Blepharochalasis, the Ageing Eyelid, Blepharoplasty
(Chalasis: to become loose – Greek)
- Blepharochalasis means a certain looseness in the components of the eyelids. Loss of elasticity affects the skin and the orbital septum. Loss of tone affects mainly the orbicularis oculi but may also affect the levator palpabrae superioris. In addition ageing may soften the otherwise firm fibrocartilaginous tarsal plate, which turns soft, becomes patulous and may get deformed (please see para 8).
- Loss of elasticity in the skin produces wrinkles along the transverse axis. Sometimes the condition is so severe that the supra-tarsal skin may be heaped as a single fold and overlaps the skin over the tarsus in the upper eyelid. The skin over the tarsus is closely bound to the tarsal part of the orbicularis oculi which is more fascial in nature here and therefore shows fewer changes as compared to the rest of the eyelid which is naturally loose to allow movement (see Fig. 1). In the lower eyelid the skin tends to fall away from the tarsus. In a test called the traction test the skin returns quickly to its original position after being pinched away in cases of Dermatochalasis which spares the rest of the structures in the eyelid, for e.g. the orbital septum or the orbicularis oculi (please see traction test in Blepharochalasis in next para).
- Loss of elasticity of the orbital septum can lead to herniation of intra-orbital fat in the submuscular plane (Orb. Oculi) (see Fig. 2). This may further stretch the muscle. This herniation is in three distinct compartments, medial, central and lateral. The wrinkled eyelid skin therefore now also looks unevenly ‘puffed up’ or swollen. Together with the lax skin this condition is called Blepharochalsis in which the traction test (see above) will be followed by the skin returning slowly to its original position. These tests are subjective.
- In a small percentage of cases the levator palpebrae superioris also may lose its tone and the eyelid tends to droop. Blepharochalasis therefore may be accompanied by senile ptosis.
- The deformation of the tarsal plate (see para 8) has greater consequences in the lower lid because this deformation can lead to an ectropion and rarely an entropion because the lower conjunctival fornix is shorter and the eyelid is closely draped over the eyeball. In many ways the lower eyelid anatomically is quite different from the upper lid and the effect of ageing in the lower eyelid is different in some ways in comparison to the upper eyelid. The depressor of the lower eyelid (the counterpart of the levator of the upper eyelid) is indistinct, poorly described in the literature and it is said to work in conjunction with the inferior rectus and the inferior oblique which send extensions to it at the time of their insertions into the globe. This helps in a synchronous action at the time of the downward gaze pulling the lower lids down to allow the eyeball to see over the descended lids (Fig. 3).
- The lower eyelid is subject to gravity and when the orbicularis oculi loses its tone and gets stretched out, the eyelid descends resulting in a scleral show the eyelid having lost its normal level at the lower limbus of the cornea. In the event, in all lower lid blepharoplasties, the lid requires to be suspended upwards. This involves fixing the eyelid (the tarsus) to the lateral canthal ligament by a buried stitch. The stretched out skin in the lower eyelid is then excised along the lid margin and is then pulled up. In the upper eyelid the excision of the skin is done only in the supra-tarsal region (Fig. 4).
- The fixation of the tarsal plate of the lower eyelid to the lateral canthus is subject to the location of the lateral canthus which might have been stretched or might have migrated downwards because of the laxity of the peri-orbital ligaments and the traction by the lower eyelid on account of gravity. In the event the lateral canthus needs to be relocated and fixed to the bone to take away the drag. In this maneuver it is considered best to fix the tarsus to the canthus and then the canthus to the bone through a drill hole or a periosteal stitch. This single suture is usually of an unabsorbable type and remains buried. The skin of the eyelid after adequate excision is then draped over and fixed to its new location (Fig. 5).
- The deformed / patulous tarsal plate in the lower eyelid may not be quite suitable for the above technique because in the process of relocation it tends to deform further. In such a situation the tarsus can be built up by the piece of a conchal cartilage or a graft of palatal mucoperiosteum. The new unit then is then swung upwards and laterally for fixation (Fig. 6).
- Ageing can also affect the eye in two different ways through changes in the lachrymal glands. If their secretions are reduced, the eye might be drier than normal. Also the lachrymal gland can descend from its perch under the frontal bone to prolapse in to the upper eyelid if its capsule becomes lax. This adds to the swelling caused by the prolapsed intra-orbital fat in the lateral compartment. This situation can be remedied during surgery by pushing the gland back in its fossa and then reconstructing its capsule.
- When the lower lid blepharoplasty is complete, not infrequently the naso-jugal groove along the lower bony orbital rim may start appearing hollow. This results from loss of fat which has already occurred with age with the effect having been previously masked by the drooping lower lid and the herniation of intra-ocular fat due to blepharochalasis. This hollowness can be filled with a free-fat graft to improve the hollow, vacant and sunk appearance (Fig. 7).
- As in other branches of aesthetic surgery so also in blepharoplasty it is better to ascertain in advance the expectations of the patient, frequently a woman who might have a variety of hidden causes which prompt her to seek relief. Menopause, a divorce or an impending separation, loneliness in general and such causes can only be unveiled by sympathetic interviews, preferably two or three over a period of time. Amongst men, retirement blues, premature loss of employment might be aggravating factors in seeking relief. In addition diseases of old age, abuse of tobacco and alcohol also need to be discovered. In addition the otherwise normal patient must be told not to expect a complete rejuvenation of the orbital area but only a certain amount of improvement. No two patients are similar and to show photographs of post-operative results to patients does not always help but might in fact raise expectations because usually the surgeon will tend to show the best results. The patient must be told that a blepharoplasty does not cure a dry eye, might in fact produce some dryness post-operatively, will need lubricants and does not always relieve epifora if present pre-operatively. Above all the patients must be warned that cases of blindness following a blepharoplasty due to optic artery thrombosis or a retrobulbar haematoma have been reported in literature though a cause and effect relationship has not been statistically established.
- Surgery for blepharochalasis (and certainly for dermatochalasis) is in a vast majority of cases performed under local anaesthesia usually mixed with adrenaline. Occasionally in blepharochalasis when the fat pads are excised, some sedation might be employed because the drag on the prolapsed fat tends to cause some extreme discomfort. For extremely apprehensive patients general anaesthesia might be employed. When the procedure is combined with face lift general anaesthesia may be preferred. The incisions have already been described in para 6, fig. 4. Because the operative field is small and photographs cannot adequately explain the steps, photoshopped line drawings and clinical photographs are reproduced below (Fig. 8-11).
- While mild senile ptosis can be corrected at the time of blepharoplasty the general consensus is not to combine the two surgeries for two reasons. One, the two corrections together might lead to over-correction. Two, the principle of one wound, one repair might come to apply here because the defect created by the excised or plicated levator, the excised orbicularis together with removal of skin tend to overlap each other producing what is known as one wound, one repair effect. This might lead to a thick scar negating the very purpose for which the surgery was done rendering the lid static and somewhat deformed.
- Precautions and one complication has been given in para 11. The other common complications are over or under correction, narrowing of the orbital fissure on the lateral side near the canthal area particularly following a lower lid blepharoplasty. Over corrected lids are difficult to repair and might need a full thickness graft the colour match of which is not bad. Under correction in the upper lid can be sorted out by treating ptosis if that element was present pre-operatively. Otherwise more skin can be excised. In the lower lid too an ectropion will need a full thickness graft but further hitching up of the tarsus might also be needed. An entropion may be helped by depilation of the lashes if surgical correction by excising the convex outer surface of the tarsus fails.
- When browlift needs to be done together with a blepharoplasty, occasionally the incision in the upper lid below the orbicularis oculi can be retracted upwards up to the eyebrow. The frontalis is identified and then after cutting its periosteal attachment can be shortened to effect a browlift. Please see previous chapter (Fig. 12).
- In a similar way as in above, steps to effect a mid-face lift can be taken through a lower lid blepharoplasty incision which will be addressed in the next chapter on face lift.
All clinical photographs courtesy Parag Telang, aesthetic surgeon, Mumbai, India.
The following pictures have been sent by Milind Wagh, an aesthetic surgeon from Mumbai as examples of Blepharoplasties. One of them has a mid-facial face lift done through the Blepharoplasty approach. That subject will be covered in the next chapter. The last photograph in this collection dramatically brings out the prolapsed fat in different compartments of the eyelids and also a post-operative result.