The lower palpebral pockets are related to excess fat volume in the orbit, which protrudes anteriorly from the bony orbital rim.
If there is no significant sagging and excess skin, they can be removed by the conjunctival route, i.e. through the inside of the eyelid. This avoids a scar on the skin and thus the risk of scarring skin retraction.
Cutaneous carcinomas are frequently localized on the eyelids and frequently diagnosed late because these lesions are painless and not very visible. The fall of the eyelashes and the perception of an indurated cord to the touch should make you think of this diagnosis and consult your doctor.
The malignant nature of the lesion will lead to a safety margin of 4 to 10 mm depending on the location and nature of the carcinoma. Reconstruction is complex for the eyelids because 2 layers have to be reconstructed with a combination of flap (neighbouring tissue that remains blood-fed) and grafts (tissue removed elsewhere and replaced over the flap). The objective is to protect the eye while recreating a natural and aesthetic shape of the opening between the 2 eyelids.
Entropion is a bad position of the eyelid which turns inwards, this leads to a rubbing of the eyelashes on the eye which causes discomfort (sensation of foreign body, redness, glare, pain).
Most often, as here, eyelid instability is due to sagging with age (involutionary form). The treatment is surgical and consists of tightening the eyelid in its different axes by reattaching it to the external orbital rim and recreating a palpebral fold.
Ectropion is a malpositioning of the eyelid that tilts outwards. The conjunctiva will be exposed to the air and become red, tears will run down the cheek instead of being evacuated in the nose, the eye is no longer well protected with a more or less important discomfort (sensation of foreign body, redness, crusts, burns).
This tilt can be related to a simple relaxation of the tissues supporting the eyelid with age, but also to a retraction of the skin as in the case described below. Retraction can be caused by tearing, chronic inflammation, retraction of a scar, dryness of the skin aggravated by sun exposure etc...
The treatment is surgical and consists of tightening the slack tissue (reattachment to the orbital rim) and lengthening the retracted tissue (skin graft or skin and muscle flap).
The scarring entropion is due to a retraction of the deep part (posterior lamella) of the eyelid which turns inwards, causing the eyelashes to rotate and rub the eye, which then becomes damaged (keratitis).
The treatment is surgical with a separation of the anterior and posterior lamellae that make up the eyelid, and an ascent of the anterior lamellae in relation to the posterior one. To do this, the levator muscle must be moved backwards.
An initial overcorrection is sought to take into account the healing process. The objective is to bring the eyelashes back to the horizontal without modifying the shape of the opening between the 2 eyelids.
An eyelid consists of two flaps, one posterior which must be non-abrasive because it is mobile in front of the eye, the other anterior made of the orbicular muscle and the skin which must not be in contact with the eye at the free edge.
When almost the entire eyelid is missing but the corners are still present, the posterior flap is reconstructed with a flap (tissue that is displaced but still supplied with blood) from the deep part of the upper eyelid . The anterior flap is recreated with a skin graft taken from the other upper eyelid.
15 days later the flap is cut, the upper eyelid lift muscle is pulled back (to prevent the upper eyelid from being too high) and the free edge is sutured. This technique is very efficient because it rebuilds an eyelid with tissue that comes from an eyelid itself, giving a natural final appearance with good mobility. Its limitations are the absence of eyelashes,, sometimes redness of the free edge and asymmetry in the shape of the eyelid opening.
If there is an excess of lower skin, it can be used by making a flap rather than a skin graft.
Ptosis is a drooping of the upper eyelid due to a dysfunction of the eyelid lift muscle.
When this muscle no longer functions at all, as in the case described below, the eyelid is suspended from the frontal muscle which, by contracting, will lift the eyelid. A strip (here made of silicone) is used which will be placed very precisely to give a harmonious shape to the palpebral opening, place the palpebral fold in the right place and orient the eyelashes horizontally.
The strip will limit the closing of the eyelids, the more it will be stretched, the wider the opening will be (and the better the aesthetics will be) but the more the closing will be limited with risks of drying out the eye. The tension applied to the strips during the operation therefore seeks a compromise which is the maximum tolerable opening.
It may sometimes be necessary to replace the strip in 3 situations: satisfactory aesthetic result but the eye does not tolerate the opening, aesthetically imperfect result (under correction or inharmonious form), spontaneous rupture of the strip.
Ectropion is an outward tilt of the eyelid. It is related to a relaxation of the tissues supporting the eyelid.
In the case described below, the skin and the orbicular muscle are not retracted (which would aggravate the rocking motion) but, on the contrary, relaxed, which produces a slight deformation above and outside the cheekbone called malar pad .
The operation consisted of tightening the posterior lamella in its 2 axes (refixation to the external bone edge and refixation of the retractor muscle) and raising the anterior lamella (skin, orbicular and suborbital fat) also fixed to the bone edge (mesolift or "cheeklift"). An initial over-correction is deliberately sought to take into account the slackening within 6 months post-operatively.
Ptosis is a drooping of the upper eyelid related to a dysfunction of the eyelid lift muscle. In the case described below, the muscle contracts normally but its attachment to the eyelid has relaxed (ptosis of the aponeurotic type). This phenomenon may be related to aging, an inflammation of the surrounding area or prolonged lens wear.
The injection of neosynephrine drops by causing the muscle to contract and the eyelid to rise makes it possible to distinguish this type of ptosis from those linked to a loss of muscle contractibility. The operation, usually performed for aesthetic purposes, is delicate because the slightest imperfection is very visible. The objective is of course to raise the eyelid but also to give it a regular and harmonious curvature, as well as to reposition the palpebral fold and the orbital fat in order to eliminate the appearance of sunken eyes.
The operation is done under potentiated local anaesthesia (with a supplement given by the anaesthetist which allows to be destresssed). Both sides are operated on at the same time. There is no scar because the eyelid is turned over and the muscle is approached from the inside. The thread at this level is resorbable and will be uncomfortable for about 4 weeks (foreign body sensation). The main risk is an aesthetic imperfection (asymmetry, inharmonious curvature) which would lead to a retouch this time with a skin approach. There is no risk of palpebral malocclusion here as the shortening is moderate.
With an excess of skin gradually appears on the upper eyelids, making the palpebral fold go down and then disappear.
At this stage, the skin touches the eyelashes which gives a closed look to the eyes and often leads to a feeling of heaviness of the eyelids. To compensate, the forehead muscles contract, which raises the eyebrows abnormally and creates wrinkles on the forehead.
The procedure removes excess skin and fat and replaces the palpebral fold.
When the eye must be removed (enucleation which is a complete removal, or evisceration where the globe wall is retained) the loss of volume is compensated by the insertion of an intra-orbital implant.
Sometimes it can be rejected and become externalized, leading to infection and abundant and embarrassing secretions. The dermofat graft taken from the buttocks will then allow volume to be recreated after removal of the infected marble. The graft also makes it possible to reconstitute the conjunctiva which will reform on the white dermal part left bare.
The graft takes about 15 days and the conjunctiva will reform in about 6 weeks. A prosthesis with the appearance of an eye is then custom-made by an ocularist. Partial resorption of the graft (about 30%) will occur in the first 6 months. This is anticipated by voluntarily placing a graft that is too large at the beginning.
If the facial nerve is affected, the contraction of the orbicular muscle that closes the eyelids is compromised and the eye remains open at night (lagophthalmos) with absent or incomplete blinking during the day. When this leads to deterioration of the eye (keratitis, corneal ulcer, decreased vision, pain etc...), resuscitation of the eyelid can be achieved through gravity by placing a gold implant under the eyelid lift muscle. A test is performed before the operation to choose the most suitable weight. The definitive gold implant will be placed in such a way as to maintain a harmonious shape at the palpebral opening.
If there is a retraction of the eyelid (which is the case here), the weight will correct both the retraction and the lagophthalmos.
In the absence of retraction, it will result in a slightly lower position of the eyelid in relation to the opposite side, which can be aesthetically disturbing. Therefore, the minimum weight capable of achieving eyelid closure is always chosen.
Blepharoplasty will correct excess skin, slackening of the orbicular muscle and excess fat in the orbit.
Lipostructure is a recent technique that also allows to correct hollows by performing micro fat grafts using cannulas (foam needles, i.e. not pointed so as not to be aggressive).
Fat is removed from the inner side of the knees, centrifuged to take only the fat cells (adipocytes) which are then deposited in the form of multiple small clusters in all the areas where volume is desired. A film is visible to visualize the technique.
These grafts also provide stem cells that will improve tissue quality and skin radiance.
An overcorrection is voluntarily sought at the time of the operation to take into account a partial resorption of 30 to 40% of the graft volume in the 6 months post-operatively.
This technique is a huge advance in eye surgery, especially when the face has become thinner overall or when the dark circles are very pronounced.