Evolution of Lower Lid Surgery II

Although eyebags may be removed by making an incision below the eyelashes, the disadvantages of this approach are many including:

a. a scar extending along the length of the lower eyelids which may take time to heal

b. longer down time as the approach is associated with more bruising and swelling

c. risk of lower eyelid retraction especially if the skin and muscle are removed.

 

To avoid these complications, the fat may be removed from behind the eyelids (a transconjunctival approach) in suitable patients.

 

Julien Bourguet (1876-1952), a French surgeon was the first to introduce transconjunctival blepharoplasty. His results were described and published in 1924 with photographs (see photographs below).

 

One of the patients of Julien Bourguet who

had had transconjucntival blepharoplasty.

 

Bourguet's method is still in use and the steps are shown in the diagrams below.

 

Diagrams showing transconjunctival approach for fat removal.

 

 

Transconjunctival approach is used mainly in patients whose main problem is eyebag. This method does not address the problem of loose skin and therefore is not suitable for patients who need skin tightening. Most of my patients having this procedure are patients in their 20s and 30s.

 

Transconjunctival fat removal at one month post-operative.

Transconjunctival fat removal at two week post-operative.

 

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Evolution of Lower Eyelid Surgery I

Lower eyelid surgery is one of the most common surgery performed to rejuvenate the face. The first photographs of lower eyelid surgery were published in 1907 by Charles Conrad Miller, a plastic surgeon in Chicago. In this published article, the excess skin was excised from the lower eyelid between the cheeks and eyelids (very similar to the pictures shown here taken in early 20th century). Although the lower eyelids were tighten, there were obvious scarring and the lower eyelids were retracted causing exposure and tearings. Later on, Miller modified his technique so that the incision was made below the eyelashes (subciliary) very to the modern technique. However, the problem of eyelid retraction remain.

 

Early technique of lower lid blepharoplasty. a. Excess skin below the lower lids;

b. Removal of excess skin between the eyelid and cheek;

 c. Lower eyelid retraction after the excision;

d. Tightening of the lower eyelids but the lower eyelids were retracted.

 

Complications of Tear Trough Treatment II

 

Ever since the invention of syringe and hypodermic needles, various substances have been injected into human faces in the name of beauty. Some of these substances were initially embraced with great enthusiasm only to be discovered later that they cause delayed and serious side effects. One of the these substances is liquid silicone as mentioned in the previous post. Unfortunately, it is still being used by unscrupulous unlicensed personnels due to their cheapness. Many of these gullible victims are left with disfigurements years later and when they tried to get answers from the perpetrators they  are often told that the problems have nothing to do with the initial injections as the complications did
not occur immediately.

The history of seeking the perfect filler began with miner oil (Vaseline). It was first injected in Austria in 1899 to replace a patient’s testicle removed because of TB infection. The initial report was favourable which led to the use of Vaseline and similar product such as paraffin in the first 20 years of the 20th century. However, even with initial good results, seoncdary or late severe complications appeared due to their dispersion causing nodule formations. The most famous victim of paraffin injection was Gladys Spencer-Churchill (1881- 1977), second wife of the 9th Duke of Marlborough. She was an American beauty and was regarded as the most beautiful woman in the West. However, she was unhappy with a kink on her nose and had paraffin injection. The paraffin later migrated to her chin producing paraffinomas (inflammation of tissues caused by paraffin) throughout her face. She became so distressed by her appearance that she did not permit any mirrors in her house. She became a recluse and develop ed mental illness.

Gladys before and after paraffin injection.

 

Incredibly, paraffin injection is still very much alive in the 21st century. A quick search in the medical literature yield reports of complications from  their uses to enhance various body organs such as penises and breasts. A few years ago, a woman consulted me because of progressively swollen cheeks after paraffin injection by an oversea “doctor”. She was persuaded by her beautician to have the injections to remove her tear troughs and make her cheek bones more attractive. The “doctor” reassured her that the injection was not silicone but the “safe” paraffin. Following the injections, the face appeared more pleasing but 9 months later the cheeks began to swell. She went back to the beauty saloon to seek help but was told the doctor had left with no forwarding address. She asked for removal of the swellings as they are causing discomfort and constant redness. However, such operation is often fought with difficulty because of the diffused nature of the swellings. The swellings were eventually removed after a lengthy operation and extensive reconstruction was needed to reconstruct the midface.

Swollen cheeks from paraffin injections.

Removal of the paraffinoma. This operation should not be

taken lightly as the reconstruction is extensive.

 

 

 

Weekend Talk in Penang

Complications of Tear Trough Treatment I

Patients with tear troughs can be managed non-surgically with filler injection. The commonly used fillers are autologous fat and hyaluronic acid.

Tear trough (arrowed) was treated

with hyaluronic acid injection.

 

Unfortunately, some patients went to unlicensed personnels for dangerous fillers such as liquid silicone. Initially, the injections give dramatic and aesthetic improvement. However, over time, most of these patients develop complications such as foreign-body reactions, nodule formation, ulcerations, chronic cellulitis, and distant migration of the material. Patients not only suffer from facial deformity but also have psychological embarrassment with withdrawal behaviors. Treatment is fought with difficulties because the injected materials are diffusedly integrated into the facial tissue and radical resection is often needed leaving unsightly scars. Therefore, patients should go to licensed medical personnels for safe injections or live to regard their decisions.

Progressive swelligns of the lower eyelids two years

after silicone injection. Procedure done by a beautician.

Silicone migration causing asymmetry of the face.

Procedure done in a beauty saloon.

Progressive skin thickening and deformation and

chin elongation five years after silicone injection.

Patient had multiple silicone injections

in a beauty saloon.

 

 

 

Correction of Complication of Lower Blepharoplasty 2

This patient had lower lid blepharoplasty in a beauty saloon two year ago. She complains of dryness of the eyes and rounding of the lower eyelid contour. Examination shows the lower eyelid is tight from excessive skin removal. To restore the normal of the appearance of the eyelid, the skin needs to be replaced. However, the use of skin graft would not aesthetically satisfactory. I recruit the skin by performing disinsertion of the orbiculomalar ligament (see diagram below) and lift the lower eyelid skin by using orbicularis flap (see diagram below) to correct the roundings. 

 

Tightenss of the lower lid and rounding

of the lower lid contours.

Disinsertion of the orbiculomalar ligament.

Disinsertion of the orbiculomalar ligament to recruit

the skin and also to lift the lower lid.

Orbicularis flap is sutured to the orbital periosteum

to lift the lower eyelid.

The picture below was taken at one week after the operation

showing improvement of the retraction

and lower lid contour roundings.

Correction of Complication of Lower Blepharoplasty

Lower eyelid retraction is a common complication of lower blepharoplasty. The main causes are either excessive lower lid skin removal or lower lid laxity.

This 65 year-old man presented with progressive lower lid retraction. He underwent lower blepharoplasty 3 years ago in a beauty saloon. The surgeon was an unlicensed personnel from oversea. He suffered from ocular irritation and recurrent watering eyes. Examination showed severe lower eyelid laxity without significant skin loss.

 

Severe lower eyelid retraction.

Lifting the corner of the eyelid restore the contour of

the lower eyelid. There was no skin shortage.

 

The procedure of choice for this complication is to tighten the lower eyelid as shown in the pictures below.

Steps showing tightening of the lower eyelid using

a procedure known as lateral tarsal strip.

The appearance of the lower eyelids 2 months

post-operative.

 

 

Lower Lid Retraction - A Common Complication of Lower Blepharoplasty

Postoperative changes to eyelid position is a common complication of lower lid blepharoplasty. Most of these cases resolved spontaneously, however, some cases can be permanent resulting in lower lid retraction and rounding of the lower eyelid contour. In addition to the poor cosmetic appearace, these patients can suffer from watering eyes and poor eyelid closure.

 

These complications occur in transcutaneous (in which the skin below the eyelashes is incised) lower blepharoplasty often performed by inexperienced surgeons with removal of too much lower lid skin. Patients at risk are those with lower eyelid laxity when even lesser amount of skin removal can cause lid retraction.

 

The pictures below show different severities of these complications in patients seeking revisional lower blepharoplasty:

 

Mild lower lid retraction with moderate rounding

of the lower lid. The operation was done in a

beautician saloon by unlicensed foreing doctor.

 

Moderate lower lid retraction with

significant rounding of the lower lid. The operation

was done in a beauty saloon by unlicensed doctor.

 

Severe retraction of the lower eyelids with the lower

lids turning out. More severe on the right.

 

Severe retraction of the right lid after transcutaneous

lower blepharoplasty.

 

 

The Surface Anatomy of an Eyebag

The various structures of eyebags are illustrated through diagram and live anatomy.

The various structures of an eyebag shown through cross section of the lower eyelid.

The various structures of an eyebag as shown through live anatomy of the lower eyelid.

What Are the Causes of Eyebags?

I often receive phone calls and emails enquiring eyebag treatments, however, without seeing the patients it is difficult to ascertain what the patients mean by "eyebags". The patients' perception of eyebags may be one or a combination of the following things: loose skin, hypertrophy of eyelid muscle, fat pockets, tear trough, fluid retention to descends of the midface. Therefore, no single anatomic structure can explain eyebags and it is important for the patients to be assessed thoroughly by the surgeon face to face.

The following pictures show pictures of patients presenting with "eyebags":

Eyebags contributed by a = muscles of the eyelid;

b = prolapsed fat and c = tear trough.

Eyebags from tear troughs.

Protruding fats and tear troughs.

Loose skin and descent of the midface.

Protruding fats

Protruding fats and descent of the midface.

Right eye has prominent eyelid muscle

 and the left protruding fat.



Midface descent with protruding fats

and swollen skin on the cheeks (festoons; arrowed)

Lower Eyelid Surgery

Compared with upper eyelid surgery, the lower eyelid tends to be more complicated and if not performed well is associated with more complications. Part of the reasons is the contribution of various anatomical structures that the surgeon needs to address. Not surprisingly, there are many more surgical techniques for the lower than the upper eyelids because of the relative importance of each anatomical structure. It is unlikely that a single technique is sufficient for all aesthetic problems of the lower lid and some inexperienced surgeons avoid doing the lower lid altogether.

 

The different techniques for lower eyelid include:

• simple fat excision (usually performed from behind the eyelid ie transconjunctival lower blepharoplasty)
• simple fat excision with lower lid skin excision (transcutaneous lower blepharoplasty)
• lateral canthal tightening suspension with limited fat and skin excision
• fat transposition
• release of retaining structures to abolish the tear trough
• lower lid bony augmentation with implantation 

Very often the above techniques are used in combination to treat the different aspects of the lower lid blemishes. For example a patient with fat herniation, tear trough and lower lid laxity will need fat excision or transposition, release of retianing structures and lateral centhal tightening.

The photo of this young patient is a good example of the complexity of the lower lid anatomy.  The surgeon need to analyse the importance of each anatomical structure contributing to the lower lid blemish in order to get good aesthetic results.

 

 

a = orbicularis oculis (the muscle under the skin), in some

patient this may be prominent and may be mistaken for eyebag;

b = herniated fat that eyebag usually refers to;

c = tear trough this is a groove marking the attachment

of the muscle to the underlying bony structure.

 

 

Incision Method for Double Eyelid

Eyelids which are puffy as a result of underlying fat tissue do not do well with the suture technique. The treatment of choice is the incision method as shown in the steps below.

 

This patient has a puffy upper lid (left). To create the

double eyelid (right), incision method was performed.

Before the operation, the desired height was agreed upon by

indenting the upper eyelid with a wire to simulate different

heights of the double eyelid. The desired height

was then makred on the eyelid.

A small amount of skin was first removed, marked a.

Then the orbicularis was removed (marked b), followed by

the orbital septum (marked c) to expose the underlying

 fatty tissue (marked d).

Underneath the fat was the levator aponeurosis (arrowed),

an important anatomy crucial for the success of incision method

and must be exposed along its length. To expose the levator muscle,

 the overlying fat was excised.

The exposed levator aponeurosis (arrowed) was sutured to

the orbicularis muscle along the inferior cut edge.

 

The skin was then closed using interrupted sutures.

 

The incision method causes more swelling than the suture method.

However, most swelling should settle by two weeks.

 

 

One of the Many Suture Techniques for Double Eyelids

There are many different ways of doing suture techniques, the one shown here is one such method using three 6/0 nylon sutures.

 

Diagrams showing the placements of the sutures.

Steps in suture techniques:

a. 4 incisions are made on the eyelids.

b, c & d. A curved needle with 6/0nylon is passed full

thickness through one incised area and out through another;

e. The needle is then passed partial thickness through the skin

from the exit site to where the needle initially entered;

 f & g. The suture is tightned;

h. 2 more sutures are similar passed through the lids.

 

 

Before & after using the above technique.

 

Before & after photos using the above technique.

 

A Patient who Can’t Close His Eye after Road Traffic Accident.

This young man was involved in road traffic accident in which he was a motorcyclist. There was substantial loss of eyelid skin and he was referred to the plastic surgeon who performed skin graft using post-auricular graft. Unfortunately, there was shrinkage of the grafts resulting in upper and lower eyelid contracture. The patient was referred to my clinic for further treatment. On examination, the patient had severe lower eyelid contracture resulting in eversion of the lower eyelid (cicatricial ectropion) which interfered with eyelid closure and caused constant watering.

 

Severe eyelid contracture interfering with lid closure (right).

Arrows show shrunken grafts.

 

As there was also skin shortage in the upper lid, I performed a nasojugal flap. He was able to close his eye better at 3-week follow-up.

 

Marking of the flap before surgery (left) and at the end of surgery (right).

The eyelids were tied together for one week to minimize flap contracture.

Diagrams showing how the procedure was performed.

Right picture shows the appearance at one-week

post-operative; left three-week.