Consultant ophthalmologist and oculoplastic surgeon Miss Jane Olver discusses the cause and treatment of sagging of the eyelid
Periocular dermatochalasis is the medical term for excessive loose skin and eye bags. It most commonly affects the upper eyelids where the skin fold loses elasticity and drops both outwards and down onto the eyelashes, also known as ‘hooding’.
The excessive or redundant upper eyelid skin and subcutaneous tissue is caused by either recurrent episodes of swelling (blepharochalasis) or, more commonly, by involutional changes with age and for hereditary reasons. Medical causes of dermatochalasis, include thyroid eye disease, renal failure, trauma, Ehlers-Danlos syndrome, amyloidosis, hereditary angioneurotic edema and xanthelasma.1,2 Cutis laxa (CL), or elastolysis, is a rare, inherited or acquired connective tissue disorder in which the skin becomes inelastic and hangs loosely in folds. The orbital fat, especially the medial fat pad of the upper eyelid, can prolapse through the thin attenuated orbital septum and appear as an unsightly bulge. These are involutional age changes.3
Patients may request blepharoplasty to resolve dermacholasis, which is vital in facial rejuvenation and can be both a functional and cosmetic procedure designed to restore a more youthful, bright, and energetic appearance to the eyes. Dermatochalasis can cause a sensation of heaviness and affect the visual field, especially if it is severe with lateral hooding.
The condition can also disturb the normal upper eyelid pretarsal show, sometimes interfering with the application of eye makeup. For patients it can cause mascara to run due to the skin touching the upper lid lashes, and further cause watering eyes from the exfoliation of skin cells and debris dropping into the eyes from excess skin. With lateral hooding, this can cause tears to form at the lateral corner of the eye.
Dermatochalasis may be associated with upper eyelid ptosis (drooping) secondary to disinsertion or dehiscence of the levator aponeurosis. It may cause a pseudo-ptosis because of the weight of tissue pushing the upper eyelid down.4 There can also be associated eyebrow ptosis (droop) and compensatory eyebrow elevation to lift the skin and soft tissue.
Assessment is key to choosing the correct surgical approach to ensure success. It is crucial to ascertain the patient’s concerns, assess their eyelids and prepare a clear surgical plan.
The patient sometimes complains about tired eyes, sad eyes, or extra tissue around the eyes.6 Ask how the eye bags affect them to determine whether the problem is cosmetic or whether it also affects vision. The patient should provide photographs taken prior to the eye bags becoming noticeable.
Does dermatochalasis run in the family? Do they have a dry eye and have they had corneal refractive surgery? Patients attending for a revision blepharoplasty are a dissatisfied patient requiring additional attention and careful listening. Outline a realistic plan to meet their goals.7
The patient’s entire face and eyelids are examined during the consultation, and an ophthalmic assessment is carried out. Assess the amount of loose tissue to determine if there is co-existent eyelid or eyebrow ptosis, or brow compensatory elevation. Look for fat herniation or protrusion. Medially, the small medial fat pad often herniates forwards. Centrally, the pre-aponeurotic fat pad forms a gentle fullness and helps maintain the skin fold. Also centrally, the sub-brow fat or ROOF (retro-orbicularis oculi fat pad)8 can descend because of loose connective tissue and can contribute to the heaviness and bulging.9 Ptosis is detected by measuring the vertical palpebral aperture in mm though the level of the pupil, and also the upper margin re ex distance in mm, between the light reflex on the cornea and the upper eyelid margin. Normally the upper eyelid margin rests 3.5 to 4.5mm above the centre of the pupil. If there is less than 2.5mm, the ptosis may require correction at the same time as blepharoplasty surgery.10 A simple test with a drop of 2.5% phenylephrine placed on the eye will help unmask a small ptosis on one side as it will raise the eyelid and show the “normal” position in many patients. Measure the visual function and examine the eyelid and ocular surface on the slit lamp. Test for eyelid and eye surface conditions such as blepharitis, dry eye, horizontal eyelid laxity or any other conditions that could be exacerbated by a blepharoplasty. The height of the supra-tarsal crease where the levator aponeurosis pull is exerted is an essential landmark usually 7-9 mm above the lid margin in women, and 6.5-8 mm in men.
A computerised visual field test is required to determine the extent of visual impairment. The visual fields of both eyes together are examined using a Humphrey Field Analyser test such as the Binocular Esterman. This measures functional scores of whether the patient sees tiny dots of light in different parts of their peripheral visual field. This test is well known to the DVLA as it is the current gold-standard for testing binocular visual fields for driving used by many national driving authorities. Binocular Esterman visual fields will show pre-operatively whether the upper eyelids are interfering with the superior visual field and if the dermatochalasis is causing a functional problem. Photographic documentation should also be taken in primary gaze, 30 degrees downgaze, oblique and side views both before and after the procedure.
The goals of upper eyelid blepharoplasty are to create a sculpted upper lid with a visible pre-tarsal strip and subtle fullness along the lateral upper lid-brow complex. There is an increasing trend towards volume preservation and creating a very natural look compared to 15-20 years ago. Then the emphasis was on creating high skin creases, with a skeletonised and hollow upper lid due to overaggressive fat resection. The aesthetic benefits of preserving periorbital fat are now valued.11 In Asian blepharoplasty the aims are different in that the pre-tarsal show is minimised and more soft tissue (fat) removed, unless requiring a Westernisation type blepharoplasty.12
An information sheet about the surgery and potential complications must be given to the patient at the assessment, and a consent form signed before surgery, showing the surgeon understands the patients’ expectations and reinforcing realistic goals.13
Very early dermatochalasis with a slight brow ptosis can be managed in certain cases with botulinum toxin A brow elevation.14 However, the treatment for more severe upper eyelid dermatochalasis is eyelid blepharoplasty, a delicate oculoplastic surgery. Associated eyelid should be corrected, and if there is brow ptosis causing a secondary dermatochalasis, then brow surgery is performed first or simultaneously to the blepharoplasty.
The skin crease is marked with the patient sitting up prior to administering local anaesthetic. The height of this varies between six and eight millimetres and is commonly lower in Asian patients who have a naturally low skin crease, unless ‘Westernisation’ is requested, and is always lower in men than women. After mark-up, a minimum of 20 mm of skin should remain.
A mixture of long acting and short acting local anaesthesia is injected, with weak adrenaline 1 in 400,000. Approximately 5ml are required each side, with top ups available throughout the surgery. Topical anaesthetic drops are placed on the eyes at the start and throughout the surgery. A protective contact lens is advised.
The incision is made along the natural eyelid skin crease a few millimetres above the eyelashes and follows the pre-marked lines.
An elliptical piece of skin and muscle is removed in two separate layers using a blade or a Colorado needle, which greatly reduces bleeding and helps keep the surgery very neat. Great care is made to avoid damage to the underlying thin levator aponeurosis.
The patient is sat up several times during the surgery in order to check the eyelid appearance.
Bipolar coagulation-assisted orbital (BICO) septoblepharoplasty is where the exposed orbital septum (unopened) is treated with bipolar coagulation, as opposed to excision. This “shrinks” the fat pads in.16 TIP: If possible preserve fat otherwise the eyelid may have an A frame deformity (deep central sulcus) with loss of a soft skin crease fold, which looks ageing.
The skin incision is then closed using delicate absorbable or non- absorbable sutures and /or fibrin adhesive.
A drooping brow ptosis or eyelid ptosis may be operated on during the same procedure. A brow ptosis can be corrected before or at the same time. Less brow lifting surgery is being done now than it was 10 years ago when there was an enthusiasm to do more invasive endoscopic forehead and eyebrow lifts.
Complications occur because of inadequate assessment, poor surgery decisions and patients’ expectations not being met. It is imperative that the patient be fully informed of the potential risks of upper eyelid blepharoplasty surgery.17,18,19 (See Table 1).
|Mild bruising and swelling||This can last for up to three weeks|
|Blurred vision||This can occur for a few hours or overnight. It is usually due to surface ocular drying from effect of the anaesthetic. If this persists for more than 24 hours, you should inform you oculoplastic surgeon.|
|Watery eyes ||Reflex tearing commonly occurs for one to two days following surgery due to mild ocular discomfort and surface dryness|
|Dry gritty eyes||This can last for two to three weeks due to reduced blinking. You will be prescribed artificial tears to take during the day (e.g. Hypromellose, Systane, Viscotears or Celluvisc 0.5%) and an ointment at night (e.g. Lacrilube or ‘Simple Eye’ Ointment) to ease this. Topical antibiotics such as Chloromycetin are used for one week if surgery has been done from inside the eyelid.|
|Scratched surface of the eye (corneal abrasion)||Even minor injury to the eye surface during surgery can result in a small abrasion and pain lasting twenty-four hours. If it persists or is severe, the oculoplastic surgeon must be informed.|
|Marked bruising||Marked eyelid bruising or haematoma may occur and is easily visible. Bleeding behind the eye, however, occurs rarely and is not always visible. Haematoma is characterised by severe pain and it may cause loss of vision if not dealt with urgently by lateral canthotomy and cantholysis.|
|Blindness||This is very rare and is thought to be due to bleeding deep behind the eye, see above.19|
|Wound infection||This may occur during the first seven to ten days after blepharoplasty surgery.|
|Incomplete eyelid closure||The eyelids may feel stiff for one to two days and be unable to completely cover the surface of the eye when closed. This usually settles in a few days. If it does not, most likely too much skin was removed.|
|Asymmetry||There may be a minimally uneven skin crease or lid height. Asymmetry may be noticeable if there is swelling. If the asymmetry persists after three weeks, it is possible that it can be corrected with later surgery.|
|Scarring||This is rare in the periocular area. Scarring can usually be later revised with ‘Z-plasty’ type surgery to break up and conceal the scar.|
|Repeat surgery||Patients should be warned of the need for further surgery if an optimum result is not achieved.|
Table 1: Information that should be given to patients on potential complications of upper eyelid blepharoplasty.12, 13, 14
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