Overview of Blepharoplasty, Lower Lid, Canthal Support
Lower blepharoplasty, or lower eyelid surgery, is a very popular type of facial plastic surgery. The goal of this surgery is to enhance the look of the lower eyelids. It does this by dealing with issues like loose skin, fatty areas, and adjusting the position of the eyelid.
Knowing the details about how the lower eyelid is built and spending a good amount of time discussing the possible results and potential risks with the patient, is absolutely essential for the surgery to be successful.
Support for the outer corner of the eyelid (lateral canthal support) is used to fix the issue of a loose lower eyelid. This is done by performing two types of surgeries: canthopexy or canthoplasty.
This rewritten piece will take you through the way the lower eyelid is structured, the way lower blepharoplasty is done, the initial check-up done prior to the surgery, and the various methods of supporting the outer corner of the eyelid.
Anatomy and Physiology of Blepharoplasty, Lower Lid, Canthal Support
Understanding the structure of the eyelid and area around the eye is
crucial for successful lower eyelid surgery. Surgeons need to know how
changes from surgery will impact the eyelid’s function, shape, and
position. Sound knowledge of the anatomy and the changes that come
with aging help surgeons avoid complications and achieve the best
results.
The skin covering the eyelid is the thinnest in our body. It’s
noticeably different from the thicker skin on the cheek which has a
well-defined layer of fat under it. The lower eyelid is made up of
two layers. The front layer is composed of skin and a muscle called the
orbicularis oculi. The back layer includes several components and a
lining of the eyelid called the conjunctiva. There’s also a separate
element called the septum which acts as a barrier between the front
and back layer. There’s a fine line, known as the grey line, which
helps as a guide for surgeons while performing surgery.
The space between the margins of the eyelids is known as the
palpebral fissure. When the eyes are open, it measures around 30mm
horizontally and 10mm vertically. The lower eyelid is usually at or
slightly above the lower edge of the cornea, while the upper eyelid
covers a tiny part of the upper edge of the cornea. The points where
the upper and lower eyelids meet form a kind of angle called the
canthus. In most people, the outer canthus is positioned slightly
higher than the inner canthus, creating what’s known as a positive
canthal tilt. If the inner canthus is higher, it’s known as a
negative canthal tilt. This can lead to complications after surgery,
so surgeons often use techniques to support the outer canthus in these
cases.
The areas of white part which are visible on either side of the cornea
are called scleral triangles. The size of these triangles can impact
the perceived shape of the eyes. Aspects like position of the lower
eyelid can affect the size of these triangles. Patients are usually
informed about this before surgery. The crease of the lower eyelid is
not as clearly defined as the upper eyelid and tends to be positioned
5mm from the inner edge of the eyelid sloping slightly towards the
outer side.
The orbicularis oculi muscle lies just beneath the skin and is the
main muscle that closes the eyelid. It can be divided into three
parts. The capsulopalpebral fascia and inferior tarsal muscles are the
main muscles that open the lower eyelid.
The tarsal plate helps give the eyelid its shape and is located at the
back of the eyelid. It’s connected to the walls of the eye socket. As
we age, it often becomes lax, causing the eyelid to separate from the
eyeball. The tarsal plate is about 25mm long, 1mm thick, and 4mm
high.
The eyelids contain two main and three smaller compartments of fat. In the lower eyelid, for example, one compartment is separated from another by a small eye muscle, and there’s a risk of complications from surgery if this muscle accidentally gets sewn into a stitch. The area also contains two additional fat compartments located beneath the skin around the eye. This extra fat in the mid-face area helps give the face a youthful appearance, though it can become less prominent with age.
The layer of tissue covering the white part of the eye is called the conjunctiva. In the lower eyelid, the part where the conjunctiva folds back to meet the eyelid is about 10mm from the lower edge of the eyelid.
The blood and lymph supply to the eyelids is complex. The blood comes mainly from arteries related to the carotid artery that runs up the neck to the brain, with most of the blood coming from a branch that passes near the nose. This is the main cause of postoperative bleeding beneath the skin. It’s crucial to make a blepharoplasty incision carefully to maintain a good blood supply for the eyelid.
Why do People Need Blepharoplasty, Lower Lid, Canthal Support
Lower blepharoplasty, or eyelid surgery, is primarily carried out for cosmetic reasons. Most people who get this surgery have aesthetic concerns such as excess skin on the lower eyelids, known as dermatochalasis, or a fat pad that has slipped out of place, known as steatoblephron. Functional issues, or problems that affect how the eyelid works, are less common reasons for this procedure compared to upper eyelid surgery. All patients who undergo lower eyelid surgery should be evaluated for the need for canthal support, which may involve procedures called canthopexy or canthoplasty to strengthen and hold up the outer corners of the eyelids.
When a Person Should Avoid Blepharoplasty, Lower Lid, Canthal Support
There are some situations in which a person should not have the surgical procedure called lower blepharoplasty. These are known as “absolute contraindications”. Absolute contraindications include if a person has expectations that are not realistic, or if they have body dysmorphic disorders, a condition where a person can’t stop thinking about one or more perceived defects in their physical appearance. Other situations include if a person has an untreated eye disease, such as acute blepharitis (inflammation of the eyelids), active myasthenia gravis (a chronic autoimmune neuromuscular disease), undiagnosed dry eye syndrome, or thyroid orbitopathy (an autoimmune condition that affects the eye muscles and fatty tissue behind the eyes). Moreover, if glaucoma is not controlled, or if a person only has one functioning eye, these are also situations where lower blepharoplasty should not be performed.
There are also “relative contraindications”, where surgery might still be possible, but certain measures or precautions would need to be taken. For example, if a person has recently had a particular kind of eye surgery called LASIK, they should wait at least 6 months before having lower blepharoplasty to give the cornea enough time to properly heal. Serious health conditions such as heart failure or respiratory failure are also relative contraindications, but surgery may still be performed using local anesthesia. If a person is taking a high dose of blood-thinning medication or has uncontrolled high blood pressure, these conditions could increase the risk of a complication called retrobulbar hematoma, a collection of blood in the space behind the eye, and surgery should be postponed until these conditions can be properly managed.
Equipment used for Blepharoplasty, Lower Lid, Canthal Support
In a typical eyelid surgery equipment set, several tools and materials would be included:
A marker for guiding the surgery, eye drops that help numb the eye (containing 0.5% Tetracaine Hydrochloride), a local anesthetic to numb the area being operated on (like 1% Lignocaine with an added adrenaline solution), a measuring tool to make accurate cuts, and a corneal shield which can be used along with a special lubricant to protect the eye’s surface (the cornea).
Other essential surgical tools that the surgeon might use include a blade handle for holding surgical blades, small gripping tools (Bishop forceps) that help handle soft tissues without damaging them, small surgical scissors (Westcott), and small surgical retractors (Desmarre retractors) that can help keep the surgical area open and are sometimes insulated for safety.
Additionally, the set should include insulated bipolar forceps and needle tip cautery devices (like types Barraquer or Castroveijo) that are used to control bleeding, a cotton-tip applicator for applying medications or wiping away fluids, a fine tool for separating tissues (Freer or Cottle periosteal elevator), a fine tool for holding a needle (needle holder), and different types of sutures (stitching materials) such as 6-0 polyglactin, 6-0 polypropylene, and 4-0 silk which is used for traction during surgery.
One important thing to remember is that chlorhexidine, a common skin cleanser used before surgery, should be avoided around the eyes. This is because it can cause serious complications in the cornea, the clear, front surface of the eye.
Who is needed to perform Blepharoplasty, Lower Lid, Canthal Support?
A procedure called lower blepharoplasty with canthal support, which firms up the area around your eyes, can be done in a fully-equipped surgery room or even in a doctor’s office. This procedure can either be performed under general anesthesia (where you’re completely asleep) or local anesthesia (where just the area being worked on is numbed) with some sedation to help ease any discomfort.
The procedure should be conducted by a specially trained doctor – either a plastic surgeon or an oculoplastic surgeon, who focuses on the area around the eyes. The surgeon will decide the best method of anesthesia and the right place to perform the surgery for your comfort and the best results.
The surgical team will also include a scrub nurse, who knows the surgical tools well, a surgical assistant to help the surgeon during the procedure, and an anesthesiologist (a doctor who specializes in delivering anesthesia) especially if general anesthesia is needed.
Preparing for Blepharoplasty, Lower Lid, Canthal Support
Patients seeking lower eyelid surgery, or ‘blepharoplasty,’ often complain about issues such as wrinkled skin or puffy eyelids. Before proceeding with this type of surgery, doctors need to conduct a physical check-up. This helps them understand the patient’s reasons for surgery, their health condition, and their expectations from the procedure.
To start with, doctors ask patients why they want the surgery. It’s important that the decision should be the patient’s own choice. Doctors also discuss what results patients hope for and they caution against unrealistic expectations. People who are unhappy with their body even when it appears normal (a condition known as body dysmorphic disorder), might not benefit from surgery. Doctors also inquire if patients have a history of dry eyes, as dryness can be measured using the Schirmer test. A check-up of vision and eye movement is also conducted, along with tests for Bell’s phenomenon (an inability to move the eye upward when the eyelid is lifted).[2]
Doctors examine the lower eyelid skin, eye muscles, tendons, fat compartments, and several other factors. Based on the result of the detailed exam, they will recommend either a non-surgical treatment, lower blepharoplasty, or a mix of lower blepharoplasty and a mid-facelift. This decision varies from patient to patient, depending upon their particular conditions and overall health. The doctor will discuss the recovery period and possible side effects with the patient.[14]
Excess skin, muscle, and fat around the eyes, named dermatocalasis, often leads patients to consider eyelid surgery. Skin wrinkles can be active or static. Active wrinkles appear during a smile and can be tackled with botulinum toxin injection. Static wrinkles are permanent and can be treated with dermal fillers, lasers, or chemical peels. Surgery can help with dark circles caused by puffed-up fat but not those caused by skin pigmentation. Doctors can use treatments like an intense pulsed light skin treatment or hydroquinone to lighten the skin.[16]
In case of any lesions or inflammation around the surgical site, the doctor will discuss it with the patient, and post-surgery care will be adjusted accordingly. If inflammation is active, surgery might need to be postponed until it settles down.[14]
Sometimes, lower lid fullness is due to thickening of the muscles around the eye (orbicularis oculi muscle) and not puffed-up fat. If this is identified, part of the muscle may need to be removed.[17]
Bags under the eyes can be due to looseness or weakness in the lower eyelid and supporting structures (tarsoligamentous laxity). To check for this condition, doctors employ a simple test, if the eyelid does not snap back to its original position quickly when pulled down, it indicates weakness. Another test where the lower eyelid is gently pulled away from the eyeball can also help identify this condition. If the eyelid can be pulled away more than 6mm, it is a sign of significant tarsoligamentous laxity.[14]
Loosely attached connective tissue in the eyes (conjunctivochalasis) makes patients more susceptible to conjunctival swelling after the operation. Therefore, patients should be informed about this risk and a possible need for surgical treatment if required.[9]
Recognizing the shape of the eye and the tilt of the eye corners (canthal tilt), the extent to which the eye protrudes from the socket (eye prominence), and the prominence of the cheekbone (malar prominence) are also crucial elements that go into planning for the operation. Detailed measurements take place and are discussed with the patient before the surgery.[19]
In conclusion, the decision to pursue a lower eyelid surgery depends on the patient’s particular conditions, their expectations, and the overall health. Consultation with the doctor ensures that the patient is well-informed and improves the likelihood of a successful outcome.
How is Blepharoplasty, Lower Lid, Canthal Support performed
There are two main approaches to eyelid surgery: transcutaneous and transconjunctival.
The transcutaneous approach involves making a step-like cut beneath your lower eyelashes, followed by the careful separation of skin and muscle layers while keeping some of your eye muscles in place. The surgeon then cuts a certain ligament around your eye, goes into deeper layers of your eye structure, and more directly cuts a layer known as the orbital septum. Swelling or bulging fat around your eyes can be cut down or repositioned towards your cheek. Supporting structures on the side of your eyes are crucial for maintaining your lower eyelid position. Any extra skin can be removed carefully, making sure not to cause too much tension on the inner part of your eye to prevent it from rolling outwards.
The transconjunctival technique, on the other hand, involves making the cut on the inside of your lower eyelid and can approach the deeper structures in your eye more directly. This method can either reduce or reposition the bulging fat in your eyes after releasing the ligaments around your eye. It’s important to ensure the eyelid is not overly extended during the procedure. Any looseness or laxity in your eyelid should typically be addressed in these cases. While this method mainly focuses on the bulging fat, it can also address excess skin through careful removal or through treatment after the procedure. One key limitation is smoothing out the appearance of your lower eyelid, as getting rid of or tightening a certain eye muscle can not be done through this method.
Preoperatively, any looseness in your lower eyelid is assessed. Depending on the extent of this looseness or laxity, and the position of your eye, there are two different supporting procedures that can be done: Canthopexy or Canthoplasty. Canthopexy is chosen if mild loosening can be fixed by the usual tucking of the lower eyelid towards the eye. However, if there’s a lot of looseness, Canthoplasty is chosen. The procedure is usually decided once the surgery has begun.
In both procedures a cut starting from the corner of your eye is made. The canthal tendon (a structure that supports your eyelid) and the lateral part of a plate-like structure in your eye are exposed, and part of the hard outer wall of your eye socket is shown. Strong stitches are passed through the tendon and then securely fixed to the inner part of the eye socket wall. Double stitches should be made at the corner of your eye and fastened to the hard outer wall as deep as possible. The eye muscle is stitched on top of the deep anchoring stitches followed by the stitching of the skin.
During Canthoplasty, the lower and upper parts of the canthal tendon are divided from each other and a certain ligament is also divided to allow greater movement. A part of the structure inside your eye is separated to ease the reshaping of the corner of your eye. Excess skin, muscles, and conjunctiva (a thin clear layer of tissue over your eye) are removed. The outer wall of your eye socket is shown and strong stitches are securely fastened in the same manner as before. The eye muscle and skin are then stitched up.
The height of the anchor suture depends on the prominence of your eyes. The normal position is fixed at the level of the middle of your pupil. However, if your eyes are deeply set, the stitches should be securely positioned deeper and lower than the typical level. If your eyes are prominent with a ‘negative vector’ (meaning your eyes appear more prominent than your cheekbones), the stitch should be located at the level of the top part of your pupil.
In terms of the materials used for stitching, most surgeons prefer non-absorbable, long-lasting materials, such as a double-armed 4-0 prolene suture with a small half-circle needle. Some surgeons, however, prefer absorbable sutures, claiming that the anchor stitches aren’t necessarily permanent and using absorbable ones can prevent possible stitch side effects like abscess formation. These complications are however uncommon.
After the surgery, patients are recommended to rest in bed with their head elevated for the first day. Within this period, the regular application of cold compresses, especially in the first two days, is very beneficial. Stitches are typically taken out after a week. Patients are advised to avoid strenuous activities for roughly two weeks post-surgery.
Possible Complications of Blepharoplasty, Lower Lid, Canthal Support
After an eye surgery, there are possible problems that might happen, though they are quite rare.
1. Retrobulbar hematoma is one such serious complication. It is a condition where there is bleeding behind the eye, and it calls for immediate treatment to relieve the pressure. It happens very rarely, about in 1 in 2,000 cases; the chance of subsequently developing blindness is even less common, about 1 in 22,000 cases.
2. A rupture in the eye globe, or the eye ball, is another possibility – it can happen either directly from the surgery or from the local anesthetic injection.
3. Corneal abrasion or ulceration, which is a scratch or sore on the surface of the eye, is another potential complication, but it can usually be treated with antibiotic eye drops.
There could also be issues with the position of the lower eyelid, where it either turns outward (ectropion) or inward (entropion), or experiences changes that alter its normal round shape (canthal rounding/dystopia).
If too much tissue is removed from fat compartments around the eye, it might be necessary to add volume back in, using a dermis fat graft or fat transfer. It’s important to be careful with how much fat is transferred, as it might stay there permanently. If not enough tissue is removed, then more surgery may be needed to remove the excess fat.
When it comes to adnexal injury, or damage to the nearby parts of the eye, there might be issues like:
– Movement of the eye muscles leading to double vision and pain after surgery, which might require another surgery.
– Dry eye syndrome, particularly for patients receiving hormone replacement therapy and having both upper and lower eyelid surgeries.
– Damage to a part of the eye’s nervous system called the ciliary ganglion.
– Inflammation or swelling after surgery, which can become persistent and need additional surgery.
– Temporary inability to fully close the eyes, especially if the surgery involved the upper eyelid.
Guess what, complications can also arise from the stitches used in surgery, including stitch sinus (an abnormal canal or passageway), inclusion cyst (a type of skin cyst), and granuloma (a type of inflammation).
Lastly, it’s possible that the results of the surgery might not meet expectations, or that the original symptoms might come back.
What Else Should I Know About Blepharoplasty, Lower Lid, Canthal Support?
Lower blepharoplasty with lateral canthal support is a type of eye surgery that’s designed to enhance the look of your lower eyelids and the area around your eyes. Understanding the structure of this area, how it changes with age, and planning properly for the procedure are crucial steps to getting the best results. It’s also important to talk with your doctor about what you can expect from the surgery to ensure you’re happy with the outcome.
