Overview of Blepharoplasty Subciliary Approach
Lower blepharoplasty, sometimes known as eyelid surgery, is often performed because people feel they look old or weary. It can also correct issues like saggy or swollen eyelids. Some specialists believe the popularity of social media has increased the need for cosmetic facial procedures.
There are many ways to perform lower blepharoplasty, but the best approach combines multiple techniques to meet individual patient needs. This means the surgeon is expected to be familiar with a range of methods so they can create a “tailor-made” procedure for every patient. In simple terms, blepharoplasty is a procedure that changes the eyelid’s shape for either practical reasons or appearance.
Subciliary blepharoplasty and Transcutaneous blepharoplasty are two common types of this procedure. Subciliary blepharoplasty reaches the deeper structures of the lower eyelid through an external cut, whereas transcutaneous blepharoplasty is performed to fix slack skin and muscle or fatty bulges. Each technique is chosen based on the condition and appearance of the patient’s eyelid.
Regardless of the type of procedure, complications like eyelid misposition can occur. A thorough examination before the operation can help prevent such issues. A transconjunctival procedure, which avoids some complications, may be chosen in some cases.
The choice between a transcutaneous or transconjunctival approach always prompts debates. Although, each approach has been proven safe and effective. Modern blepharoplasty has evolved significantly with advanced knowledge about the aging process and physical changes associated with it. Current procedures aim for a younger look by smoothing the junction between the eyelid and the cheek. This is achieved using techniques like ligament release, fat adjustment, and mid-face enhancement procedures.
The best results are achieved when surgeons combine multiple methods to minimize problems during lower lid blepharoplasty. For patients without excess skin and muscle, a transconjunctival approach combined with fat adjustment and skin laser treatment may be used. For patients with excess loose skin and muscle, other techniques may be required. Ultimately, the surgeon uses a personalized approach which results in the most natural and harmonious contour of the lower eyelid.
Anatomy and Physiology of Blepharoplasty Subciliary Approach
The eyelids have a complex structure that is comprised of numerous parts. This includes a groove that separates the orbital and tarsal parts, as well as the nasojugal fold on the inner corner of the eye and the malar fold on the outer corner. The skin on the eyelids is the thinnest on our body and only has a small amount of fatty tissue beneath it. This skin transitions into thicker skin as it extends down to the cheek.
There’s a muscle called the orbicularis oculi located beneath the skin and fatty tissue of your eyelids. This muscle has three parts and surrounds your eye in a circular shape. This muscle plays a crucial role in blinking and tear drainage. It gets its blood supply from the temporal and zygomatic branches of the facial nerve, which deliver nutrients and oxygen to the muscle tissue.
Another structure called the orbital septum is located beneath the orbicularis oculi muscle. It’s a thin, fiber-like layer that acts as a barrier to help keep the fatty tissues of the eyelid in their proper position. There are three fat pockets that are located within your lower eyelid that all serve different purposes and are of various colors and sizes.
As we age, changes occur to our eyelids. The skin begins to thin, wrinkle, and lose its elasticity. The muscle tissues can also become looser over time. These changes might lead to orbital fat prolapse (bulging of the fat in the lower eyelid), drooping of the eyelid, and eyelids tilting away or towards the eyeball. Because of these changes, there can become a more noticeable difference between the appearance of the eyelid and the cheek, creating two bulges with a groove in between.
Most of these age-related changes are part of the normal aging process and are due to a combination of factors including tissue shrinkage, loss of structural support, and gravity. There are ways to address these changes, should they become problematic, with a range of procedures and treatment options available.
Why do People Need Blepharoplasty Subciliary Approach
Lower eyelid surgery, also known as blepharoplasty, done through an incision just beneath the eyelashes, can be performed for both cosmetic and functional reasons. Here are some very common reasons for performing this kind of surgery:
1. Dermatochalasis: This is a fancy name for excess lower eyelid skin that has become loose and thin. This is the most common reason for this kind of eyelid surgery. Sometimes, there are also changes in the muscle around the eyelid, or even loosening of where the eyelid connects to the eye socket, that need to be looked after during the operation.
2. Steatoblepharon: This term refers to the condition when fat pushes forward in the lower eyelid. If a younger patient has this problem but does not have any excess skin, doctors might prefer to reach the fat by making an incision inside the eyelid. But if there is also excess skin, it’s more common to use an external incision. Sometimes, there is an unattractive double bulge at the point where the eyelid meats the cheek, and rearranging the fat can soften this look.
3. Ectropion or entropion: These terms refer to aging-related changes of the eyelid where the eyelid turns outward (ectropion) or inward (entropion). These changes often come with extra skin, and fixing the problem with these eyelids is a functional reason for using an external incision for eyelid surgery.
When a Person Should Avoid Blepharoplasty Subciliary Approach
Sometimes, having a type of eyelid surgery called Transcutaneous Blepharoplasty would not work or be unsafe for a patient due to various reasons. These reasons are often linked to those that apply to any optional or cosmetic surgery. They might be either absolute reasons (they must be taken into account), or relative reasons (they can be worked around if safety is ensured).
Absolute reasons a person can’t have this surgery include:
1. If a person expects the surgery to do more than what it’s meant to do.
2. If the person undergoing surgery can only see out of one eye.
3. If the person has active blepharitis or hordeolum, which are inflammation or small bumps on the eye.
4. If the person has uncontrolled glaucoma, which is a serious eye condition that damages the optic nerve.
5. If the person has active myasthenia gravis, which is a chronic disease causing muscle weakness.
Relative reasons a surgery might not be recommended include:
1. If the patient has serious other health issues (such as uncontrolled high blood pressure, heart failure, lung disease, blood-clotting disorders and others) that make surgery too risky.
2. If the patient has history of scarring badly (hypertrophic scarring or keloid formation) after surgery.
3. If the patient has history of skin diseases like pemphigus vulgaris or Stevens-Johnson syndrome.
4. If the patient is taking medicines to prevent blood clots. The medicine should be stopped 1 to 2 weeks before the surgery.
5. If the patient has certain eye conditions such as thyroid orbitopathy that present with a bulged eye or fat prolapse (fatty tissue bulging out). These patients might need another type of procedure called “orbital decompression” instead of blepharoplasty.
Equipment used for Blepharoplasty Subciliary Approach
For a type of eye surgery called ophthalmic plastic surgery, the doctor will need a specific set of tools. These include:
Local anesthesia, which is a medicine to numb your body in the area where the surgery will happen, specifically 2% lignocaine with adrenaline. This helps you not feel pain during the surgery. A topical anesthetic, a cream or gel that also helps numb an area of your body for a short time, is also used. In this case, it’s 0.5% proparacaine.
The doctor will also use a surgical marker, which is like a pen used to mark where on your body the surgery will happen. To cut your body in the exact right places, the doctor will use a tool called a radio-frequency cautery with fine cutting needles. Bipolar cautery is a tool that uses electricity to stop bleeding during surgery, and retractors are tools that hold your skin, muscles or organs out of the way so the doctor can see and work on the area being operated on. The Desmarre retractor is a specific kind of retractor used in eye surgery.
Tissue forceps are used to hold and move tissues, and it has fine teeth like a comb for a good grip. Small scissors, specifically the Wescott or Steven scissors, are used in this surgery for cutting. A needle holder is a tool that securely holds a needle so the doctor can accurately use it to stitch up the surgical area after they’re done. In this surgery, the Barraquer or Castroveijo types of needle holders could be used.
The periosteal elevator is a tool that is used to lift and hold back the periosteum, the thin layer that covers the bones, so the doctor can work on the bone or the tissue beneath it. The Freer is a specific kind of this tool. Artery forceps, sometimes called mosquito forceps, are used to close off your arteries to control bleeding during surgery. They come in varying sizes.
Sutures, or stitches, hold your skin together after the doctor has made a cut. Several types of stitches will be used in this surgery such as the 6-0 polyglactin, 6-0 polypropylene, and 4-0 silk for traction. Traction stitches are used to keep an area of tissue steady.
Who is needed to perform Blepharoplasty Subciliary Approach?
A lower lid blepharoplasty is a procedure done to reshape the lower eyelid. It’s often performed on an outpatient basis, using a subciliary approach. This means the surgeon makes an incision along the edge of the eyelid. This can be done using local anesthesia that numbs the area, but many patients prefer deeper anesthesia or sedation for comfort, especially if a lot of repositioning of fat within the eyelid is necessary.
The surgery needs to be performed in a place well-equipped for these types of procedures, commonly known as a surgical theater. There, a team of medical professionals will work together to make sure everything goes smoothly. This team typically includes a surgeon who will perform the operation, an anesthesiologist to handle the anesthesia, a scrub nurse who assists with sterilization and handing instruments, a surgical assistant who provides direct assistance to the surgeon, and a technician who helps with equipment and other supporting functions.
Each of these professionals plays a crucial role in your care, working together to make sure the surgery is safe and successful. So, you are in good hands from start to finish.
Preparing for Blepharoplasty Subciliary Approach
In cosmetic procedures, it’s crucial to understand the patient’s point of view, their goals, and what they hope to achieve from the procedure. To do this, the patient should be made comfortable and given a mirror to highlight their concerns or changes they’d like to see post-surgery. They should be clearly informed about the available treatment options, the expected results from each procedure, and the potential risks. Once a mutually agreed plan is set, a date for the operation can be arranged, and photographs are taken for record purposes.
Before the surgery, a few assessments are conducted. These include checking the lower eyelid’s position, looking for any signs of inflammation or dysfunction in the lower eyelid margin, and conducting a ‘snap-back’ test, where the eyelid is pulled down and released to see how quickly it returns to its original position. A normal eyelid should snap back immediately, while any delay indicates a loosening of the eyelid, which should be considered in the surgical planning.
The distraction test is also conducted, where the lower eyelid is pulled forward. If it distracts more than 2 mm from the eyeball, it’s considered abnormal. Another test examines the looseness of the tendons at the outer corner of the eye by pulling the lower eyelid towards the nose. The tests give rise to three grades: mild, moderate, and severe, depending on how long it takes for the eyelid to return to its original position, and how much the eyelid can be distracted.
Other assessments include checking the presence of fat pads, presence of a tear trough and lid-cheek junction, relationship of the centre of the eyeball to the most prominent part of the cheek, and any changes to the skin. A ‘pinch test’ is also done to assess excess skin.
Before the operation, the patient’s blood pressure, blood sugar levels, and heart rhythm may be measured. If the patient is on blood-thinning medication, they may be asked to stop it 1-2 weeks before the surgery. On the day of the operation, the surgical area is cleaned, and markings are made on the skin. Depending on the patient and procedure, either local or general anesthesia is used. If a tightening procedure is planned, the eye’s topical numbing drops can be used.
How is Blepharoplasty Subciliary Approach performed
Your doctor will make a small cut or incision in your skin, just under your lash line or in the naturally occurring crease in your skin. This helps in hiding the scar post-surgery. It’s important that the incision doesn’t extend beyond the eye socket to avoid visible surgical scars. Once the incision is made, a type of thread known as a Frost suture is placed to protect the eye and make the operation easier. The decision to place a corneal shield, a protective cover for the eye, is up to your surgeon.
The surgeon will then raise either a skin-only or skin-muscle flap depending on the type of surgery planned. This is achieved by careful and precise cutting and moving of tissue in that area. During this time, maintaining control over bleeding is very important and is achieved by using a device known as bipolar electrocautery. Depending on the type of flap, the cut into the skin is made differently.
There are many ways to perform this surgery, with some doctors preferring to preserve muscle which helps in blinking and tear drainage. Others prefer to move the fat back into the eye socket, strengthening it similar to a hernia repair. Studies show similar aesthetic results but fewer side effects with this fat preserving technique.
Locating the right amount of fat pads to be removed is important and is done before the surgery with you sitting upright. The removal of too much fat can result in the appearance of a sunken eye.
If a skin-flap is elevated, a small cut is made to reach the fat pads. If a skin-muscle flap technique is used, the fat compartments can be exposed all at once through a single cut. Excess orbital fat is then removed safely.
The surgeon then releases certain elements of your eye socket and creates pockets for the repositioning of fat, filling in the tear-trough further. This smooths the junction between your eyelid and cheek. A number of different techniques can be used during this process, such as re-planting fat to recontour prominent facial grooves, or fat transposition in conjunction with a mid-face lift.
Following this, any excess muscle is removed to create a smooth contour. The surgeon will then ensure support for your lower eyelid, as leaving this untreated can lead to complications such as an improperly positioned eyelid. Various techniques can be chosen for this purpose, based on your needs and the preference of your surgeon.
Lastly, the surgeon will be very careful when removing excess skin from the lower lid, as taking too much can lead to visible white of the eye. Fat and skin are then removed and sutured as needed. Some surgeons may prefer a ‘pinch blepharoplasty’ to remove excess skin, which helps avoid incision in the middle layer of eyelid.
Possible Complications of Blepharoplasty Subciliary Approach
One of the most serious complications of cosmetic eye surgery, known as blepharoplasty, is loss of vision. This could be due to a condition called retrobulbar hemorrhage, where bleeding happens behind the eye, leading to damage of the optic nerve or retina due to increased pressure inside the eye socket. Though quite severe, this condition and subsequent vision loss is extremely rare. Most people experience retrobulbar hemorrhage within 24 hours after surgery, typically within the first 3 hours. The chances of this occurring after cosmetic eye surgery is said to be 1 in 2,000 and chances of vision loss after such bleeding is 1 in 22,000.
Signs of retrobulbar hemorrhage include swelling around the eye, severe pain, and loss of vision. The pain can be very intense and may be accompanied by double vision and vomiting. Other signs include a bulging eye, swelling of the eye’s outer layer, increased eye pressure, and loss of pupil light reaction. Any sudden, intense eye pain after cosmetic eye surgery is a medical emergency that should be checked immediately. Vision loss can occur if bleeding continues, causing increased pressure on the eye nerve and retina at the back of the eye.
The priority in treating this condition is to prevent further damage by reducing the eye and eye socket pressure. This is done through surgery to remove any blood clot and stopping the bleeding. Sometimes, a procedure the cuts and loosens the outer corner of the eyelid may also be needed to relieve eye pressure. Only relying on medicine to treat this condition isn’t effective, as it takes too long to work.
Infections after cosmetic eye surgery are also rare but can occur, especially in patients with diabetes or weakened immune systems. Initial symptoms may include swelling, redness, pain, and fever. If left untreated, this can turn into a skin infection or abscess. These infections are treated with strong antibiotics delivered intravenously.
Double vision, or diplopia, can either be temporary or permanent. Temporary double vision can be caused by swelling and usually goes away after a few days. Permanent double vision can result from damage to a muscle in the eye and may need surgical correction. Luckily, this is also quite rare.
Issues with the lower eyelid position can occur after eyelid surgery. Conditions such as showing the white part of your eye more than normal, lid retraction, or eyelid drooping can happen with a certain approach to the surgery. Mild forms of these complications can be managed simply by massaging the area and using adhesive strips. Severe drooping might need additional tightening procedures or even skin grafting.
Injuries to the eye, like corneal abrasion or ulcer, are also rare complications of cosmetic eye surgery. These might need treatment with antibiotic drops and eye patching. Temporary dry eyes are a common side effect of the surgery, which usually resolves 1 to 3 weeks post-surgery. Patients experiencing dry eyes might need eye drops to help lubricate the eyes.
What Else Should I Know About Blepharoplasty Subciliary Approach?
Blepharoplasty is a kind of surgery that is fundamental in making the area around the eye, and ultimately, the entire face look younger. This surgery, often done through the lower eyelid, has been used for a long time, is reliable, and works well for removing extra skin and fatty tissue from under the lower eyelid.
