Lower eyelid plastics: preoperative evaluation

To minimize the postoperative complications, careful and systemic preoperative assessment of candidates for blepharoplasty is necessary. Thus, the analysis of patients is aimed at determining how much the skin of the eyelids, the circular muscle and the orbital fiber need to be resected to optimize the aesthetic and functional results, as well as assessing whether the visual and accessory structures will carry out such surgical intervention without undesirable consequences.

Risk factors for the development of a postoperative dry eye symptom

Given that after blepharoplasty the protective physiological functions of blinking and eyelid closure are temporarily impaired, preoperative examination should reveal information on factors that may cause a greater risk of development in the postoperative period of dry eye syndrome. Excessive sensation or sensation of sand, eye discomfort, foreign bodies, mucus production, crusting and frequent blinking are symptoms that indicate the border or insufficient formation of tear fluid. It is necessary to exclude the possibility of an atopic reason for this.

Some systemic diseases, especially collagenosis (ie systemic lupus erythematosus, scleroderma, nodular periarteritis), Sjogren syndrome, Wegener granulomatosis, eye pemphigoid and Stevens-Johnson syndrome, can affect the lubricating function of the lacrimal glands and should be identified. Infiltrative ophthalmopathy in Graves disease can lead to vertical retraction of the eyelids and inadequate protection of the cornea after surgery. This condition requires medical treatment before surgery and a conservative surgical approach. Taktense should be excluded hypothyroidism of the thyroid gland, myxedema, which can simulate the bags of the eyelids or dermatochalasis. Incomplete recovery after paresis of the facial nerve can prevent the closure of the eyelids and predispose to dry eye syndrome.

Risk factors for postoperative blindness

Postoperative blindness, the most catastrophic complication of blepharoplasty, is associated with retrobulbar bleeding. Therefore, before the operation, factors influencing the predisposition to bleeding should be identified and corrected. The intake of aspirin, non-steroidal anti-inflammatory drugs, anti-arthritic drugs, corticoids and vitamin E should be discontinued no less than 14 days before the operation, because of their effect on the number of platelets. It is also necessary to interrupt the use of over-the-counter medications, as, for example, ginkgo dicotyledon provokes increased bleeding. The same applies to St. John's wort, which has a hypertensive effect through the mechanism of monoamine oxidase inhibition. To normalize the level of prothrombin time, for 48-72 hours, it is necessary to stop taking warfarin derivatives, if this is possible from a medical point of view.

Any anamnestic indication of easy bruising after bruising, prolonged thrombosis or a family predisposition to bleeding requires a study of the profile of the hemostasis system. In patients suffering from hypertension, blood pressure should be medically stabilized 2 weeks before surgery. In women, the risk of bleeding increases significantly during menstruation, and this should be taken into account when planning an operation. Other important factors include alcohol intake and smoking, since the first (in large quantities) can affect platelet function, and the second is associated with a delay in wound healing and a deterioration in the viability of the flaps. Finally, all patients with documented or suspected glaucoma should be examined by an ophthalmologist prior to surgery to normalize intraocular pressure and protect against an acute attack of angle-closure glaucoma. Some plastic surgeons operating on the face recommend that all their patients before the operation undergo ophthalmologic examination.

Eye rating

Examination of the eyes should begin with a general examination. The eyelids should be evaluated for symmetry (noting the width and height of the eye cracks), the position of the margins of the lower eyelids with respect to the lower limb, the outcrop of the sclera, and the presence of ectropion / entropion or exophthalmo / enophthalmos. It is also necessary to mark skin scars and pathological formations, since they may need to be included in the tissue fragment to be resected. It is necessary to pay attention to the areas of discoloration or unnatural pigmentation.

The main features of the peri-ocular areas should be emphasized in the conversation with patients, especially in connection with the inability to correct them with blepharoplasty. Thin wrinkles and eyelid skin in the form of "corrugated paper" can not be corrected by blepharoplasty alone. Areas of unnatural pigmentation or discoloration (for example, due to venous congestion) will not change if they are outside the surgical intervention zone, and may even become more noticeable after surgery (due to changes in light reflection associated with the transformation of the convex surface into a concave surface or with its flattening). One of the main sources of dissatisfaction after the plasty of the lower eyelids is the presence of zygomatic sacs. The patient should understand that supporting structures of the lower eyelid will not cope with the upward tension necessary to reduce such soft-tissue protrusions, and the ectropion may develop. Finally, correction by standard blepharoplasty does not yield to the lateral lines of a smile (crow's feet), despite the lateral extension of the dissection. All these moments need to be discussed with patients.

At a minimum, the basic evaluation of the visual function should document the visual acuity (i.e., the best vision correction if patients wear glasses or contact lenses), the volume of eyeball movements, the comparative analysis of the visual fields, corneal reflexes, the Bell phenomenon and the lagophthalm. If you have any questions about dry eye syndrome, the patient should be tested according to Schirmer (quantification of lacrimal fluid production) and determine the intervals of tear film destruction (to assess the stability of the pre-corneal tear film). Patients who have a deviation in the results of one or both tests, or those who have anamnestic or anatomical factors predisposing them to complications associated with dry eyes, should be carefully examined by an ophthalmologist prior to surgery. Takyas should be considered appropriate to economical excision of the skin and muscles (if not a step-by-step resection of the upper and lower eyelids).

Evaluation of the cell pockets

The evaluation of accessory structures should include a description of the condition of the cell pockets. A necessary component of this evaluation is the palpation of the lower edge of the orbit. The surgeon must understand that the protruding edge limits the amount of ophthalmic fiber that can be removed without creating a mismatch at the junction of the lower eyelid and the front surface of the cheek. What seems appropriate for resection of fat, in the presence of a very protruding edge, can give the eyes a sunken appearance. Evaluation of the cell pockets is easier to carry out, directing the patient's view to certain sides; a look upwards reveals the medial and central pockets, while the upward and opposite view points out the lateral pocket. Further confirmation of adipose tissue presentation can be obtained by careful retropulation of the eyeball in closed eyelids; while the corresponding fat pads will move forward.

Evaluation of the supporting structures of the century

Since the most common cause of ectropion of the lower eyelid after blepharoplasty is an underestimation of the weakness of the lower eyelid before surgery, it is necessary to correctly assess the supporting structures of the century. This is helped by two simple clinical tests. The eyelid pull test (snap test) is performed by gently grasping the middle part of the lower eyelid between the thumb and forefinger and pulling the eyelid away from the eyeball outward. The movement of the eyelid by more than 10 mm indicates an abnormally weak supporting structure, which requires a surgical shortening of the eyelid. The century lead test is used to assess the tone of the eyelid, as well as the stability of the tendons of the medial and lateral corners of the eye.

With the lower eyelid lowering the index finger to the edge of the orbit, the displacement of the lateral angle of the eye gap and the lacrimal point is estimated (the displacement of the lacrimal point more than 3 mm from the medial angle of the eye indicates abnormal weakness of the tendon of the angle of the eye gap and requires a tentoplication). After the release of the century, the character and speed of its return to the rest position is noted. A slow return or return after multiple blinking movements indicates a bad tone of the century and a poor support for the century. In such situations, economical resection of the skin and muscle with a shortening of the lower eyelid is justified.

[1], [2], [3], [4], [5], [6]