Blepharoplasty

What is Eyelid Laxity?
Eyelids protect your eyes from any foreign bodies while keeping them lubricated throughout. Any alteration in the shape, position or function of your eyelids can predispose your eyes to a plethora of ailments or interfere with our vision.  

Our eyelid is a complex structure consisting of three theoretical layers:
  • Anterior Layer contains the skin and orbicularis muscle
  • Middle Layer contains  the orbital septum and eyelid retractors
  • Posterior Layer contains tarsus and conjunctiva.


Eyelid malpositions include any unnatural or incorrect positioning and orientation of eyelids due to various factors that influence any of the three layers of the eyelids. They may be caused due to ageing, trauma, scarring, birth defects or medical disease involving any or all of the three layers.
The most common forms of eyelid malposition are eyelid retraction, Ptosis, entropion and ectropion.

Types of Eyelid Malpositions

Upper eyelid malpositions: Upper lid ptosis (drooping down of upper eyelid), retraction of the upper eyelid (causing apparently bulging eyes), entropion (in-turning of eyelid and lash line) and ectroprion (out-turning of the eyelid)
Lower eyelid malpositions: Retraction of lower eyelid (lid margin below inferior limbus), entroprion (inward rotation of the eyelid margin) and ectroprion (outward rotation of the eyelid margin)

Common Consequences of Eyelid Malpositions

  • Decreased vision due to blockage of visual axis by the mal-positioned eyelid or secondary to corneal ulcer formation.
  • Irritation of the eyes due to an eyelash rubbing the cornea or conjunctiva
  • Corneal ulcer due to repeated rubbing of corneal surface by the eyelashes or eyelid margin.
  • Corneal or conjunctival dryness due to exposure leading to irritation, discomfort, keratitis or corneal ulcer.
  • Repeated infections of the lachrymal sac due to a blocked punctum.


Common Symptoms associated with Eyelid Malpositions

  • Dry eye and irritation
  • Painful eye
  • Disfigurement of the eyes
  • Excessive watering of eyes
  • Corneal ulcer
  • Photophobia
  • Decreased vision due to visual axis blockage by eyelids or corneal ulcer
  • Disfigurement

Evaluation and treatment of eyelid malpositions needs to be disease-specific and tailored to the patient’s needs. This requires consultation with an eye surgeon familiar with treating various eyelid malpositions. More detailed explanations on each particular eyelid malposition is provided elsewhere for your ready reference 



Eyelid Positional Disorders

Ectropion is the medical term used to describe sagging and outward turning of the lower eyelid and eyelashes. The margin of the eyelid and the eyelashes revert (turn out) . This rubbing can lead to excessive tearing, crusting of the eyelid, mucous discharge and irritation of the eye

Entropion is the medical term used to describe sagging and outward turning of the lower eyelid and eyelashes. The margin of the eyelid and the eyelashes invert (turn in) . This rubbing can lead to excessive tearing, crusting of the eyelid, mucous discharge and irritation of the eye




Ectropion
Ectropion is the medical term used to describe sagging and outward turning of the lower eyelid and eyelashes.

The margin of the eyelid and the eyelashes evert (turn out).

This rubbing can lead to excessive tearing, crusting of the eyelid, mucous discharge and irritation of the eye.

During blinking, the eyelids normally sweep across the surface of the cornea (Tearing occurs because the eyelids are not able to wipe the surface of the cornea properly to pump the tears into the tear duct.

Most cases of entropion are due to relaxation of the tissues of the eyelid as a result of aging. Some cases result from scarring of the eyelid caused by chemical and thermal burns, trauma, skin cancers, or previous eyelid surgery. Rarely Ectropion can be present at birth if the eyelids do not form properly.

Classification of Ectropion

  • Involutional
  • Paralytic
  • Cicatricial
  • Mechanical


Involutional Ectropion

Etiology: due to horizontal laxity
Treatment: lateral canthoplasty, full thickness pentagonal wedge resection

Cicatrical Ectropion

  • burns
  • trauma
  • ocular rosecea
  • dermatitis including eczema
  • chronic inflammations suchas as erythema multiforme, bullous pemphigoid, sarcoid, icthiosis
  • zoster
Treatment: lubrication, surgery (skin graft for vertical elongation)   Photographs below show a patient who sustained SEVERE facial burns, with resultant cicatrical changes, complete eversion of the left upper eyelid with scarring of the lid margin/lashes to the area of the eyelid crease


Paralytic

Anatomy & Function of the facial nerve

  • The facial nerve (CNVII) has two major divisions and controls the muscles of facial expression, including the frontalis muscle (raises the eyebrows), the orbicularis oculi muscle (closes the eyes), the zygomaticus muscles (raises the angle of the mouth)
  • The upper zygomatic branch supplies the frontalis, upper lid orbicularis oculi, corregator supercilli and procerus.
  • The lower zyqomatic branch supplies the lower lid orbicularis.
  • The nervus intermedius gives off the greater petrosal nerve which carries parasympathetic secretary fibers to the lacrimal gland


Etiologies

Congenital

  • Moebius' Syndrome

Acquired

  • Bell's Palsy
  • vascular lesions

Tumors & Trauma

  • Acoustic Neuroma
  • Parotid gland
  • temporal bone tumor


Symptoms

Tearing, atonic eyelids

Treatment:

Medical

  • Temporary: Lubrication, moisture chamber

Surgical

  • Permanent: lateral tarsorraphy permis closure of the eyelids to narrow the palpebral fissure and decrease evaporation.
  • Brow suspension,
  • fascia lata or silicone sling to lower eyelid
  • gold weight insertion a light (1 mg weight ) manufactured by Meddev Corp is fixed to pretarsal space of the upper eyelid. This weight allows the eyelid to close more easily




Entropion

Entropion is a medical condition in which the eyelid (usually the lower lid) folds inward. It is very uncomfortable, as the eyelashes constantly rub against the cornea.

The upper or lower eyelid can be involved, and one or both eyes may be affected. When entropion occurs in both eyes, this is known as "bilateral entropion." Trachoma infection may cause scarring of the inner eyelid, which may cause entropion. In human cases, this condition is most common to people over 60 years of age.



Four basic anatomic defects which may lead to entropion:

  • Horizontal lid laxity
  • disinsertion or attenuation of retractors
  • preseptal orbicularis overiding the pretarsal orbicularis muscle
  • enophthalmos

 

Forms of Entropion


    Congenital
    • rare
    • differentiate from epiblepharon
    • treat by excising skin and orbicularis below eyelid margin

    Acute Spastic
    • due to ocular inflammation and irritation
    • Treat underlying disease or quickert suture

    Involutional entropion
    • Etiologies  
      • laxity or defect of the lower eyelid retractors (involutional=senile), due to lid retratctor dehiscence of the lower eyelid retractors (analogue of mueller's muscle) or of capsulopapebral fascia (analogue of levator)
      • horizontal eyelid laxity
      • preseptal orbicularis override
      • enophthalmos
    • Treatment
      • Thermal cautery
      • quickert suture
      • re-attachment of lower eyelid retractors
      • full thickness horizontal eyelid lid splitting and marginal rotation
      • orbicularis muscle tightening procedures
      • horizontal lid shorteing
      • tarsal strip


    Etiology of Cicatricial entropions

    • trauma
    • inflammation
    • pemphigus
    • pemphigoid
    • stevens-johnson syndrome
    • trachoma

    Treatment

    • contact lenses
    • epilation
    • lubrication
    • mucous membrane graft
    • scleral grafts
Procedures
Anophthalmos
- Anophthalmia is a medical term used to describe the absence of the globe and ocular tissue from the orbit. - This was first reported more than 400 years ago, yet it is only recently that significant reconstructive options became available. - There are many reasons why one might lose an eye. - Surgeries which result in anophthalmos
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Blepharoplasty
What is Blepharoplasty?
- Your eyes including your eyelids, are perhaps one of the first things people notice in you. This makes your eyes and eyelids one of the most important components for an appealing facial expression and aesthetic appearance. Any visible change in the shape or size of the orbital or periorbital region can spoil the look of your face.
- As you age and grow older, your eyelids may become ‘droopy’ or ‘baggy’ due to the stretching of your eyelid skin and gradually decreasing tone of your eyelid muscles. Your droopy eyelids and brow together cut a sorry figure for your face making you look tired, sleepy and haggard, further leading to eyelid or brow straining or both. In extreme cases, your saggy, baggy eyelids can even obstruct your vision, particularly peripheral vision causing difficulty in reading or driving.
- Blepharoplasty ensures cosmetic or functional corrections to the area around your eyes to enhance your look or to correct any abnormalities in function.
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Blepharospasm
- Blepharospasm is defined as an abnormal, involuntary, sustained and forceful closure or twitching of the eyelids. It is derived from the Greek word ‘blepharon’ which means eyelid, and ‘spasm’ which is an uncontrolled muscle contraction. Blepharospasm is usually associated with headache, eyebrow strain and occasionally loss of vision.
- Isolated blepharospasm is rare and represents a minority of patients presenting with blepharospasm. Blepharospasm is commonly associated with lower facial spasms as part of a syndrome or disease complex. Some examples are:
   - Meige Syndrome: Characterized by spasm of the eyelids and midface.
    - Brueghel’s Syndrome: Presents with blepharospasm and marked spasms in the lower face and neck.
    - Segmental Cranial Dystonia: In addition to the usual spasms of the eyelids and facial muscles it is associated with spasms along distribution of various cranial nerves, most frequently involving the Facial Nerve.
    - Generalized Dystonia: Presents with spasms across various body parts in addition to blepharospasm and facial spasms.
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Brow Lift
A forehead lift, also known as a browlift or browplasty, is a cosmetic surgery procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep worry lines that run across the forehead and may portray to others anger, sternness, hostility, fatigue or other unintended emotions
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Congenital
Congenital anomolies include :
- Eyelid Disorders
- Orbital Disorders
- Congenital Ptosis
- Congenital Nasolacrimal Duct Obstruction

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Dry Eye
What is Dry Eye?
- Dry eye is a reduction in your eye’s ability to produce sufficient natural tears.
- Insufficient tear production can lead to irritation and pain, and even scarring of the cornea (the transparent part of the eye that covers the pupil and iris).
- Many people will experience dry eye symptoms at some point in their lives.
- Often due to environmental factors such as indoor heating or air conditioning, it can also be caused by occupational factors such as prolonged computer use.
- Dry eye symptoms can affect anyone.
- Some of the symptoms of dry eye include a burning sensation or gritty feeling in the eyes. You may also experience decreased tolerance to contact lens wear or sensitivity to light.
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Eyelid Laxity
- Eyelids protect your eyes from any foreign bodies while keeping them lubricated throughout. Any alteration in the shape, position or function of your eyelids can predispose your eyes to a plethora of ailments or interfere with our vision.
Our eyelid is a complex structure consisting of three theoretical layers:
   - Anterior Layer contains the skin and orbicularis muscle
   - Middle Layer contains the orbital septum and eyelid retractors
   - Posterior Layer contains tarsus and conjunctiva.

- Eyelid malpositions include any unnatural or incorrect positioning and orientation of eyelids due to various factors that influence any of the three layers of the eyelids. They may be caused due to ageing, trauma, scarring, birth defects or medical disease involving any or all of the three layers.
- The most common forms of eyelid malposition are eyelid retraction, ptosis, entropion and ectropion.
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Face
The world of cosmetic surgery has advanced tremendously over the last two decades. New procedures have emerged that can make an individual look and feel younger in a matter of a few minutes. Amongst the vast number of cosmetic procedures currently available, the face lift is a commonly performed one that is sought after by both men and women. Here we shall take a look at this procedure in a little more detail.

- What is a face lift?    - A face lift is called a rhytidectomy in the world of medicine. It involves tightening the muscles of the face and smoothening of the skin so that the face appears younger.    - However, it must be remembered that a face-lift is not an anti ageing solution.
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Lacrimal System
- The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.    (1) excess tearing (tears may run down the face) and    (2) mucous discharge - This may lead to recurrent red eyes and infections. - The excessive tearing can also produce secondary skin changes on the lower eyelids.
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Lagophthalmos
Patients with lagophthalmos have an inability to close eyelids. This may occur, for instance, in patients with Thyroid eye disease.
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Latisse
LATISSE® makes lash growth possible because of its active ingredient: bimatoprost. Although the precise mechanism of action is not known, research suggests that the growth of eyelashes occurs by increasing the percent of hairs in, and the duration of, the anagen (or growth) phase. Lashes can grow longer, thicker and darker because bimatoprost can also prolong this growth phase.
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Orbital Tumors
- Orbital Tumor is any tumor that occurs within the orbit of the eye. The orbit is a bony housing in the skull about 2 inches deep that provides protection to the entire eyeball except the front surface. It is lined by the orbital bones and contains the eyeball, its muscles, blood supply, nerve supply, and fat.
- Tumors may develop in any of the tissues surrounding the eyeball and may also invade the orbit from the sinuses, brain, or nasal cavity, or it may metastasize (spread) from other areas of the body. Orbital tumors can affect adults and children. Fortunately, most are benign.
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Ptosis
- Ptosis is an abnormally low position (drooping) of the upper eyelid
- Ptosis occurs when the muscles that raise the eyelid (levator and Müller's muscles) are not strong enough to do so properly.
- It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate.
- Compare with dermatochalsis (extra skin and fat)
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Skin Rejuvination
A radiant, smooth, youthful skin is the essence of beauty and trendy looks. Skin care routine highly contributes in the slowing down of rate of aging of the skin. Choosing the right skin care products for your skin type enhances your beauty keeping the skin cleansed, moisturized and well toned. Use of superficial skin resurfacing treatments to counter fine lines and wrinkles, acne scars and blemishes before they deepen ensures skin rejuvenation.
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Skin Tumors
Cancer of the eyelid, like any other cancer, can be a worrying thing. Treatments are variable and depend on the type of cancer. In this article, we shall take a brief look at the different kinds of eyelid tumors.
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Symblepharon
A symblepharon is a fibrous tract that connects bulbar conjunctiva to conjunctiva on the eyelid.
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Thyroid
Graves' disease is an autoimmune disease.
It most commonly affects the thyroid, causing it to grow to twice its size or more (goiter), be overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos).
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Trauma
Eye injuries are extremely common with over 2 million cases reported every year that require medical treatment. Blindness in one eye is most commonly due to cataract and this is followed closely by eye injuries. In addition, in children, injury to the eye is a recognized as the most common cause of blindness in one eye that is not due to a birth defect.
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