Bleph & Brow Flashcards
1
Q
What are features of an aesthetically pleasing eye?
A
- positive canthal tilt
- Smooth arch along eyelid margins
- especially upper lid, where highest point occurs between medial limbus and pupil
- Smooth and crisp supra-tarsal crease
- normal: women 9-12 mm above margin; men 6-9; asian 2-3
- smooth contours along transitions
- brow to pre-orbital lid to pre-palpebral/tarsal lid
- lower lid to midface/cheek
2
Q
What is the etiology of unsatisfactory eyelids?
A
- Age related / involutional changes to tissues
- skin - atrophy, loss of elasticity, redundancy, attenutation of levator-dermal attachments
- muscle - hypertrophy, festoon, relaxation/ptosis
- fat - herniation secondary to ligamentous attenuation (Lockwood, orbital septum)
- Lid ptosis - congenital, acquired
- Edema - idiopathic, acute, chronic, allergic
- Brow ptosis (not a true eyelid problem)
3
Q
Describe anatomic findings associated with aged upper and lower lids
A
- Upper
- static / dynamic upper lid rhytids / crows feet
- lateral hooding / dermatochalasis and “lid skin ptosis”
- retraction/hollowing of supratarsal crease
- can be associated w brow ptosis
- Lower
- nasojugal fold
- tear trough deformity - groove overlying orbital rim (intact orbitomalar ligament with overlying fat herniation, underlying malar festoons)
- malar festoons (redundant orbicularis)
- excess skin / lax skin
- orbicularis hypertrophy
4
Q
describe history for patient presenting with unsatisfactory eyelids
A
- aesthetic / chief complaint: specific problem, aesthetic vs. functional, goals and expectations of treatment
- HPI: duration of problem, progression of problem (over time vs within a day), acute & unilateral ptosis, treatments to date, previous injuries or unrelated procedures to peri-orbita
- Ocular: gross VA, corrective lenses/contacts, previous/planned lasic, dry eye, excess tearing, allergies, history of edema/swelling
- PMHx: autoimmune or CTD (incl raynauds, sjrogren’s, lupus, scleroderma), DM, thyroid or other endocrinopathy, HTN, bleeding d/o; MEDS/ALLERGIES/SMOKING STATUS
5
Q
describe your physical exam for patient presenting with unsatisfactory eyelids
A
- exam will follow: overall/general, ocular, globe, forehead/brow, upper lid, lower lid
- overall/general: body habitus of patient, excess fat, skin care/quality, sun damage, rhytids, evidence of smoking
- ocular: gross VA, pupil assessment, EOM, Bell’s phenomenon
- special: schirmer’s test for dry eyes
- globe: symmetry, dystopia, enopthalmos, exopthalmos, negative globe vector, canthal tilt
- forehead/brow: rhytids (vertical, horizontal), resting tone, primary brow ptosis (how much below the rim), compensated lid ptosis
- upper lid: lateral hood, skin excess/laxity, lacrimal excess, lid ptosis (position at central limbus), excess intra/extra-ocular fat (globe pressure), position of supratarsal crease, amount of pre-tarsal lid show
- lower lid: nasojugal groove, tear trough, malar bag, orbital festoon, skin excess/laxity
- special tests: squint test - resolve festoon = ptotic muscle; not resolved then hypertrophic; snap test and distraction test for lid laxity; levator excursion
6
Q
what are risk factors for dry eye post op after eye lid surgery
A
- abrnomal peri-ocular anatomy
- Proptosis, lagophtlamos, exophthalmos, no/poor bell’s phenomenon, dry eye, intolerance of contacts, scleral show, negative vector/maxillary hypoplasia
- abnormal peri-ocular history
7
Q
What are the goals of blepharoplasty?
A
- Both
- restore youthful appearance
- judicious excision of excess fat and skin
- smooth skin
- be aware of and avoid post-operative complications
- Upper
- accuentuation of appropriately positioned supratarsal fold
- smooth arch to supratarsal fold
- smooth skin over pre-tarsal lid
- sufficient pre-tarsal lid show
- restoration of volume
- Lower
- maintain lid position and shape
- smooth contour from lid to cheek
- resuspension of excess fat
- tighten lower lid skin
8
Q
List treatment options for aged eyelids
A
- Non-surgical
- nothing
- laser, peel, botox
- Surgical / blepharoplasty - grouped into
- what’s excised: skin, fat, muscle, combination
- approach: transcutaneous, transconjunctival
9
Q
describe your markings for an upper lid blepharoplasty?
A
- patient is sitting, brow compentation or contribution is eliminated w/ gentle pressure
- first mark with subtle dashed line the existing supra-tarsal fold
- then mark the lenticular incision
- inferior component
- A - ~ 10mm above margin @ pupil (7mm for men)
- B - ~ 4mm above margin @ punctum
- C - ~ 4mm above margin @ or just lateral to LCT
- then mark superior component - how much to excise?
- D point is above A point
- pinch test - leave < 1mm lagophthalmos
- leave 20mm total brow to margin (therefore >=10mm above D point to brow + 10mm from A point to margin = 20mm)
- connect to inferior incision apices via lenticular approach, laterally superior point is lateral and following a rhytid
10
Q
Describe your steps in an upper lid bleph
A
- informed consent
- marked sitting as described
- supine position
- GA or conscious sedation or local
- excise skin with scalpel
- assess need for lateral pre-septal fat excision w/ lateral hood
- raise thin layer of palpebral/orbicular muscle using steven’s and excise
- adv: better demarcation of fold, smooth contour of fold, minimizes lid bulk
- disadv: leaving it preserves fullness
- assess need for medial fat pad excision - make small septal perforation and gentle pressure on globe; only excise that which herniates through septum
- ensure repeat local and use bipolar
- hemostasis
- closure - running 5-0 prolene
- Consider adjuncts
- lacrimal gland pexy
- lateral brow pexy to supraorbital rim periosteum
- excision of corrugator
- lid ptosis correction with open tarso-levator plication/advancement
11
Q
which patients would you want to consider techniques to emphasize supra-tarsal crease?
A
- Asian eyelid requesting a crease
- Crease < 4-7mm
- Male w/ associated brow ptosis
- revision
12
Q
List approaches during blepharoplasty that are described to enhance supra-tarsal crease definition
A
- 3 commonly described approaches
- flowers
- permanent suture from skin, levator and tarsus
- sheen
- suture from pre-palpebral OO to levator
- baker
- no suture
- excise sufficient pre-palpebral OO to allow skin to adhere to levator
13
Q
describe your marking for a transcutaneous lower lid bleph
A
- from medial limbus, lateral to LCT along a rhytid
- 1-2mm below margin (subciliary incision)
14
Q
what makes you decide between transcutaneous vs. transconjunctival approach to lower lid bleph?
A
- transcutaneous
- adv: allows for redraping/excision of post septal fat and excision/redraping of excess skin,
- disadv: external scar (not usually visible),
- transconjunctival
- adv: lower risk ectropion, good for excising or redraping post-septal lower lid fat when there is not excess // redundant skin, good for smoothing contour from lid to malar prominence, no external scar, with retroseptal approach
- disadv: no ability to excise redundant skin, possibility to injure internal oblique at CPF (rare), entroption (rare)
15
Q
describe your steps and thought process during lower lid transcutaneous bleph
A
- informed consent
- skin markings as described while upright
- GA or conscious sedation
- globe protection
- incise skin only along subciliary marking
- stairstep down to pre-palpebral OO then drop into submuscular (pre-periosteal) plane
- release the orbital retaining ligament
- assess the post-septal fat pad and consider your options
- pull out medial fat pad, suture to I/O margin, reset the septum slightly more inferiorly
- other maneuvers to re-suspend/re-drape the post-septal fat (suture to periosteum)
- vs. excision of excess middle, lateral +/- medial fat
- consider position of canthal tilt and LCT - should we do a pexy or plasty?
- if vector is negative or lid laxity, to a canthoplasty and release inferior attachment, excise excess and re-suspend slightly over-corrected to whitnall’s tubercle
- to secure repair or prevent ectroption, consider canthopexy
- redrape skin-muscle flap, determine amount to excise so closure is tension free
- consider fat augmentation to smooth lid-cheek junction
- consider temporary tarsorrhaphy to prevent corneal exposure and ectroption
