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Dr Pierre ESCALAS
OPHTHALMOLOGIST OCULOPLASTICIAN
As we age, the lower eyelids may develop malar bags rather than fatty bags, due to the retention of lymphatic fluid. The cause of this phenomenon is unknown, but sun exposure and smoking are aggravating factors.
These bags are very unsightly, but they are accompanied by a disturbance in lymphatic circulation that makes healing difficult, with oedema that can take many months to resolve, and a tendency to shrink in the first few weeks. An operation should therefore only be considered if the aesthetic damage is major.
The operation consists in removing the abnormal tissue that retains the lymph by a direct approach along the orbital bone margin. It is essential to leave enough skin to avoid deforming the palpebral opening.
The after-effects are generally difficult, with at least prolonged oedema lasting several months.
Be careful, it may happen that the edema does not disappear 100%.
For most surgeons, eshetic surgery of the upper eyelids, also known as upper blepharoplasty, involves removing skin and fat.
Over time, excess skin gradually appears on the upper eyelids, causing the palpebral crease to droop and disappear, and the skin to come into contact with the eyelashes, which cease to be visible. This gives a closed, tired look to the eyes, and often leads to a feeling of heaviness in the eyelids.
It is therefore necessary to remove the skin, but other procedures will also be necessary and will depend on the anatomy, we speak of eye surgery .
The bony arch is clearly above the globe, the eyebrow is in a normal position, the fat compartments are also of normal volume, and the opening between the 2 eyelids is harmonious.
This is the least complex situation, but the skin must be removed with precision to achieve the objective of the operation, which is to clear the free edge of the eyelid and recreate a fold parallel to and at the right distance from the eyelashes, i.e. at the level it occupied around the age of 30.
When the eyebrow and bony arch are low, there is very little space between the eye and the bony orbital rim.
Removing excess skin alone is usually not enough to free the eyelashes. The fold is repositioned by connecting the skin to the muscle that lifts the eyelid. The skin will then be pulled into the eye socket by the lifter muscle when the eyes are opened, allowing the eyelashes to be freed while leaving enough skin not to compromise eye closure and blinking quality.
2 volumes of fat shape the eyes: the first is located in the orbit and is bounded at the front by a sort of curtain called the septum, while the second is located in the eyebrow and descends more or less low in front of the septum.
To understand the aesthetic impact of a look at these volumes of fat, here are 3 extreme examples
Here's an example of a low eyebrow with minimal excess skin but associated with excess orbital and eyebrow fat volume. This situation is common in men.
Lipostructure, also known as fat micrografting, involves using the patient's own fat to fill volume defects in the peri-ocular region and facial hollows. It's the best filler because it's an autograft. As it is the patient's own tissue, he or she will not develop any reaction against it, eliminating the risks of inflammation, granulomas and fibrosis associated with synthetic products.
The grease is placed in grease and therefore behaves in the same way, without any mass effect or appearance of infiltration.
It contains stem cells and growth factors that have a regenerative effect on tissues.
Finally, the effect is long-lasting: partial resorption occurs in the first few weeks, then the result is stable. The integrated cells will then evolve like the surrounding fat.
This advantage is also the main difficulty of this technique, since fat cannot, or only with great difficulty, be removed. This operation therefore requires great expertise on the part of the surgeon, who must perfectly recognize the areas to be filled on the one hand, and on the other hand have developed a technique in which he masters the rate of resorption so as to place the right volume of fat.
The topography and chronology of these volume variations will be specific to each individual. There are many possible scenarios
Bags are an advance of orbital fat (orange), while dark circles are a resorption of fat behind and in front of the orbicularis, along the lower rim of the orbit.
It usually appears around the age of 40, but sometimes much earlier, and results in a sad, tired look.
If there is no sagging of the skin (which is the case in young patients), the excess fat (bags) is removed via the inside of the eyelid (conjunctival route), so there is no skin scar.
This procedure improves aesthetics, but the result will be much more spectacular if the hollow is filled in.
General anaesthesia is used to avoid injection of a local anaesthetic, which would swell the tissues and prevent correct assessment of volumes.
The fat is removed from the inside of the knees by lipo-aspiration and then centrifuged to concentrate the fat cells (adipocytes)
Stem cells and growth factors are also concentrated, which will have a regenerative effect on the quality of the skin (improvement of skin radiance).
Using a cannula, the fat is placed in small clusters. They will be distributed in different planes and in a very precise way to restore the face's initial volumetry.
Part of the grafted volume will reabsorb, so a slight overcorrection is deliberately sought. We want to avoid excess volume in the long term, as this would be very difficult to correct.
After this initial resorption, the result is long-lasting and the injected fat will evolve like the natural fat that surrounds it.
Note that the result will depend entirely on the way the fat is arranged, and will therefore be a function of the surgeon's vision of aesthetics.
It is essential that the patient is fully informed, aware and in agreement with the goal the operator is trying to achieve.
For my part, I've been practicing lipostructure since 2006, with the aim of restoring the volumetry of the face as it was between the ages of 20 and 30. In other words, fat is placed only where a hollow has appeared. The aim is to rejuvenate the face, not transform it, and restore a dynamic, natural expression.
Here is another example of skin distension mas without relaxation of the underlying orbicularis muscle.
In this case, the lower pockets are removed conjunctivally, the hollows are filled with micro-fat grafts (lipostructure) and the excess skin is removed without touching the muscle (pinch technique).
This technique has the enormous advantage of avoiding the risk of retraction and downward displacement of the eyelid. This complication, known as round eye, is dreaded because it modifies the shape of the palpebral opening, with a formidable aesthetic impact.
Lipostructure is a breakthrough technique in eye surgery, and I've been practicing it in the peri-ocular region since 2006.
When an eye stops functioning, for example as a result of trauma or retinal detachment, it may atrophy (i.e. get smaller and smaller) and become painful and unsightly.
In order to eliminate pain and restore a more natural look, it is possible to perform an evisceration that removes the cornea (the transforming part in front of the iris) as well as the contents of the eyeball. In order to restore a normal anatomy, it is essential to compensate for the loss of volume with a spherical implant of a size close to that of a normal eye.
In this case, the implant used is made of acrylic (plastic), with the white wall of the eye (called the sclera) retained and used to cover the implant. As the oculomotor muscles are attached to the sclera, the implant will mobilize when the sighted eye moves. Surgical techniques now make it possible to place implants large enough to compensate for the entire loss of volume.
This will recreate a natural palpebral opening, a curved upper eyelid and a palpebral crease at a near-normal height.
The whole is covered by a prosthesis which is a fairly thin lens that looks like an eye. This lens will be mobilised by the movement of the implant, but this mobility will remain lower than that of the normal eye.
Removal of the eyeball results in an orbital volume defect. If this has not been corrected by the insertion of an orbital implant, or if this implant is of insufficient size, the volume defect will cause significant aesthetic damage.
To compensate for this, the prosthesis (which is a kind of large lens that looks like an eye) will be abnormally thick. Over time this will cause the lower eyelid to droop with the development of a deep hollow in the upper eyelid.
To recreate volume, a graft of both dermis and fat was taken from the buttock (the area where the fat is densest). The volume is close to that of an eyeball, the oculomotor muscles are reattached to the dermal part of the graft to give mobility.
A fraction of about 20-50% of the graft volume will resorb. The mobility of the prosthesis will be present, which is essential for aesthetics, but will always be significantly less than on the normal side.
The objective is to restore the most natural look possible, with a harmonious palpebral opening, a well-placed crease and an absence of offset of the prosthesis with the contralateral eye.
This technique is used when it is not possible to place an implant in the orbit.
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.
Some thyroid diseases, notably Graves' disease, cause an increase in the volume of the orbit and a retraction of the levator muscle.
This leads to a complex transformation of the gaze with abnormally exposed bulging eyes.
Several interventions were necessary here:
When the facial nerve is affected, contraction of the orbicularis muscle that closes the eyelids is compromised, and the eye remains open at night (lagophthalmos), with an absent or incomplete blink during the day. When this leads to deterioration of the eye (keratitis, corneal ulcer, reduced vision, pain, etc.)
To protect the eye and improve comfort, the eyelid can be resuscitated using gravity by placing a gold implant under the eyelid's levator muscle. If there is eyelid retraction (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.
A test is performed before the operation to select the most suitable weight. The final gold implant is placed in such a way as to maintain a harmonious shape to the palpebral opening. This technique is only possible if the levator muscle has remained sufficiently elastic. If this is not the case, the implant will not be effective and the muscle itself will have to be retracted, resulting in ptosis (drooping of the eyelid).
Ptosis is a drooping of the upper eyelid due to dysfunction of the eyelid levator muscle.
In the case described below, the muscle contracts normally, but its attachment to the eyelid has loosened (aponeurotic ptosis). This may be due to ageing, inflammation in the vicinity or prolonged contact lens wear.
Injecting drops of neosynephrine (2nd photo) causes the muscle to contract and the eyelid to lift, making it possible to distinguish this type of ptosis from those linked to a loss of muscle contractibility. The procedure, usually performed for aesthetic purposes, is a delicate one, as even the slightest imperfection is highly visible. The aim is, of course, to lift the eyelid, but also to give it a regular, harmonious curvature, and to reposition the palpebral crease and orbital fat to eliminate the hollow-eye appearance.
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.
Ptosis is a drooping of the eyelid's free edge due to an abnormally weak contraction of the eyelid's levator muscle. When the residual contraction is sufficient (around 8 mm), the free edge can be raised by shortening the muscle.
This is a delicate procedure, as it also aims to restore the aesthetics of the eyes, which means not only lifting the eyelid, but also recreating a harmonious curvature, a fold that is parallel to the lash line and symmetrical, and keeping the lashes horizontal. We also need to take into account the need to close the eye to protect the cornea, which may limit the possibilities of correction.
The aim is to achieve a natural look, which does not imply absolute symmetry. On the other hand, even the slightest imperfection can be highly visible, such as an inharmonious shape.
Restoring aesthetic appeal to the eyes is a highly ambitious goal, since the appearance on the operating table is not the same as that which will ultimately exist, and the slightest imperfection will compromise the result. It's surgery by experience, and very intuitive.
The main risk is the need for repeat surgery, which occurs in around 15% of cases.
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 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).
When it's linked to a loosening of the eyelid's support tissues, as in this case, it's called involutional: the skin and orbicularis muscle are not retracted (which would aggravate the tilt) but, on the contrary, loosened, resulting in a slight deformity above and outside the cheekbone called malar pôche.
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.
In this case, relaxation of the deep part of the eyelid is combined with retraction of the superficial part (skin and possibly the orbicularis muscle). The estropion is said to be cicarectile.
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).
Lower eyelid reconstruction: Kollner Technique
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.
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.
The bite tore off the lower eyelid with the ciliary margin, as well as the external angle. The child had undergone temporary suturing in the emergency department.
The deep part of the eyelid (posterior lamella) was reconstructed with a graft taken from the contralateral upper eyelid, and the angle and upper eyelid structures were repositioned.
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 in this case, eyelid instability is due to the relaxation of tissues with age (involutional form). Treatment is surgical, and consists of repositioning the eyelid in its various axes by reattaching it to the external orbital rim and recreating a palpebral crease.
Upper entropion is usually cicatricial. It is due to retraction of the deep part (posterior lamella) of the eyelid, which turns inwards, causing the eyelashes to rotate and rub the eye, damaging its surface (keratitis).
Treatment is surgical, with separation of the 2 lamellae - anterior and posterior - that make up the eyelid, and elevation of the anterior lamella relative to the posterior. To achieve this, the eyelid's levator muscle must be pulled back.
An initial overcorrection is sought to allow for healing. The aim is to bring the eyelashes back into a horizontal position without altering the shape of the opening between the 2 eyelids.
The lower palpebral pockets are related to excess fat volume in the orbit, which protrudes anteriorly from the bony orbital rim.
In this case, there are no rings, i.e. hollows in front of the inferior orbital rim.
In this example, the defect is isolated: in fact, there is no ring (which is a hollow along the orbital rim), nor any sagging of the skin or orbicularis muscle. Pockets can therefore be removed conjunctivally (through the inside of the eyelid), since there is no excess skin to remove, and there is no need to consider lipostructure to add volume.
No skin scars are thus created and the risk of scar retraction is avoided, which can lead to deformation of the palpebral opening (round eye), a complication that is dreaded because it degrades the expression of the eyes.
