Dermatochalasis

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Background

Redundant and lax eyelid skin and muscle is known as dermatochalasis. Dermatochalasis is a common finding seen in elderly persons and occasionally in young adults. Gravity, loss of elastic tissue in the skin, and weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well.

Some systemic diseases also may predispose patients to develop dermatochalasis. These include thyroid eye disease, renal failure, trauma, cutis laxa, Ehlers-Danlos syndrome, amyloidosis,[1] hereditary angioneurotic edema, and xanthelasma. Genetic factors may play a role in some patients.

Dermatochalasis can be a functional or cosmetic problem for the patients. When functional, dermatochalasis frequently obstructs the superior visual field. In addition, patients may note ocular irritation, entropion of the upper eyelid, ectropion of the lower eyelid, blepharitis, and dermatitis. When cosmetic, patients note a fullness or heaviness of the upper eyelids, "bags" in the lower eyelids, and wrinkles in the lower eyelids and the lateral canthus.

Steatoblepharon describes the herniation of the orbital fat in the upper or lower eyelids. It is associated frequently with dermatochalasis. However, some patients may present with isolated steatoblepharon. Herniation of the orbital fat in the eyelids is because of a weakening of the orbital septum, usually because of age. Most commonly, it is noted in the medial upper eyelid but can give the appearance of "bags under the eyes."

Blepharochalasis syndrome is separate and distinct from dermatochalasis and is a rare disorder that typically affects the upper eyelids. Blepharochalasis syndrome is characterized by intermittent eyelid edema, which frequently recurs. This results in relaxation of the eyelid tissue and resultant atrophy. In approximately 50% of patients, it is unilateral.

Dermatochalasis can be separated into early and late phases. The early phase is divided further into hypertrophic and atrophic forms. The cause is probably a localized form of angioedema. Sequelae include conjunctival edema and injection, entropion, ectropion, steatoblepharon, ptosis, and excessively thin skin. Blepharochalasis rarely can be associated with agenesis of the kidney, vertebral abnormalities, and congenital heart defects.

Pathophysiology

The pathophysiology of dermatochalasis is consistent with the normal aging changes seen in the skin. This includes loss of elastic fibers, thinning of the epidermis, and redundancy of the skin. Histopathologic studies have shown that the orbicularis oculi remains morphologically intact as patients age and that the predominant findings were located in the epidermis and dermis.[2] When associated with dermatitis, a nonspecific chronic infiltrate is seen. The pathology of blepharochalasis typically shows loss of elastic fibers, lymphedema, epithelial atrophy, and vasculitis.

Epidemiology

Frequency

United States

Dermatochalasis most frequently occurs in elderly persons and is very common; the severity is quite variable. The age of onset most frequently is noted in the 40s and progresses with age. Some patients have a familial tendency and develop dermatochalasis in their 20s.

Mortality/Morbidity

Visual-field loss is the most frequent sequelae of dermatochalasis. In severe cases of dermatochalasis, patients can lose more than 50% of their superior visual field. Patients with a purely aesthetic deformity may not have any visual field defects.

Blepharitis frequently is seen in patients with moderate-to-severe dermatochalasis. It is characterized by eyelid skin edema and erythema; scurf; meibomian gland inflammation and plugging; and, occasionally, hordeolum.

Eyelid deformities, such as upper eyelid entropion and lower eyelid ectropion or retraction, can be seen with redundant upper or lower eyelid skin. The redundant upper eyelid skin overhangs the lashes, causing lash ptosis and entropion with resultant keratitis. In patients with severe lower eyelid dermatochalasis, laxity of the lower eyelid develops with resultant eyelid retraction or ectropion.

Blepharoplasty surgery for dermatochalasis has been found to provide significant improvement in vision, peripheral vision, and quality-of-life activities. Predictors of improvement in quality of life include superior visual-field loss of at least 12°, a chin-up posture, symptoms of eye fatigue due to droopy lids, a marginal reflex distance 1 (MRD-1) of 2 mm of less, and down-gaze ptosis impairing reading.[3]

Race

Race does not seem to play a role in dermatochalasis; however, patients of Asian origin frequently note fullness in the upper eyelid. This is due to the difference in eyelid anatomy. The Asian patient's orbital septum fuses with the levator aponeurosis low above the eyelid margin or not at all. This allows the preaponeurotic fat to prolapse anteriorly in the eyelids.

Sex

Dermatochalasis occurs with equal frequency in males and females.

Age

Dermatochalasis most commonly occurs in elderly persons, and its presence and severity increase with age.

Blepharochalasis is a disease of young persons, especially seen at puberty.

History

The patients who complain of dermatochalasis frequently report visual difficulties.

Patients should be questioned about a history of periorbital trauma, thyroid disease, recurrent edema, dry eye syndrome, dry mouth, kidney disease, and dermatologic conditions.

Physical

The physical examination in patients with dermatochalasis should begin by measuring the patient's distant visual acuity with best-corrected lenses. Once this is complete, the examination should proceed in an orderly fashion as described below.

Causes

The most common cause of dermatochalasis is the normal aging phenomenon, which is associated with a loss of elastic tissue and resultant eyelid skin and muscle redundancy. Other causes may include the following:

Laboratory Studies

In most cases of dermatochalasis, no laboratory work is necessary.

Imaging Studies

In most cases, no imaging studies are necessary. If a patient is noted to have proptosis or enophthalmos, CT scan of the orbit is indicated.

Other Tests

Schirmer testing with topical anesthetic drops may be considered in patients who have significant dry eye symptoms and who desire blepharoplasty.[4] However, most ophthalmic plastic surgeons do not consider Schirmer tear testing to be the medical standard of care in evaluating blepharoplasty patients.[5]

Other tear function testing, including the Schirmer test I, Schirmer test II and the phenol red thread test may be indicated.

Procedures

Blepharoplasty is the procedure of choice for upper and/or lower eyelid dermatochalasis. This can be combined with fat removal in patients with steatoblepharon.

In patients noted to have ptosis of the upper eyelid, a concurrent ptosis surgery may be indicated. Similarly, patients with lower eyelid laxity or malposition may require corrective surgery.

Periocular fillers may be considered in patients with minor hollowing, steatoblepharon, or lid abnormalities. Several authors have also proposed the injection of periocular fillers in place of blepharoplasty for periorbital rejuvenation.[6, 7]

Histologic Findings

In most cases of dermatochalasis, normal skin and muscle are identified. With dermatitis, a chronic nonspecific inflammatory infiltrate may be seen.

Medical Care

In general, the treatment of dermatochalasis is surgical. The following medical treatments may be appropriate:

Surgical Care

Upper eyelid blepharoplasty should always be performed following a careful history and examination prior to the surgery.

Note the before-and-after images below.


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Preoperative image prior to upper blepharoplasty.


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Postoperative image after upper blepharoplasty.

Transconjunctival lower eyelid blepharoplasty is indicated for the correction of steatoblepharon without dermatochalasis.[9]

Note the before-and-after images below.


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Preoperative image of a patient with thyroid eye disease, dermatochalasis, eyelid retraction, and steatoblepharon.


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Postoperative image after 4-lid blepharoplasty and canthopexy.

Autologous fat grafting has been used in the periorbital and midface regions for rejuvenation.[12] In the periorbital region, submuscular and preperiorbital fat grafts may be placed to minimize the appearance of steatoblepharon. Studies have demonstrated a long-term graft survival rate of 32%. Additionally, use of a variety of filler materials has been shown to be useful in the periorbital region.[13]

The completed clinical trial Vibration-Assisted Anaesthesia may be of interest.

Consultations

All the patients undergoing blepharoplasty should have a careful ophthalmology consultation prior to surgery.

Activity

Smoking and rubbing the eyes postoperatively can delay wound healing. In addition, activity in the first postoperative week should be limited. No activity that causes the patient to Valsalva (ie, lifting) should be allowed. Postoperative vomiting is uncommon but should be controlled medically to prevent persistent bleeding and possible retrobulbar hematoma.

Medication Summary

Treatment with topical steroid ointment is indicated in patients with dermatitis of the eyelid skin.

Dexamethasone/tobramycin (TobraDex)

Clinical Context:  Tobramycin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane.

Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Class Summary

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Inpatient & Outpatient Medications

Topical antibiotics and lubrication of the cornea are indicated postoperatively.

Most patients with dermatochalasis have difficulty in closing their eyes fully in the first week after surgery. For this reason, topical erythromycin ointment is used to keep the cornea moist at night.

Deterrence/Prevention

Smoking and eyelid rubbing should be avoided.

Complications

Lagophthalmos in dermatochalasis

Keratitis in dermatochalasis

Scarring is rarely a significant problem after blepharoplasty. If hypertrophic scarring develops, it is treated with topical steroid ointment, massage, and silicone gel.

Corneal topography may change after upper eyelid blepharoplasty surgery. With a skin-only excision, minimal astigmatic changes are noted.[14, 15] However, with removal of large fat pads, corneal astigmatism has been shown to change approximately 0.2 diopters.

Diplopia is very rare after blepharoplasty and occurs most commonly after lower eyelid blepharoplasty. In most cases, it is due to injury to the inferior oblique or inferior rectus muscle; rarely, the lateral rectus muscle can be injured.[16]

Prognosis

The prognosis is excellent with blepharoplasty surgery.

Author

Grant D Gilliland, MD, Private Practice, Texas Ophthalmic Plastic, Reconstructive and Orbital Surgery Associates

Disclosure: Nothing to disclose.

Specialty Editors

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD, Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

References

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Pinch technique for measuring redundant skin in upper eyelid blepharoplasty.

Preoperative image prior to upper blepharoplasty.

Postoperative image after upper blepharoplasty.

Preoperative image of a patient with thyroid eye disease, dermatochalasis, eyelid retraction, and steatoblepharon.

Postoperative image after 4-lid blepharoplasty and canthopexy.

Preoperative image prior to upper blepharoplasty.

Postoperative image after upper blepharoplasty.

Preoperative image of a patient with thyroid eye disease, dermatochalasis, eyelid retraction, and steatoblepharon.

Postoperative image after 4-lid blepharoplasty and canthopexy.

Pinch technique for measuring redundant skin in upper eyelid blepharoplasty.