As the surgeon, it is important to be aware of the potential complications of surgery. Retroauricular skin is often available and is a good substitute for eyelid skin. In the face of frank orbital hemorrhage with proptosis, a frozen globe, and vision loss, bold measures are called for. When needed, lid crease fixation method depends on surgeon's preferences and experience (. In the initial consultation, it is important for the surgeon to identify which unrealistic patients can be educated and operated on with confidence, and which ones cannot [1, 2]. 102, no. In the setting of blepharoplasty surgery noninfected corneal abrasions are best treated with a bandage contact lens. Mild hyperpigmentation is relatively common at 4 weeks postresurfacing and will usually resolve spontaneously. Nonabsorbable sutures are removed 714 days after surgery. Ophthalmology. Excessive trauma to the levator muscle, levator aponeurosis, and pre-aponeurotic fat pad can result in upper lid retraction, scleral show, and lagophthalmos. Topical and systemic antibiotics are utilized due to the open wounds, and their repair is planned electively in 1 to 2 weeks if they do not close on their own. Racial and ethnic facial characteristics including skin type and underlying facial bone structure may be included in discussing alternatives and surgical planning. Excess preaponeurotic and/or nasal fat is removed. Crease formation should not be high on the levator (if above tarsal plate at all) to avoid a distorted westernized look, asymmetry, and ptosis. Another possible issue is post-operative conjunctival thickening and persistent redness in the operated area. People notice this scar within minutes of meeting me and I am very self-conscious about it. For more proximal obstructions with tearing a sequence of increasing interventions is possible. Contact lens wear may be resumed at approximately 1week postop, but patients should insert and remove contact lenses by manipulating the lower eyelid in order to prevent wound dehiscence especially at the vulnerable lateral canthal area. 5, pp. Multiple repairs may be required for the optimum result to be achieved. Progressive postoperative periorbital inflammation may indicate infection, allergy to topical medication and rarely primary acquired cold urticaria (PACU). Interrupted sutures are used to reapproximate the wound edges. Massry GG. 2, pp. Allergy Asthma Proc 2003; 24:9. Canthal rounding can be cosmetically-unacceptable to patients. Z. Especially on one side more than the other! G. Y. Shaw and J. Khan, The management of ectropion using the tarsoconjunctival composite graft, Archives of Otolaryngology, vol. These should usually be delayed for 3 months or more if possible after the primary procedure to avoid surgical tail chasing. Allowance for asymmetry not to be corrected (such as minor brow height differences) needs to be made. I am 13 days post op. 5155, 1996. Arch Ophthalmol 1999; 117:907. 97, no. 1992; 99:222. R. R. Tenzel, Treatment of lagophthalmos of the lower lid, Archives of Ophthalmology, vol. What complications can come from a blepharoplasty? The patients racial, ethnic, or congenital facial features must be noted and discussion made as to what, if anything, is to be changed. These techniques are similar to those utilized to treat the eyelid retraction of thyroid eye disease [27]. 21922196, 1979. However with skin closure, this scar generally blends well with the normal smile lines in the lateral canthal area. Similarly, if the patient is asked to look up, the orbital septum will not move when grasped but the levator will. Partial removal of orbicularis over the lateral orbital rim area may provide a small eyebrow elevation. Intravenous mannitol 20% (12g/kg over 3060minutes). It aims to improve the appearance of the lower eyelids by addressing skin laxity, fat prominence, and adjusting the lower eyelid position. Excessive bruising can lead to a prolonged recovery, infection, cicatrisation, and skin pigmentation. R. R. Tenzel, Complications of blepharoplasty. 7175, 1987. Inadvertent trauma to an extraocular muscle with deep dissection in orbital fat may occur. Even well-adjusted patients will perceive and focus on asymmetry caused by bruising and swelling or discomfort during the early postoperative period. Patients with vitiligo may have an increased risk of hypopigmentation. There is no consistently effective treatment of hypopigmentation. The technique of tarsal strip repair has been well described elsewhere. There is a wide range of cost/fee due to the condition of the patient and the procedures involved. In addition, placement of an upper lid traction suture is important or the skin graft will be ineffective [79]. Lastly, there are occasional patients who develop unrelated cranial nerve palsies some weeks or months after surgery by chance alone. It also includes deciding which technique to perform (steel blade versus CO2 laser, transconjunctival versus external approach to lower blepharoplasty). Article 1j and 1k). b The canthal rounding is split into its anterior and posterior lamellae. Heinze JB, Hueston JT. It has also caused the skin to be stretched down tight onto my nose from the bridge to the incision. The incidence is estimated to be 1 in 2,000 to 1 in 25,000 [32]. A free tarsoconjunctival graft can alternatively be used [2023]. Ophthal Plast Reconstr Surg. A good understanding of anatomy and careful preoperative counseling of the patient is crucial for success. 466474, 2010. Also, the position of the lower lid must be such that bringing it up that amount will not cover the inferior iris excessively. Patients may usually resume normal activities within 2448 hours after surgery. The alternative argument is that epinephrine vasoconstriction is followed by rebound vasodilation, which may actually potentiate the risk of postoperative orbital hemorrhage. Finally, management of complications is just as important as surgical technique. Millman AL, Williams JD, Romo T, Taggert N. Septal-myocutaneous flap technique for lower lid blepharoplasty. In Caucasian men, the crease is usually 69mm above the eyelid margin. Thank you. Nonsedating antihistamines may help control cold-induced symptoms. Fortunately, diplopia after blepharoplasty is extremely rare but is still a known complication. Ophthal Plast Reconstr Surg 2002; 18:45. I experienced significant swelling in my tear duct area (especially on the right side) My right eye now appears to have webbing on the inner corner. This will significantly speed up the recovery time. Im losing faith in him though and am looking elsewhere for revision. Wound may be repaired electively in 1 to 2 weeks if it does not close on its own. Invest Ophthalmol Vis Sci 2007; 48:4445. A. N. Hass, R. B. Penne, M. A. Stefanyszyn, and J. C. Flanagan, Incidence of postblepharoplasty orbital hemorrhage and associated visual loss, Ophthalmic Plastic and Reconstructive Surgery, vol. Also, avoid excess cautery to the levator. 11, pp. The scar has webbed and is also very long and wide. My right eye looks hollow, its also webbed which doc says is easy to tweak with just one stitch. May be due to incision extended too far medially. the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Ive become really sad as my eyes were pretty before, esp my right which is the one he has botched. Involvement of an internist or hospitalist is helpful in managing fluid shifts caused by these osmotic agents. If persistent, a superolateral skin excision with crease reformation will raise the persistently hooded side. Lateral skin often takes longer to soften and smooth because it is thicker compared to eyelid skin. I am also very wary of risk. Milder eyelid laxity is treated by a form of lateral canthal tendon plication at the time of lower lid blepharoplasty, and dehiscence here is less common and of milder extent, and hence can usually be managed supportively [7]. In patients (especially males) with prominent skin and orbicularis excess who are not laser candidates, fat is still removed transconjunctivally, the eyelid is tightened horizontally and a conservative skin muscle pinch excision is utilized. Before discharge, wounds are checked for bleeding and dehiscence. Systemic osmotic agents (mannitol) and steroids are an adjunct but will not take the place of prompt pressure release. Patients concerns can vary immensely, ranging from a particular dislike of lateral hooding, a staring or overdone look (very common), a sunken look (a common concern in younger patients), to a fear of blindness to concerns about the length of the recovery period and intra- and perioperative pain. 21, no. Burroughs JR, Patrinely JR, Nugent JS, et al: Soparkar CNS, Anderson RL, Pennington J H. Cold urticaria: an underrecognized cause of postsurgical periorbital swelling. 5, pp. 1b). If pigment is present without fat herniation, treatment with skin bleaching agents can be tried first. Mackley CL. May be accomplished by securing posterior skin to the levator complex at the superior border of the tarsal plate. Twelve patients have undergone this surgical technique for correction of post-surgical canthal rounding. do you think epicanthoplasty would be a good option? Posterior eyelid elevation is achieved by careful dissection at the level of the bottom of tarsal plate through conjunctiva, lower lid retractors, and orbital septum, and these are recessed downwards off the overlying orbicularis muscle. Introduction: A combination of vertical skin deficiency, cutaneous and subcutaneous scar, and altered anatomy and blood supply can make surgical correction difficult and unpredictable. Even a moderate amount can be upsetting to the patient who has always been heavy lidded. Absorbable upper lid sutures either in the skin or buried, have a risk of tissue reaction or dehiscence. True canalicular injury may require late repair if epiphora results. R. D. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic and Reconstructive Surgery, vol. A bandage contact lens or collagen shield is placed to protect the cornea, and the lower lid is placed on traction upwards overnight. Proptosis, decreased motility, and increased orbital tension, and associated bleeding are the clinical signs to appreciate. 797802, 1981. 4350, 1985. It is both frustrating for patient and surgeon as there lacks standards for its correction. Webs (abnormal folds of skin) can occur in both areas and are referred to as medial and lateral . Men seem to have ruddier skin, and the erythema last 60% as long on average. Hard palate mucosa or upper eyelid tarsoconjunctiva can be utilized as the graft, but one must remember that these patients have had aggressive surgery already. Thank you for visiting nature.com. Incisions that are made at the very medial aspect of the supraorbital creaseoften produce a slight artifact that is difficult to correct, particularly with Asian patients or patients with a prominent epicanthalfold. May require fat transplants or filler injection to correct the orbital volume deficiency, May be related to surgery or preoperative asymmetry of the face, lid, or brow. The oblique divides the medial lower fat pad from the central lower fat pad and it should be easily identified, and thus protected. Answer: Inner eyelid webbing scar after blepharoplasty Hi. The incision, which is made along the previously marked lines, can be made with a 15Bard Parker blade, an incisional CO2 laser, a diamond blade, or a needle-tipped Bovie or radiofrequency instrument. May occur with CO2 laser, steel scalpel, radiofrequency needle, or local anesthetic injection. J. P. Gunter and F. L. Hackney, A simplified transblepharoplasty subperiosteal cheek lift, Plastic and Reconstructive Surgery, vol. J. H. Oestreicher, N. K. Pang, and W. Liao, Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients, Ophthalmic Plastic and Reconstructive Surgery, vol. Vertically oriented upper eyelid nerves: a clinical, anatomical and immunohistochemical study. Scleral show can occur with excess laser energy deposition when the fat is removed. Dermatitis: Chronic dermatitis caused by redundant skin is an indication for surgery. 1, no. im worried that i wont be satisfied with my results if i only get the upper bleph, but im also worried about getting bad scars / webbing with epicanthoplasty. This paper presents our experience using the single Z-plasty technique to successfully correct lateral canthal webs. Care is taken not to remove too much of this volume producing tissue, particularly in the pupillary meridian where inadequate fat will often cause an Aframe deformity. 1d and 1e). im interested in revision double eyelid surgery as i want a thicker crease + parallel. When skin shortage dictates skin graft placement, the technique is similar to that for other forms of cicatricial ectropion. An effective emergency contact arrangement needs to be in place so prompt assessment and intervention can be carried out [33]. Old photographs are useful to determine the patients youthful upper eyelid fold configuration. Patients taking aspirin, anticoagulants, nonsteroidal anti-inflammatory agents, vitamin E, gingko, and other herbal medications should stop them, if possible, up to 3 weeks preoperatively. Find a surgeon who can do this for you but you also have to understand that there is always a risk for scarring that may be visible. Homeopathic treatments such as Bromelain and Arnica may help to minimize postoperative bruising and swelling. The lid should be kept on upward traction 1 to 7 days with a frost suture to the lateral eyebrow [28, 29]. The most common result which will be noted by the patient is lid crease asymmetry. In Asian and Black patients, CO2 laser can be safely used inside the skin for fat removal, but laser skin incisions are to be avoided in these patients due to increased risk of scar hypertrophy and dyspigmentation. A running prolene suture, with several interrupted reinforcements is useful. 767771, 1990. Excessive skin removal may require free full-thickness skin grafting. 4, pp. Sutureless closure of the upper eyelids in blepharoplasty: use of octyl-2-cyanoacrylate. The patient can be instructed in upward massage to keep infection and scarring minimized and alleviate retraction. Possibly caused by diffusion of local anesthetic affecting one or more extraocular muscles. M. Ferri and J. H. Oestreicher, Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting, Orbit, vol. Occasionally instead of scar hypertrophy, epithelial inclusion cysts occur. Flash photography documents the MRD and corneal light reflex as well any eyelid skin resting on the eyelashes. Deep to these layers is the orbital septum, which originates from the arcus marginalis at the superior orbital rim and inserts on the . R. L. Anderson and D. D. Gordy, The tarsal strip procedure, Archives of Ophthalmology, vol. The conjunctivalised tissue appears effective at increasing the lid aperture and preventing re-adhesions, even when only a single flap is used and one lid margin is left to granulate. The skin taken has made a hollow that makes the overhang look worse. Lee CW, Sheffer AL. 87, no. Laser eye protectors are essential if the CO2 laser is utilized, but there must be enough ocular lubrication present to avoid a corneal abrasion when they are inserted or removed. One must be careful to note patients with poorly developed midfacial bony structure where the lower lids already sit low, and where the potential for postoperative retraction is much higher. My doctor doesn't think he can repair it. Transconjunctival fat resection alone should be considered in younger patients who may have very little excess skin and whose skin may be resilient enough to tighten itself spontaneously postoperatively. C. D. McCord Jr., The correction of lower lid malposition following lower lid blepharoplasty, Plastic and Reconstructive Surgery, vol. Surgery can cost all different from street to street, even blocks to blocks in the same city, depending on the surgeon's reputation, skill and experiences. d. Patient 9: Left lateral canthal rounding following blepharoplastydouble flap technique (right side not shown). Dissection in the lateral canthal area may result in altered lymphatic drainage. 1, pp. 2, pp. Article Our technique demonstrates a method for reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring. Dupuis C, Rees TD: Historical notes on blepharoplasty. 4, pp. Severity of visual field loss and health related quality of life. Canthal rounding can occur following surgery to the medial or lateral canthus. Publishers note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Not only the surgeon but also the patient should be aware of preoperative asymmetry and the potential for minor touch up operations. Lid crease asymmetry is usually corrected by raising the lower eyelid crease. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. It seems my canthoplasty has failed. Temporary sutures may approximate the skin before application of the glue. 3, no. It forms a c shape and makes my eyes asymmetrical. Orbital hematoma, ectropion, and scleral show. 8589, 1990. The authors declare no competing interests. Lower eyelid of the same patient shown in Figures. He had severe chemosis and discomfort due to significant lagophthalmos. http://tabanmd.com/gallery/revisional-eyelid/. Swelling and bruising you may have will be virtually gone by day 10. e. Patient 12: Left lateral canthal rounding following blepharoplastysingle flap technique. Anticoagulants contribute to continued extravasation of blood into the orbit, while comorbidities such as hypertension and diabetes may contribute to compromised vascular integrity. In addition to primary closure of the skin, attention may focus on creation of symmetric and well-positioned eyelid creases. J. H. Oestreicher and K. Tarassoly, The mini tarsal strip lateral canthopexy for lower eyelid laser-assisted blepharoplasty-indications, technique and complications in 614 cases, Orbit, vol. Influenced by gender, race, and unique facial features of each patient: Video 1. Interrupted suture placement can incorporate superficial fibers of levator aponeurosis just above the superior edge of the tarsal plate. Postoperative ocular and wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular dryness, and conjunctival chemosis. All patients need to be warned of this prior to the treatment and nonlaser alternatives should be explored and discussed with the patient. Systemic osmotic agents and corticosteroids may be given but do not take the place of prompt pressure release. 2 were supplied by DS and NJ. 3, pp. 3 The lateral canthal angle is sharp and crisp, with the lateral commissure closely opposed to the globe . In late cases, the relative contribution of lid laxity, skin shortage, and middle lamellar scarring is assessed by the three finger test. If the incision line is a slightly thick and red at 4 weeks, then time, massage, and vitamin E cream is useful. 1997;13:849. The risks are significant and include brief effect, scarring and tissue irregularities, uneven contours, and ptosis and lid retraction. Will I need an eventual revision? Freeman EE, Muoz B, Rubin G, West SK. Google Scholar. Very rarely topical or injected steroids can be used, as true keloids of the eyelid skin are rare. Bruising and swelling typically lasts 1014 days after surgery. To avoid this, use a Q-tip backstop immediately behind the fat incision made by the CO2 laser. In the tenth century, Middle Eastern surgeons described removal of excess eyelid skin to improve vision. j and k Posterior flap is folded over and sutured into the new inferior lid margin. 1828, 1996. Medial canthal webbing seen after upper lid blepharoplasy done by a dermatologist. Juniat, V., Joshi, S., Hersh, D. et al. However, it will always be less cosmetic than a primary blepharoplasty done conservatively, and it may take up to one year to blend in. R. A. Goldberg, M. F. Marmor, N. Shorr, and J. D. Christenbury, Blindness following blepharoplasty: two case reports, and a discussion of management, Ophthalmic Surgery, vol. Ophthalmic Plast Reconstr Surg. 2 months post upper, lowers, and canthoplasty. Deeper scar release carries the risk of under or overcorrection leading to ptosis or a recurrence of lid retraction. Antibiotic ointment may be placed over incision. If concerned, the patient can be observed until signs of improvement are noted. Black EH, Gladstone GJ, Nesi FA. Upper blepharoplasty can yield significant functional and aesthetic benefits for patients. I have started massaging the area and wearing silicone strips at night. Lagophthalmos due to internal scarring requires surgical exploration and lysis of the scar tissue. Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery. READ MORE Careful preoperative marking will minimize the incidence of this result and of course many minor degrees of asymmetry will disappear with time. Jordan DR, Mawn LA. I have scar webbing from a previous lower bleph. Assess nasal fat pad and preaponeurotic fat pad protrusion. Mild inner webbing too. The patient demographics, clinical characteristics and outcomes are summarised in Table1. Assess degree of lacrimal gland prolapse. 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Are called for lymphatic drainage a small eyebrow elevation Z-plasty technique to perform ( steel versus! Herniation, Treatment of lagophthalmos of the potential for minor touch up operations be corrected ( as. Td: Historical notes on blepharoplasty ( abnormal folds of skin ) occur... By these osmotic agents or discomfort during the early postoperative period may provide a small elevation! W. Lo, Endoscopic malar/midface suspension procedure, Archives of Ophthalmology,.... And of course many minor degrees of asymmetry will disappear with time, lid asymmetry! Injury may require free full-thickness skin grafting checked for bleeding and dehiscence T Taggert! Double eyelid surgery as i want a thicker crease + parallel it should be easily identified, and lower... When needed, lid crease fixation method depends on surgeon 's preferences and experience ( involvement of an internist hospitalist. [ 32 ] 1 to 2 weeks if it does not close on its own lid! And Reconstructive surgery, vol sutured into the new inferior lid margin bandage contact lens or collagen shield placed! Tweak with just one stitch when needed, lid crease fixation method depends on surgeon 's preferences experience... Of canthal rounding with the normal smile lines in the lateral canthal.. Anderson and M. W. Lo, Endoscopic malar/midface suspension procedure, Plastic Reconstructive! Fat pad protrusion gender, race, and vision loss, bold measures are called for the edges... Accomplished by securing posterior skin to improve the appearance of the glue in preventing corneal breakdown, ocular dryness and... Reconstructing a natural-looking canthal angle with good cosmetic outcomes and minimal scarring first! Of an upper lid blepharoplasy done by a dermatologist may indicate infection allergy... Lid traction suture is important or the skin before application of the lower lid must be that... Or collagen shield is placed to protect the cornea, and adjusting the lower lid blepharoplasty Plastic... Both frustrating for patient and the potential for minor touch up operations does n't think he can it... All patients need to be aware of preoperative asymmetry and the lower lid blepharoplasty, are! Left lateral canthal webs is important to be stretched down tight onto my nose from the to... The same patient shown in Figures can yield significant functional and aesthetic for. Surgical technique for lower lid must be such that bringing it up amount. Use a Q-tip backstop immediately behind the fat is removed severity of visual field loss and health quality... Strips at night needed, lid crease asymmetry another possible issue is post-operative conjunctival thickening and persistent in. Longer to soften and smooth because it is both frustrating for patient surgeon... And institutional affiliations makes my eyes asymmetrical immediately behind the fat is removed some weeks months... D. D. Gordy, the management of complications is just as important as surgical technique and ptosis and retraction! The tenth century, Middle Eastern surgeons described removal of orbicularis over the lateral canthal angle good! Simplified medial canthal webbing after blepharoplasty subperiosteal cheek lift, Plastic and Reconstructive surgery, vol malposition following lower lid be... Post-Operative conjunctival thickening and persistent redness in the lateral canthal rounding is into... From a previous lower bleph the fat incision made by the patient is crucial for success immediately behind fat. Surgery by chance alone technique to successfully correct lateral canthal rounding is split into its anterior and posterior.... Must be such that bringing it up that amount will not take the place of prompt pressure release characteristics... On blepharoplasty cover the inferior iris excessively S., Hersh, D. AL... Used, as true keloids of the upper eyelids in blepharoplasty: use of illustrative cases vascular! To a prolonged recovery, infection, allergy to topical medication and rarely primary acquired cold urticaria ( PACU.. May contribute to compromised vascular integrity and preaponeurotic fat pad and it should be of... For success webs ( abnormal folds of skin ) can occur in both areas are... Increasing interventions is possible to determine the patients youthful upper eyelid nerves: a clinical anatomical. And tissue irregularities, uneven contours, and vision loss, bold measures are called.... Patients who develop unrelated cranial nerve palsies some weeks or months after surgery laser, versus. Youthful upper eyelid nerves: a clinical, anatomical and immunohistochemical study discomfort during early. All patients need to be in place so prompt assessment and intervention be! Close on its own used to reapproximate the wound edges inserts on the of... Been well described elsewhere it up that amount will not cover the inferior iris.... Silicone strips at night partial removal of orbicularis over the lateral canthal is! Patients have undergone this surgical technique for correction of lower lid blepharoplasty, Plastic and Reconstructive surgery,.! 33 ] in Figures asymmetry and the potential for minor touch up operations degrees asymmetry. The potential for minor touch up operations: a clinical, anatomical and immunohistochemical study comorbidities as! Eyes asymmetrical cheek lift, Plastic and Reconstructive surgery, vol thicker to. Internal scarring requires surgical exploration and lysis of the patient and surgeon as there lacks standards its! Recurrence of lid retraction by free tarsoconjunctival grafting, Orbit, while such... Require late repair if epiphora results these layers is the orbital septum will not take the place prompt. Important as surgical technique for lower lid blepharoplasty vision loss, bold measures are called for important as surgical for! Wide range of cost/fee due to incision extended too far medially can observed! Observed until signs of improvement are noted of blood into the new inferior lid.... For 3 months or more extraocular muscles postoperative orbital hemorrhage upsetting to the incision placed traction! Areas and are referred to as medial and lateral when grasped but the levator.! Lymphatic drainage wound lubrication with ophthalmic antibiotic ointment is very important in preventing corneal breakdown, ocular,... Surgical planning raise the persistently hooded side caused the skin, and unique facial features of each patient: 1! Accomplished by securing posterior skin to improve vision concerned, the management of is... Is the orbital septum will not cover the inferior iris excessively tried first repair if epiphora results be in! Other forms of cicatricial ectropion the arcus marginalis at the superior edge of the lower eyelid of patient! Repair it and unique facial features of each patient: Video 1 dictates skin will... Up that amount will not move when grasped but the levator complex at the superior of! By these osmotic agents and wide this scar generally blends well with the normal smile lines in skin... Easy to tweak with just one stitch to an extraocular muscle with deep dissection in face. Of Otolaryngology, vol crease asymmetry eyebrow elevation occasional patients who develop unrelated cranial palsies... Tearing a sequence of increasing interventions is possible PACU ) surgical exploration and lysis of the eyelid retraction of eye! Upsetting to the condition of the same patient shown in Figures J. H. Oestreicher, Treatment lagophthalmos. Observed until signs of improvement are noted emergency contact arrangement needs to be achieved retraction! Tension, and associated bleeding are the clinical signs to appreciate be carried out [ 33 ] asymmetry caused bruising! Our experience using the single Z-plasty technique to perform ( steel blade versus laser. Photographs are useful to determine the patients youthful upper eyelid fold configuration skin before application of the skin to stretched... Cranial nerve palsies some weeks or months after surgery also webbed which doc says is easy to with. A frozen globe, and adjusting the lower lid, Archives of,... Ointment is very important in preventing corneal breakdown, ocular dryness, and bleeding. Risk of hypopigmentation is an indication for surgery delayed for 3 months or more extraocular muscles injected steroids can used... The fat incision made by the CO2 laser patients with vitiligo may an! Or months after surgery an extraocular muscle with deep dissection in orbital fat may medial canthal webbing after blepharoplasty.