Figure 1. With attention to natural crease demarcations, upper eyelids are marked indicating area of skin to be excised
Emily Bjore BA
Dr Leonid Skorin Jr
OD DO MS FAAO FAOCO
Mayo Clinic Health System,
Albert Lea MN, USA
Dermatochalasis refers to loose or redundant skin of the eyelid. This is a common condition, thought to be a part of the normal ageing process. The exact cause is unknown but contributing factors include reduced elasticity of the skin around the eyelid, gravity, weakened connective tissue and systemic conditions.1
As the eyes and the periocular area are the focal point of human conversation and communication, droopy eyelids may seem to others to be inappropriate tiredness or sadness. In moderate to severe cases, there may be concerns related to dissatisfaction of eyelid appearance or superior visual field loss.2 Other patients may have difficulty reading or endure frontal headaches due to constant brow elevation.1
Upper lid blepharoplasty is a common surgery to relieve aesthenopic symptoms and to help improve facial appearance. This is considered a very safe and relatively simple surgery; however, any surgical procedure can be affected by blood thinning medications or natural supplements taken by the patient.
The blepharoplasty procedure
Preoperative examination should start with a detailed history, enquiring about periorbital trauma, thyroid conditions, dry eye syndrome and skin conditions.1 Automated visual fields should be performed prior to surgery to demonstrate any superior visual field loss. This testing is repeated with the lids taped to decrease the field loss and simulate post-operative results.
A photograph of the eyes should be taken and included to document the natural position of the lids. Visual acuities, ocular motilities and a Schirmer dry eye test must be completed preoperatively to look for any amblyopia, diplopia or dry eyes that can cause postoperative patient dissatisfaction.3
After an appropriate consent for surgery is signed, the patient is brought into the operating room and placed in a supine position. Topical anaesthetic, commonly proparacaine 0.5% or tetracaine 0.5% is instilled into the lower cul-de-sacs of both eyes.
Using a marking pen and forceps, the redundant upper lid tissue is measured and marked from the lateral to the medial canthus, paying attention to the natural crease demarcations (Figure 1).
The marked areas in both eyes are measured in width and height to ensure that the eyelids will look symmetrical postoperatively. Five to six millilitres (cc) of lidocaine 2% with 1:100,000 epinephrine is injected into the right and left upper eyelid. The patient’s lids are then prepared in a sterile manner with povidine-iodine swabs and isolated with surrounding facial drapes.
Using a #15 Bard-Parker blade, an incision is made through the skin and subcuticular tissue along the previously made markings of the right upper eyelid. Then, using blunt-tipped Westcott scissors and toothed forceps, the redundant skin is lifted up and excised.
Bleeding is controlled at this time with gauze pads and cautery (Figure 2). Once haemostasis is achieved, a 6-0 silk suture is used to create a running stitch from the lateral to the medial side, reapproximating the remaining skin (Figure 3).
|Figure 2. Haemostasis achieved with cautery after removing excess skin and subcuticular tissue of the upper lid
|Figure 3. A running suture closes incision in the upper lid at the completion of the blepharoplasty surgery
In the USA, an ophthalmic antibiotic ointment such as erythromycin or bacitracin is applied over the suture and incision site. Exactly the same procedure is then repeated on the left upper eyelid. The ophthalmic antibiotic ointment is to be continued postoperatively twice a day for the next week to 10 days.1 The sutures are removed in one week.
Bleeding and pharmaceutical prevention
Surgeons should routinely inform patients of complications that can occur during and after blepharoplasty surgery. Bleeding complications, in particular, include retrobulbar haemorrhage and superficial haematoma or bruising. Although rare, retrobulbar haemorrhage is a very serious complication that may quickly lead to partial or total vision loss.
Estimated incidence of retrobulbar haemorrhage is between one in 2,000 to one in 25,000 patients.4 With an acute retrobulbar haemorrhage, blood starts to fill the orbit behind the eye. It accumulates in a compartment fashion within four bony walls and the orbital septum. As the orbit becomes filled with blood, pressure is put on the optic nerve. Secondarily, intraocular pressure of the globe rapidly rises, causing the patient to lose vision.
Recognition during the surgery is key, as is a rapid response. Treatment beyond one to six hours of total or near-total vision loss is unlikely to be effective. A superficial haematoma or bruising is not a complication but rather an expected side-effect. Some bleeding is likely during surgery. It can be minimised with meticulous intraoperative surgical cautery and preoperative cessation of any anticoagulant medication by the patient.
Commonly prescribed blood-thinning medication includes warfarin, heparin and aspirin. Other prescription medications that have blood-thinning properties are found in Table 1.
|Table 1. Medications with blood-thinning properties7,8
Some natural substances, in the herbal form or supplementation, can have blood-thinning properties as well. There are thousands of herbal and related substances used presently and available for consumption with a growing population seeking holistic or over-the-counter health care.5
A study of 755 surveys showed that 32 per cent of patients admitted to the hospital are self-administering one or more herb-related compounds. Nearly 70 per cent of these patients did not report this information when asked about it during routine anaesthetic assessment before the scheduled surgery.5 Specific natural supplements that contribute to blood thinning are vitamin E, Ginkgo biloba, omega-3 or fish oil and garlic.6
Other popular blood-thinning, over-the-counter substances can be found in Table 2. Warfarin is stopped two days before surgery. All the other prescription medications and holistic substances are stopped one week before surgery.
|Table 2. Popular holistic substances with blood-thinning properties5,6,7,8,9
One of our patients did not report taking any blood-thinning medication or substances prior to surgery. The morning of his scheduled blepharoplasty, he mentioned he was currently taking omega-3. When we became aware, we took precautions for any excessive intraoperative bleeding. Even with the precautions in place, it was apparent that haemostasis with cautery took longer to achieve than in a patient taking no blood thinners.
Blepharoplasty is a safe and effective eyelid corrective surgery. Like any ophthalmic surgery, there are possible complications with bleeding that can occur from the expected superficial haematoma to the very serious and vision-threatening retrobulbar haemorrhage. All blood-thinning medications, conventional and holistic, should be addressed and stopped before surgery to minimise these bleeding complications, and maximise the postoperative benefits and patient satisfaction.
- Sudtelgte A, Skorin Jr L. Functional blepharoplasty: Diagnosis and surgical management. Optometry Today 2002: 38-40.
- Castro E, Foster JA. Upper lid blepharoplasty. Facial Plastic Surgery 1999; 15: 3: 173-181.
- Iliff C. Dermatochalasis and blepharochalasis of the upper lids. Ophthalmology 1978; 85 (7 Pt 1); 709-711.
- Oestreicher J, Mehta S. Complications of blepharoplasty: Prevention and management. Plastic Surgery International 2012; article ID 252368; http://dx.doi.org/10.1155/2012/252368; accessed April 15, 2014.
- Kaye AD, Clarke RC, Sabar R et al. Herbal medicines: Current trends in anesthesiology practice—a hospital survey. Journal of Clinical Anesthesia 2000; 12: 468-471.
- Hannon J, Skorin Jr L. Supplementation and surgery: Can optometry play a role? Optometry Pharma 2011: 12-13.
- Shore J, Menke A. Hemorrhage associated with ophthalmic procedures: Focus on blepharoplasty. Ophthalmic Mutual Insurance Company: A Risk Retention Group; http://www.omic.com/wp.../04/Hemorrhage-and-Ophthalmic-Procedures.pdf; accessed April 4, 2014.
- Stuart A. Bleed or clot concerns in the anticoagulant patient. American Academy of Ophthalmology; http://www.aao.org/publications/eyenet/200802/feature.cfm (accessed March 30, 2014).
- Tsen LC, Segal S, Pothier M et al. Alternative medicine use in presurgical patients. Anesthesiology 2000; 93: 148-151.