Excess eyelid Tissue surgery

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Cosmetic Surgery - Excess lid tissue,
Cosmetic surgery is both challenging and rewarding. The challenge posed is to effect the realistic expectations of the patient. It is important to remember that there are certain differences in facial structure between the female and male, such as brow and upper eyelid configuration, as well as racial variations.

The male brow has a "T" shape configuration whilst that in the female is "Y" shaped. Assess the eyebrows for ptosis and symmetry, remembering that a patient may initially complain of eyelid ptosis when in fact the underlying problem is one of brow ptosis. The correct operation in this situation is a brow lift rather than blepharoplasty since the latter will if anything further accentuate the patient's problem. Brow ptosis and excess upper eyelid skin often co-exist; surgery should correct each of these components.
Assess the eyelids for symmetry, excess lid tissue, i.e. is the problem one of dermatochalasis or blepharochalasis, and fat prolapse. Specifically examine for lower lid eyelid laxity. If this is present to any significant degree and lower lid blepharoplasty is contemplated then a lower lid tightening procedure may well be necessary. The lower lid skin is assessed for excess tissue, skin wrinkles and altered skin texture. If the latter is the case then periocular laser resurfacing may provide a better result with less risk of complications than skin excision. Is the patient suffering from festoons of excess lower lid skin? If so a variation in the surgical approach from conventional blepharoplasty may be needed.

Anaesthetic or Anesthetic considerations
Most procedures can be undertaken with local anaesthesia but supplementary intravenous anaesthesia provided by a trained anaesthetist should be considered in all cases, especially if the procedure is likely to be prolonged or the patient is apprehensive or nervous. Allow adequate time for the anaesthetic to take effect and ensure skin marking is undertaken before local infiltration.

Direct brow lift
This procedure is particularly suitable for male patients with thick bushy eyebrows and receding hairlines. Complications including loss of brow hair and/or an unsightly scar may result from poor surgical technique. An unacceptable brow position or contour is usually due to inappropriate marking. Permanent forehead parasthesia may occur with supraorbital nerve damage.

Lasers in oculoplastic surgery
The use of lasers in oculoplastic surgery has become increasingly widespread of late. Two lasers are at present pre-eminent in the field; the carbon dioxide and more recently erbium YAG lasers. The basic principle for all these lasers is that of delivering high laser energy in short pulses or bursts, thus maximizing tissue ablation whilst minimizing adjacent thermal damage and hence scarring.

Brow surgery

Brow ptosis generally results from ageing changes of the skin and soft tissues but may be secondary to other causes such as trauma or seventh nerve palsy.
This is useful for the treatment of mild unilateral or bilateral, predominantly lateral, brow ptosis. It is often undertaken in conjunction with blepharoplasty.

Complications
Complications including skin dimpling, skin erosion and cheese-wiring of the sutures can occur with superficial placement. Contour and brow height abnormalities are seen with inappropriate suture placement. Recurrent brow ptosis may occur particularly if absorbable sutures have been used.

Upper Eyelid surgery
Excess upper eyelid tissue and/or herniated orbital fat can be excised for functional or aesthetic reasons. In the former the excess tissues abut or overhang the lash margin, thus interfering with visual function. Significant coincidental brow ptosis must be repaired or it will be worsened by blepharoplasty.

Lower eyelid blepharoplasty
Lower eyelid blepharoplasty is generally undertaken for cosmetic purposes. Three different approaches are described.

Anterior approach blepharoplasty

Anterior approach blepharoplasty is indicated in patients with excess lower eyelid skin and fat prolapse.
Technique - The skin is incised with a scalpel and deepened centrally on to the tarsus. A skin muscle flap is initially fashioned and elevated off the tarsus and septum, then extended laterally and medially using scissors.
Transconjunctival blepharoplasty
Transconjunctival blepharoplasty is indicated in patients with fat prolapse but without excess skin.
External direct lower eyelid blepharoplasty
This procedure is reserved for excision of significant lower eyelid tissue in the form of festoons.

	Endoscopic forehead and brow lift This small incision technique is an alternative to the more extensive coronal brow lift. It facilitates brow elevation with coincident reduction of forehead creases whilst minimizing scarring.
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