Blepharoplasty

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Upper eyelid blepharoplasty: The blue-ink delineated surgical plan, and the incisions made to correct a defect of the patient′s upper eyelid.
Blepharoplasty
Intervention
ICD-9-CM 08
MeSH D019882
Illustration depicting incision lines for blepharoplasty

Blepharoplasty (Greek: blepheron, “eyelid” + plassein “to form”) is the plastic surgery operation for correcting defects, deformities, and disfigurations of the eyelids; and for aesthetically modifying the eye region of the face. With the excision and the removal, or the repositioning (or both) of excess tissues, such as skin and adipocyte fat, and the reinforcement of the corresponding muscle and tendon tissues, the blepharoplasty procedure resolves functional and cosmetic problems of the periorbita, which is the area from the eyebrow to the upper portion of the cheek.

The operative goals of a blepharoplastic procedure are the restoration of the correct functioning to the affected eyelid(s), and the restoration of the aesthetics of the eye-region of the face, which are achieved by eliminating excess skin from the eyelid(s), smoothing the underlying eye muscles, tightening the supporting structures, and resecting and re-draping the excess fat of the retroseptal area of the eye, in order to produce a smooth anatomic transition from the lower eyelid to the cheek.

In an eye surgery procedure, the usual correction or modification (or both) is of the upper and the lower eyelids, and of the surrounding tissues of the eyebrows, the upper nasal-bridge area, and the upper portions of the cheeks, which are achieved by modifying the periosteal coverings of the facial bones that form the orbit (eye socket). The periosteum comprises two-layer connective tissues that cover the bones of the human body: (i) the external layer of networks of dense, connective tissues with blood vessels, and (ii) the internal, deep layer of collagenous bundles composed of spindle-shaped cells of connective tissue, and a network of thin, elastic fibres.

Indications[edit]

Transconjunctival blepharoplasty: The removal of orbital fat for the cosmetic modification of the lower eyelid.[broken citation][1]

The thorough pre-operative medical and surgical histories, and the physical examination of the patient’s periorbital area (eyebrow-to-cheek-to-nose), determine if the patient can safely undergo a blepharoplasty procedure to feasibly resolve (correct or modify, or both) the functional and aesthetic indications presented by the patient. Sequentially, lower eyelid blepharoplasty can successfully address the anatomic matters of excess eyelid skin, slackness of the eye-muscles and of the orbital septum (palpebral ligament), excess orbital fat, malposition of the lower eyelid, and prominence of the nasojugal groove, where the orbit (eye socket) meets the slope of the nose.[medical citation needed]

Concerning the upper eyelid, a blepharoplasty procedure can resolve the loss of peripheral vision, caused by the slackness of the upper-eyelid skin draping over the eyelashes; the outer and the upper portions of the field of vision of the patient are affected, and cause him or her difficulty in performing mundane activities such as driving an automobile and reading a book.[2]

Procedures[edit]

Blepharoplasty: The yellow fat (adipocyte tissue) and the skin (linear tissue) removed during a quadruple blepharoplasty. The fat from the lower eyelid was removed with a transconjunctival technique.

A blepharoplasty procedure usually is performed through external surgical incisions made along the natural skin lines (creases) of the upper and the lower eyelids, which creases then hide the surgical scars from view, especially when effected in the skin creases below the eyelashes of the lower eyelid. According to the technique applied by the plastic surgeon, the incisions can be made from the conjunctiva, the interior surface of the lower eyelid, as in the case of a transconjunctival blepharoplasty. Such a technique permits the excision (cutting and removal) of the lower-eyelid adipocyte fat without leaving a visible scar, but, the transconjunctival blepharoplasty technique does not allow the removal of excess eyelid-skin.[2]

A blepharoplasty operation usually requires 1-3 hours to complete. Post-operatively, the initial swelling and bruising consequent to the surgery will subside and resolve with 1–2 weeks; the final, stable results of the blepharoplastic correction will become apparent after several months. The results of a blepharoplasty procedure are best appreciated by comparing pre- and post-operative (before-and-after) photographs of the eye region of the patient.[medical citation needed]

The anatomic condition of the eyelids, the (wear-and-tear) quality of the patient’s skin, his or her age, and the general condition of the adjacent tissues, consequent to the anatomic conditions of the patient, affect the functional and aesthetic results achieved with the eyelid surgery. Additional to the anatomic conditions of the eye region of the patient, the occurrence, or not, of medical complications is determined by factors such as:[medical citation needed]

  • Dry-eye syndrome — which can become exacerbated by the disruption of the natural, lacrimal (tear) film of the eyes
  • Palpebral skin laxity — looseness of the lower eyelid margin, which predisposes the lower eyelid to malposition
  • Eyeball prominence — the protrusion of the eyeball in relation to the malar (cheek) complex, which predisposes the lower eyelid to malposition
Transconjunctival blepharoplasty of the right lower eyelid.
Fat is removed from the lower eyelid by means of an incision to the inner surface of the eyelid. A surgical suture retains the inner tissue of the eyelid over the eyeball. 
The fat is held with forceps (left), and clamped with a hemostat (right), while a small medical retractor keeps away the extra tissue, so that the surgeon can operate. (bottom right). 
The fat is excised (cut away) with surgical scissors. gallery 

Asian blepharoplasty (double eyelid surgery) is a blepharoplasty procedure used to create a supratarsal epicanthic fold in the upper eyelid of the patient who lacks such a crease.[3] The supratarsal epicanthic fold is common to most ethnic groups, but is absent in approximately half of the Asian population.[medical citation needed]

Patient Safety[edit]

Although the American healthcare system provides high quality care for most patients most of the time, there is significant room for the improvement of patient safety. Medical errors harm approximately one in seven Medicare patients during their hospital stay [4]. According to a recent review of studies published between 2008 and 2011, between 210,000 and 400,000 deaths each year in the United States are associated with preventable harm [5]. One in 20 hospitalized patients suffer from healthcare-acquired infections, such as catheter-related bloodstream infections, hospital-acquired pneumonia, or surgical site infections 3 [6].

Simple checklists are often used to reduce costly and dangerous mistakes in complex industries such as aviation and medicine. Checklists for doctors have been shown to reduce patient complications and even death [7]. Checklists have been particularly successful in improving outcomes after surgery. Peter Pronovost, an intensive care specialist at Johns Hopkins Hospital, patient safety expert, and leading advocate for checklists, has demonstrated that simple checklists are effective in reducing preventable harm. In a program developed at Johns Hopkins, Dr. Pronovost has shown that a simple checklist of safety procedures can significantly reduce catheter-associated bloodstream infections in the intensive care unit (ICU), saving lives and millions of dollars [8]. In Michigan, Dr. Pronovost’s introduction of an intensive care checklist protocol over an 18 month period saved 1,500 lives and $100 million [9]. Dr. Pronovost has described his findings on physician checklists in a book he co-authored: Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out [10]. Training surgeons in communication and using a procedure checklist before, during, and after surgery has also been shown to significantly decrease patient complications up to 30 days after surgery [11]. One study found that a surgical safety checklist used at 8 hospitals around the world reduced major complications after surgery by 36% and lowered the death rate by nearly half [12].

Checklists including essential questions for the doctor are also an important way for patients to ensure that they receive high quality health care. Asking doctors key questions at each stage of care improves communication between patients and their health care team, leading to better, safer, and more efficient health care [13]. Many leading health care organizations including the Centers for Disease Control and Prevention (CDC), the Cleveland Clinic, and the U.S. Department for Veterans Affairs provide key questions for patients to ask their doctors. The Agency for Healthcare Research and Quality (AHRQ) provides tips and tools for patients to ask their doctors informed and important questions. Better communication between patients and doctors leads to better health care for patients, as well as greater satisfaction among physicians. In a recent randomized controlled trial of knee and hip replacement patients who were given a structured list of questions to ask their surgeon, significantly more patients in the intervention group (58%) reached an informed decision during the first visit on whether or not to have surgery compared to a control group (33%). Surgeons had higher ratings of the number and appropriateness of patient questions, better satisfaction with the efficiency of the visit, and were more satisfied overall with patients in the intervention group compared to the control group [14]. Patients can find tailored lists of questions for their surgeon and doctors on many websites. Lists of questions to ask your doctor can be found here. Lists of questions to ask your doctor can be found here.

Society and culture[edit]

Removal of double eyelids[edit]

A Korean woman, before (left) and after (right) undergoing East Asian blepharoplasty

East Asian blepharoplasty, also known as "double eyelid surgery", is a type of cosmetic surgery where the skin around the eye is reshaped (blepharoplasty). The purpose of the procedure is to create an upper eyelid with a crease (i.e. "double eyelid") from an eyelid that is naturally without a crease (a.k.a. "single eyelid").[15]

Anatomically, there are a number of subtle differences in the upper eyelids of many East Asians, compared with the eyelids of Caucasians.[16] While some East Asians have a double eyelid and some do not, there is also a large variation in the crease position (double eyelid size) of the East Asian upper eyelid. The upper lid fold can range from 1 mm (0.039 in) above the eyelash line to about 10 mm (0.39 in). Several methods can be used to create the double eyelid — including the full-incisional, partial incision and no incision methods (e.g. the DST method). Each has its advantages depending on the patient's anatomy and desires.

East Asian blepharoplasties have been reported to be the most common aesthetic procedure in [17] South Korea[18] and other parts of East Asia.[19] The procedure has been reported to have some risk of complications, but is generally quite safe if done by an expert plastic surgeon.[20] Practitioners of Asian double eyelid surgery include plastic surgeons (facial plastic and reconstructive surgeons), otolaryngologists, oral and maxillofacial surgeons, and ophthalmologists (oculoplastic surgeons). A procedure to remove the epicanthal fold (i.e. an epicanthoplasty) is often performed in conjunction with an Asian blepharoplasty.[21]

The procedure to alter the natural East Asian "single eyelid" appearance has been a subject of controversy. For example, opponents of the procedure, such as author David Mura, described it as being "indoctrinated by white standards of beauty",[22] although New York-based cosmetic surgeon Dr. Edward Kwak states that many patients who get the procedure done are "not trying to look white", but look like the many Asians who naturally have an eyelid fold.[23] There is also a belief that double eyelids provide a more energetic appearance, and the procedure is popular among high school graduates in China with the view that it will improve their job prospects.[24]

History[edit]

Initial incision along the upper left eyelid

Karl Ferdinand von Gräfe coined the phrase blepharoplasty in 1818 when the technique was used for repairing deformities caused by cancer in the eyelids.[medical citation needed]

As techniques began developing the ancient Greeks and Romans began writing down and collecting everything they knew involving these procedures. Aulus Cornelius Celsus, a first-century Roman, described making an excision in the skin to relax the eyelids in his book De Medicine.[25]

Laser[edit]

Laser blepharoplasty is the performance of eyelid surgery using a laser instead of a scalpel. Laser blepharoplasty is often combined with laser eyelid rejuvenation, as the two procedures can be performed in conjunction.

Historically there has been some contention as to the categorisation of laser treatment on upper or lower eyelids as blepharoplasty, which is itself by definition surgical. The statutory definition of surgery and that supported by the American College of Surgeons states that surgery is the "treatment ... by any instrument causing localized alteration or transportation of live human tissue, which include lasers.." .[26]

See also[edit]

References[edit]

  1. ^ [broken citation]Kami Parsa, MD
  2. ^ a b Pan, Brian S. Blepharoplasty, Lower Lid Subciliary (2006). http://www.emedicine.com/plastic/topic4.htm
  3. ^ McCurdy Jr, JA (2005). "Upper blepharoplasty in the Asian patient: the "double eyelid" operation". Facial Plastic Surgery Clinics of North America 13 (1): 47–64. doi:10.1016/j.fsc.2004.07.001. PMID 15519927. 
  4. ^ "Adverse events in hospitals: National incidence among Medicare beneficiaries". Retrieved 2014-04-01. 
  5. ^ James JT (September 2013). "A new, evidence-based estimate of patient harms associated with hospital care". J Patient Saf. 9 (3): 122–8. doi:10.1097/PTS.0b013e3182948a69. PMID 23860193. 
  6. ^ "Key facts about patient safety". Retrieved 2014-04-01. 
  7. ^ "Checklists to improve patient safety". Retrieved 2014-04-22. 
  8. ^ Pronovost PJ (Apr 2011). "His program reduces bloodstream infections across the country. What’s next?". Manag Care 20 (4): 28–31. PMID 21553685. 
  9. ^ Pronovost, Peter (December 9, 2007). All Things Considered. (Interview). National Public Radio. 
  10. ^ Vohr, Eric; Pronovost, Peter. Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. New York, NY.  Unknown parameter |Date= ignored (|date= suggested) (help); Unknown parameter |eISBN= ignored (help); Unknown parameter |Publisher= ignored (|publisher= suggested) (help)
  11. ^ Bliss LA, Ross-Richardson CB, Sanzari LJ, Shapiro DS, Lukianoff AE, Berstein BA, Ellner SJ (December 2012). "Thirty-day outcomes support implementation of a surgical safety checklist". J Am Coll Surg. 215 (6): 766–76. PMID 22951032.  Text "doi: 10.1016/j.jamcollsurg.2012.07.015 " ignored (help)
  12. ^ Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group (January 29 2009). "A surgical safety checklist to reduce morbidity and mortality in a global population". N Engl J Med. 360 (5): 491–9. PMID 19144931.  Text "doi: 10.1056/NEJMsa0810119 " ignored (help);
  13. ^ "Questions to ask your doctor: Questions are the answer". Retrieved 2014-04-01. 
  14. ^ Bozic KJ, Belkora J, Chan V, Youm J, Zhou T, Dupaix J, Bye AN, Braddock CH 3rd, Chenok KE, Huddleston JI 3rd (September 2013). "Shared decision making in patients with osteoarthritis of the hip and knee: results of a randomized controlled trial". J Bone Joint Surg Am. 95 (18): 1633–9. doi:10.2106/JBJS.M.00004. PMID 24048550. 
  15. ^ Chen WP (1996). "Concept of triangular, trapezoidal, and rectangular debulking of eyelid tissues: application in Asian blepharoplasty". Plast. Reconstr. Surg. 97 (1): 212–8. doi:10.1097/00006534-199601000-00035. PMID 8532781. 
  16. ^ Jeong S, Lemke BN, Dortzbach RK, Park YG, Kang HK (1999). "The East Asian upper eyelid: an anatomical study with comparison to the Whites eyelids". Arch. Ophthalmol. 117 (7): 907–12. PMID 10408455. 
  17. ^ Liao WC, Tung TC, Tsai TR, Wang CY, Lin CH (2005). "Celebrity arcade suture blepharoplasty for double eyelid". Aesthetic Plast Surg 29 (6): 540–5. doi:10.1007/s00266-005-0012-5. PMID 16237581. 
  18. ^ http://leeds.academia.edu/RuthHolliday/Papers/744838/Gender_Globilization_and_Cosmetic_Surgey_in_South_Korea
  19. ^ Kim JW, Lee JO (1998). "Asian blepharoplasty with a short-pulsed contact Nd-Yag laser: limited-incision resectable laser double fold with internal medial and lateral functional epicanthoplasty". Aesthetic Plast Surg 22 (6): 433–8. doi:10.1007/s002669900230. PMID 9852177. 
  20. ^ Chen SH, Mardini S, Chen HC, et al. (2004). "Strategies for a successful corrective Asian blepharoplasty after previously failed revisions". Plast. Reconstr. Surg. 114 (5): 1270–7; discussion 1278–9. doi:10.1097/01.PRS.0000135951.55118.59. PMID 15457048. 
  21. ^ Yen MT, Jordan DR, Anderson RL (2002). "No-scar Asian epicanthoplasty: a subcutaneous approach". Ophthal Plast Reconstr Surg 18 (1): 40–4. PMID 11910323. 
  22. ^ http://www.fashionwindows.com/fashion_review/2000/eyelid_surgery.asp
  23. ^ http://www.slanteyefortheroundeye.com/2008/05/more-on-asian-eyelid-surgery.html
  24. ^ Waldmeir, Patti (July 23, 2013). "When one pair of eyelids isn’t enough". Financial Times. Retrieved July 23, 2013. 
  25. ^ Cecilia Tran, Preoperative Considerations in Blepharoplasty, Baylor College of Medicine, 25 September 2006, http://www.bmc.edu/oto/grand/04_22_04.htm
  26. ^ Grill, C, 'Defining surgery' Bulletin of the American College of Surgeons, May 2012, http://www.facs.org/fellows_info/bulletin/2012/grill0512.pdf