Eyelid Surgery (Blepharoplasty) in New Jersey Clinical Cost & Safety Audit

Blepharoplasty, or eyelid surgery, is a widely performed ophthalmic surgical procedure used to correct various aesthetic and functional impairments associated with the eyelids. https://en.wikipedia.org/wiki/Blepharoplasty

Indications and Contraindications

Blepharoplasty indications for both upper and lower eyelids can be broadly classified into functional and aesthetic purposes. Functionally, the procedure aims to correct vision impairments resulting from lid malpositions, or drooping eyelids, which can obstruct the field of vision and cause complications such as amblyopia, or more commonly known as lazy eye. From an aesthetic perspective, an excess of adipose tissue in the eyelids can contribute to an aged appearance. Contraindications for eyelid surgery include lid retraction, lid laxity, epiphora, and active infection of the eyelids among other conditions. https://emedicine.medscape.com/article/873213-overview Blepharoplasty is generally contraindicated in patients undergoing immunosuppressive therapy, as well as individuals with autoimmune disorders. Blepharoplasty may also be contraindicated in patients with systemic or dermatologic conditions like rosacea, seborrheic keratoses, or neurofibromatosis-1.

Preoperative Assessment and Marking

Preoperative marking for blepharoplasty typically involves precise localization of the lid creases and palpation of the orbital septum. The eyelid crease marking procedure can be aided by the use of the 'Surfacer' or the 'Snap Back' method. The 'Surfacer' approach is a reliable method of demarcating the superior lid crease. The superior limb of the lid crease can be determined by displacing the globe of the eye downward and having the patient gaze upward. The inferior limb is best identified by having the patient gaze upward while displacing the globe of the eye laterally. Alternatively, there is the use of 'Snap Back Method', in which the lid margin is gently everted. The patient is then asked to look upward and an 11-0 nylon suture is used to mark the superior limb. For the inferior lid, the 'Snap Back Method' is repeated with a similar 11-0 suture marking in place. While this method is a bit more labor-intensive, it can be advantageous for procedures to be preoperatively marked bilaterally. Another means of achieving these results can be observed using the lateral canthotomy, an incision that is applied in conjunction with the lateral or lateral and medial cantholysis. This allows the globe's displacement allowing the accurate localisation by the orbital fat and muscle retraction of the superior and inferior lid crease. A similar method is sometimes utilized to locate the superior and inferior eyelid crease markings.

Surgical Technique

Following the local anesthesia administration, the superior periorbital skin is gently retracted to aid in the orbital septal exposure. Initially, the orbicularis oculi is resected in the supratarsal fold to allow adequate clearance of the preaponeurotic tissue. The skin and orbicularis oculi complex are subsequently incised in a supratarsal fold, making it ideal for preseptal orbicularis oculi myectomy and orbicularis oculi resection. A preseptal orbicularis oculi myectomy is commonly done in association with blepharoplasty and can be combined with various blepharoplasty subtypes. Concomitant preaponeurotic tissue reduction is beneficial. In conjunction with a limited fat excision, the resection of the preaponeurotic tissue can further enhance the surgical outcomes of blepharoplasty. Excess subcutaneous adipose tissue can cause a 'dog-eared' appearance, with excess adipose tissue that protrudes over the superior margin of the pretransal tarsal plate. For the inferior eyelid procedure, access to the orbital fat requires careful undermining of the orbicularis oculi muscle and resection of the orbicularis portion at the infraorbital groove, typically performed concurrently with a fat excision in blepharoplasty. The preseptal fascia is then dissected free from the tarsus, thus liberating the periorbita from the skin edge with the help of the anterior retraction of the orbicularis oculi.

Complications and Treatment of Blepharoplasty

While complications from blepharoplasty procedures are generally rare, their incidence is not negligible. The most common post-operative complication is dry eye, resulting in increased tear retention time, usually presenting with chronic inflammation and corneal staining. When treating post-operative dry eye, the use of 0.02% fluorometholone ophthalmic implantation may provide a favorable outcome and could aid in patient comfort post-procedure. Complications such as bleeding, orbital haematoma, chemosis, ectropion, or lagophthalmos are also common complications that can manifest as a result of poorly performed eye lid surgery. A well-orchestrated postoperative eye care protocol, along with aggressive treatment of postoperative complications is necessary. When treating a postoperative drooping eyelid or 'Ptosis', an elevator may be used in conjunction with botulinum toxin injections to aid in reversing the facial nerve impairment and restoring a more aesthetically pleasing presentation of the ocular area.

Surgical Outcomes

When properly performed, blepharoplasty can be an extremely beneficial cosmetic and ophthalmological procedure, leading to an aesthetically pleasing oculo-orbital appearance with improved functional vision. Cosmetic outcomes for blepharoplasty are dependent on patient expectations and surgical experience, along with the anatomical characteristics of the patient. In some cases, complications can arise from facial asymmetry, resulting in patient dissatisfaction with their surgery and ultimately leading to further revisionary surgery.

Literature Review and Clinical Recommendations

There are an abundance of research studies supporting the efficacy and safety of eyelid surgery. Numerous studies have shown that eyelid surgery has the potential to offer patients relief and cosmetic rejuvenation, enhancing the oculofacial region and allowing the patient to appear younger. Furthermore, a well-executed and precisely marked preoperative procedure has potential for patient satisfaction due to aesthetically pleasing surgical out come. The 'Surfacer' and 'Snap Back' techniques can be highly effective for both bilateral lid marking. Surgical out comes for procedures utilizing these techniques offer patients a high potential for improvement after eyelid surgery. Complications arise from poorly conducted procedures, but can be managed accordingly.