additional bulge. Removal of this
fat can be performed via the transconjunctival route, which is fairly straightforward
for the experienced surgeon. If this treatment method is not a consideration, re-
moval through the reopened transcutaneous route is indicated.The additional ap-
plication of cautery to some of the lateral tissue overlying the lower lateral fat pad
area after secondary fat pad removal is helpful for reducing muscle bulk.

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INCREASED SCLERAL SHOW AND ECTROPION
The most common complications of lower lid blepharoplasty are increased scleral
show and ectropion, which share similar etiologies. Exposure keratopathy may result
from lid retraction, especially if upper lid blepharoplasty was also performed. Patients
with poor corneal tear lm and corneal dehydration quickly become symptomatic
with even minimal scleral show.However,although ectropion of the lower lid and lid
retraction with scleral show are often associated with dry-eye symptoms, the results
of the Schirmer test may be normal or increased.The causes of scleral show and ec-
tropion are varied and additive.16 Measurements should be taken to avoid excessive
skin and muscle resection from the lower lid.Careful attention to the position of the
lid margin relative to the limbus, precise cephalad redraping of the lower lid ap
without tension, and having the patient open the mouth or gaze upward while the
amount of necessary resection is evaluated are techniques to better estimate the
amount of lower lid redundancy for accurate resection during blepharoplasty.
Excessive skin removal

Adhesions of the orbital septum
Excessive fat removal

Hematoma
Excessive muscle removal

Lax lid margin
Scar contracture

Proptosis
Damage to orbicularis oculi muscle

Unilateral high myopia (elongated eyeball)
Causes of Postblepharoplasty Ectropion
From Carraway JH, Mellow GC.The prevention and treatment of lower lid ectropion following blepharoplasty. Plast
Reconstr Surg 85:971, 1990.
Although excessive skin removal will cause ectropion, it is not necessarily the prin-
cipal cause. Excessive fat and muscle removal can also play a role. The lower lid
pretarsal orbicularis oculi muscle and its innervation must not be disrupted. Dam-
age to the pretarsal orbicularis oculi muscle, especially by deep lateral dissection
with division of facial nerve innervation, reduces its ability to support the lid post-
operatively. Another cause of scleral show is excessive edema in the lids with resul-
tant thickening that, combined with the pull of gravity, causes the lid to become
xed to deeper tissues in the orbital rim area, bringing the lid position downward.
Scar contracture in the septum and the capsulopalpebral fascia, and unnecessary
suturing of the orbital septum, are also implicated as causative factors. Hematoma
may produce a severe cicatrix deep within the lid or in the subcutaneous tissue, and
inflammation of the fat pockets can produce inflammatory bands between the
pocket and the skin, causing contracture of the scar and pulling the lower lid down-
ward.17,18 Factors predisposing to postoperative scleral show, eyelid bowing, or ec-
tropion include a unilateral large globe that is unmasked by blepharoplasty, early
Grave’s disease, shallow orbits, hypoplastic malar eminences, and incipient senile
ectropion. The last condition is manifested by hypotonicity or flaccidity of the
lower lids or weakened canthal tendons.

If the lower lid seems to have lost adequate motility in the upward vertical direc-
tion, one must evaluate the deep lamella. If the skin is adequate and the tarsal mar-
gin is tight, release of the middle layer or lamella is the treatment of choice. Al-
though this area can be approached via the transconjunctival route, often there is
scarring of the orbital septum and the deeper capsulopalpebral fascia, and it is hard
to release all of this scar tissue from a transconjunctival approach.Therefore an in-
fraciliary incision is made to reopen the blepharoplasty wound, and the orbicularis
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Options for Correction of Lower Lid Retraction
Problem
Corrective Procedure
Relaxed tarsal margin
Wedge excision tarsectomy
Tarsal strip procedure
Lateral canthopexy
Shortness of skin
Full-thickness graft
Extensive massage
Deep lamellar scar contracture
Release of capsulopalpebral fascia
Add spacer of sclera, fascia, or cartilage
Combination problems
Fascia sling
Release of capsulopalpebral fascia
Skin graft
Tightening of tarsal margin
Scleral show, punctal eversion, lower lid hypotonicity, and lateral canthal tendon
laxity must be appreciated preoperatively so that surgical tightening of the lower lid
or lateral canthal elevation can be made a part of the operative plan. When scleral
show or ectropion is recognized postoperatively, effective treatment should be in-
stituted without delay to avoid an irreversibly xed lower lid.16 Scleral show or ec-
tropion is best managed initially with conservative methods such as massage and/or
injection of minute amounts of steroids.The use of an intermarginal tarsorrhaphy
or Frost suture may be required. If these measures are unsuccessful, surgery may be
necessary, with excision of scar tissue, release of the capsulopalpebral fascia, skin
grafting, and/or insertion of a lid spacer such as cartilage, sclera, or fascia lata. In
addition, horizontal eyelid shortening, lateral canthal tendon plication, tarsal strip
procedure, or dermal pennant ap technique may be used to tighten and lift the
lower lid. Surgery should be reserved for failure of conservative methods.
LOW ER LID R ETRACTION
When it becomes obvious postoperatively that simple massage will not result in
tissue relaxation and improvement of the lid retraction, an operative procedure may
be necessary.To select the proper operative procedure from the wide array of tech-
niques available, it is helpful to separately consider the various components of the
lower lid problem that must be corrected.

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After blepharoplasty, this patient had a retracted, tightly scarred left lower eyelid
that was immobile.The deep lamellar scar and capsulopalpebral fascia of the left eye
were released. A cartilage graft was not necessary. Postoperatively the eyelid was
soft and mobile.
Lateral canthopexy19 may be performed if there is dehiscence of the lateral canthal
tendon, downward displacement of the lateral canthal tendon, or need for minimal
movement of the lateral canthus in the upward and lateral direction. Dermal pen-
nant canthopexy described by Jelks and Jelks20 is a convenient way to isolate the lat-
eral canthal tendon, mobilize it in an upward and lateral direction, and anchor it to
the lateral orbital rim. This procedure does not give as good a “pull” to the tarsal
margin as the tarsal strip procedure or wedge excision tarsectomy, simply because
oculi muscle is preserved in the pretarsal area. The pretarsal and preseptal planes
are split, allowing access to the orbital septum and the capsulopalpebral fascia. A
sharp No. 15 blade is used to push on the bers, which are tense when a skin hook
is placed on the lower lid, and to separate the tight tissue, allowing complete release
of the lid in the vertical direction.The lid is then pulled with traction on the mid-
dle, medial, and lateral areas, and complete separation of the scar tissue is performed.
This maneuver allows upward motility. At that point hemostasis is obtained, and the
need for a spacer graft may be considered. If the orbicularis oculi muscle seems to
have adequate length, and if there is good substance to the lower lid, then a spacer
probably will not be needed. However, if the lid is atrophic and thin, and the orbic-
ularis oculi muscle itself is poor in character, then a cartilage graft may be necessary.

it is not possible to get enough movement in the lateral direction in many cases. In
addition, if the patient has signi cant scleral show laterally, or if there is signi cant
relaxation of the tarsal margin, a procedure in addition to canthopexy such as re-
lease of the capsulopalpebral fascia, skin graft, and/or insertion of a spacer graft be-
tween the relaxed edges of capsulopalpebral fascia may be indicated.
Wedge Excision Tarsectomy
When scleral show is present, wedge excision tarsectomy is an option, but this tech-
nique has limited usefulness.Wedge excision tarsectomy (modi ed Szymanowski)
may be performed when the tarsal margin is relaxed and the lateral canthus does
not need to be repositioned further laterally.To perform this procedure, the tarsus
should be excised with perpendicular cuts, but the pretarsal orbicularis oculi mus-
cle should be spared. Preserving this muscle maintains continuity of innervation to
the remainder of the pretarsal orbicularis oculi muscle segment medial to the ex-
cision area, which is important for the blink re ex. If there is proptosis or exoph-
thalmos, a wedge excision may be contraindicated because it tends to shorten the
lid and pull it behind the axis of the anterior part of the eye, thus increasing expo-
sure of the cornea and sclera. In that instance a sling procedure using either tarsal
strip or fascia to pull the lid in the upward direction is indicated.
Tarsal Strip Procedure
The tarsal strip procedure takes up where wedge excision and lateral canthopexy
leave off in terms of correction of moderate or moderately severe deformities.
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Preoperative markings
Excision of tarsus
Postoperative closure

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Inferior tarsal plate
Tarsal strip
Attachment to
lateral orbital rim periosteum
The tarsal strip procedure allows preservation of the pretarsal muscle, upward “sling-
ing” of the lower tarsal margin, and shortening of the tarsal margin in a horizontal
dimension. In addition, because the surgical approach is made through the lateral
ssure, the capsulopalpebral fascia is completely released, which in itself is an ex-
tremely valuable maneuver in the case of contracture of the deep lamella.
This procedure is performed by making an incision in the lateral ssure, grasping
the lateral tarsal margin and elevating it away from the attachments to the lateral or-
bital rim inferiorly, and then releasing the capsulopalpebral fascia to about the mid-
dle part of the lower lid. The lid margin then can be brought upward about 1 cm
higher than the usual point of attachment at Whitnall’s tubercle.The amount of lid
to be deepithelialized and sutured to the lateral orbital rim is determined,and deepi-
thelialization of the anterior, superior, and posterior areas of the tarsal strip is per-
formed.
After deepithelialization, and with the pretarsal orbicularis oculi muscle segment
spared, the tarsal strip is brought up and sutured to the anterior border of the lat-
eral orbital rim about 6 to 10 mm higher than the normal position. This maneu-
ver allows the lid margin to come up and, with the release of the deeper scar tis-

This procedure has been gratifying to use in many cases of bowing of the lower lid
with exposure of the sclera. Although some surgeons have noted that this tech-
nique creates smaller eyes, this has not been our experience. A normal almond-
shaped eye seems to be the rule rather than the exception.
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Chapter 17
Reoperative Blepharoplasty
sue, corrects any lid retraction problems. The preservation of the pretarsal orbicu-
laris oculi muscle prevents the usual postoperative droop that may occur within
1or 2 weeks after the tarsal strip procedure is performed. In the literature no men-
tion of the preservation of the pretarsal orbicularis oculi muscle is made, but we be-
lieve it is an important step in the overall success of the procedure.
In more severe cases of lower lid retraction, use of a fascia sling from the fascia lata
area to actually pull the lid margin up may be indicated.

Attached to drill hole
in lateral orbital rim
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We perform fascia sling procedures by taking a direct excision of fascia from the fas-
cia lata and threading this 2 to 3 mm wide piece of fascia from the medial canthal
tendon to the lateral orbital rim through a drill hole.This fascia sling runs between
the pretarsal muscle and the tarsal plate.
Medial canthal tendon

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Full-Thickness Graft
A full-thickness graft is indicated when there is an actual shortage of skin. If a post-
operative blepharoplasty problem is approached and release of the tightness of the
tarsal margin is performed, leaving a de nite skin de cit, then a full-thickness graft
is the best option. One reason for leaving the pretarsal muscle in place when cor-
recting a lower lid deformity is to facilitate placement of a full-thickness graft di-
rectly on top of the muscle for optimal take.
The best donor sites for a full-thickness graft include the upper lid skin that has
been thinned by removing the orbicularis oculi muscle and postauricular skin.The
latter should be thinned well so that it will not have a bulky appearance.The full-
thickness graft should be slightly larger than the defect but not more than 20%
larger. If the graft is larger than the defect by a large margin, then some excessive
wrinkling of the graft will occur. Usually the graft is sutured in place with a run-
ning 6-0 Prolene or nylon suture. If the graft is more than 0.5 mm wide, a bolus
dressing is usually left in place over the sutures. An intermarginal tarsorrhaphy stitch
may be placed to reduce lid motion, and a patch is placed over the eye after baci-
tracin ointment is applied.
Cartilage Graft
If it is determined that lower lid retraction cannot be corrected by wedge excision
or a tarsal strip procedure, another method of correction can be considered. If loss
of the substance of the tarsal margin and lid seems to be the major problem, recon-
stitution of this thickness of the lower lid with a cartilage graft from the nasal sep-
tum may be a good approach.This technique offers the possibility of adding some
bulk to the lower lid, makes massage easier, and gives more support to push the
lower lid upward.The underlying principle is to place a stiff material in the lower
lid that helps to push the lid margin up to a higher level, thus overcoming the lid
retraction.The traditional grafts have been banked sclera, ear cartilage graft, or split
nasal septal cartilage graft, which is our preference. Banked sclera is a good stiffener
of the lower lid, but it causes in ammation for a longer period of time than autolo-
gous cartilage and also tends to have some curling problems. In addition, scleral
grafts, unless irradiated or kept in absolute alcohol, may pose a risk of transmission
of the AIDS virus. Although this possibility is very unlikely because of donor se-
lection, it is a consideration that must be kept in mind. Ear cartilage is a good al-
ternative for lower lid grafting, but it can be somewhat bulky and is more dif cult
to delicately sculpt and put in place than septal cartilage.

Mucoperichondral flap
Septal cartilage
Septal
cartilage
graft
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If a split nasal septal cartilage graft is considered, the patient history must be re-
viewed. Prior submucous resection or septoplasty precludes the use of this graft in
most instances unless adequate cartilage is available for harvest without jeopardiz-
ing the integrity of the septum. The nasal septum is evaluated preoperatively to
determine whether it is straight enough to use as a at graft for the lower lid.The
graft donor site is approached through a standard L-shaped incision at the muco-
cutaneous junction as for a submucous resection.The mucoperichondrium is ele-
vated from the hyaline cartilage for a distance large enough to allow the unim-
peded harvest of the graft. A 4 mm strut is left in the caudad and dorsal septum, and
an incision is made through the cartilage to the mucoperichondrium on the con-
tralateral side. A periosteal elevator is then inserted, and the mucoperichondrium is
lifted from the contralateral side of the septum.
Once the mucosa is lifted from both sides of the septum and has been freed so that
some “working space” has been created, sharp scissors are used to cut the superior
and inferior limbs of the graft. Posteriorly it is best to use a small periosteal dissec-
tor to separate the cartilage from the perpendicular plate and vomer at its point of
insertion.The template for the graft, which is usually a piece of glove paper, is then
laid onto the graft and a section is cut to size.
The cartilage is held between the thumb and fore nger of the nondominant hand
while a No. 10 blade is used to gradually split the edge of the cartilage to the point
that it separates into two parts. The cartilage is usually thick enough so that it can
be split down the middle. As the cartilage is split, the two edges separate away from
the split and the pieces of cartilage take on a slight concave-convex curvature con-
sistent with the scoring or shaving of cartilage in the usual manner.

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After splitting of the cartilage is complete, the graft size is reappraised and the graft
is placed in a pocket that has been dissected under the pretarsal muscle, and almost
up to the lid margin.
Tarsal plate
Graft
The graft is then sutured in place between the
edges of the released capsulopalpebral fascia
and anchored to the medial and lateral tarsal
plate, with the dorsal part of the graft left in a
somewhat straight plane. This configuration
pushes the lower lid into a straighter position,
helps to overcome the lid retraction, and pre-
vents the capsulopalpebral fascia from healing
back to itself.
Graft
In addition, after seating the graft as noted, the capsulopalpebral fascia and any mid-
dle lamellar scar tissue can be excised right down to the conjunctiva, which should
be left intact. At that point the lid margin is elevated, good support for the lid mar-
gin has been created, and enough lower lid laxity secondary to the release of the
capsulopalpebral fascia is present that it is possible to maintain this position by dili-
gent massage postoperatively.

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This patient had lower lid retraction after blepharoplasty. Deep scar tissue was re-
leased and steroids were injected. A cartilage graft was then inserted to support the
lower lid. Postoperatively splinting and Frost sutures were used to temporarily se-
cure the elevated position of the lower lids.
Cartilage
graft

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LOW ER LID NOTCHING
Lower lid notching occasionally occurs when wedge excision tarsectomy is per-
formed with the primary blepharoplasty. In this instance, reexcision of the wedge
area, leaving the pretarsal muscle intact, can be done. A small Burow’s triangle of
skin may also be removed close to the wedge of tarsus to prevent puckering of the
skin adjacent to the wedge excision. In cases of hypertrophic scarring, one impor-
tant principle must be kept in mind. The hypertrophic scar is usually formed as a
result of tension and can be overcome only by release of the tension on the scar. Re-
lease can be achieved by Z-plasty or full-thickness graft.
USE OF ALLOPLASTIC IMPLANTS FOR LOWER
LID SPACER SUPPORT MECHANISM
Although the use of cartilage grafts21 is an excellent choice, sometimes this cartilage
is not available because of the previous submucous resection/septoplasty or because
of a severely deviated septum. Both of these situations make the cartilage graft from
the nasal septal area a poor choice. Additionally, use of ear cartilage for a spacer of-
ten results in a mild to moderate irregularity of the lower lid which does not show
the type of smoothness that we like to see for a good aesthetic result. The basic
purpose for using either an alloplastic implant or the cartilage graft is to furnish
stiffness and support to slightly push the lower lid up. Comparison of a stiff spacer
to other techniques such as tarsal strip, lower lid sling, or buccal mucosa to the con-
junctival surface all have their advantages, but may leave something to be desired.
A fascia sling support to the lower lid can be very useful when there is simply lax-
ity of the lower lid without much scar pulling the lid in the downward direction.
When there is a lot of scar tissue, it is best to release the scar and overcome the cica-
tricial retraction with a stiffener of some sort. Use of a buccal mucosal graft to the
conjunctival side allows release of the capsulopalpebral fascia and placement of a
full-thickness palatal graft, which allows the lid to come up. However, this tissue
does not have the stiffness needed to actually hold the lid up. It is for this reason that
it is preferable to use a stiffener such as cartilage graft or alloplastic implant to per-
form this maneuver. Medpor (Porex Corporation, Newnan, GA), has become avail-
able for this application.This material does not have to be harvested from the nasal
septum, sticks to the tissue once it is implanted, and furnishes the same support
that a cartilage graft was able to furnish in my patients. With the use of the Med-
por implant, I have been able to almost completely eliminate the use of nasal sep-
tal cartilage grafts and nd that the support for the middle portion of the lower lid
is the best that I have seen for any technique. Sometimes, with lateral inferior drift,
a tarsal strip or canthopexy procedure may also be indicated to augment the use of
the lower lid implant. However, it is the implant that can give support to the mid-
dle portion of the lower lid.This support cannot be provided as effectively by any
other technique. I have also used this technique for both postcosmetic and recon-
structive surgical problems.

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OPERATIVE TECHNIQUE
The patient is prepared in the usual manner and, under local anesthesia, a standard
infraciliary incision, as used in a blepharoplasty, is made.The skin is elevated off of
the pretarsal and the preseptal muscle using a skin hook, and a blue mark is placed
in the area of entry to the submuscular space.The muscle is split about 4 or 5 mm
below the lid margin. Once the muscle is split, the inferior pocket is created in the
submuscular plane so that the implant can rest inferiorly.The superior pocket must
be carefully dissected to elevate or “roll” up the orbicularis pretarsal muscle off of
the rather narrow and friable lower tarsal plate. It is sometimes dif cult to see the
plane between the muscle and the tarsal plate, but it is essential to have that space
created well so that the edge of the implant can t high up into the lid margin
preventing either roll-out ectropion or roll-in entropion. Once this is done, a use-
ful technique is to take a little bit of the thin cardboard that comes in suture packs
and make a prototype for the size of implant that is needed to lift the lid margin.
The paper model is usually cut and put in place and then trimmed to give support
to the middle, lateral, or medial part as needed. Any portion of the prototype that
is too high will be seen later in the form of a slight bulge or a slight prominence of
the Medpor. Once the model is cut, the Medpor implant can be approximated to
size and positioned. Then, using the ngertips and a hemostat, the curve of the
Medpor implant is made to conform to the convex surface of the globe in the ho-
rizontal direction. Once this curve is given to the implant, it can be put in place and
the lower edge of the implant settled below on the orbital rim margin or adjacent

tissue. The muscle is then closed with several 6-0 nylon sutures that are inverted.
This gives complete coverage of the implant from the skin side and prevents extru-
sion of the implant.The skin is also closed using 6-0 nylon sutures. A tape support
is placed on the lower lid for about 3 days until the sutures are removed. On the
third postoperative day, the patient is instructed to massage the lid in the upward di-
rection so that the whole lid unit is mobile, but within the mobile lid unit there is
a stiffener to support the middle part of the lower lid. This has been an ideal situ-
ation, and I (J.H.C.) have performed about 20 of these implant procedures with no
extrusion, and with the reoperative rate of 3 of 20, which amounted to only trim-
ming down a small prominent portion of either the medial or lateral part of the im-
plant where it had become prominent with time.This procedure gives an excellent
clinical result.
PATIENT EXAMPLES
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This 59-year-old patient has bilateral scleral show with extreme laxity of the lids.
It was felt that a tarsal strip would augment but not completely correct this prob-
lem, and that a spacer or stiffener would be indicated for use.
Two months postoperatively, with Medpor implant spacers in place, a normal con-
tour to the lids is evident and the scleral show has been overcome.The patient has
ptosis of the left upper lid, which is to undergo correction at a later date.

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This 65-year-old patient had a previous blepharoplasty with problems including
lid retraction of the right lower lid. Placement of a spacer is indicated to give good
support to the lid.
Two months postoperatively, the patient shows good support to the lower lid and
normal contour. Good closure was achieved in the lower lid.
UPPER AND LOWER LID PROBLEMS
Some problems are encountered in both the upper and lower eyelids after bleph-
aroplasty.The most common problems are inadequate removal of skin, inadequate
removal of orbital fat, irregular or hypertrophic scars, and excessive removal of skin
or fat. In addition, it is possible to either denervate or excise pretarsal muscle of ei-
ther the upper or lower lid, causing dif culty with lid closure.
With overcorrection of upper lid skin, there are generally two approaches to im-
provement.The rst is to recreate the defect of the original incision and to insert a
full-thickness skin graft. A good donor area for a full-thickness skin graft of the up-
per lid does not exist but a thinned postauricular graft is probably the best option.
Full-thickness skin grafts heal reasonably well and often are imperceptible postoper-
atively.However, some hypertrophy around the edges of these grafts can occur,mak-
ing them visible. Another technique is to simply incise the scar line, reopening the
wound,and have the patient massage the site over the next few days until the wound
heals.The patient is instructed to tape the lids in the closed position before sleeping.
This technique will allow the upper lid to heal in the stretched position.

Overresection of skin in the lower lid can be diagnosed by good motility of the lid
in the upper direction, but obvious shortage of the skin with eversion of the lid
margin. Correction is best achieved by recreating the defect where the skin was
excised and then placing a full-thickness graft from the postauricular area. In the lat-
eral orbital area, the scar must de ect laterally and downward rather than upward.
Overcorrection by about 30% to 40% is generally adequate; any more than that
gives the scar a “crumpled” appearance.
Inadequate excision of fat is not uncommon in the lower lid; the lateral pocket is
sometimes missed even by experienced surgeons.There is a “secondary” fat pad in
the lateral lower lid that may not be evident during the original blepharoplasty
procedure but may present as a bulge laterally after fat has been removed from the
middle and medial pockets. Although simple reentry into the wound and excision
of this fat as a small bolus is somewhat of a nuisance to have to do because the fat
is so minimal, it is the most common cause for reoperative blepharoplasty surgery.
Inadequate removal of fat in the upper lid manifests most often as a bulge in the
medial corner; it too must be resected.This fat can be removed with minimal dif-
culty through a small incision with the patient under local anesthesia.
Although inadequate skin removal is better than excessive skin removal, it must be
corrected, especially in patients who are particular about obtaining the absolute
maximal effect from the operative procedure. Some patients may simply have a few
wrinkles on squinting or a tiny fold of skin in the lateral upper lid and they may re-
quest that this excess skin be removed. One must be careful not to be pushed by the
patient to the point that excessive amounts of skin are removed.This situation leads
to lid retraction or lagophthalmos, possibly resulting in corneal drying and injury.
It is better to perform a secondary resection of skin than to insert a skin graft be-
cause of overresection during secondary blepharoplasty.
If patients requesting secondary surgery for skin excision or fat removal were ini-
tially operated on by another surgeon, it is wise to test the motility of the lower lid
in particular and to ask the patient about closure of the eyes during sleep. If a pa-
tient’s eyes do not close during sleep because the upper lids are lagging, then addi-
tional skin resection will serve only to make this condition worse and cause corneal
problems. A Schirmer test must be performed to determine whether the patient has
marginal tearing abilities or in fact has dry eyes.
ADJUNCTIVE TECHNIQUES TO IMPROVE
THE BLEPHAROPLASTY RESULT
CHEMICAL PEEL
Most patients are placed on a regimen of topical glycolic acid and tretinoin (Retin-
A) products when they are rst evaluated for aesthetic surgical procedures.The ap-
plication of the combination of these two agents reduces ne wrinkles, causes peel-
ing and some thickening of the skin, and tends to improve healing from surgical
procedures or chemical peels at a later date. Many glycolic acid products are avail-
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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
able;most creams or gels range in strength between 8% and 12%.Tretinoin is avail-
able in a gel as well as a cream form and it comes in different strengths. It is best to
warn the patient that these products will cause some redness and peeling.The pa-
tient should be instructed not to go outside without applying sunscreen, and to
remain in the sunshine for only a short period of time.
Trichloroacetic acid is also used after blepharoplasty when ne wrinkles and crêpey
skin seem to persist (see Chapter 15). If the glycolic acid and tretinoin combination
does not improve skin problems, then 35% trichloroacetic acid may be used on the
upper lids to tighten the skin as well as to reduce ne wrinkles. It is best to prepare
the skin with tretinoin application for 4 to 6 weeks before the use of trichloroacetic
acid products. Treatment with this topical acid can be performed with minimal
preoperative sedation and analgesia. Although it causes some burning, a small hand-
held fan helps to alleviate this sensation, which lasts for only a few minutes. Good
results are achieved, but the patient cannot be promised more than simple improve-
ment of minor wrinkles and tightening of relaxed or crêpey skin.
Residual ne wrinkles around the eyes persisted after blepharoplasty in this patient,
and she wished to have their appearance diminished. A 35% trichloroacetic acid
peel was performed that resulted in the resolution of some rhytids.
The Baker phenol formula is also useful in patients who are fair skinned and have
ne wrinkles.The disadvantage of the Baker phenol formula is that it causes a loss
of pigmentation in the skin around the eyes;to some patients this result is unaccept-