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New approach treats lower lid

Article-New approach treats lower lid

Dr. Patipa
Colorado Springs, Colo. — Techniques for minimizing and managing complications related to transblepharoplasty lower eyelid and midface rejuvenation range from suturing techniques to treatment algorithms with a decidedly hands-on flair.

One common complication that doctors must combat after performing cosmetic lower-eyelid surgery is conjunctival chemosis, a pronounced swelling of the lower eyelid conjunctiva.

"In my patients," says Michael Patipa, M.D., "whenever I do lower eyelid cosmetic or reconstructive surgery, I use a Frost suture, which is a suture that goes to the outer part of the lower eyelid and then is either taped to the forehead or sutured to the eyebrow for four days after surgery. That suture and fluorometholone 0.1 percent steroid drops used four times a day for four to seven days after surgery significantly have reduced the incidence of chemosis in my patients."

Dr. Patipa, an ocular plastic surgeon based in West Palm Beach, Fla., frequently sees patients with lower lid complications who have been referred by other doctors.

"When patients are referred to me with chemosis after having had surgery elsewhere," he says, "I have them massage the lower lids upward, thereby pushing the fluid out of the swollen eyelid (for a few seconds, four times daily) and start the drops. If the chemosis does not improve, I will occasionally put a Frost suture in their lower lid for four to seven days, which significantly accelerates the resolution of the chemosis."

Since Dr. Patipa began publishing on his method in 2000, it has become a standard of care that's now used quite regularly and successfully. Before Dr. Patipa's method became available, doctors could offer patients few options for conjunctival chemosis.

"Surgeons just felt frustrated and said that the chemosis will get better, which it does," Dr. Patipa says. However, his treatment seems to prevent the complication from developing and, should it occur, accelerate its resolution.

To treat lax lateral canthal tendons, another common complication of lower lid and mid-face cosmetic surgery that contributes to lower eyelid retraction, Dr. Patipa simply excises the 1 mm or 2 mm of lax tendon and reattaches the lower lid back to its normal anatomic location at the lateral orbital tubercle (Plast Reconstr Surg. 106: 438; 2000.). The technique requires a 3 mm lateral canthotomy, a 3 mm vertical cantholysis, and the resection of 0 mm to 3 mm of lax tendon. As such, it's called the 3 mm technique.

"I use that when I do cosmetic eyelid surgery or cosmetic mid-face surgery for people who have laxity," Dr. Patipa tells Cosmetic Surgery Times.

Four finger algorithm For patients in the latter category, he uses an algorithm that involves placing from one to four fingers along the lower lid and cheek to guide his repositioning of malpositioned lower lids.

"If I put one finger at the outer corner of the eye and that puts the lid back where it belongs," Dr. Patipa explains, "I tighten the lateral canthal tendon. If one finger is inadequate and the second finger at the lower lid margin puts the lid back where it belongs, then I tighten the lateral canthal tendon and insert a hard palate mucosal spacer graft behind the lid to push the lid up to where it belongs. If that's inadequate, I use three fingers — one over the cheek, one at the lateral canthus and one at the lower lid margin — then I'll do a cheek lift or malar fat pad lift, tighten the lateral canthal tendon and insert a spacer graft. If the patient has a very tight midface from multiple previous facelifts or eyelid surgeries, laser surgery or other cosmetic surgeries, then I use the four fingers, which is basically a subperiosteal midface lift, lateral canthal tendon tightening, and spacer graft. Using that algorithm, I've been very successful in repositioning the lower lid in patients who have had complications that get referred to me."

Disclosure: Dr. Patipa possesses no financial interests related to this article.

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